Comprehensive Assessment SH Transcript, Sub, Obj & Documentation

Transcript Hello, my name is . I will be conducting an interview and later perform a 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 when I was in a dusty house for a long time. . . I would get allergies, like sneezing and stuff, and then my asthma would act up. But that hasn’t happened since I got my daily inhaler. What inhaler do you use? The daily inhaler is Flovent, and the rescue inhaler is Proventil. How often do you use flovent? Twice a day. When did you most recently use the flovent inhaler? I use my Flovent inhaler two times a day. When did you last use your inhaler? I used my Flovent inhaler this morning–I have to take it twice a day. My albuterol. . . I’ve maybe used it twice since I came in with those asthma problems. Once three months ago, and before that it had been months, too. How much Albuterol do you use? I have a few friends I’ve known since middle or high school, and we’re all pretty close. Plus I have my friends from church. What is your relationship like with your family? 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. That is great. Empathize Thanks. Are you involved in church? 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. Are you feeling stressed?I’m actually feeling really good lately. . . not stressed at all. How do you cope with stress? I’ve realized that I got kind of overwhelmed with everything back when I was having those sleep problems. Just coming in and talking to someone here about it helped a little because I felt like I was doing something. So I’ve been trying to address problems as they come when I can, and that helps. That, plus the stuff I’ve always done–going to church, especially–is all working well for me. That is good to hear. Empathize Thanks. Are you feeling depressed? No, I’m actually feeling really good these