Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective

Hello, my name is . I will be conducting an interview and later perform a physical exam.

Greet 07/22/20 5:37 PM EDT

Hey.

What is your name?

Question 07/22/20 5:37 PM EDT

Tina Jones.

Your date of birth?

Question 07/22/20 5:37 PM EDT

February 17th.

How old are you?

Question 07/22/20 5:43 PM EDT

I’m 28.

What brought you into the clinic today?

Question 07/22/20 5:43 PM EDT

I came in because I’m required to have a recent physical exam for the health insurance at my new job.

Do you have any current health problem?

Question 07/22/20 5:44 PM EDT

I don’t have anything specific going on today. I mean, I still have asthma and diabetes, but both of those are under control. I’m taking good care of my health these days.

What is your new job? Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

Question 07/22/20 5:44 PM EDT

I’m going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. I’ll be helping a more experienced accountant with her clients, and then eventually I’ll get more responsibility, and build my own client list. I start in two weeks–I’m really excited!

That is great.

Empathize 07/22/20 5:45 PM EDT

Thanks.

When was your last physical exam?

Question 07/22/20 5:45 PM EDT

Let’s see . . . I had two doctor’s appointments earlier this year. About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. Then a few weeks later I saw a gynecologist for a pap smear.

What did your gynecologist say?

Question 07/22/20 5:45 PM EDT

She said everything looked good, except that I had PCOS, which the nurse here had said was possible. She started me on birth control, and it seems to be helping things.

How often do you take birth control?

Question 07/22/20 5:48 PM EDT

I take it every morning, with breakfast.

What is the name of the birth control pill you took?

Question 07/22/20 5:49 PM EDT

They’re called Yaz.

Has your menstrual cycle improved since taking Yaz?

Question 07/22/20 5:50 PM EDT

Now that I’m on the pill I’m getting my period every month.

That is great. I am glad you are having your period every month.

Empathize 07/22/20 5:50 PM EDT

Thanks.

How long have you had asthma.

Question 07/22/20 5:51 PM EDT

I’ve had asthma a long time. . . since I was really little.

What age were you diagnosed with asthma?

Question 07/22/20 5:51 PM EDT

My doctor told me when I was pretty little… I think I was about two and a half? I used to have a lot of trouble with asthma attacks back then.

I am sorry about the experience.

Empathize 07/22/20 5:52 PM EDT

Thanks.

How do you manage your asthma?

Question 07/22/20 5:52 PM EDT

I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler.

What are your triggers for asthma?

Question 07/22/20 5:53 PM EDT

Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. I haven’t had a full asthma attack in years, though.

It is important to stay away from triggers.

Educate 07/22/20 5:54 PM EDT

Thanks for telling me.

What happens when you are around dust?

Question 07/22/20 5:54 PM EDT

I used to have a reaction when I was in a dusty house for a long time. . . I would get allergies, like sneezing and stuff, and then my asthma would act up. But that hasn’t happened since I got my daily inhaler.

What inhaler do you use?

Question 07/22/20 5:59 PM EDT

The daily inhaler is Flovent, and the rescue inhaler is Proventil.

How often do you use flovent?

Question 07/22/20 6:00 PM EDT

Twice a day.

When did you most recently use the flovent inhaler?

Question 07/22/20 6:01 PM EDT

I use my Flovent inhaler two times a day.

When did you last use your inhaler?

Question 07/22/20 6:03 PM EDT

I used my Flovent inhaler this morning–I have to take it twice a day. My albuterol. . . I’ve maybe used it twice since I came in with those asthma problems. Once three months ago, and before that it had been months, too.

How much Albuterol do you use?

Question 07

I have a few friends I’ve known since middle or high school, and we’re all pretty close. Plus I have my friends from church.

What is your relationship like with your family?

Question 07/22/20 7:39 PM EDT

Things are pretty good between all of us–we’re a tight knit family. I think we’re pretty special, the way we all get along.

That is great.

Empathize 07/22/20 7:39 PM EDT

Thanks.

Are you involved in church?

Question 07/22/20 7:39 PM EDT

Yeah. We go to First Baptist, and we do a lot with our church community. We socialize before and after church, and I go to Bible study on Wednesdays, too.

Are you feeling stressed?

Question 07/22/20 7:40 PM EDT

I’m actually feeling really good lately. . . not stressed at all.

How do you cope with stress?

Question 07/22/20 7:40 PM EDT

I’ve realized that I got kind of overwhelmed with everything back when I was having those sleep problems. Just coming in and talking to someone here about it helped a little because I felt like I was doing something. So I’ve been trying to address problems as they come when I can, and that helps. That, plus the stuff I’ve always done–going to church, especially–is all working well for me.

That is good to hear.

Empathize 07/22/20 7:40 PM EDT

Thanks.

Are you feeling depressed?

Question 07/22/20 7:41 PM EDT

No, I’m actually feeling really good these days.

How do you feel about your life?

Question 07/22/20 7:41 PM EDT

Well, I’m starting my new job in two weeks, and I’m really excited about that. I’m going to be an Accounting Clerk at this really nice accounting firm. I’m hoping I’ll learn a lot in that position, and within a couple years, I’ll get promoted and be given new responsibilities. I just always want to be learning new things and getting better at my job.

Are you feeling anxious?

Question 07/22/20 7:41 PM EDT

I guess I had anxiety back when I was having those sleep problems. . . I’ve been feeling much better lately, though.

Do you have sleeping problems?

Question 07/22/20 7:42 PM EDT

I’m sleeping a lot better now, which is a relief.

Good to hear.

Empathize 07/22/20 7:42 PM EDT

Thanks.

How many hours are you sleeping a night?

Question 07/22/20 7:42 PM EDT

I’m usually asleep by 11:30, and I wake up at 8, so. . . about 8 or 9 hours a night.

That is great.

Empathize 07/22/20 7:42 PM EDT

Thanks.

Have you ever smoked tobacco?

Question 07/22/20 7:43 PM EDT

No. I think it’s gross.

Have you ever used cocaine?

Question 07/22/20 7:43 PM EDT

No way, I have no interest in that. That stuff can mess you up.

Have you ever used heroin?

Question 07/22/20 7:49 PM EDT

Uh, no.

Have you ever used illegal drugs?

Question 07/23/20 3:17 PM EDT

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