Tag: Clinical-Nursing

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Transcript

Started:
Mar 25, 2020 |
Total Time:
59 min

Hi Dr. Douglas, My name is Danielle. I will be your provider today

Greet

03/25/20 12:48 AM CDT

Hello.

What is the reason for you visit today?

Question

03/25/20 12:48 AM CDT

I’m here because I’ve got an awful cough, a fever, and my chest feels like I’ve been kicked by a horse. I’m sure this is some kind of upper respiratory infection. I was hoping it would go away on its own, but it hasn’t, so my husband Jeffrey convinced me to come in. As amusing as it is for Jeffrey to serve me my meals, this has gone on long enough. I need to feel better.

I’m sorry to hear that you are so uncomfortable from your symptoms. Your frequent cough sounds like it’s aggravating your already uncomfortable chest pain. You have done a great job toughing it out so far, and we’ll find a treatment plan to help you feel better.

Empathize

03/25/20 12:52 AM CDT

Thank you.

When did your symptoms start?

Question

03/25/20 12:53 AM CDT

Most of my symptoms started three days ago. I developed this nasty cough, and my nose has been all stuffed up. That’s also when the chest pain started, and when I began to feel exhausted. The fever set in last night. That was the last straw, so Jeffrey brought me in.

How often do the symptoms occur?

Question

03/25/20 12:54 AM CDT

Most of my symptoms — the hacking cough, chest pain, fatigue, achiness, stuffy nose — started three days ago. The fever started yesterday. None of it has let up since.

Where is your pain?

Question

03/25/20 12:54 AM CDT

Most of the chest pain is located in the lower right part of my chest. Aside from that, I have some general aches and muscle soreness; this is mostly a deep, dull sort of ache, but it feels more severe when I cough.

I’m sorry to hear that you’re in constant pain, and that your cough makes your pain worse. I will work on finding a therapy that will give you some relief.

Empathize

03/25/20 12:56 AM CDT

I appreciate your saying that.

Are you coughing up any mucous?

Question

03/25/20 12:58 AM CDT

I’m coughing up rust-colored sputum.

Are there any factors that make your symptoms worse? (Clarified to Does anything make your symptoms worse?.)

Question

03/25/20 12:59 AM CDT

Coughing makes this chest pain much worse. Deep breathing also seems to aggravate it, or talking too much. I also can’t move around too much . . . I’ve been staying in bed because any kind of activity makes my pain worse and leaves me exhausted. (Clarified to if anything makes my symptoms worse.)

What helps relieve your symptoms

Question

03/25/20 1:00 AM CDT

Rest has helped me feel a little better. Exerting myself in any way just makes me feel worse. Jeffrey has also been bringing me hot tea and soup. We’ve also kept my humidifier going. Other than that, I tried taking aspirin to help with my fever and chest pain, but that didn’t give me much relief.

how bad is the pain?

Question

03/25/20 1:00 AM CDT

I think that this cough is pretty severe. It brings my chest pain up from a 2 out of 10 to a 5 out of 10.

sorry to hear that

Empathize

03/25/20 1:01 AM CDT

Well, that’s very nice.

Lets talk about your past medical history (Clarified to What is your past medical history?.)

Question

03/25/20 1:01 AM CDT

I have hypertension and chronic kidney disease. stage 2. (Clarified to what health problems I have had.)

how long have you had the conditions? (Clarified to How long have you had your preexisting health problems?.)

Question

03/25/20 1:02 AM CDT

I was diagnosed with stage 2 chronic kidney disease 9 years ago, when I had some blood work done for my hypertension. I don’t know how long I had it before that, but I was diagnosed with hypertension 14 years ago, so it could have been a long time. (Clarified to how long I have had my preexisting health problems.)

any recent hospitalizations?

Question

03/25/20 1:03 AM CDT

I have not been hospitalized recently.

do you have any allergies

Question

03/25/20 1:03 AM CDT

No, I don’t have allergies.

Are you up to date on vaccines?

Question

03/25/20 1:04 AM CDT

Let me think . . . I had a flu shot about three months ago. Other than that, it’s been quite a while since I’ve needed any vaccines. I had a pneumococcal vaccine 12 years ago.

You are due for a pneumococcal vaccine, which you should receive again in your adulthood five to ten years after your first shot. These vaccines protect against the bacteria that most commonly cause pneumonia.

Educate

03/25/20 1:07 AM CDT

Alright.

What medications do you take?

Question

03/25/20 1:09 AM CDT

I take two prescription medications; a trandolapril/verapamil combo and chlorothiazide. I also take two supplements, vitamin D and calcium. And for the last three days I’ve been taking aspirin.

tell me about the trandolapril/verapamil

Question

03/25/20 1:10 AM CDT

I take my trandolapril/verapamil once a day for my stage 2 chronic kidney disease and hypertension.

how long have you taken the chlorothiazide?

Question

03/25/20 1:11 AM CDT

I have taken chlorothiazide for 14 years.

whats is the dosage of your medications?

Question

03/25/20 1:11 AM CDT

The trandolapril/verapamil combination is 2 milligrams of trandolapril and 180 milligrams of verapamil. The chlorothiazide pill is 500 milligrams. The aspirin is 325 milligrams each pill. As for the supplements: the calcium is 1200 milligrams and the vitamin D is 15 micrograms.

are you compliant with all of your medications? (Clarified to Are you compliant with your medications?.)

Question

03/25/20 1:12 AM CDT

I never miss doses of my medication. Jeffrey and I are very diligent, and the pillbox keeps track for us. (Clarified to if I am compliant with medication.)

That is great

Empathize

03/25/20 1:13 AM CDT

Thank you. I appreciate that.

what you taken any antibiotics? (Clarified to Have you taken antibiotics recently?.)

Question

03/25/20 1:13 AM CDT

I haven’t taken any antibiotics in some time . . . I honestly can’t remember when that would’ve been. (Clarified to if I have taken antibiotics recently.)

Do you drink, smoke, or use illicit substances?

Question

03/25/20 1:14 AM CDT

I’ve never used any illicit drugs.

do you exercise?

Question

03/25/20 1:15 AM CDT

I try to stay active by taking a few short walks a week. Jeffrey and I will walk around our neighborhood for about ten minutes. We try to do this two or three times a week. Unfortunately, right now all I can do is rest.

any difficulties with activities of daily living? (Clarified to Do you have trouble performing daily activities?.)

Question

03/25/20 1:16 AM CDT

I’ve been struggling a little with everything of late, but I am quite capable in general, thank you. [AUDIO COMING SOON] (Clarified to if I have trouble performing daily activities.)

tell me about your diet?

Question

03/25/20 1:16 AM CDT

In the morning, Jeffrey and I will have a piece of toast with some eggs, or maybe a fresh croissant that he picks up from the bakery around the corner. We normally eat a very light lunch — a sandwich, or some homemade soup — and for dinner we like to go out to eat a few times a week. Normally we get pasta, or a salad.

For people with hypertension and with chronic kidney disease, some foods are healthier and safer than others. It’s important to consider how your health will be affected when making everyday meal choices.

Empathize

03/25/20 1:18 AM CDT

That’s kind of you to say.

whats your family medical history

Question

03/25/20 1:20 AM CDT

My parents have both passed away. My mother was fairly healthy, but my father had hypertension. [AUDIO COMING SOON]

just want to follow up on the aspirin (No matching questions found.)

Question

03/25/20 1:20 AM CDT

How often do you take the aspirin

Question

03/25/20 1:20 AM CDT

Not normally, but since I got sick three days ago, I have been taking two aspirins three times a day. That’s a 325 milligram pill.

does it help with pain?

Educate

03/25/20 1:21 AM CDT

I’ll keep that in mind.

does it help with pain (No matching questions found.)

Question

03/25/20 1:21 AM CDT

does the aspirin relieve your pain

Question

03/25/20 1:22 AM CDT

It has done a little good, I suppose, both for my chest pain and my fever . . . I suppose it’s hard to tell, though, because I’ve been taking it since my symptoms started, so I haven’t really felt how bad my symptoms are sans aspirin. [AUDIO COMING SOON]

While it’s great that the aspirin has relieved your symptoms, it is not approved for older adults nor for people taking some of your medications. Always ask a healthcare provider before starting a new medication.

Educate

03/25/20 1:24 AM CDT

I’ll remember that.

Hi, i will educate you on the new prescription

Question

03/25/20 1:38 AM CDT

I appreciate it.

Take the medication with a full glass of water

Question

03/25/20 1:38 AM CDT

Shouldn’t be a problem.

Take the full course of medications

Question

03/25/20 1:39 AM CDT

I’ll be sure to take the whole course.

Be sure to avoid the sun

Question

03/25/20 1:39 AM CDT

I won’t be leaving my bed much anyway.

Contact your doctor if you experience rapid weight gain

Question

03/25/20 1:40 AM CDT

Alright then.

call 911 if you show signs of a severe allergic reaction

Question

03/25/20 1:40 AM CDT

I’ll have Jeffrey call 911 if that happens.

take tylenol for pain and fever

Question

03/25/20 1:41 AM CDT

Thanks for that.

guaifenesin will help with your cough

Question

03/25/20 1:41 AM CDT

Good to know.

you should start feeling better in a few days

Question

03/25/20 1:42 AM CDT

Hmm. Okay.

drink plenty of fluids

Question

03/25/20 1:42 AM CDT

I can do that. Does tea work?

yes Mrs Douglas

Question

03/25/20 1:42 AM CDT

That works for me.

THank you

Question

03/25/20 1:42 AM CDT

Alright. Thank you for all of your help today.

Education & Empathy
: 5 of 6 (83.3%)

During the patient interview, there are a number of opportunities to provide patient education and empathy. The opportunities listed below are those identified by nursing experts to be of particular importance to this patient. A
Model Statement
is provided as an example of an appropriate response to each opportunity.

Opportunities marked as
Not Encountered
are opportunities that were not elicited in the interview

Opportunities marked as
Not Followed Up
are missed opportunities that were present in the interview, but where no statements were made

Opportunities marked as
Followed Up
were followed up by students, and include the dialogue between student and patient

1 Urinary Pain and UTI Symptoms

Followed Up

Description:
Ms. Henderson reports discomfort with her associated urinary symptoms such as pain, cramping, burning, and feelings of increased urgency to urinate.

What brings you in today?

Question

09:47 PM CDT

I’ve had to pee a lot lately. It burns when I pee, and it looks weird. I thought it would go away on its own, but it hasn’t. So I was like, fine, I need to see someone. [AUDIO COMING SOON]

I’m sorry that you’re experiencing pain and burning during urination. I’ll try to find a medication that will help alleviate these symptoms.

Empathize

09:49 PM CDT

Thanks.

How long have you had these symptoms?

Question

09:50 PM CDT

Three days ago, I started feeling pretty bad. I kept having to pee, and each time I did, it burned. It was gross, too. The pee looked different. [AUDIO COMING SOON]

any other symptoms?

Question

09:51 PM CDT

Other than the pain and burning, I have a little bit of cramping in my lower abdomen. [AUDIO COMING SOON]

where is the pain?

Question

09:52 PM CDT

It hurts the most when I pee, right where it comes out. It’s this burning, stinging feeling.

do the urine have an odor?

Question

09:52 PM CDT

It smells really strong. It’s basically rank. It’s also, like, dark . . . cloudy.

how bad does it hurt (Clarified to: How painful is urinating?)

Question

09:53 PM CDT

It burns every time I pee and I am really not OK with how much pain I’m in. I’d call it a 7 out of 10. (Clarified to: how painful urinating is)

any factors that make it worse? (Clarified to: What aggravates the pain?)

Question

09:54 PM CDT

Well, it burns every time I pee, so peeing makes the pain worse, I guess. (Clarified to: what makes my pain worse)

what do you do to relieve the pain?

Question

09:54 PM CDT

Since it only burns and stings when I pee, I thought maybe it would hurt less if I didn’t pee so much. I tried drinking less water, but I’m not sure how much good it’s doing.

I know that you tried to alleviate your symptoms by not drinking fluids; you should try to stay hydrated by drinking more water and avoiding drinks that irritate the bladder such as soda coffee or alcohol

Educate

09:59 PM CDT

Yeah, OK.

Model Statement:
“I’m sorry that you’re experiencing pain and burning during urination and an increased sense of urgency. I’ll try to find a medication that will help alleviate these symptoms.”

2 Breast Cancer

Followed Up

Description:
Ms. Henderson discloses that her mother is a breast cancer survivor.

any family history of illness

Question

10:20 PM CDT

My dad’s really healthy. My mom’s a breast cancer survivor. She’s fine now, though. Totally cancer free. My Nana — that’s my Mom’s mom — died of it, though.

I’m sorry that your mother had breast cancer. That must have been a difficult thing for your family to go through. I’m glad that she is OK and that you and your sister are are not at risk

Empathize

10:23 PM CDT

OK.

Model Statement:
“I’m sorry that your mother had breast cancer. That must have been a difficult thing for your family to go through. I’m glad that she is OK and that you and your sister are not at risk.”

3 Hydration

Not Followed Up

Description:
Ms. Henderson reports that she avoided drinking fluids in order to alleviate her pain, burning, and increased urinary urgency.

do you drink

Question

10:15 PM CDT

I usually drink one or two nights a week, depending on if there’s good parties or not. But I never have more than a drink or two. Gotta keep my brain right so I can take over the world.

do you practice safe sex

Question

10:16 PM CDT

Model Statement:
“I know that you tried to alleviate your symptoms by not drinking fluids; you should try to stay hydrated by drinking more water and avoiding drinks that irritate the bladder such as soda, coffee, or alcoholic beverages.”

4 Urinating After Intercourse

Followed Up

Description:
Ms. Henderson reports that she does not have any post-intercourse habits, such as urinating after intercourse.

do you urinate after sex?

Question

10:03 PM CDT

Oh . . . I guess I didn’t know you were supposed to.

Urinating after sex helps lower the risk of UTIs by clearing the urinary tract of any bacteria. Making this a regular habit might decrease your chances of getting a UTI again in the future

Educate

10:05 PM CDT

Hm. Alright.

Model Statement:
“Urinating after intercourse helps lower the risk of UTIs by clearing the urinary tract of any bacteria. Making this a regular habit might decrease your chances of getting a UTI again in the future.”

5 Safe Sex

Followed Up

Description:
Ms. Henderson reports that she is sexually active.

do you practice safe sex

Question

10:16 PM CDT

Uh, I always use protection. I take birth control and I use those spermicidal condoms.

good, practice sex safe with partners of all genders in order to minimize the risk of STIs

Educate

10:17 PM CDT

Thanks for the info.

Model Statement:
“Practice safe sex with partners of all genders in order to minimize the risk of STIs.”

6 Cranberry Pills

Followed Up

Description:
Ms. Henderson reports she took cranberry pills to treat her UTI.

do you take any other medications

Question

10:10 PM CDT

I don’t know if it qualifies as medication, but I took some cranberry supplements cause apparently they help with UTIs, which I figured I had when my pee started burning.

do you cranberry pills help (Clarified to: Are the cranberry pills effective?)

Question

10:10 PM CDT

I don’t know . . . I’ve heard you’re supposed to take them for UTIs, but it’s been three days and nothing’s gotten better. And I even took two at a time. I don’t know the dosage, but regardless, you’d think they’d be doing something. (Clarified to: if the cranberry pills are effective)

Cranberry pills aren’t an effective treatment against UTIs. In the future when you notice these symptoms contact a healthcare provider sooner so that you can receive medication that will be more effective treatment

Educate

10:13 PM CDT

Thank you. That makes sense.

Model Statement:
“Cranberry pills aren’t an effective treatment against UTIs. In the future when you notice these symptoms contact a healthcare provider sooner so that you can receive medication that will be more effective treatment.”

Transcript

Started:
Mar 30, 2020 |
Total Time:
66 min

Hi Miss Henderson, My name is danielle, I will be your provider today

Greet

03/30/20 9:47 PM CDT

Hey.

What brings you in today?

Question

03/30/20 9:47 PM CDT

I’ve had to pee a lot lately. It burns when I pee, and it looks weird. I thought it would go away on its own, but it hasn’t. So I was like, fine, I need to see someone. [AUDIO COMING SOON]

I’m sorry that you’re experiencing pain and burning during urination. I’ll try to find a medication that will help alleviate these symptoms.

Empathize

03/30/20 9:49 PM CDT

Thanks.

How long have you had these symptoms?

Question

03/30/20 9:50 PM CDT

Three days ago, I started feeling pretty bad. I kept having to pee, and each time I did, it burned. It was gross, too. The pee looked different. [AUDIO COMING SOON]

any other symptoms?

Question

03/30/20 9:51 PM CDT

Other than the pain and burning, I have a little bit of cramping in my lower abdomen. [AUDIO COMING SOON]

where is the pain?

Question

03/30/20 9:52 PM CDT

It hurts the most when I pee, right where it comes out. It’s this burning, stinging feeling.

do the urine have an odor?

Question

03/30/20 9:52 PM CDT

It smells really strong. It’s basically rank. It’s also, like, dark . . . cloudy.

how bad does it hurt (Clarified to How painful is urinating?.)

Question

03/30/20 9:53 PM CDT

It burns every time I pee and I am really not OK with how much pain I’m in. I’d call it a 7 out of 10. (Clarified to how painful urinating is.)

any factors that make it worse? (Clarified to What aggravates the pain?.)

Question

03/30/20 9:54 PM CDT

Well, it burns every time I pee, so peeing makes the pain worse, I guess. (Clarified to what makes my pain worse.)

what do you do to relieve the pain?

Question

03/30/20 9:54 PM CDT

Since it only burns and stings when I pee, I thought maybe it would hurt less if I didn’t pee so much. I tried drinking less water, but I’m not sure how much good it’s doing.

I know that you tried to alleviate your symptoms by not drinking fluids; you should try to stay hydrated by drinking more water and avoiding drinks that irritate the bladder such as soda coffee or alcohol

Educate

03/30/20 9:59 PM CDT

Yeah, OK.

When was the last date of intercourse (Clarified to When did you last have sex?.)

Question

03/30/20 10:03 PM CDT

I had sex with this guy like four days ago. We’ve had a pretty regular thing for a couple of months. (Clarified to when my last sexual encounter was.)

do you urinate after sex?

Question

03/30/20 10:03 PM CDT

Oh . . . I guess I didn’t know you were supposed to.

Urinating after sex helps lower the risk of UTIs by clearing the urinary tract of any bacteria. Making this a regular habit might decrease your chances of getting a UTI again in the future

Educate

03/30/20 10:05 PM CDT

Hm. Alright.

Any past medical condition?

Question

03/30/20 10:07 PM CDT

Besides what I’m here for now, I’m pretty healthy, honestly.

do you have any allergies?

Question

03/30/20 10:08 PM CDT

I have seasonal allergies in spring and summer. I don’t know to what exactly, but my eyes itch, my throat gets scratchy, I get a stuffy nose, and all that fun stuff.

do you take any for you allergies?

Question

03/30/20 10:08 PM CDT

I just take these antihistamines ahead of time so I don’t get symptoms. It’s loratadine.

what dosage do you take? (Clarified to How much loratadine do you use at once?.)

Question

03/30/20 10:09 PM CDT

It’s a pill that’s 10 milligrams a day. (Clarified to what dosage the loratadine is.)

do you miss doses

Question

03/30/20 10:09 PM CDT

I never miss doses. I just take all my pills in the morning together, and they’re all once a day, so it’s easy. And with my birth control, I can track it with the click pack.

do you take any other medications

Question

03/30/20 10:10 PM CDT

I don’t know if it qualifies as medication, but I took some cranberry supplements cause apparently they help with UTIs, which I figured I had when my pee started burning.

do you cranberry pills help (Clarified to Are the cranberry pills effective?.)

Question

03/30/20 10:10 PM CDT

I don’t know . . . I’ve heard you’re supposed to take them for UTIs, but it’s been three days and nothing’s gotten better. And I even took two at a time. I don’t know the dosage, but regardless, you’d think they’d be doing something. (Clarified to if the cranberry pills are effective.)

Cranberry pills aren’t an effective treatment against UTIs. In the future when you notice these symptoms contact a healthcare provider sooner so that you can receive medication that will be more effective treatment

Educate

03/30/20 10:13 PM CDT

Thank you. That makes sense.

any medication allergies?

Question

03/30/20 10:13 PM CDT

Actually, now that you mention it, I’m hypersensitive to penicillin.

what is you reaction to penicillin (Clarified to What type of reaction do you have to penicillin?.)

Question

03/30/20 10:14 PM CDT

My penicillin reaction is pretty bad. I get a red, itchy rash, and I get all sick to my stomach and throw up a lot. (Clarified to what my reaction to penicillin is.)

do you use any illicit substances

Question

03/30/20 10:14 PM CDT

I tried weed at a party at my first semester here, but I just didn’t like it. I never bothered with it again after that. But before you say anything, no, I’ve never touched tobacco.

do you drink

Question

03/30/20 10:15 PM CDT

I usually drink one or two nights a week, depending on if there’s good parties or not. But I never have more than a drink or two. Gotta keep my brain right so I can take over the world.

do you practice safe sex

Question

03/30/20 10:16 PM CDT

Uh, I always use protection. I take birth control and I use those spermicidal condoms.

good, practice sex safe with partners of all genders in order to minimize the risk of STIs

Educate

03/30/20 10:17 PM CDT

Thanks for the info.

any family history of illness

Question

03/30/20 10:20 PM CDT

My dad’s really healthy. My mom’s a breast cancer survivor. She’s fine now, though. Totally cancer free. My Nana — that’s my Mom’s mom — died of it, though.

I’m sorry that your mother had breast cancer. That must have been a difficult thing for your family to go through. I’m glad that she is OK and that you and your sister are are not at risk

Empathize

03/30/20 10:23 PM CDT

OK.

when was your last period

Question

03/30/20 10:23 PM CDT

My last period started two and a half weeks ago, so the last day was two weeks ago. [AUDIO COMING SOON]

Hi

Question

03/30/20 10:32 PM CDT

Hey, sure thing. [AUDIO COMING SOON]

take the full course of medications

Question

03/30/20 10:32 PM CDT

Ok – but what if I start feeling better?

even if you start feeling better

Question

03/30/20 10:32 PM CDT

Oh, ok. That makes sense.

take with meal

Question

03/30/20 10:33 PM CDT

Ok. Can do.

use backup contraceptives to prevent unwanted pregnancy

Question

03/30/20 10:33 PM CDT

Ok. Got it.

contact provider for reactions

Question

03/30/20 10:34 PM CDT

I’ll look out for that.

take to relieve pain

Question

03/30/20 10:34 PM CDT

Ok. Yeah, that’s pretty important. Will do.

continue this while on the antibiotic

Question

03/30/20 10:34 PM CDT

Ok, I will.

urine will appear orange

Question

03/30/20 10:35 PM CDT

Weird! Thanks for letting me know.

contact provider is you notice and rashes

Question

03/30/20 10:35 PM CDT

Got it.

pee before and after sex

Question

03/30/20 10:35 PM CDT

Oh, I didn’t know. I’ll be sure to do that. [AUDIO COMING SOON]

wear loose fitting cotton clothes

Question

03/30/20 10:36 PM CDT

I’ll be sure they’re made from cotton. [AUDIO COMING SOON]

wipe front to back

Question

03/30/20 10:36 PM CDT

Oookay. Gotcha. [AUDIO COMING SOON]

thank you

Question

03/30/20 10:36 PM CDT

Ok. See you later.

Patient Teaching Score: 9 out of 10

Greet the patient’s guardian

Topics priorized for patient teaching

Education Items

Greet the patient’s guardian and explain why you need to educate them.

Greet the patient’s guardian and explain why you need to educate them.

Sophia’s test came back positive.

Statement

10/3/2020 7:17:20 AM

Alright. Thank you.

Model Statement:
Hi, Omar. We’re going to be going over how to safely give Sophia her medication.

amoxicillin

6.5 out of 7

Model Plan

(1 point) Only use the dosing instrument that comes with medication

(1 point) Shake medication well before use

(1 point) Check to make sure you are administering the correct dose

(1 point) Give your child rewards and incentives for taking medication

(1 point) Take the full course of antibiotics

(1 point) Contact a health provider if symptoms do not improve

(1 point) Discontinue if you see signs of amoxicillin allergy

Topics priorized for patient teaching

Education Items

(1 point) Only use the dosing instrument that comes with medication

(1 point) Keep medication in a safe pace, out of reach of the child

(1 point) Check to make sure you are administering the correct dose

(1 point) Symptoms should improve in a few days

(1 point) Take the full course of antibiotics

(0.5 points) Look for signs of thrush

(1 point) Discontinue if you see signs of amoxicillin allergy

Only use the dosing instrument that comes with medication

Follow the instructions on the medication

Statement

10/3/2020 7:17:48 AM

I’ll be sure to do that.

Model Statement:
It’s important to give Sophia the precise dose prescribed to her. Only use the dosing instrument that came with medication and never use a kitchen utensil like a spoon.

Keep medication in a safe pace, out of reach of the child

Keep medication in safe place, out of children reach

Statement

10/3/2020 7:18:11 AM

Good call. I don’t think she’d pour it out or something, but—oh, you mean she might drink it. Right, that too.

Model Statement:
Keep medication in a safe pace, where Sophia can’t reach it.

Check to make sure you are administering the correct dose

Check to be sure the dose is correct

Statement

10/3/2020 7:18:35 AM

I bet it’s really dangerous to give a kid too much medicine. Better be careful.

Model Statement:
Check carefully to make sure you are administering the correct dose of medication using age-appropriate weight-based calculations.

Symptoms should improve in a few days

Symptoms should improve in a couple of days

Statement

10/3/2020 7:19:05 AM

That’s really good to hear. I hate to see her like this.

Model Statement:
Sophia’s symptoms should begin to improve in a few days.

Take the full course of antibiotics

Sophia will be able to return to school in 3 days

Statement

10/3/2020 7:19:24 AM

Yeah, I can do that. Make sure Sophia takes all of her medicine. No matter how much she doesn’t want to. Make her do the thing she doesn’t want to do. I got it.

Model Statement:
If Sophia doesn’t take the full course of antibiotics, she could get sick again. Make sure she takes all of her medicine just like the instructions say.

Look for signs of thrush

Looks for a rash in here mouth

Statement

10/3/2020 7:19:47 AM

Oh, thrush is terrible. I’ll let you know right away if I see any signs of it.

Model Statement:
Contact your clinician if you see signs of thrush in Sophia’s mouth and throat.

Discontinue if you see signs of amoxicillin allergy

Stop the medication of you see any signs of an allergic reaction, like difficulty breathing

Statement

10/3/2020 7:20:34 AM

Sophia already has some of those things because of the strep. How do I know if she’s also having a reaction to the amoxicillin?

Hives and if your daughter cant breathe

Statement

10/3/2020 7:21:04 AM

Understood.

Model Statement:
Discontinue if you see signs of an allergic reaction to amoxicillin, which includes swelling, rash, and queasiness.

Symptoms and Care

2.5 out of 3

Model Plan

(1 point) Throw away toothbrush after 48 hours

(1 point) Give child ibuprofen or acetaminophen to treat fever

(1 point) Give Sophia a lot of liquids to keep her hydrated

Topics priorized for patient teaching

Education Items

(1 point) Throw away toothbrush after 48 hours

(0.5 points) When she can return to school

(1 point) Give Sophia a lot of liquids to keep her hydrated

Throw away toothbrush after 48 hours

change the toothbrush

Statement

10/3/2020 7:21:15 AM

She’s pretty attached to her butterfly toothbrush, but I’m sure we can find another one . . . probably . . .

Model Statement:
Throw away Sophia’s toothbrush after 48 hours. Strep can linger on the toothbrush, and potentially reinfect her.

When she can return to school

she can return to school in 3 days

Statement

10/3/2020 7:21:49 AM

That’s good to know. Thanks.

Model Statement:
Sophia can return to school after 48 hours, if her symptoms have improved.

Give Sophia a lot of liquids to keep her hydrated

She can drink plenty of water

Statement

10/3/2020 7:22:19 AM

Sophia’s pretty good about drinking water. Normally I’d go for tea, but I don’t think I need a caffeinated Sophia stuck at home from school. Bad times for everybody.

Model Statement:
Make sure that Sophia drinks plenty of liquids so she stays hydrated.

Say Goodbye

Topics priorized for patient teaching

Education Items

Educate the patient’s guardian on anything else and say goodbye

Educate the patient’s guardian on anything else and say goodbye

Have a good day

Statement

10/3/2020 7:22:43 AM

Ok. See you later.

Transcript

Started:
Mar 10, 2020 |
Total Time:
60 min

Hi, Sophia. My name is Danielle and I will be your provider today.

Greet

03/10/20 1:45 AM CDT

Hi there.

Hi Omar, My name is Danielle, and I will be your provider today

Question

03/10/20 1:46 AM CDT

Hello.

What brings you and Sophia in today? (Clarified to What brings you to the office today?.)

Question

03/10/20 1:46 AM CDT

My daughter’s sick. A high fever and a sore throat. (Clarified to what brings me to the office.)

What brings you in to the office

Question

03/10/20 1:48 AM CDT

I’m here because they sent me home at school because I was cold and tired and the teacher sent me to the nurse, and when I told her my throat had been hurting all morning she called my Baba. He’s the guy over there.

I am sorry you are not feeling well, i hope i can help

Empathize

03/10/20 1:49 AM CDT

Thank you.

Where is the pain?

Question

03/10/20 1:50 AM CDT

It hurts in the back of my throat. AND my head hurts.

Why are you sick?

Question

03/10/20 1:51 AM CDT

My throat hurts, and I’m all cold and tired.

When did you notice the pain?

Question

03/10/20 1:51 AM CDT

I was eating breakfast this morning and it hurt to swallow and I realized my throat hurt all the time.

When did your fever start?

Question

03/10/20 1:52 AM CDT

I started feeling all chilly and achy at school, during science class.

How bad does your throat hurt?

Question

03/10/20 1:52 AM CDT

Uh. Bad. It hurts kinda bad.

Do you have problems talking?

Question

03/10/20 1:53 AM CDT

My throat hurts worse when I talk.

Are you able to swallow?

Question

03/10/20 1:53 AM CDT

I can swallow, but it hurts my throat really bad.

Do you drink water?

Question

03/10/20 1:53 AM CDT

I like drinking water. I had some already today.

Do you take any medications?

Question

03/10/20 1:54 AM CDT

Only when Baba makes me. Medicine tastes so bad.

Im sorry you feel that way

Empathize

03/10/20 1:55 AM CDT

OK. Thanks.

Medicines can help us feel better

Educate

03/10/20 1:55 AM CDT

Hmm . . . OK.

How long has sophia been sick?

Question

03/10/20 1:56 AM CDT

The school called me about 2 hours ago saying Sophia had a fever of 102 and a sore throat.

What was your daughters fever at school?

Question

03/10/20 1:57 AM CDT

The school said her fever was 102. I feel so bad she has that on top of a sore throat.

Did she have a fever at home? (Clarified to When did your daughter’s fever start?.)

Question

03/10/20 1:57 AM CDT

I’m not sure, to be honest. I didn’t realize she had a fever this morning, but I do know her temperature was 102 this morning at the school clinic. (Clarified to when my daughter’s fever started.)

When did the pain start?

Question

03/10/20 1:58 AM CDT

I didn’t notice the sore throat or the fever this morning. I feel pretty bad for missing it.

Its okay

Empathize

03/10/20 1:58 AM CDT

OK, thanks.

Are you daughters classmates sick? (No matching questions found.)

Question

03/10/20 1:59 AM CDT

Are your daughters classmates sick?

Question

03/10/20 1:59 AM CDT

The school nurse said that strep throat is going around at her school. I think a few of her classmates are out sick right now.

Is anyone sick in your family?

Question

03/10/20 1:59 AM CDT

No one at home has had strep. My wife and I are both healthy.

What have you done for your daughter’s throat/

Question

03/10/20 2:00 AM CDT

I gave Sophia some ibuprofen for her fever. She also drank a little bit of cold water, which I think helped her throat.

Did you give your daughter medication recently?

Question

03/10/20 2:01 AM CDT

I gave her the ibuprofen on our way here, as we were leaving school.

Does sophia take any home medications

Question

03/10/20 2:01 AM CDT

Sophia doesn’t take any regular medications, thankfully. She really doesn’t handle it well.

How much ibuprofen did sophia receive?

Question

03/10/20 2:02 AM CDT

I gave her children’s ibuprofen, the liquid kind. The strength was . . . 100 mg per 5 mL.

how does your daughter handle taking medications?

Question

03/10/20 2:03 AM CDT

Sophia doesn’t handle taking medicine well. She’s been pretty stubborn about it for a long time.

How does you daughter handle swallowing pills? (No matching questions found.)

Question

03/10/20 2:04 AM CDT

How does you daughter swallow pills? (No matching questions found.)

Question

03/10/20 2:04 AM CDT

What happened when you tried to give sophia the medication?

Question

03/10/20 2:05 AM CDT

When I try to give Sophia medication . . . well, life isn’t great. It’s hard to convince her to do it, and when Sophia doesn’t want to do something, she’s really headstrong about it. For example, before we got here, I gave Sophia some ibuprofen. Sophia took the medicine eventually, but she started crying when I told her that she needed to take it. She used to spit medication out, but she doesn’t do that much anymore.

Is your daughter up to date on vaccines?

Question

03/10/20 2:06 AM CDT

Yes, Sophia’s up to date on her vaccinations.

Has sophia had any surgeries in the past

Question

03/10/20 2:07 AM CDT

Sophia had ear tubes put in when she was two, but no surgeries other than that.

did you daughter have a tonsillectomy? (No matching questions found.)

Question

03/10/20 2:07 AM CDT

did your daughter have a tonsillectomy?

Question

03/10/20 2:07 AM CDT

No, Sophia’s never had her tonsils removed.

When is the last time your daughter had a sore throat?

Question

03/10/20 2:08 AM CDT

I don’t know the last time Sophia had a sore throat . . . she’s never had strep before.

When was your daughters last ear infection?

Question

03/10/20 2:08 AM CDT

It’s been a long time. A few years. They stopped shortly after she got her ear tubes put in, when she was two.

What medications is your daughters allergic to

Question

03/10/20 2:09 AM CDT

Sophia isn’t allergic to any medications.

Does your head hurt/

Question

03/10/20 2:10 AM CDT

Yes. I have a headache right now. It feels kind of achy and heavy.

Does your chest feel tight?

Question

03/10/20 2:10 AM CDT

No, my chest doesn’t feel tight.

Have you been coughing a lot?

Question

03/10/20 2:10 AM CDT

No, I haven’t been coughing at all.

Are you vomiting?

Question

03/10/20 2:11 AM CDT

I haven’t thrown up.

Do you have any lumps or bumps on your skin?

Question

03/10/20 2:11 AM CDT

Yes, I have these red bumps on my chest.

Does you daughter have a runny nose? (No matching questions found.)

Question

03/10/20 2:12 AM CDT

Does your daughter have a runny nose?

Question

03/10/20 2:12 AM CDT

Sophia’s nose hasn’t been runny.

Does your daughter have a cough?

Question

03/10/20 2:12 AM CDT

Sophia doesn’t have a cough.

When did you notice your daughter’s rash/

Question

03/10/20 2:13 AM CDT

The school nurse told me about the rash when I picked Sophia up from school a few hours ago. I didn’t notice it before that.

Can i take a look at sophias throat and rash/

Question

03/10/20 2:14 AM CDT

Yes, I suppose. Go ahead.

can I look at the rash?

Question

03/10/20 2:14 AM CDT

OK, you can look at my rash . . . but I’m warning you, it’s NOT pretty.

Can I please look at your throat? (Clarified to Can I look at your throat?.)

Question

03/10/20 2:14 AM CDT

Yeah, you can look at my throat. (Clarified to if I can look at your throat.)

Sophia’s test came back positive.

Question

03/10/20 2:17 AM CDT

Alright. Thank you.

Follow the instructions on the medication

Question

03/10/20 2:17 AM CDT

I’ll be sure to do that.

Keep medication in safe place, out of children reach

Question

03/10/20 2:18 AM CDT

Good call. I don’t think she’d pour it out or something, butoh, you mean she might drink it. Right, that too.

Check to be sure the dose is correct

Question

03/10/20 2:18 AM CDT

I bet it’s really dangerous to give a kid too much medicine. Better be careful.

Symptoms should improve in a couple of days

Question

03/10/20 2:19 AM CDT

That’s really good to hear. I hate to see her like this.

Sophia will be able to return to school in 3 days

Question

03/10/20 2:19 AM CDT

Yeah, I can do that. Make sure Sophia takes all of her medicine. No matter how much she doesn’t want to. Make her do the thing she doesn’t want to do. I got it.

Looks for a rash in here mouth

Question

03/10/20 2:19 AM CDT

Oh, thrush is terrible. I’ll let you know right away if I see any signs of it.

Stop the medication of you see any signs of an allergic reaction, like difficulty breathing

Question

03/10/20 2:20 AM CDT

Sophia already has some of those things because of the strep. How do I know if she’s also having a reaction to the amoxicillin?

Hives and if your daughter cant breathe

Question

03/10/20 2:21 AM CDT

Understood.

change the toothbrush

Question

03/10/20 2:21 AM CDT

She’s pretty attached to her butterfly toothbrush, but I’m sure we can find another one . . . probably . . .

she can return to school in 3 days

Question

03/10/20 2:21 AM CDT

That’s good to know. Thanks.

She can drink plenty of water

Question

03/10/20 2:22 AM CDT

Sophia’s pretty good about drinking water. Normally I’d go for tea, but I don’t think I need a caffeinated Sophia stuck at home from school. Bad times for everybody.

Have a good day

Question

03/10/20 2:22 AM CDT

Ok. See you later.

Objective Data Collection: 23 of 23 (100%)

Correct

Partially correct

Incorrect

Missed

Inspected chest

1 of 1 point

Symmetry
(1/2 point)

Symmetric

Asymmetric

Appearance
(1/2 point)

No visible abnormal findings

Prominent pulsation

Abnormal apical impulse

Heaves or lifts

Inspected for jugular venous distention

1 of 1 point

Height Of Venous Pressure
(1/1 point)

4 cm or less above the sternal angle

More than 4 cm above the sternal angle

Inspected hands and fingernails

1 of 1 point

Right: Nail Changes
(1/3 point)

No visible abnormal findings

Pallor

Cyanosis

Splinter hemorrhages

Clubbing

Left: Nail Changes
(1/3 point)

No visible abnormal findings

Pallor

Cyanosis

Splinter hemorrhages

Clubbing

Capillary Refill Time
(1/3 point)

3 seconds or less

Greater than 3 seconds

Inspected lower extremities and toenails

1 of 1 point

Right: Edema
(1/9 point)

No edema

Pitting

Non-pitting

Right: Severity Of Edema
(1/9 point)

No edema

1+ Slight pitting

2+ Deeper pit, disappears in 10 to 15 seconds

3+ Noticeably deep pit that lasts more than a minute

4+ Very deep pit that lasts 2 to 5 minutes

Right: Appearance
(1/9 point)

No visible abnormal findings

Visible distortion or swelling

Discoloration

Skin thickening

Ulceration

Varicose veins

Right: Nail Changes
(1/9 point)

No visible abnormal findings

Pallor

Cyanosis

Splinter hemorrhages

Clubbing

Left: Edema
(1/9 point)

No edema

Pitting

Non-pitting

Left: Severity Of Edema
(1/9 point)

No edema

1+ Slight pitting

2+ Deeper pit, disappears in 10 to 15 seconds

3+ Noticeably deep pit that lasts more than a minute

4+ Very deep pit that lasts 2 to 5 minutes

Left: Appearance
(1/9 point)

No visible abnormal findings

Visible distortion or swelling

Discoloration

Skin thickening

Ulceration

Varicose veins

Left: Nail Changes
(1/9 point)

No visible abnormal findings

Pallor

Cyanosis

Splinter hemorrhages

Clubbing

Capillary Refill Time
(1/9 point)

3 seconds or less

Greater than 3 seconds

Palpated temporal arteries

1 of 1 point

Right: Vibration
(1/4 point)

No thrill

Thrill

Right: Amplitude
(1/4 point)

0 Absent

1+ Diminished or barely palpable

2+ Expected

3+ Increased

4+ Bounding pulse

Left: Vibration
(1/4 point)

No thrill

Thrill

Left: Amplitude
(1/4 point)

0 Absent

1+ Diminished or barely palpable

2+ Expected

3+ Increased

4+ Bounding pulse

Palpated carotid arteries

1 of 1 point

Right: Vibration
(1/4 point)

No thrill

Thrill

Right: Amplitude
(1/4 point)

0 Absent

1+ Diminished or barely palpable

2+ Expected

3+ Increased

4+ Bounding pulse

Left: Vibration
(1/4 point)

No thrill

Thrill

Left: Amplitude
(1/4 point)

0 Absent

1+ Diminished or barely palpable

2+ Expected

3+ Increased

4+ Bounding pulse

Palpated PMI

1 of 1 point

Location
(1/3 point)

Present at midclavicular line and 5th intercostal space

Displaced laterally

Amplitude
(1/3 point)

Brisk and tapping

Increased amplitude (hyperkinetic)

Diameter
(1/3 point)

Less than 3 cm

Greater than 3 cm

Palpated radial arteries

1 of 1 point

Right: Vibration
(1/4 point)

No thrill

Thrill

Right: Amplitude
(1/4 point)

0 Absent

1+ Diminished or barely palpable

2+ Expected

3+ Increased

4+ Bounding pulse

Left: Vibration
(1/4 point)

No thrill

Thrill

Left: Amplitude
(1/4 point)

0 Absent

1+ Diminished or barely palpable

2+ Expected

3+ Increased

4+ Bounding pulse

Palpated brachial arteries

1 of 1 point

Right: Vibration
(1/4 point)

No thrill

Thrill

Right: Amplitude
(1/4 point)

0 Absent

1+ Diminished or barely palpable

2+ Expected

3+ Increased

4+ Bounding pulse

Left: Vibration
(1/4 point)

No thrill

Thrill

Left: Amplitude
(1/4 point)

0 Absent

1+ Diminished or barely palpable

2+ Expected

3+ Increased

4+ Bounding pulse

Palpated femoral arteries

1 of 1 point

Right: Vibration
(1/4 point)

No thrill

Thrill

Right: Amplitude
(1/4 point)

0 Absent

1+ Diminished or barely palpable

2+ Expected

3+ Increased

4+ Bounding pulse

Left: Vibration
(1/4 point)

No thrill

Thrill

Left: Amplitude
(1/4 point)

0 Absent

1+ Diminished or barely palpable

2+ Expected

3+ Increased

4+ Bounding pulse

Palpated popliteal arteries

1 of 1 point

Right: Vibration
(1/4 point)

No thrill

Thrill

Right: Amplitude
(1/4 point)

0 Absent

1+ Diminished or barely palpable

2+ Expected

3+ Increased

4+ Bounding pulse

Left: Vibration
(1/4 point)

No thrill

Thrill

Left: Amplitude
(1/4 point)

0 Absent

1+ Diminished or barely palpable

2+ Expected

3+ Increased

4+ Bounding pulse

Palpated tibial arteries

1 of 1 point

Right: Vibration
(1/4 point)

No thrill

Thrill

Right: Amplitude
(1/4 point)

0 Absent

1+ Diminished or barely palpable

2+ Expected

3+ Increased

4+ Bounding pulse

Left: Vibration
(1/4 point)

No thrill

Thrill

Left: Amplitude
(1/4 point)

0 Absent

1+ Diminished or barely palpable

2+ Expected

3+ Increased

4+ Bounding pulse

Palpated dorsalis pedis arteries

1 of 1 point

Right: Vibration
(1/4 point)

No thrill

Thrill

Right: Amplitude
(1/4 point)

0 Absent

1+ Diminished or barely palpable

2+ Expected

3+ Increased

4+ Bounding pulse

Left: Vibration
(1/4 point)

No thrill

Thrill

Left: Amplitude
(1/4 point)

0 Absent

1+ Diminished or barely palpable

2+ Expected

3+ Increased

4+ Bounding pulse

Auscultated temporal arteries

1 of 1 point

Right
(1/2 point)

No bruit

Bruit

Left
(1/2 point)

No bruit

Bruit

Auscultated carotid arteries

1 of 1 point

Right
(1/2 point)

No bruit

Bruit

Left
(1/2 point)

No bruit

Bruit

Auscultated breath sounds

1 of 1 point

Breath Sounds
(1/3 point)

Present in all areas

Diminished in some areas

Absent in some areas

Adventitious Sounds
(1/3 point)

No adventitious sounds

Wheezing

Fine crackles

Stridor

Rhonchi

Rales

Location
(1/3 point)

All areas clear

Adventitious sounds in anterior right upper lobe

Adventitious sounds in anterior right middle lobe

Adventitious sounds in anterior right lower lobe

Adventitious sounds in anterior left upper lobe

Adventitious sounds in anterior left lower lobe

Adventitious sounds in posterior right upper lobe

Adventitious sounds in posterior right lower lobe

Adventitious sounds in posterior left upper lobe

Adventitious sounds in posterior left lower lobe

Auscultated heart sounds

1 of 1 point

Heart Sounds
(1/2 point)

S1 and S2 audible

S1, S2, and S3 audible

S1, S2, and S4 audible

S1, S2, S3, and S4 audible

Extra Heart Sounds
(1/2 point)

No extra sounds

Gallops

Murmur

Friction rub

Valve clicks

Auscultated abdominal aorta

1 of 1 point

Sounds
(1/1 point)

No bruit

Bruit

Auscultated renal arteries

1 of 1 point

Right
(1/2 point)

No bruit

Bruit

Left
(1/2 point)

No bruit

Bruit

Auscultated iliac arteries

1 of 1 point

Right
(1/2 point)

No bruit

Bruit

Left
(1/2 point)

No bruit

Bruit

Auscultated femoral arteries

1 of 1 point

Right
(1/2 point)

No bruit

Bruit

Left
(1/2 point)

No bruit

Bruit

Performed ankle-brachial index test

1 of 1 point

Abi
(1/1 point)

> 1.40 (noncompressable)

1.00 – 1.40 (normal)

0.90 – 0.99 (borderline ischemia)

< 0.90 (abnormal) Performed EKG 1 of 1 point Sinus Rhythm (1/2 point) Regular Irregular St Changes (1/2 point) No ST changes ST changes present

Transcript

Started:
Jun 27, 2020 |
Total Time:
109 min

Hello my name is Danielle I will be your provider today

Greet

06/27/20 3:27 PM CDT

Hey.

Can you verify your name

Question

06/27/20 3:27 PM CDT

Tina Jones.

Your date of birth

Question

06/27/20 3:27 PM CDT

February 17th.

Thank you

Question

06/27/20 3:27 PM CDT

You’re welcome.

What brings you in today

Question

06/27/20 3:27 PM CDT

I’ve been noticing my heart seems to be beating too fast every once in a while lately, and it started to worry me. My mom said I should make an appointment. You don’t want to ignore heart stuff, I guess.

I’m sorry to hear you’re experiencing those symptoms, they can be very uncomfortable. I’ll ask you some questions to learn more about your symptoms, and we will try to determine what’s causing you to feel this way

Empathize

06/27/20 3:29 PM CDT

Thanks for saying that.

When did you first notice these symptoms

Question

06/27/20 3:30 PM CDT

I think the first time was about a month ago.

What were you doing when you noticed these symptoms (Clarified to What were you doing when you got the palpitations?.)

Question

06/27/20 3:30 PM CDT

I usually notice them on my way to class in the mornings. My schoolwork has really been picking up and I’ve been drinking energy drinks to help keep me focused during the day, so maybe the caffeine or whatever else is in those things has something to do with it. (Clarified to what I was doing when the palpitations occured.)

How many energy drinks do you drink per day

Question

06/27/20 3:31 PM CDT

Usually just one in the morning, kind of like some people have a cup of coffee. Some mornings lately I’ve had two, though.

Drinking high levels of caffeine can make you feel stressed or anxious, and can dehydrate you. over time, lots of caffeine can make you experience “crashes” during the day, too. let’s talk about healthy alternatives

Educate

06/27/20 3:33 PM CDT

Sure, I think I understand what you mean.

How often were you experiencing these symptoms

Question

06/27/20 3:33 PM CDT

No.

How often do you notice your heart racing fast (Clarified to How often does your heart beat fast?.)

Question

06/27/20 3:33 PM CDT

It’s been about once a week for the past month. (Clarified to how often my heart beats fast.)

Can you describe it for me (Clarified to What is your heartbeat like?.)

Question

06/27/20 3:34 PM CDT

It’s usually normal, but it’s way faster during these episodes I’ve been having. (Clarified to what my heartbeat is like.)

How do you feel when your heart is racing fast

Question

06/27/20 3:34 PM CDT

Well, when my heart starts beating really fast, it just feels like a thumping in my chest. It makes me anxious and uncomfortable.

Is there anything that relieves the fast heartbeat (Clarified to Does anything relieve your symptoms?.)

Question

06/27/20 3:35 PM CDT

I haven’t tried anything specific, other than just trying to relax and breathe deep. (Clarified to if anything relieves my symptoms.)

Do you take any medications to help you with your symptoms

Question

06/27/20 3:35 PM CDT

Nope.

What medications are you taking

Question

06/27/20 3:35 PM CDT

I have a daily inhaler and a rescue inhaler for my asthma.

Are you taking any new medications

Question

06/27/20 3:36 PM CDT

Yeah, I have a daily inhaler now that I’ve been using.

What’s the name of the medication

Question

06/27/20 3:36 PM CDT

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

Do you have any new allergies

Question

06/27/20 3:36 PM CDT

No, not that I know of.

Do you have a history of hypertension

Question

06/27/20 3:37 PM CDT

…I’ve never been diagnosed with blood pressure problems. But I think it can be on the high side sometimes.

Do you check your blood pressure

Question

06/27/20 3:37 PM CDT

Only when I’m here at the clinic.

Do you have any health history that would contribute to hypertension (No matching questions found.)

Question

06/27/20 3:38 PM CDT

Do you have diabetes

Question

06/27/20 3:38 PM CDT

Yeah, I was diagnosed a few years ago.

Do you have high cholesterol

Question

06/27/20 3:38 PM CDT

I’ve never had it tested. My family has problems with high cholesterol, but I don’t think I do.

Any history of a heart murmur

Question

06/27/20 3:38 PM CDT

No.

Do you have health insurance

Question

06/27/20 3:39 PM CDT

I have health insurance through work. To be honest, though, I’m not exactly sure what it covers.

Are you able to afford your Medications

Question

06/27/20 3:41 PM CDT

It wasn’t the cost that was a problem. I just didn’t like taking it.

What is your access to healthcare

Question

06/27/20 3:42 PM CDT

I have health insurance through my job, so I can go to the doctor if I need to. It’s always a hassle though, so I try to avoid it unless I really have to like right now.

Do you have anything that stresses you out (Clarified to Are you stressed out?.)

Question

06/27/20 3:44 PM CDT

Yeah, I’ve been pretty stressed lately. (Clarified to if I am stressed out.)

What are you stressed about

Question

06/27/20 3:44 PM CDT

School is really busy right now, like I have a lot of projects due all around the same time. And on top of that, I’ve had to cover more at work lately, and I’m in charge of a big project at work, too.

Sounds like you’re working really hard. I’m sorry you’re dealing with so much stress.

Empathize

06/27/20 3:45 PM CDT

Thanks for understanding.

Tell me about your diet (Clarified to What is your diet like?.)

Question

06/27/20 3:46 PM CDT

It’s pretty good, I think. I’m not a huge health nut or anything. (Clarified to what my diet is like.)

What are usually eat in a typical day

Question

06/27/20 3:46 PM CDT

Let’s see . . . a muffin or pumpkin bread for breakfast, a sandwich for lunch, and some kind of meat with a veggie for dinner.

Do you have snacks

Question

06/27/20 3:46 PM CDT

Yeah, I usually have some snacks during the day.

What type of snacks

Question

06/27/20 3:46 PM CDT

I try to eat snacks that are kind of healthy like pretzels–sometimes if I’ll treat myself and get french fries, but I try not to do that too often.

Do you exercise

Question

06/27/20 3:47 PM CDT

I’m pretty exhausted by the end of the day, so I don’t have the energy to do any extra exercise. But I’m on my feet all the time at work so I feel like that’s a little bit of exercise most days at least.

I understand being busy and having very little free time. however, exercise is healthy for you, and can even relieve stress. even small amounts of exercise, such as taking a short walk, can improve your health

Educate

06/27/20 3:49 PM CDT

Thanks for telling me.

Do you use any recreational drugs

Question

06/27/20 3:49 PM CDT

No.

Do you use tobacco products

Question

06/27/20 3:49 PM CDT

No. I think it’s gross.

Do you drink alcohol

Question

06/27/20 3:50 PM CDT

I do sometimes, yeah, when I go out with my friends.

How often do you drink alcohol

Question

06/27/20 3:50 PM CDT

No more than once or twice a week, sometimes less.

How much do you drink when you go out

Question

06/27/20 3:50 PM CDT

Just a few. I’m not a big drinker.

How do you feel overall

Question

06/27/20 3:51 PM CDT

I’m feeling fine right now, but I wanted to make sure there’s nothing serious going on with my heart.

Do you have any other symptoms

Question

06/27/20 3:51 PM CDT

I guess when it happens I feel a bit worried, like anxious, but that’s all.

Do you experience any fatigue

Question

06/27/20 3:51 PM CDT

Yeah, most days I feel pretty exhausted by the end of the day.

Do you have any nausea vomiting

Question

06/27/20 3:51 PM CDT

I haven’t had thrown up, or even had an upset stomach, in a long time.

Have you noticed any swelling in your legs

Question

06/27/20 3:52 PM CDT

No, not that I have noticed.

Do you have a family history of heart problems

Question

06/27/20 3:52 PM CDT

Um, none that I know of. Wait, my Poppa–that’s Mom’s dad–died of a heart attack.

Do you have a family history of heart disease

Question

06/27/20 3:52 PM CDT

Um, none that I know of. Wait, my Poppa–that’s Mom’s dad–died of a heart attack.

Any family history of high cholesterol

Question

06/27/20 3:53 PM CDT

Cholesterol runs high in my family. All four of my grandparents have high cholesterol, and Mom and Dad, too.

Family history of obesity

Question

06/27/20 3:53 PM CDT

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.

Family history of a stroke

Question

06/27/20 3:53 PM CDT

Yeah, that’s how my Nana died.

Any family history of hypertension

Question

06/27/20 3:53 PM CDT

We’ve got high blood pressure in our family for sure. Granny, Mom, and Dad had it…and honestly I think my other three grandparents might’ve had issues with that, too.

A family history of hypertension means that you may be at risk for developing it, too, and you’ve had some high blood pressure readings. keeping your blood pressure low is important to avoid health problems in the future with your health and other organs

Educate

06/27/20 3:55 PM CDT

Alright, thanks for letting me know.

I am going to examine you now

Question

06/27/20 3:56 PM CDT

Alright.

Inspected anterior chest wall

Exam Action

06/27/20 3:56 PM CDT

Inspected right side chest wall

Exam Action

06/27/20 3:56 PM CDT

Inspected anterior chest wall

Exam Action

06/27/20 3:56 PM CDT

Inspected left side chest wall

Exam Action

06/27/20 3:56 PM CDT

Inspected anterior chest wall

Exam Action

06/27/20 3:56 PM CDT

Inspected for jugular venous distention: JVP 1 cm above sternal angle

Exam Action

06/27/20 3:56 PM CDT

Inspected fingernails of right hand

Exam Action

06/27/20 3:57 PM CDT

Checked capillary refill in fingernails

Exam Action

06/27/20 3:57 PM CDT

Checked capillary refill in fingernails

Exam Action

06/27/20 3:57 PM CDT

Checked capillary refill in fingernails

Exam Action

06/27/20 3:57 PM CDT

Checked capillary refill in fingernails

Exam Action

06/27/20 3:57 PM CDT

Inspected fingernails of left hand

Exam Action

06/27/20 3:57 PM CDT

Checked capillary refill in fingernails

Exam Action

06/27/20 3:58 PM CDT

Checked capillary refill in fingernails

Exam Action

06/27/20 3:58 PM CDT

Checked capillary refill in fingernails

Exam Action

06/27/20 3:58 PM CDT

Checked capillary refill in fingernails

Exam Action

06/27/20 3:58 PM CDT

Inspected fingernails of right hand

Exam Action

06/27/20 3:58 PM CDT

Inspected legs

Exam Action

06/27/20 3:59 PM CDT

Inspected right leg

Exam Action

06/27/20 3:59 PM CDT

Inspected legs

Exam Action

06/27/20 3:59 PM CDT

Inspected left leg

Exam Action

06/27/20 3:59 PM CDT

Inspected legs

Exam Action

06/27/20 3:59 PM CDT

Inspected right leg for edema: No edema

Exam Action

06/27/20 3:59 PM CDT

Inspected toenails

Exam Action

06/27/20 3:59 PM CDT

Checked capillary refill in toenails

Exam Action

06/27/20 3:59 PM CDT

Checked capillary refill in toenails

Exam Action

06/27/20 3:59 PM CDT

Checked capillary refill in toenails

Exam Action

06/27/20 4:00 PM CDT

Checked capillary refill in toenails

Exam Action

06/27/20 4:00 PM CDT

Checked capillary refill in toenails

Exam Action

06/27/20 4:00 PM CDT

Checked capillary refill in toenails

Exam Action

06/27/20 4:00 PM CDT

Checked capillary refill in toenails

Exam Action

06/27/20 4:00 PM CDT

Checked capillary refill in toenails

Exam Action

06/27/20 4:00 PM CDT

Checked capillary refill in toenails

Exam Action

06/27/20 4:00 PM CDT

Checked capillary refill in toenails

Exam Action

06/27/20 4:00 PM CDT

Inspected legs

Exam Action

06/27/20 4:00 PM CDT

Inspected left leg for edema: No edema

Exam Action

06/27/20 4:00 PM CDT

Palpated temporal arteries: No thrill on either side, 2+ on both sides

Exam Action

06/27/20 4:02 PM CDT

Palpated temporal arteries: No thrill on either side, 2+ on both sides

Exam Action

06/27/20 4:03 PM CDT

Palpated right carotid pulse: No thrill, 2+

Exam Action

06/27/20 4:03 PM CDT

Palpated left carotid pulse: No thrill, 2+

Exam Action

06/27/20 4:03 PM CDT

Palpated chest at PMI: Present at midclavicular line and 5th intercostal space, brisk and tapping, diameter 2 cm

Exam Action

06/27/20 4:04 PM CDT

Palpated right radial pulse: No thrill, 2+

Exam Action

06/27/20 4:05 PM CDT

Palpated left radial pulse: No thrill, 2+

Exam Action

06/27/20 4:05 PM CDT

Palpated right brachial pulse: No thrill, 2+

Exam Action

06/27/20 4:05 PM CDT

Palpated left brachial pulse: No thrill, 2+

Exam Action

06/27/20 4:05 PM CDT

Palpated right femoral pulse: No thrill, 2+

Exam Action

06/27/20 4:06 PM CDT

Palpated left femoral pulse: No thrill, 2+

Exam Action

06/27/20 4:06 PM CDT

Palpated right popliteal pulse: No thrill, 2+

Exam Action

06/27/20 4:06 PM CDT

Palpated left popliteal pulse: No thrill, 2+

Exam Action

06/27/20 4:06 PM CDT

Palpated right tibial pulse: No thrill, 2+

Exam Action

06/27/20 4:07 PM CDT

Palpated left tibial pulse: No thrill, 2+

Exam Action

06/27/20 4:07 PM CDT

Palpated right dorsalis pedis pulse: No thrill, 2+

Exam Action

06/27/20 4:07 PM CDT

Palpated left dorsalis pedis pulse: No thrill, 2+

Exam Action

06/27/20 4:07 PM CDT

Auscultated right temporal pulse

Exam Action

06/27/20 4:08 PM CDT

Auscultated left temporal pulse

Exam Action

06/27/20 4:08 PM CDT

Auscultated right temporal pulse

Exam Action

06/27/20 4:08 PM CDT

Auscultated right carotid pulse

Exam Action

06/27/20 4:12 PM CDT

Auscultated left carotid pulse

Exam Action

06/27/20 4:12 PM CDT

Auscultated right carotid pulse

Exam Action

06/27/20 4:12 PM CDT

Auscultated breath sounds in posterior left upper lobe

Exam Action

06/27/20 4:13 PM CDT

Auscultated right temporal pulse

Exam Action

06/27/20 4:13 PM CDT

Auscultated breath sounds in anterior left upper lobe

Exam Action

06/27/20 4:13 PM CDT

Auscultated breath sounds in anterior right upper lobe

Exam Action

06/27/20 4:13 PM CDT

Auscultated breath sounds in anterior right middle lobe

Exam Action

06/27/20 4:13 PM CDT

Auscultated breath sounds in anterior left mid-chest (upper lobe)

Exam Action

06/27/20 4:13 PM CDT

Auscultated breath sounds in anterior right lower lobe

Exam Action

06/27/20 4:13 PM CDT

Auscultated breath sounds in anterior left lower lobe

Exam Action

06/27/20 4:14 PM CDT

Auscultated breath sounds in posterior left lower lobe on side

Exam Action

06/27/20 4:14 PM CDT

Auscultated breath sounds in posterior left lower lobe near spine

Exam Action

06/27/20 4:14 PM CDT

Auscultated breath sounds in posterior right lower lobe near spine

Exam Action

06/27/20 4:14 PM CDT

Auscultated breath sounds in posterior right lower lobe on side

Exam Action

06/27/20 4:14 PM CDT

Auscultated breath sounds in posterior right lower lobe

Exam Action

06/27/20 4:14 PM CDT

Auscultated aortic area with the bell

Exam Action

06/27/20 4:14 PM CDT

Auscultated aortic area with the diaphragm

Exam Action

06/27/20 4:14 PM CDT

Auscultated pulmonic area with the diaphragm

Exam Action

06/27/20 4:15 PM CDT

Auscultated Erb’s point with the diaphragm

Exam Action

06/27/20 4:15 PM CDT

Auscultated tricuspid area with the diaphragm

Exam Action

06/27/20 4:15 PM CDT

Auscultated mitral area with the diaphragm

Exam Action

06/27/20 4:15 PM CDT

Auscultated aorta in abdomen

Exam Action

06/27/20 4:15 PM CDT

Auscultated right renal pulse

Exam Action

06/27/20 4:15 PM CDT

Auscultated left renal pulse

Exam Action

06/27/20 4:15 PM CDT

Auscultated right iliac pulse

Exam Action

06/27/20 4:16 PM CDT

Auscultated left iliac pulse

Exam Action

06/27/20 4:16 PM CDT

Auscultated right femoral pulse

Exam Action

06/27/20 4:16 PM CDT

Auscultated left femoral pulse

Exam Action

06/27/20 4:16 PM CDT

Tested ABI: 141/145 = 0.972

Exam Action

06/27/20 4:16 PM CDT

Performed EKG: Regular sinus rhythm, no ST changes

Exam Action

06/27/20 4:17 PM CDT

Tested ABI: 141/145 = 0.972

Exam Action

06/27/20 4:17 PM CDT

Any family history of high cholesterol

Question

06/27/20 5:40 PM CDT

Cholesterol runs high in my family. All four of my grandparents have high cholesterol, and Mom and Dad, too.

A family history of hypertension means that you may be at risk for developing it, too, and you’ve had some high blood pressure readings. keeping your blood pressure low is important to avoid health problems in the future with your health and other organs

Educate

06/27/20 5:40 PM CDT

That makes sense.

Any family history of high cholesterol

Question

06/27/20 5:41 PM CDT

Cholesterol runs high in my family. All four of my grandparents have high cholesterol, and Mom and Dad, too.

A family history of hypertension means that you may be at risk for developing it, too, and you’ve had some high blood pressure readings. keeping your blood pressure low is important to avoid health problems in the future with your health and other organs

Empathize

06/27/20 5:42 PM CDT

Thanks for understanding.

Do you know your family history of high blood pressure is a risk for heart disease

Question

06/27/20 5:45 PM CDT

Yeah, I know.

A family history of hypertension means that you may be at risk for developing it, too, and you’ve had some high blood pressure readings. keeping your blood pressure low is important to avoid health problems in the future with your health and other organs

Educate

06/27/20 5:45 PM CDT

Alright, thanks for letting me know.

A family history of hypertension means that you may be at risk for developing it, too, and you’ve had some high blood pressure readings. keeping your blood pressure low is important to avoid health problems in the future with your health and other organs

Empathize

06/27/20 5:45 PM CDT

Thanks for saying that.

Transcript

Started:
Jun 14, 2020 |
Total Time:
71 min

Hi Ms. Jones, my name isXXX. I will be you Health care provider today

Greet

06/14/20 7:26 PM CDT

Hey.

What brings you in today?

Question

06/14/20 7:26 PM CDT

I decided to come in because I’m tired all the time now. . . I have this really important exam coming up, and I’m stressed and too foggy to study most of the time. I really need help sleeping so I can focus on preparing for my exam.

I’m sorry to hear about your trouble sleeping and stress. I’m glad you came in today. let me learn more about what you’re experiencing, and i will try to help

Empathize

06/14/20 7:31 PM CDT

I appreciate you saying that.

when did you start have trouble sleeping?

Question

06/14/20 7:33 PM CDT

This all started almost a month ago. . . it’s been happening regularly for about three and a half weeks, I’d say.

How often do you have difficulty sleeping?

GET SHADOW HEALTH HELP HERE

Question

06/14/20 7:33 PM CDT

It’s happening most nights, I’d say. Four. . . more like five nights a week.

What are factors that prevent you from sleeping? (No matching questions found.)

Question

06/14/20 7:34 PM CDT

What prevents you from sleeping? (Clarified to What were you thinking about when you couldn’t sleep?.)

Question

06/14/20 7:34 PM CDT

Mostly I start out worrying about this exam I have coming up, and how much I need to study, and then I start thinking about what happens if I don’t pass the exam, and even if I do, whether I’ll actually be able to find an accounting job once I graduate, and then if I do find a job, what if I’m bad at it. . . it just sort of builds on itself like that, just, like, worry upon worry. (Clarified to what I was thinking about when I could not sleep.)

Do you drink coffee

Question

06/14/20 7:35 PM CDT

Never. I don’t like it. Too bitter for my taste.

ORDER EXAMS, iHUMAN, ASSIGNMENTS HERE

Do you take naps during the day?

Question

06/14/20 7:36 PM CDT

I’m not really a big nap person–if I fall asleep, I want to sleep for hours, not wake up in twenty minutes feeling groggy. Plus I don’t have time for them, anyway.

Is there anything preventing you from falling asleep (Clarified to Is there anything that helps you fall asleep?.)

Question

06/14/20 7:36 PM CDT

Basically the only way I get to sleep easily is if I manage to feel less stressed out–sometimes I can sort of turn my thoughts away from what I’m worried about by distracting myself with something, like thinking about what I’m going to wear the next day or something like that. I’d rather avoid having to take medication if possible. Taking deep breaths can help a little, too. (Clarified to if I anything helps me sleep.)

Do you exercise

Question

06/14/20 7:37 PM CDT

I just don’t have time to exercise, honestly.

Do you drift off during the day?

Question

06/14/20 7:38 PM CDT

No, though I do feel groggy during the day.

Are you tired during the day?

Question

06/14/20 7:38 PM CDT

I’m pretty much tired all the time. I just really need more sleep.

do you have anxiety?

Question

06/14/20 7:39 PM CDT

I’ve never been diagnosed with anxiety or anything. . . I think usually I’m a pretty relaxed person. At least until recently.

Do you have a history of panic attacks

Question

06/14/20 7:40 PM CDT

I’ve never had a panic attack, no.

How does anxiety affect daily life (Clarified to How does your anxiety interfere with your daily life?.)

Question

06/14/20 7:41 PM CDT

Being anxious is mostly just interfering with my sleep, and then not being able to get enough sleep is interfering with my life. (Clarified to how my anxiety interferes with my daily life.)

how is you quality of sleep (Clarified to Do you sleep ok?.)

Question

06/14/20 7:41 PM CDT

Lately I haven’t been getting enough sleep at all. It takes me so long to fall asleep at night–it’s really frustrating. (Clarified to if I sleep well.)

what are you sleep habits?

Question

06/14/20 7:42 PM CDT

Well. . . I usually get into bed around midnight, but at that point I feel too nervous to sleep, so I’ll read to try and wind down for maybe an hour, sometimes longer. Then I turn out the light and try to sleep. If it takes a really long time, then sometimes I’ll turn the light back on and read a little more until I feel sleepier.

how are you coping with stress

Question

06/14/20 7:42 PM CDT

Usually I try to stay organized, you know, make to-do lists, plan my time, that kind of thing. Sometimes I’ll talk to friends or family. . . going to church usually helps, too. Lately, though, none of that is really helping like it should.

What is causing the stress

Question

06/14/20 7:43 PM CDT

I’m stressed now because I can’t sleep, but I can’t sleep because I keep worrying about all this other stuff, like graduating, and passing this exam that’s coming up, and getting a job, and finding my own place to live. . . it’s a lot.

It sounds like you have a lot on your plate. I am sorry you are dealing with so much stress

Empathize

06/14/20 7:44 PM CDT

I appreciate you telling me that.

What were you thinking about when you couldn’t sleep?

Question

06/14/20 7:46 PM CDT

Mostly I start out worrying about this exam I have coming up, and how much I need to study, and then I start thinking about what happens if I don’t pass the exam, and even if I do, whether I’ll actually be able to find an accounting job once I graduate, and then if I do find a job, what if I’m bad at it. . . it just sort of builds on itself like that, just, like, worry upon worry.

what are your sleep patterns (Clarified to What are your sleep habits?.)

Question

06/14/20 7:47 PM CDT

Well. . . I usually get into bed around midnight, but at that point I feel too nervous to sleep, so I’ll read to try and wind down for maybe an hour, sometimes longer. Then I turn out the light and try to sleep. If it takes a really long time, then sometimes I’ll turn the light back on and read a little more until I feel sleepier. (Clarified to what my sleep habits are.)

It”s hard to function at our best when we don’t get enough sleep. I know you are busy with work and school, but let’s talk about some strategies to help you get more sleep and make sure you’re getting good quality sleep.

Empathize

06/14/20 7:49 PM CDT

Thanks.

Tell me more about “feeling put of it”

Question

06/14/20 7:49 PM CDT

I don’t know what you want to know. . . mostly, it’s that I can’t get to sleep at a reasonable time, but I also feel like the quality of my sleep is worse in general.

what do you mean by “feeling out of it”

Question

06/14/20 7:50 PM CDT

It’s like. . . I just feel slowed down and tired all the time from not sleeping. It’s harder to focus, or get things done efficiently. . . I’m just generally less sharp.

Tell me about your medical history

Question

06/14/20 7:50 PM CDT

I’ve had asthma since I was little, and I have sugar diabetes, too.

Do you take any medications?

Question

06/14/20 7:51 PM CDT

All I have is a Proventil inhaler and a Flovent inhaler for my asthma.

Do you take any medications for sleep

Question

06/14/20 7:51 PM CDT

I haven’t tried taking anything to sleep–I would really rather avoid having to take medication if possible.

Do you have any new allergies

Question

06/14/20 7:52 PM CDT

Nope.

Do you have a history of sleeping problems?

Question

06/14/20 7:52 PM CDT

Well. . . the only other time I’ve had sleep problems was right after Dad died. It felt a little like this, with my
mind racing, but honestly, not as bad
. Other than that month or two, I’ve always been a really good sleeper. I could fall asleep right away, and then I’d sleep like a log.

DO you have a history of depression

Question

06/14/20 7:53 PM CDT

I was pretty sad after Dad died, but I wouldn’t say it was, like, true depression. I definitely wasn’t diagnosed with it or anything.

Do you have difficulty making decisions?

Question

06/14/20 7:53 PM CDT

Only in the sense that, like, everything I do is a little harder because I’m out of it from not sleeping.

Do you feel hopeless

Question

06/14/20 7:54 PM CDT

I don’t feel hopeless, just frustrated and stressed out.

Do you have thoughts of wanting to hurt yourself

Question

06/14/20 7:54 PM CDT

No, I’ve never wanted to hurt myself.

Do you have suicidal thought?

Question

06/14/20 7:54 PM CDT

No, never.

Do you have any past traumas

Question

06/14/20 7:55 PM CDT

No, not really.

Do you have a history of violence

Question

06/14/20 7:55 PM CDT

No, never.

Are you employed

Question

06/14/20 7:55 PM CDT

I’m a supervisor at Mid-American Copy & Ship. I’ve been working there since high school, and I’ve just kept moving up.

Are you in school

Question

06/14/20 7:56 PM CDT

Yeah, I’m about to get my B.A. in Accounting.

Do you have an hobbies

Question

06/14/20 7:56 PM CDT

I
read a lot
, especially since I bought one of those e-book readers. My friends and I have thought about starting a book club actually. Oh, and there’s these free talks at church that I like to go to if I have time. I watch TV, but usually on DVD or streaming. I like to marathon the shows I really like. I’m really interested in documentaries, too.

Have you been in the military

Question

06/14/20 7:56 PM CDT

No, I’ve never been in the military.

Do you have a legal history

Question

06/14/20 7:57 PM CDT

No way.

What is you current living situation

Question

06/14/20 7:57 PM CDT

I’m living back at my mom’s house with her and my sister. It’s the house I grew up in–we each have our own bedroom, and there’s also a kitchen and a living room. It’s all one story. It can be kind of weird, being my age and living with my family again, but I’ve enjoyed spending time with my family, and I’m happy to help out. I’m
looking forward to getting my own place soon
, though.

Do you get along with your family

Question

06/14/20 7:57 PM CDT

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.

Do you have religious preference?

Question

06/14/20 7:58 PM CDT

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.

does your family support you

Question

06/14/20 7:59 PM CDT

Yeah, definitely. We’re all pretty tight knit. I think we’re a pretty special family, the way we all get along. My brother moved in with his fiance, but we still see him once a week at least, and I eat dinner with my mom and sister as much as possible, plus they always go to church with me on Sundays.

It sounds like you have a healthy support system through your family and friends which is great. it sounds like you work hard to manage your time effectively, too. remember to take out to relax or take a walk

Empathize

06/14/20 8:04 PM CDT

Thanks for understanding.

Do you use illicit drugs?

Question

06/14/20 8:05 PM CDT

No.

Have you used marijuana

Question

06/14/20 8:06 PM CDT

Well, I used to smoke pot. . . but I don’t do that anymore.

when was the last time you smoked marijuana

Question

06/14/20 8:06 PM CDT

I haven’t smoked pot since I was twenty or twenty-one.

Do you drink alcohol

Question

06/14/20 8:06 PM CDT

I do sometimes, yeah, when I go out with my friends.

how often do you drink

Question

06/14/20 8:06 PM CDT

No more than once or twice a week. . . a lot of time less than that.

how much do you drink

Question

06/14/20 8:07 PM CDT

Not often–a couple times a month I’ll go out for a few drinks with friends.

how many drink do you drink per month (Clarified to How many times a month do you drink?.)

Question

06/14/20 8:07 PM CDT

Not much. I go out for drinks with friends maybe a couple times a month. (Clarified to how many times a month I drink alcohol.)

how many drink do you drink in a month (Clarified to How many drinks do you have per month?.)

Question

06/14/20 8:07 PM CDT

Oh, I don’t know. Let’s see. . . I might go out every few weeks, so twice a month. . . and I maybe have 2 or 3 drinks at a time, so that’s like 6 drinks a month.
I guess if I’m free to go out more than that
, it might be up to 12 drinks in a month, but that’s pretty rare. (Clarified to how many alcoholic drinks I have a month.)

do you drink and drive

Question

06/14/20 8:08 PM CDT

We usually take a cab when we go out.

so you use tobacco products

Question

06/14/20 8:08 PM CDT

No, never.

do you vape

Question

06/14/20 8:08 PM CDT

I don’t vape. Ew. [AUDIO COMING SOON]

Do you

Question

06/14/20 8:09 PM CDT

No! I don’t know

What is your

Question

06/14/20 8:09 PM CDT

I’m

how long have you

Question

06/14/20 8:09 PM CDT

I

Are you

Question

06/14/20 8:10 PM CDT

No, I haven’t

have anyone

Question

06/14/20 8:10 PM CDT

No, never.

do you have any family members with a history of mental illness

Question

06/14/20 8:11 PM CDT

No. They’re crazy, but nobody’s diagnosed with anything.

Education & Empathy
: 4 of 4 (100.0%)

During the patient interview, there are a number of opportunities to provide patient education and empathy. The opportunities listed below are those identified by nursing experts to be of particular importance to this patient. A
Model Statement
is provided as an example of an appropriate response to each opportunity.

Opportunities marked as
Not Encountered
are opportunities that were not elicited in the interview

Opportunities marked as
Not Followed Up
are missed opportunities that were present in the interview, but where no statements were made

Opportunities marked as
Followed Up
were followed up by students, and include the dialogue between student and patient

1 Symptoms

Followed Up

Description:
Tina describes problems sleeping and stress-symptoms like racing thoughts.

What brings you in today?

Question

07:26 PM CDT

I decided to come in because I’m tired all the time now. . . I have this really important exam coming up, and I’m stressed and too foggy to study most of the time. I really need help sleeping so I can focus on preparing for my exam.

I’m sorry to hear about your trouble sleeping and stress. I’m glad you came in today. let me learn more about what you’re experiencing, and i will try to help

Empathize

07:31 PM CDT

I appreciate you saying that.

Model Statement:
“I’m sorry to hear about your trouble sleeping and stress. I’m glad you came in. Let me learn more about what you’re experiencing, and I will try to help.”

2 Stress

Followed Up

Description:
Tina describes how busy she is with school and work.

What is causing the stress

Question

07:43 PM CDT

I’m stressed now because I can’t sleep, but I can’t sleep because I keep worrying about all this other stuff, like graduating, and passing this exam that’s coming up, and getting a job, and finding my own place to live. . . it’s a lot.

It sounds like you have a lot on your plate. I am sorry you are dealing with so much stress

Empathize

07:44 PM CDT

I appreciate you telling me that.

Model Statement:
“It sounds like you have a lot on your plate. I’m sorry you’re dealing with so much stress.”

3 Sleep

Followed Up

Description:
Tina describes her sleep hygiene and routine.

What is causing the stress

Question

07:43 PM CDT

I’m stressed now because I can’t sleep, but I can’t sleep because I keep worrying about all this other stuff, like graduating, and passing this exam that’s coming up, and getting a job, and finding my own place to live. . . it’s a lot.

It sounds like you have a lot on your plate. I am sorry you are dealing with so much stress

Empathize

07:44 PM CDT

I appreciate you telling me that.

What were you thinking about when you couldn’t sleep?

Question

07:46 PM CDT

Mostly I start out worrying about this exam I have coming up, and how much I need to study, and then I start thinking about what happens if I don’t pass the exam, and even if I do, whether I’ll actually be able to find an accounting job once I graduate, and then if I do find a job, what if I’m bad at it. . . it just sort of builds on itself like that, just, like, worry upon worry.

what are your sleep patterns (Clarified to: What are your sleep habits?)

Question

07:47 PM CDT

Well. . . I usually get into bed around midnight, but at that point I feel too nervous to sleep, so I’ll read to try and wind down for maybe an hour, sometimes longer. Then I turn out the light and try to sleep. If it takes a really long time, then sometimes I’ll turn the light back on and read a little more until I feel sleepier. (Clarified to: what my sleep habits are)

It”s hard to function at our best when we don’t get enough sleep. I know you are busy with work and school, but let’s talk about some strategies to help you get more sleep and make sure you’re getting good quality sleep.

Empathize

07:49 PM CDT

Thanks.

Model Statement:
“It’s hard to function at our best when we don’t get enough sleep. I know you’re very busy with work and school, but let’s talk about some strategies to help you get more sleep and make sure you’re getting good quality sleep.”

4 Coping and Support Systems

Followed Up

Description:
Tina describes her coping mechanisms and support systems.

Do you get along with your family

Question

07:57 PM CDT

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.

Do you have religious preference?

Question

07:58 PM CDT

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.

does your family support you

Question

07:59 PM CDT

Yeah, definitely. We’re all pretty tight knit. I think we’re a pretty special family, the way we all get along. My brother moved in with his fiance, but we still see him once a week at least, and I eat dinner with my mom and sister as much as possible, plus they always go to church with me on Sundays.

It sounds like you have a healthy support system through your family and friends which is great. it sounds like you work hard to manage your time effectively, too. remember to take out to relax or take a walk

Empathize

08:04 PM CDT

Thanks for understanding.

Model Statement:
“It sounds like you have healthy support systems through your family and friends, which is great. It sounds like you work hard to manage your time effectively, too. Remember to take time out to relax or take a walk.”