Shoshanna Tillman Follow Up Sick Visit: Musculoskeletal Shadow Health Transcript

Shoshanna Tillman Follow Up Sick Visit: Musculoskeletal Shadow Health Transcript

Hello. How are you today? I will talk with you and check your body today.

Hi.

What brings you here today?

I’m here to talk about my last visit regarding my joint pain and how tired I’ve been.

I understand.

Thank you.

How long have you had joint pain?

The joint pain started about 3 months ago.

Where do you feel the joint pain?

Primarily in my hands and wrists, but I also experience pain all over my body.

Can you describe your pain?

I feel stiff and achy all over, with a dull, throbbing pain in my hands and wrists.

What makes your pain worse?

Activities like holding my coffee cup or typing aggravate the pain.

What helps relieve your pain?

Hot showers and diclofenac medication provide some relief.

On a scale of 1 to 10, how would you rate your pain?

Since starting diclofenac, maybe a 2 out of 10.

How long have you felt fatigued?

For about 3 months.

Is your fatigue constant?

Yes, it’s always there.

Does anything make your fatigue worse?

It tends to worsen as the day goes on.

What contributes to your fatigue?

I’m not sure, possibly stress.

I’m sorry to hear that.

Thank you.

Can you still manage your daily activities?

Yes, but it takes longer due to fatigue.

What might be causing your fatigue?

I’m not sure, maybe hormones or stress.

Do you have any allergies?

Yes, to codeine.

Any food allergies?

No.

How often do you experience pain?

It’s constant, especially in the morning.

Any other health issues?

Besides joint pain and fatigue, nothing diagnosed.

Have you experienced any mental health concerns?

Nothing diagnosed, but I’ve been feeling down and anxious lately.

I’m sorry to hear that.

Thank you.

Have you been hospitalized before?

Only for childbirth.

Have you had any surgeries?

No.

Are you taking any medications?

Yes, diclofenac and previously ibuprofen, and I have an IUD.

What’s the dosage of diclofenac?

50 mg.

Why were you prescribed diclofenac?

For joint pain.

How much ibuprofen did you take?

400 mg, 2 or 3 times a day.

Which IUD do you have?

Levonorgestrel.

Do you take your medications as directed?

Yes, always.

When did you last take your medication?

This morning, the diclofenac.

Do you smoke?

No, never.

Do you drink alcohol?

Yes, occasionally.

What’s your typical diet?

I try to eat healthy with lots of fruits, veggies, and lean proteins.

How much water do you drink daily?

About 6 to 8 glasses.

Do you consume caffeine?

Yes, a few cups of coffee daily.

It’s important not to overdo it with caffeine.

Got it.

Do you exercise?

I walk the dog a few times a week, but not much else.

Regular exercise is important for overall health.

I understand.

How many hours of sleep do you get?

About 5 or 6 hours.

What do you do for work?

I run an art gallery called Bricolage with my husband, and I’m also an artist.

What’s your education level?

I have degrees in studio art and art history.

Are you satisfied with your income?

The gallery is profitable now, but running a small business is challenging.

Feeling stressed?

Yes, it’s been tough.

NURS-6051N Week 11: Assignment POLICY/REGULATION FACT SHEET EXAMPLE

Started:
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Hi. xxx . I will interview and examine today

Greet
05/24/23 12:15 PM EDT

Shoshanna Tillman.
Hi.
Your Avatar.
Why are you here today?

Question
05/24/23 12:34 PM EDT

Shoshanna Tillman.
I’m here to follow up on my last visit, about my joint pain, and how tired I’ve been.
Your Avatar.
Sorry about that

Empathize
05/24/23 12:34 PM EDT

Shoshanna Tillman.
Thank you.
Your Avatar.
How long have you had joint pain?

Question
05/24/23 12:35 PM EDT

Shoshanna Tillman.
The joint pain started about 3 months ago, now.
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Where is the joint point located?

Question
05/24/23 12:36 PM EDT

Shoshanna Tillman.
In my hands and wrists, mainly, but also I have this all-over sort of pain.
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Is your pain like? (Clarified to Can you describe your pain?.)

Question
05/24/23 12:38 PM EDT

Shoshanna Tillman.
I feel sort of stiff and achy all over. And my hands and wrists are stiff — there’s this dull, throbbing sort of pain. (Clarified to what the pain is like.)
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What worsens your pain?

Question
05/24/23 12:38 PM EDT

Shoshanna Tillman.
Holding my coffee cup in the morning is tough on my hands and fingers, and my wrists. Also typing and holding my art tools hurts after a while.
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What relieves your pain?

Question
05/24/23 12:39 PM EDT

Shoshanna Tillman.
Long, hot showers can help a little. Also, the diclofenac has been helping some.
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can you rate your pain on a scale of 1 to ten? Shoshanna Tillman Follow Up Sick Visit: Musculoskeletal Shadow Health Transcript

Question
05/24/23 12:40 PM EDT

Shoshanna Tillman.
I still have pain, but since starting the diclofenac, maybe a 2 out of 10. Before it was a 3 or 4.
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How long have you had fatigue

Question
05/24/23 12:41 PM EDT

Shoshanna Tillman.
Going on 3 months now.
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Is your fatigue constant?

Question
05/24/23 12:41 PM EDT

Shoshanna Tillman.
Always, yeah.
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Does your fatigue worsen?

Question
05/24/23 12:42 PM EDT

Shoshanna Tillman.
Yeah, the fatigue feels worse as the day goes on.
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What makes your fatigue worse?

Question
05/24/23 12:44 PM EDT

Shoshanna Tillman.
Nothing, I don’t think . . . but I am pretty stressed regularly.
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I am sorry about that

Empathize
05/24/23 12:44 PM EDT

Shoshanna Tillman.
I appreciate that.
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Are you able to do your daily activities?

Question
05/24/23 12:45 PM EDT

Shoshanna Tillman.
I guess so, yeah. I can do everything I need to. I just take a little longer these days, ’cause I’m so tired. And I sometimes just feel drained after everything.
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What causes your fatigue?

Question
05/24/23 12:45 PM EDT

Shoshanna Tillman.
I don’t know why I’m so tired. I haven’t noticed anything that makes me particularly tired. Maybe it’s hormones or something. Or stress, I’m very stressed these days.
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Any allergies?

Question
05/24/23 12:45 PM EDT

Shoshanna Tillman.
Yeah, a codeine allergy.
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Any food allergies?

Question
05/24/23 12:46 PM EDT

Shoshanna Tillman.
Nope.
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How frequent is your pain?

Question
05/24/23 12:46 PM EDT

Shoshanna Tillman.
It’s constant, honestly. It can feel the worst when I wake up in the morning.
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Any current health problems?

Question
05/24/23 12:48 PM EDT

Shoshanna Tillman.
Besides my joint pain, and how tired I am all the time, I don’t have anything I’ve been diagnosed with.
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Have you had any mental condition?

Question
05/24/23 12:48 PM EDT

Shoshanna Tillman.
I don’t have any clinical disorders or anything, but I’ve been feeling kind of down lately, and pretty anxious.
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I’m sorry about that (No matching questions found.)

Question
05/24/23 12:50 PM EDT

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I’m sorry about that

Empathize
05/24/23 12:50 PM EDT

Shoshanna Tillman.
That’s kind of you.
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Have you been hospitalized?

Question
05/24/23 12:50 PM EDT

Shoshanna Tillman.
Just for my 3 deliveries.
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Have you had surgeries?

Question
05/24/23 12:51 PM EDT

Shoshanna Tillman.
No.
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Are you using any medications?

Question
05/24/23 12:51 PM EDT

Shoshanna Tillman.
Yep, diclofenac. I used to take ibuprofen. And I have an IUD, if that counts.
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What is the dose to the diclofenac?

Question
05/24/23 12:51 PM EDT

Shoshanna Tillman.
The dose is diclofenac sodium 50 mg.
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Why do you take the diclofenac?

Question
05/24/23 12:52 PM EDT

Shoshanna Tillman.
I was prescribed diclofenac at my last visit for my joint pain.
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What is the dosage of Ibuprofen?

Question
05/24/23 12:52 PM EDT

Shoshanna Tillman.
I was taking 400 milligrams at a time, 2 or 3 times a day.
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Which IUD are you using?

Question
05/24/23 12:54 PM EDT

Shoshanna Tillman.
My IUD is levonorgestrel.
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Do you take your medications as prescribed?

Question
05/24/23 12:54 PM EDT

Shoshanna Tillman.
Yes, very.
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When did you last take your medication Shoshanna Tillman Follow Up Sick Visit: Musculoskeletal Shadow Health Transcript

Question
05/24/23 12:55 PM EDT

Shoshanna Tillman.
This morning. I took my diclofenac.
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Do you use tobacco?

Question
05/24/23 12:55 PM EDT

Shoshanna Tillman.
I never have, no.
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Do you drink alcohol everyday? (Clarified to Do you drink alcohol?.)

Question
05/24/23 12:55 PM EDT

Shoshanna Tillman.
Sure, yeah. (Clarified to if I drink alcohol.)
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What is your typical diet

Question
05/24/23 12:56 PM EDT

Shoshanna Tillman.
I try and eat pretty healthily. Breakfast, I’ll have fruit and yogurt, or I’ll make the kids and I eggs and pancakes on the weekends. Lunch, I really like salads, soups, tacos, and wraps. Dinner, we’ll have salmon or chicken, often with a side of veggies and a grain, pasta, or legumes. If I really need a snack, maybe I’ll have some almonds, or some fruit . . . maybe a granola bar, or some hummus with carrots.
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How much water do you drink per day?

Question
05/24/23 12:57 PM EDT

Shoshanna Tillman.
I’ll usually have between, say, 6 to 8 glasses a day.
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Do you take caffeine?

Question
05/24/23 12:58 PM EDT

Shoshanna Tillman.
I do. I’ll have somewhere between 2 to 3 cups of coffee in the morning, then another one or two in the afternoon.
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OK, but too much caffeine is not good for your health

Educate
05/24/23 12:58 PM EDT

Shoshanna Tillman.
Ah, OK.
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Do you exercise?

Question
05/24/23 12:58 PM EDT

Shoshanna Tillman.
I probably could be exercising more. I just don’t have a lot of time or energy. I’ll walk the dog 3 or 4 times a week, which is something. But I used to do these yoga classes, and spin classes, but those don’t really make sense for me now.
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I understand your concern but you should always exercise

Educate
05/24/23 1:00 PM EDT

Shoshanna Tillman.
Ah, I see.
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How many hours of sleep do you get per day?

Question
05/24/23 1:00 PM EDT

Shoshanna Tillman.
5 or 6 hours a night.
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What is your occupation?

Question
05/24/23 1:00 PM EDT

Shoshanna Tillman.
I own and operate an art gallery called Bricolage with my husband. I’m also an artist, and sometimes I contribute pieces to the gallery.
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What is your occupation?

Question
05/24/23 1:01 PM EDT

Shoshanna Tillman.
I own and operate an art gallery called Bricolage with my husband. I’m also an artist, and sometimes I contribute pieces to the gallery.
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What is your level of education?

Question
05/24/23 1:02 PM EDT

Shoshanna Tillman.
I have a BFA in studio art and a BA in art history.
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Do you make enough money at your job?

Question
05/24/23 1:02 PM EDT

Shoshanna Tillman.
Now, the gallery is turning a profit and we’re making sufficient income. It’s still a new business, so it’s taken a while to get it here, but that could change. Running a small business is hard and uncertain, especially in the art world.
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Any stress? Shoshanna Tillman Follow Up Sick Visit: Musculoskeletal Shadow Health Transcript