HEENT Tina Jones Shadow Health Transcript
Hi there. My name’s xxxx, and I’ll be asking you some questions first and then doing a physical checkup on you. Greetings
06/28/20 1:17 AM EDT
Hello.
What’s your name? Asking
06/28/20 1:17 AM EDT
Tina Jones.
Why are you here today? Asking
06/28/20 1:30 AM EDT
I’ve been dealing with a sore and itchy throat, and my nose won’t stop running. These symptoms are really bothering me.
I’m sorry to hear that. Expressing empathy
06/28/20 1:31 AM EDT
Thank you for understanding.
How long have you been experiencing these symptoms? Asking
06/28/20 1:32 AM EDT
My itchy eyes, runny nose, and sore throat all began about a week ago. [AUDIO COMING SOON]
Have you had these symptoms before? Asking
06/28/20 1:35 AM EDT
No, I haven’t.
How intense is your sore throat? Asking
06/28/20 1:36 AM EDT
It’s not too bad. It hurts a bit, like a mild to moderate level of pain. But the main issue is that it’s persistent.
Is the soreness in your throat constant? Asking
06/28/20 1:37 AM EDT
Yes, it’s pretty much there all the time.
Can you describe the discomfort? Asking
06/28/20 1:42 AM EDT
It’s quite sore and itchy, particularly towards the back of my throat.
On a scale from 0 to 10, how would you rate the pain? Asking
06/28/20 1:43 AM EDT
Probably around a 4 out of 10.
Does the pain spread elsewhere? Asking
06/28/20 1:44 AM EDT
No, it’s localized in my throat.
What do you think might be causing your sore throat? Asking
06/28/20 1:45 AM EDT
Initially, I thought it might be the onset of a cold or flu, but now I’m not so sure. It hasn’t worsened, but it hasn’t improved either.
Does anything exacerbate the pain? Asking
06/28/20 1:46 AM EDT
It’s a bit worse in the morning, but that’s the only consistent pattern I’ve noticed.
Are there any other symptoms you’re experiencing? Asking
06/28/20 1:46 AM EDT
Let me think… I’ve got quite a list: a sore and itchy throat, a runny nose, and itchy eyes.
Have you had any nasal discharge? Asking
06/28/20 1:47 AM EDT
Only when I’m around cats.
Can you describe the nasal discharge? Asking
06/28/20 1:48 AM EDT
It’s very runny and clear. Quite unpleasant, really. [AUDIO COMING SOON]
Do you have any eye issues? Asking
06/28/20 1:52 AM EDT
Apart from the current itchiness, sometimes my vision blurs when I read. It feels like my eyesight has been deteriorating over the years.
Are you experiencing shortness of breath? Asking
06/28/20 2:00 AM EDT
No, my breathing is fine.
Do you have any other medical conditions? Asking
06/28/20 2:05 AM EDT
I have diabetes and asthma, but I’m not dealing with those today.
When were you diagnosed with asthma? Asking
06/28/20 2:06 AM EDT
I was diagnosed when I was very young, around two and a half years old. I used to have frequent asthma attacks back then.
Have you ever been hospitalized for asthma? Asking
06/28/20 2:08 AM EDT
I went to the hospital numerous times during my childhood due to asthma attacks.
When was the last time you were hospitalized for asthma? Asking
06/28/20 2:09 AM EDT
I used to go quite often when I was younger, but not since I was sixteen.
Do you take any medication for asthma? Asking
06/28/20 2:10 AM EDT
Just my inhaler.
What type of inhaler do you use? Asking
06/28/20 2:11 AM EDT
It’s a regular Proventil inhaler.
How frequently do you use your inhaler? Asking
06/28/20 2:11 AM EDT
Not every day—maybe 2 or 3 times a week, sometimes even less.
How often do you experience a runny nose? Asking
06/28/20 2:18 AM EDT
It’s constant throughout the day.
Have you been exposed to any allergens recently? Asking
06/28/20 2:20 AM EDT
Not recently.
Do you have any allergies? Asking
06/28/20 2:21 AM EDT
Yes, I’m allergic to cats and dust.
Are you allergic to pollen? Asking
06/28/20 2:21 AM EDT
Not that I know of. Although, despite never having had pollen allergies before, my symptoms resemble those of my sister, who has hay fever. I’m starting to suspect allergies.
Are you allergic to mold? Asking
06/28/20 2:22 AM EDT
Not that I’m aware of.
Is there a family history of throat issues? Asking
06/28/20 2:31 AM EDT
No.
Do you take any over-the-counter medications? Asking
06/28/20 2:31 AM EDT
I’ve been trying throat lozenges lately. Occasionally, I’ll take Tylenol for headaches or Advil for cramps, but not regularly.
How often do you experience headaches? Asking
06/28/20 2:32 AM EDT
About once a week. I tend to do a lot of school work in one go, studying for 5 or 6 hours straight, which often results in a headache by the end of the night.
How would you rate these headaches? Asking
06/28/20 2:33 AM EDT
They’re not too severe, maybe around a 3. Or a 4 if
Table of Contents
Documentation – Tina Jones Neurological Shadow Health assessment
HEENT Tina Jones Shadow Health Transcript
All Lines (193)Interview Questions (102)Statements (15)Exam Actions (76)
| Hello. My name is xxxx and I will interview you today and later do a physical exam. | Greet 06/28/20 1:17 AM EDT |
|
| Hey. | ||
| What is your name? | Question 06/28/20 1:17 AM EDT |
|
| Tina Jones. | ||
| What brings you here today? | Question 06/28/20 1:30 AM EDT |
|
| My throat has been sore… and itchy. And my nose won’t stop running. These symptoms are driving me nuts. | ||
| Am sorry to hear that. | Empathize 06/28/20 1:31 AM EDT |
|
| Thanks for understanding. | ||
| How long have you had these symptoms? | Question 06/28/20 1:32 AM EDT |
|
| My itchy eyes, runny nose, and sore throat all started a week ago. [AUDIO COMING SOON] | ||
| Have you ever had these symptoms before? | Question 06/28/20 1:35 AM EDT |
|
| No. | ||
| How severe is your sore throat? | Question 06/28/20 1:36 AM EDT |
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| It’s not… terrible. I mean, it hurts a little. Like, mild to moderate. The main thing is that it won’t go away. | ||
| Is the sore throat constant? | Question 06/28/20 1:37 AM EDT |
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| Yeah, it’s sore pretty much all the time. | ||
| Can you describe the pain? | Question 06/28/20 1:42 AM EDT |
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| It’s really sore, and it itches a lot, like in the back. | ||
| How would you rate the pain on a scale of 0 to 10? | Question 06/28/20 1:43 AM EDT |
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| It’s like a 4 out of 10, maybe. | ||
| Does the pain radiate? | Question 06/28/20 1:44 AM EDT |
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| No, it’s just in my throat. | ||
| What do you think is causing the sore throat? | Question 06/28/20 1:45 AM EDT |
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| At first I thought I was getting sick, or a cold or something, but now it doesn’t seem like that. My throat hasn’t gotten worse, but it’s not going away either. | ||
| Does anything make the pain worse? | Question 06/28/20 1:46 AM EDT |
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| It’s a little worse in the morning, but that’s really the only pattern I’ve noticed. | ||
| Any other symptoms? | Question 06/28/20 1:46 AM EDT |
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| Let’s see… I have a lot going on so here’s the laundry list: sore and itchy throat, runny nose, itchy eyes. | ||
| Any nasal discharge? (Clarified to Has your nose been running?.) | Question 06/28/20 1:47 AM EDT |
|
| Just when I’m around a cat. (Clarified to if my nose has been runny.) | ||
| Can you describe the nasal discharge? | Question 06/28/20 1:48 AM EDT |
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| I have a really runny nose. Everything coming out of it is really drippy and clear. It’s gross. [AUDIO COMING SOON] | ||
| Any eye problems? | Question 06/28/20 1:52 AM EDT |
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| You mean, other than this itchy-eye stuff going on right now? I guess… my eyes get blurry sometimes when I read. It seems like my vision is getting worse over the years. | ||
| Any shortness of breath? (Clarified to Do you currently have shortness of breath?.) | Question 06/28/20 2:00 AM EDT |
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| No, my breathing has been fine. (Clarified to if I have shortness of breath right now.) | ||
| Any other health problems? | Question 06/28/20 2:05 AM EDT |
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| I have diabetes and asthma, but I can’t even deal with those today. | ||
| When were you diagnosed with asthma? | Question 06/28/20 2:06 AM EDT |
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| 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. | ||
| Have you been hospitalized for asthma? | Question 06/28/20 2:08 AM EDT |
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| I went a bunch of times when I was little, for asthma attacks. | ||
| When was the last time you were hospitalized for asthma? | Question 06/28/20 2:09 AM EDT |
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| I used to go to the hospital a lot, for asthma attacks, but not since I was sixteen. | ||
| Do you take any medication for asthma? | Question 06/28/20 2:10 AM EDT |
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| I just use my inhaler. | ||
| What is the name of the inhaler? | Question 06/28/20 2:11 AM EDT |
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| It’s just a regular Proventil inhaler. | ||
| How often do you use the inhaler? | Question 06/28/20 2:11 AM EDT |
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| I don’t use it every day — maybe I use it 2 or 3 times a week. Sometimes not at all. | ||
| How often do you get a runny nose? | Question 06/28/20 2:18 AM EDT |
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| It runs all day. | ||
| Have you been recently exposed to allergens? | Question 06/28/20 2:20 AM EDT |
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| Not lately. | ||
| Any allergies? | Question 06/28/20 2:21 AM EDT |
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| Yeah. I’m allergic to cats. And dust, too. | ||
| Are you allergic to pollen? | Question 06/28/20 2:21 AM EDT |
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| Well, no. I mean, I never had allergies to pollen or anything outdoors like that. . . But my nose is acting just like my sister’s right now, and she’s always had hay fever. I’m starting to think that this is allergies. | ||
| Are you allergic to mold? | Question 06/28/20 2:22 AM EDT |
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| Not that I know of. | ||
| Any family history of throat problems? | Question 06/28/20 2:31 AM EDT |
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| No. | ||
| Do you take over the counter medications? | Question 06/28/20 2:31 AM EDT |
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| I’ve been trying throat drops lately. In general, I take Tylenol for a headache sometimes, or Advil for cramps, but not often. | ||
| How often do you get headaches? | Question 06/28/20 2:32 AM EDT |
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| Maybe once a week? I usually do a lot of my school work at once, so I’ll study for like, 5 or 6 hours. I usually end up with a headache by the end of the night. | ||
| How would you rate these headaches? | Question 06/28/20 2:33 AM EDT |
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| Not too bad. . . I’d say about 3. Or a 4 if I really push it. | ||
| What helps your headache? | Question 06/28/20 2:33 AM EDT |
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| I just take some acetaminophen. The gel kind, 500 mg. [AUDIO COMING SOON] | ||
| Does anything make your headache worse? | Question 06/28/20 2:35 AM EDT |
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| Usually they get worse if I don’t stop studying. I try to take a break when they start most of the time, but if I have a test or something coming up, I just have to try and ignore it. | ||
| How long have you had these headaches? | Question 06/28/20 3:06 AM EDT |
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| I’m not sure — Maybe over the last year or so. | ||
| Do you take any herbal supplements? | Question 06/28/20 3:07 AM EDT |
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| No, I don’t take anything herbal. | ||
| I do sometimes, yeah, when I go out with my friends. | ||
| How many drinks do you have when you go out at night? | Question 06/28/20 3:58 PM EDT |
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| Like, two or three drinks. If I have more than two or three drinks, I feel like hell the next day, so I stop at three. | ||
| That’s moderate drinking, which is okay. | Educate 06/28/20 4:38 PM EDT |
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| Alright, thanks for letting me know. | ||
| What type of alcohol do you take? | Question 06/28/20 4:39 PM EDT |
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| I usually get rum and diet Coke. I don’t know why that matters. | ||
| How is your family medical history? (Clarified to Can you tell me about your family medical history?.) | Question 06/28/20 4:45 PM EDT |
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| My mom has some issues, and I think some of my grandparents did, too. (Clarified to to tell you about my family medical history.) | ||
| Question 06/28/20 6:25 PM EDT |
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| Grandpa Jones had colon cancer, and that caused all kinds of problems for him. Plus, he had high blood pressure, and…I’m pretty sure he had diabetes. | ||
| How did you cope with your father’s death? | Question 06/28/20 6:25 PM EDT |
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| Well, right after he died, after the funeral and everything, I just tried to get through that. Mom was having such a hard time, crying a lot, everything made her sad, she was kinda depressed. So I guess at first I just focused on getting things done–groceries, laundry, insurance papers and stuff. Knowing that Mom needed me kinda helped me get through day by day. There was about a month where it was hard for us to get to church. Even getting up and ready for church was too overwhelming. But our church family helped us out, and gave us rides to church and brought meals and all that, so they really helped build us back up. Things were only hard like that for a few months. | ||
| Seems you have a strong support system. | Empathize 06/28/20 6:32 PM EDT |
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| Thanks. | ||
| What health issues does your sister have? | Question 06/28/20 6:34 PM EDT |
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| She’s pretty healthy. She has asthma too, but she almost never has attacks. | ||
| What health issues does your brother have? | Question 06/28/20 6:40 PM EDT |
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| None that I know of. He’s got some extra weight on him, I guess. | ||
| Anyone with obesity in your family? | Question 06/28/20 6:47 PM EDT |
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| No, I don’t think so. My brother and my dad are kind of big, but I wouldn’t say they were obese or anything. | ||
| Anyone with alcoholism in your family? | Question 06/28/20 7:11 PM EDT |
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| One person in the family, my dad’s brother, has an alcohol problem, but we never see him. | ||
| What work do you do? | Question 06/28/20 7:14 PM EDT |
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| I’m a supervisor at Mid-American Copy & Ship. I’ve been working there since high school, and I’ve just kept moving up. | ||
| Am glad to hear that. | Empathize 06/28/20 7:14 PM EDT |
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| Thanks for saying that. | ||
| What is your highest level of education? | Question 06/28/20 7:15 PM EDT |
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| Well, I’m finishing up my Bachelor’s degree right now. | ||
| Any fever? | Question 06/28/20 7:19 PM EDT |
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| No, I haven’t felt feverish at all this week. That’s another reason why this seems more like allergies than a cold. | ||
| Any dizziness? | Question 06/28/20 7:24 PM EDT |
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| I’m not feeling dizzy, no. | ||
| Any eye discharge? | Question 06/28/20 7:24 PM EDT |
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| Well, they’ve been watery. | ||
| When do you get blurry vision? | Question 06/28/20 7:25 PM EDT |
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| Usually when I’m reading. | ||
| Do you have red eyes? | Question 06/28/20 7:27 PM EDT |
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| Yeah, my eyes have been kinda red. They look the way they do when I’m around a cat, but I haven’t been near one. | ||
| Have you travelled abroad for more than one month? | Question 06/28/20 7:29 PM EDT |
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| I really haven’t travelled that much…I’ve always wanted to go to France but I’ve never even been out of the country. I’m always busy with work or school anyway though. We used to go on some family vacations when I was younger, but they were usually just to see some family in other states. | ||
| Am sure when you get less busy, you will travel more. | Empathize 06/28/20 7:30 PM EDT |
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| I appreciate you telling me that. | ||
| Any wheezing? | Question 06/28/20 7:31 PM EDT |
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| No, I’m not wheezing. | ||
| Thanks for answering my questions, let me now conduct physical exam. | Educate 06/28/20 7:38 PM EDT |
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| Thanks for telling me. | ||
| Inspected general face | Exam Action 06/28/20 7:43 PM EDT |
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| Inspected forehead and scalp | Exam Action 06/28/20 7:46 PM EDT |
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| Inspected nose and mouth | Exam Action 06/28/20 7:56 PM EDT |
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| Inspected right side of face | Exam Action 06/28/20 7:56 PM EDT |
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| Inspected back of head | Exam Action 06/28/20 7:57 PM EDT |
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| Inspected left side of face | Exam Action 06/28/20 7:57 PM EDT |
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| Inspected general face | Exam Action 06/28/20 8:05 PM EDT |
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| Inspected upper conjunctiva | Exam Action 06/28/20 8:07 PM EDT |
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| Inspected right orbital area and sclera | Exam Action 06/28/20 8:07 PM EDT |
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| Inspected left orbital area and sclera | Exam Action 06/28/20 8:07 PM EDT |
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| Inspected lower conjunctiva | Exam Action 06/28/20 8:07 PM EDT |
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| Performed otoscopic examination of right naris | Exam Action 06/28/20 8:07 PM EDT |
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| Performed otoscopic examination of left naris | Exam Action 06/28/20 8:08 PM EDT |
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| Performed otoscopic examination of right ear | Exam Action 06/28/20 8:08 PM EDT |
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| Performed otoscopic examination of left ear | Exam Action 06/28/20 8:08 PM EDT |
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| Inspected mouth | Exam Action 06/28/20 8:08 PM EDT |
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| Inspected mouth: pushed tongue left with tongue blade | Exam Action 06/28/20 8:08 PM EDT |
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| Inspect mouth: pushed tongue right with tongue blade | Exam Action 06/28/20 8:08 PM EDT |
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| Inspect mouth: lifted tongue with tongue blade | Exam Action 06/28/20 8:09 PM EDT |
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| Inspected mouth: depressed tongue with tongue blade | Exam Action 06/28/20 8:09 PM EDT |
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| Inspected front of neck | Exam Action 06/28/20 8:09 PM EDT |
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| Inspected right side of neck | Exam Action 06/28/20 8:09 PM EDT |
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| Inspected back of neck | Exam Action 06/28/20 8:09 PM EDT |
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| Inspected left side of neck | Exam Action 06/28/20 8:09 PM EDT |
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| Palpated scalp: No balding or thinning hair distribution, no masses, no tenderness reported | Exam Action 06/28/20 8:10 PM EDT |
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| Palpated frontal sinuses: No tenderness reported | Exam Action 06/28/20 8:10 PM EDT |
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| Palpated maxillary sinuses: No tenderness reported | Exam Action 06/28/20 8:10 PM EDT |
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| Palpated temporal arteries bilaterally: Right: no thrill, 2+ / Left: no thrill, 2+ | Exam Action 06/28/20 8:11 PM EDT |
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| Palpated right carotid artery: No thrill, 2+ | Exam Action 06/28/20 8:11 PM EDT |
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| Palpated left carotid artery: No thrill, 2+ | Exam Action 06/28/20 8:11 PM EDT |
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| Palpated jaw: Full range of motion, no popping or clicking | Exam Action 06/28/20 8:12 PM EDT |
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| Palpated lymph nodes of head and neck: Not palpable | Exam Action 06/28/20 8:13 PM EDT |
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| Palpated supraclavicular lymph nodes: Not palpable | Exam Action 06/28/20 8:13 PM EDT |
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| Palpated axillary lymph nodes: Not palpable | Exam Action 06/28/20 8:13 PM EDT |
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| Palpated thyroid gland: No nodules, not enlarged, no irregularities, no tenderness reported | Exam Action 06/28/20 8:14 PM EDT |
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| Auscultated breath sounds in anterior right upper lobe | Exam Action 06/28/20 8:15 PM EDT |
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| Auscultated breath sounds in anterior right middle lobe | Exam Action 06/28/20 8:15 PM EDT |
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| Auscultated breath sounds in anterior left upper lobe | Exam Action 06/28/20 8:15 PM EDT |
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| Auscultated breath sounds in anterior left mid-chest (upper lobe) | Exam Action 06/28/20 8:16 PM EDT |
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| Auscultated breath sounds in anterior left lower lobe | Exam Action 06/28/20 8:16 PM EDT |
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| Auscultated breath sounds in anterior right lower lobe | Exam Action 06/28/20 8:17 PM EDT |
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| Auscultated breath sounds in posterior left upper lobe | Exam Action 06/28/20 8:17 PM EDT |
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| Auscultated breath sounds in posterior right upper lobe | Exam Action 06/28/20 8:17 PM EDT |
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| Auscultated breath sounds in posterior left mid-back (lower lobe) | Exam Action 06/28/20 8:17 PM EDT |
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| Auscultated breath sounds in posterior right mid-back (lower lobe) | Exam Action 06/28/20 8:18 PM EDT |
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| Auscultated breath sounds in posterior left lower lobe | Exam Action 06/28/20 8:18 PM EDT |
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| Auscultated breath sounds in posterior left lower lobe on side | Exam Action 06/28/20 8:18 PM EDT |
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| Auscultated breath sounds in posterior left lower lobe near spine | Exam Action 06/28/20 8:18 PM EDT |
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| Auscultated breath sounds in posterior right lower lobe | Exam Action 06/28/20 8:18 PM EDT |
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| Auscultated breath sounds in posterior right lower lobe near spine | Exam Action 06/28/20 8:18 PM EDT |
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| Auscultated breath sounds in posterior right lower lobe on side | Exam Action 06/28/20 8:18 PM EDT |
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| Auscultated right temporal pulse | Exam Action 06/28/20 8:18 PM EDT |
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| Auscultated left temporal pulse | Exam Action 06/28/20 8:18 PM EDT |
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| Auscultated right carotid pulse | Exam Action 06/28/20 8:19 PM EDT |
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| Auscultated left carotid pulse | Exam Action 06/28/20 8:19 PM EDT |
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| Tested left pupillary reaction with penlight | Exam Action 06/28/20 8:19 PM EDT |
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| Tested right pupillary reaction with penlight | Exam Action 06/28/20 8:19 PM EDT |
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| Follow my finger with just your eyes | Question 06/28/20 8:31 PM EDT |
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| Ok. | ||
| Tested EOM to the upper left | Exam Action 06/28/20 8:31 PM EDT |
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| Tested EOM to the lower left | Exam Action 06/28/20 8:31 PM EDT |
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| Tested EOM to the upper center | Exam Action 06/28/20 8:31 PM EDT |
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| Tested convergence to the center | Exam Action 06/28/20 8:31 PM EDT |
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| Tested EOM to the lower center | Exam Action 06/28/20 8:31 PM EDT |
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| Tested EOM to the upper right | Exam Action 06/28/20 8:32 PM EDT |
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| Tested EOM to the lower right | Exam Action 06/28/20 8:32 PM EDT |
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| Tell me when you can no longer see my fingers. | Question 06/28/20 8:32 PM EDT |
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| Ok, I will. | ||
| Tested peripheral vision | Exam Action 06/28/20 8:32 PM EDT |
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| Now. | ||
| Examined fundus of right eye with ophthalmoscope | Exam Action 06/28/20 8:33 PM EDT |
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| Examined fundus of left eye with ophthalmoscope | Exam Action 06/28/20 8:40 PM EDT |
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| F P | ||
| T O Z | ||
| L P E D | ||
| P E C F D | ||
| Tested visual acuity of right eye (left eye covered) | Exam Action 06/28/20 8:42 PM EDT |
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| F P | ||
| T O Z | ||
| L P E D | ||
| P E C F D | ||
| E D F C Z P | ||
| F E L O P Z D | ||
| D E F P O T E C | ||
| Tested visual acuity of left eye (right eye covered) | Exam Action 06/28/20 8:50 PM EDT |
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| D E F P O T E C | ||
| Tested visual acuity of left eye (right eye covered) | Exam Action 06/28/20 8:50 PM EDT |
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| Is the volume the same in both ears or louder in one ear | Question 06/28/20 8:52 PM EDT |
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| Ok. | ||
| Same in both ears. | ||
| Performed Weber test with tuning fork | Exam Action 06/28/20 8:52 PM EDT |
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| Tell me when you no longer hear the ringing | Question 06/28/20 8:53 PM EDT |
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| Ok, I will. | ||
| Now. | ||
| Performed Rinne test on right ear with tuning fork | Exam Action 06/28/20 8:53 PM EDT |
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| Now. | ||
| Now. | ||
| Now. | ||
| Performed Rinne test on left ear with tuning fork | Exam Action 06/28/20 8:54 PM EDT |
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| F. | Question 06/28/20 8:55 PM EDT |
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| F. | ||
| Eight | Question 06/28/20 8:55 PM EDT |
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| Eight. | ||
| W. | Question 06/28/20 8:55 PM EDT |
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| W. | ||
| Performed whisper test in right ear | Exam Action 06/28/20 8:55 PM EDT |
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| Four | Question 06/28/20 8:55 PM EDT |
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| Four. | ||
| R. | Question 06/28/20 8:55 PM EDT |
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| R. | ||
| Nine. | Question 06/28/20 8:55 PM EDT |
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| Nine. | ||
| Performed whisper test in left ear | Exam Action 06/28/20 8:55 PM EDT |
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| Tested gag reflex with tongue blade | Exam Action 06/28/20 8:56 PM EDT |
