Comprehensive Assessment SH Transcript, Sub, Obj & Documentation
Transcript
Hello, my name is . I will be conducting an interview and later perform a
... [Show More] physical exam. Hey.
What is your name? Tina Jones
Your date of birth? February 17th.
How old are you? I’m 28.
What brought you into the clinic today? I came in because I’m required to have a recent physical exam for the health insurance at my new
job.
Do you have any current health problem? I don’t have anything specific going on today. I mean, I still have asthma and diabetes, but both
of those are under control. I’m taking good care of my health these days.
What is your new job? I’m going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. I’ll be helping a more
experienced accountant with her clients, and then eventually I’ll get more responsibility, and build my own client list. I start in two weeks–
I’m really excited!
That is great. Empathize
Thanks.
When was your last physical exam? Let’s see . . . I had two doctor’s appointments earlier this year. About five months ago, I came
in here for a check-up, and the nurse practitioner got me on metformin. Then a few weeks later I saw a gynecologist for a pap smear.
What did your gynecologist say?
She said everything looked good, except that I had PCOS, which the nurse here had said was possible. She started me on birth control, and it
seems to be helping things.
How often do you take birth control? I take it every morning, with breakfast.
What is the name of the birth control pill you took? They’re called Yaz.
Has your menstrual cycle improved since taking Yaz? Now that I’m on the pill I’m getting my period every month.
That is great. I am glad you are having your period every month. Empathize
Thanks.
How long have you had asthma. I’ve had asthma a long time. . . since I was really little.
What age were you diagnosed with asthma? My doctor told me when I was pretty little… I think I was about two and a half? I used
to have a lot of trouble with asthma attacks back then.
I am sorry about the experience. Empathize
Thanks.
How do you manage your asthma? I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my
inhaler.
What are your triggers for asthma? Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. I haven’t
had a full asthma attack in years, though.
It is important to stay away from triggers. Educate
Thanks for telling me.
What happens when you are around dust?
I used to have a reaction whe [Show Less]