Tina Jones Comprehensive Health History transcript
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Height: 170 cm
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Weight: 90 kg
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BMI: 31
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Random blood glucose: 238
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Temperature: 101.1 F
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Blood pressure: 142/82
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Respiratory rate: 19
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O2 sat: 99%
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Heart rate: 86
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Hallo M. Tina, my name is Mary and i will taking care of you today
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Hey.
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how are you doing today?
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Not so great… My foot really hurts right now.
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im sorry to hear that can you tell me more about it
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I appreciate you telling me that.
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what brings you to the clinic today?
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I got this scrape on my foot a while ago, and I thought it would heal up on its own, but now it’s looking pretty nasty. And the pain is killing me!
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tell me about your more about the pain
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It’s throbbing and like, sharp if I try to put weight on it.
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how long have you been experiencing the pain?
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Well, I got the scrape a week ago, but the scrape and the pain got a lot worse in the last few days.
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did you see any doctor?
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To be honest, I haven’t been to a doctor for just a check-up in. . . at least two years. But I did see a doctor at the ER about my foot.
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were you given any medication? (Clarified to Did the ER prescribe anything?.)
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Yes, they wrote me a prescription for some pain pills. (Clarified to if the ER prescribed me any medications.)
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what type of pain pills
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It’s called tramadol.
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how many mg
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I just take the regular kind I think — 200 mg. It’s not extra strength or anything. [AUDIO COMING SOON]
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how often do you take it
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I don’t take anything now, but I used to be on the pill.
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how many pills of tramadol do you take
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I take two at a time.
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how often do you take it
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I don’t take anything now, but I used to be on the pill.
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on a scale of 1-10 how much is your pain (Clarified to On a scale of 0-10 how would you rate the pain in your right foot?.)
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I’d say a 7. It hurts a lot, and the pain pills haven’t kicked in yet. (Clarified to how I would rate my foot pain on a scale.)
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have you noticed any drainage
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Yeah, there’s definitely pus.
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is the pus has any color
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Yeah, there’s definitely pus.
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are you allergic to any medication
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Yeah, I’m allergic to penicillin.
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do you have food allergies
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Nope, no food allergies that I know of.
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do you have any environmental allergies
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No, unless cats count.
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tell me about the cat allergy
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Whenever I’m around cats, I start sneezing, my eyes get itchy. . . and my asthma starts to act up.
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do you take anything for the allergies
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I don’t take anything, unless my inhaler counts.
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do you have any other medical conditions
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Um, the only things I know I’m diagnosed with are diabetes. And asthma.
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do you take anything for diabetes
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I don’t take anything for my diabetes anymore.
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how do you control your diabetes
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I just watch what I eat and try to stay away from sweets.
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do you take any asthma medication
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I just use my inhaler.
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what is the name of your inhaler
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It’s just a regular Proventil inhaler.
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how many mg
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I just take the regular kind I think — 200 mg. It’s not extra strength or anything. [AUDIO COMING SOON]
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how many cg is your inhaler (Clarified to How many times did you use your inhaler?.)
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At my cousin’s? I did two puffs, and then I had to do another one a little later. . . that’s been happening sometimes lately. (Clarified to how many times I used my inhaler.)
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do you have any medical history
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Yeah. . . I have asthma and diabetes.
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does your family have any medical history
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My mom has some issues, and I think some of my grandparents did, too.
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what kind of issues does you mother have
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Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though.
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any other medical history in the family (Clarified to What health problems run in your family?.)
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My mom has some issues, and I think some of my grandparents did, too. (Clarified to what health problems run in my family.)
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does you father have any medical issues
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Well, he passed away. But he had a couple things . . . Type 2 diabetes, like me, and high cholesterol and blood pressure.
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do you smoke?
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No. I think it’s gross.
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do you drink alcohol
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I do sometimes, yeah, when I go out with my friends.
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how many drinks do you have when you drink
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Just a few. I’m not a big drinker.
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do you take any illegal drugs
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Well, I used to smoke pot. . . but I don’t do that anymore.
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do your friends smoke pot
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Yeah, a couple of my friends smoke when we go out. I don’t like being around smokers, though.
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what do you plan to stop smoking with your friends
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I’m pretty optimistic about the future actually. In a couple of months I’ll have my degree, and I’ll probably get my own place again. I’m planning on trying for one of the accounting jobs in our regional office, too. If that works out, I would like to start dating again… maybe I’ll find someone I want to marry, start a family with?
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do you have shortness of breath
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No, my breathing is fine right now.
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are you in pain
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Yeah, my foot’s really bothering me.
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what makes it worse
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I’d say the pain is at its worst when I have to put any weight on my foot. . . otherwise, it’s when the pain pills wear off.
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can i take a look on your foot (Clarified to May I take a look at your foot now?.)
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