Transcript Overview Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Student Survey Experience Overview
... [Show More] All Lines (198) Interview Questions (1 08) Statements (11) Exam Actions (79) Greet 01/15/19 8:21 AM EST Question 01/15/19 8:21 AM EST Empathize 01/15/19 8:22 AM EST Question 01/15/19 8:22 AM EST Question 01/15/19 8:22 AM EST Question 01/15/19 8:23 AM EST Question 01/15/19 8:23 AM EST Good morning, I am Juliana and I am a nurse practitioner candidate. I will interview and examine you today. Hey. What brings you in today, Tina? My throat has been sore... and itchy. And my nose won't stop running. These symptoms are driving me nuts. I am sorry to hear you are not feeling well today. Let us see what we can do to help these symptoms improve. I appreciate you saying that. How long have you had these symptoms? Well, no. I mean, I never had allergies to pollen or anything outdoors like that. . . But my nose is acting just like my sister's right now, and she's always had hay fever. I'm starting to think that this is allergies. How long have you had a sore throat? Like a week ago, everything started. Sore, itchy throat, runny nose. Have you ever had this problem before? (Clarified to Have you had these symptoms before?.) Well, no. I mean, I never had allergies to pollen or anything outdoors like that. . . But my nose is acting just like my sister's right now, and she's always had hay fever. I'm starting to think that this is allergies. (Clarified to if I have had these symptoms before.) How severe is your sore throat? It's not... terrible. I mean, it hurts a little. Like, mild to moderate. The main thing is that it won't go away. Question 01/15/19 8:24 AM EST Question 01/15/19 8:24 AM EST Question 01/15/19 8:24 AM EST Question 01/15/19 8:25 AM EST Question 01/15/19 8:26 AM EST Question 01/15/19 8:26 AM EST Question 01/15/19 8:26 AM EST Question 01/15/19 8:27 AM EST Does the sore throat cause shortness of breath? (No matching questions found.) Is the sore throat constant? Yeah, it's sore pretty much all the time. Can you describe the pain? I don't know how I would describe it, other than "sore." How would you rate the pain on a scale from 1 to 10? It's like a 4 out of 10, maybe. Does the pain radiate? No, it's just in my throat. What do you think is causing the sore throat? At first I thought I was getting sick, or a cold or something, but now it doesn't seem like that. My throat hasn't gotten worse, but it's not going away either. Does anything make your throat feel better? All I've done is suck on some throat drops. And I've been drinking more water, which helps. Does anything make the throat pain worse? (Clarified to Does anything make the pain worse?.) Question 01/15/19 8:27 AM EST Question 01/15/19 8:28 AM EST Question 01/15/19 8:28 AM EST Question 01/15/19 8:28 AM EST Question 01/15/19 8:29 AM EST Question 01/15/19 8:29 AM EST Question 01/15/19 8:30 AM EST It's a little worse in the morning, but that's really the only pattern I've noticed. (Clarified to if anything makes the pain worse.) Do you have any other symptoms associated with the sore throat? (No matching questions found.) Do you have any nasal discharge Yes, it won't stop running! Can you describe the nasal discharge? It's just clear. Do you have any eye symptoms? (Clarified to Do you have eye problems?.) You mean, other than this itchy-eye stuff going on right now? I guess... my eyes get blurry sometimes when I read. It seems like my vision is getting worse over the years. (Clarified to if I have eye problems.) Do you experience any shortness of breath? No, I don't have any trouble breathing on a regular basis. How often do you have a runny nose? It runs all day. Have you been exposed to any allergens? Not lately. Do you have a family history of throat problems? Question 01/15/19 8:31 AM EST Question 01/15/19 8:31 AM EST Question 01/15/19 8:31 AM EST Question 01/15/19 8:32 AM EST Question 01/15/19 8:32 AM EST Question 01/15/19 8:32 AM EST Question 01/15/19 8:32 AM EST No. Do you take any over the counter medications? I've been trying throat drops lately. In general, I take Tylenol for a headache sometimes, or Advil for cramps, but not often. How often do you get headaches? Maybe once a week? I usually do a lot of my school work at once, so I'll study for like, 5 or 6 hours. I usually end up with a headache by the end of the night. How would you rate these headaches? Not too bad. . . I'd say about 3. Or a 4 if I really push it. What helps your headaches? I just take some acetaminophen. The gel kind, 500 mg. [AUDIO COMING SOON] Does anything make your headaches worse? Usually they get worse if I don't stop studying. I try to take a break when they start most of the time, but if I have a test or something coming up, I just have to try and ignore it. How long have you had these headaches for? I'm not sure -- Maybe over the last year or so. Question 01/15/19 8:33 AM EST Question 01/15/19 8:33 AM EST Question 01/15/19 8:33 AM EST Question 01/15/19 8:34 AM EST Question 01/15/19 8:34 AM EST Question 01/15/19 8:34 AM EST Question 01/15/19 8:35 AM EST Question 01/15/19 8:35 AM EST Do you take any herbal supplements? No, I don't take anything herbal. Do you take any prescription medications? Yeah, the only prescription I have is my inhaler, but I only use it when I need it. How often do you use your inhaler? I don't use it every day -- maybe I use it 2 or 3 times a week. Sometimes not at all. Have you been diagnosed with asthma? Yeah, though it's not as bad as it used to be when I was a kid. What is the name of the inhaler you use? It's just a regular Proventil inhaler. Can you describe your asthma symptoms? My chest and throat get tight, and I start to wheeze. It feels like I can't take in air, like I can't get enough air into my lungs. 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. Do you have allergies? Question 01/15/19 8:35 AM EST Question 01/15/19 8:36 AM EST Question 01/15/19 8:36 AM EST Question 01/15/19 8:37 AM EST Question 01/15/19 8:38 AM EST Question 01/15/19 8:39 AM EST Question 01/15/19 8:39 AM EST Yeah. I'm allergic to cats. And dust, too. What do you use to improve your eye symptoms? All I've done is suck on some throat drops. And I've been drinking more water, which helps. Does anything help your itchy eyes? No, I haven't done anything to try to make my eyes less itchy. Are you exposed to allergens at work? No, I don't notice any symptoms getting worse at work. Have you had a sore throat like this before? (Clarified to Anyone around you with a sore throat?.) No, not sick, but my sister's allergies are bugging her. (Clarified to if I have been around anyone who has a sore throat.) Do you have any other symptoms? Let's see... I have a lot going on so here's the laundry list: sore and itchy throat, runny nose, itchy eyes. Have you been to the eye doctor recently? No, I haven't been to an eye doctor since I was a kid. Do you have any ear aches? No, my ears don't hurt. Question 01/15/19 8:39 AM EST Question 01/15/19 8:39 AM EST Question 01/15/19 8:40 AM EST Question 01/15/19 8:41 AM EST Question 01/15/19 8:41 AM EST Empathize 01/15/19 8:42 AM EST Question 01/15/19 8:42 AM EST Do you have any problems with your mouth? No. Do you have any problems with your teeth? No, I've got good teeth. They don't give me any problems. How severe are your asthma symptoms? My asthma has been pretty under control. I use my inhaler a few times a week and it helps. Have you ever been hospitalized? I used to go to the hospital for asthma growing up, but I hadn't been in a while until about a month ago. . . I had to go to the ER for my foot. What happened to your foot? (Clarified to Tell me about what's going on with your foot?.) My foot is doing great. It doesn't hurt at all, and the scrape is healed up. I'm glad that's all over with. (Clarified to what is wrong with my foot.) I am glad to hear your foot is much better. Thanks for understanding. Do you have any other medical problems? I have diabetes and asthma, but I can't even deal with those today. Question 01/15/19 8:42 AM EST Question 01/15/19 8:43 AM EST Question 01/15/19 8:43 AM EST Question 01/15/19 8:43 AM EST Question 01/15/19 8:43 AM EST Empathize 01/15/19 8:44 AM EST Educate 01/15/19 8:45 AM EST What medication you take for diabetes? (Clarified to What medication do you take for diabetes?.) I don't take medicine for it anymore. (Clarified to what medication I take for diabetes.) Why dont you take medicine for diabetes anymore? I just got sick of dealing with it! What medicine were you prescribed for diabetes? It was Metformin. Tell me more about why you stopped taking metformin. I just got sick of dealing with it! What do you mean you got sick of dealing with metformin? I guess I just got sick of feeling sick and gassy all the time, and it was overwhelming, remembering to take pills and check my sugar. I feel a lot better now that I'm just eating healthier than I did when I was taking the pills. That is great to hear that you have been changing your eating habits to help control your blood sugars Show Less [Show Less]