Shadow health Tina Jones Health History transcript

Shadow health Tina Jones Health History transcript

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!

Hello, my name is Gisselle. I will interview you and later examine you.

Question
11/02/21 4:33 AM EDT
Tina Jones: Hello.
Your Avatar: Hello. My name is xxx, I will interview you and later examine you.

Greet
11/02/21 5:19 PM EDT
Tina Jones: Hey.
Your Avatar: What is your name?

Question
11/02/21 5:19 PM EDT
Tina Jones: Tina Jones.
Your Avatar: Why are you here today?

Question
11/02/21 5:20 PM EDT
Tina Jones: 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!
Your Avatar: I’m sorry to hear that.

Empathize
11/02/21 5:20 PM EDT
Tina Jones: I appreciate you telling me that.
Your Avatar: When did you get the scrape?

Question
11/02/21 5:20 PM EDT
Tina Jones: Well, I got the scrape a week ago, but the scrape and the pain got a lot worse in the last few days.
Your Avatar: How severe is the pain?

Question
11/02/21 5:21 PM EDT
Tina Jones: It’s really bad.
Your Avatar: Can you describe the pain?

Question
11/02/21 5:21 PM EDT
Tina Jones: It’s throbbing and like, sharp if I try to put weight on it.
Your Avatar: Did you hurt anything else during the fall?

Question
11/02/21 5:22 PM EDT
Tina Jones: Well, at first, I thought my ankle was sprained because it hurt a lot right after I fell. But, I mean, I guess I was over-estimating it because the ankle felt pretty okay the next day and it wasn’t a problem all week. (Clarified to if I hurt anything else during the fall.)
Your Avatar: How has the pain changed over time?

Question
11/02/21 5:23 PM EDT
Tina Jones: At first, it seemed like it was healing up fine, and it didn’t give me a lot of pain. But the last two days, the pain got way worse.
Your Avatar: Does the pain radiate?

Question
11/02/21 5:23 PM EDT
Tina Jones: The pain’s worse in my foot, but I feel it moving up into my ankle, too.
Your Avatar: How did you hurt your ankle?

Question
11/02/21 5:24 PM EDT
Tina Jones: I was going down the back steps, and I tripped… I caught the railing, but I guess I kind of turned my ankle a little bit. And I scraped up my foot on the edge of the step.
Your Avatar: Can you stand on your foot?

Question
11/02/21 5:25 PM EDT
Tina Jones: No, I can’t put weight on my foot without really sharp pain.
Your Avatar: Can you rate your pain on a scale of 0 to 10?

Question
11/02/21 5:25 PM EDT
Tina Jones: I’d say a 7. It hurts a lot, and the pain pills haven’t kicked in yet.
Your Avatar: Where is the pain located?

Question
11/02/21 5:26 PM EDT
Tina Jones: It feels like the pain is just centered around the scrape, like around the ball of my foot. That’s where it hurts the most, but my whole foot feels some pain.
Your Avatar: Which foot did you injure?

Question
11/02/21 5:26 PM EDT
Tina Jones: My right foot.
Your Avatar: Were you wearing shoes?

Question
11/02/21 5:26 PM EDT
Tina Jones: No, I was barefoot.
Your Avatar: Did you have any alcoholic drinks before the injury?

Question
11/02/21 5:27 PM EDT
Tina Jones: No, I was stone-cold sober. It was the middle of the day.
Your Avatar: Did you use home remedies for your foot?

Question
11/02/21 5:27 PM EDT
Tina Jones: Yeah, I made sure to clean it and keep it bandaged. (Clarified to if I use home remedies for my foot.)
Your Avatar: What did you use to clean it?

Question
11/02/21 5:28 PM EDT
Tina Jones: Since it happened, I’ve been washing it with soap and water, and if it seemed irritated, I would put some peroxide on there and then rinse it off.
Your Avatar: When did you go to the ER?

Question
11/02/21 5:29 PM EDT
Tina Jones: I went about an hour after I fell, I think.
Your Avatar: Did you get any medication at the ER?

Question
11/02/21 5:29 PM EDT
Tina Jones: Yes, they wrote me a prescription for some pain pills.
Your Avatar: Do you know the name of the pain pills?

Question
11/02/21 5:30 PM EDT
Tina Jones: It’s called tramadol.
Your Avatar: What dosage of tramadol

?

Question
11/02/21 5:30 PM EDT
Tina Jones: I’m not 100% sure, but I think they’re 50 milligrams.
Your Avatar: How often were you taking the tramadol?

Question
11/02/21 5:30 PM EDT
Tina Jones: I’ve been taking the Tramadol morning, noon, and night. [AUDIO COMING SOON]
Your Avatar: Did tramadol relieve pain?

Question
11/02/21 5:31 PM EDT
Tina Jones: I’ve only been taking the pain pills the ER gave me and staying off it… and keeping the wound clean.
Your Avatar: Has your foot bled since the injury?

Question
11/02/21 5:32 PM EDT
Tina Jones: It’s not bleeding anymore. It only bled right after I scraped it.
Your Avatar: What happened after you scraped your foot?

Question
11/02/21 5:32 PM EDT
Tina Jones: I got the scrape to stop bleeding, and then I started to worry that I had sprained my ankle, so Mom and I decided better safe than sorry, and so we went to the ER.
Your Avatar: It is good to seek medical attention.

Educate
11/02/21 5:33 PM EDT
Tina Jones: OK, I understand.
Your Avatar: How effective is the pain medication?

Question
11/02/21 5:34 PM EDT
Tina Jones: They only help for a few hours at a time.
Your Avatar: I’m sorry to hear that.

Empathize
11/02/21 5:35 PM EDT
Tina Jones: Thanks for saying that.
Your Avatar: How have you cared for the scrape?

Question
11/02/21 5:35 PM EDT
Tina Jones: I made sure to clean it and just keep it bandaged. And I put Neosporin on it.
Your Avatar: How effective was the Neosporin?

Question
11/02/21 5:36 PM EDT
Tina Jones: Well, I had to come back to get my foot checked out even though I used the ointment. [AUDIO COMING SOON]
Your Avatar: How often have you been cleaning your scrape?

Question
11/02/21 5:37 PM EDT
Tina Jones: Twice a day — every morning and every night.
Your Avatar: Great. It is good to keep it clean.

Educate
11/02/21 5:38 PM EDT
Tina Jones: Sure, I think I understand what you mean.
Your Avatar: Is the wound swollen?

Question
11/02/21 5:38 PM EDT
Tina Jones: Yeah, it looks swollen around the scrape.
Your Avatar: Does your scrape have an odor?

Question
11/02/21 5:39 PM EDT
Tina Jones: Um, no, not that I know of… That sounds gross.
Your Avatar: Any pus?

Question
11/02/21 5:39 PM EDT
Tina Jones: Yeah, there’s definitely pus.
Your Avatar: What color is the pus?

Question
11/02/21 5:40 PM EDT
Tina Jones: It’s… white or maybe off-white.
Your Avatar: Is the scrape red?

Question
11/02/21 5:40 PM EDT
Tina Jones: Yeah, it’s red all around the scrape.
Your Avatar: Any temperature change around the scrape?

Question
11/02/21 5:41 PM EDT
Tina Jones: No.
Your Avatar: Are you having problems getting around?

Question
11/02/21 5:42 PM EDT
Tina Jones: Yes! I mean, I literally can’t put weight on my foot, the pain is so sharp.
Your Avatar: I’m sorry to hear that.

Empathize
11/02/21 5:43 PM EDT
Tina Jones: My hearing is fine.
Your Avatar: I’m sorry to hear that.

Empathize
11/02/21 5:43 PM EDT
Tina Jones: Thanks for understanding.
Your Avatar: Who has been helping you at home since you hurt your foot?

Question
11/02/21 5:44 PM EDT
Tina Jones: I’m lucky living at home because my mom is around to help me, and my sister too.
Your Avatar: Do you work?

xxxxx
I haven’t had a mammogram. I’ve just had the exam where the doctor felt around for lumps.
Your Avatar: Any pain in the breasts?

Question
11/02/21 7:11 PM EDT
Tina Jones: No. Maybe some soreness before my period, but that seems pretty typical.
Your Avatar: Any nipple discharge?

Question
11/02/21 7:11 PM EDT
Tina Jones: Uh, no, definitely not.
Your Avatar: Any nosebleed?

Question
11/02/21 7:12 PM EDT
Tina Jones: No.
Your Avatar: Any chest pain?

Question
11/02/21 7:12 PM EDT
Tina Jones: No, my chest feels tight when I have breathing problems, but it doesn’t hurt.
Your Avatar: Any difficulty moving your bowels?

Question
11/02/21 7:13 PM EDT
Tina Jones: Not really.
Your Avatar: Any skin changes?

Question
11/02/21 7:13 PM EDT
Tina Jones: Well…I guess I was noticing the other day that the skin around my neck is looking weird. Like the skin is getting darker. And my skin’s breaking out, but that’s how it is.
Your Avatar: What is your general health condition?

Question
11/02/21 7:14 PM EDT
Tina Jones: Overall, my health is pretty good. I have a couple of problems, I guess, but they don’t bother me too much.
Your Avatar: Any fatigue?

Question
11/02/21 7:14 PM EDT
Tina Jones: Most days I feel pretty exhausted by the end of the day…I’m tired now, too, but I think that’s just because I slept terribly.
Your Avatar: How is your sleep pattern?

Question
11/02/21 7:14 PM EDT
Tina Jones: I try to be in bed by eleven or midnight, and I get up at seven or eight.
Your Avatar: Any hearing problems?

Question
11/02/21 7:15 PM EDT
Tina Jones: No.
Your Avatar: Any ear discharge?

Question
11/02/21 7:15 PM EDT
Tina Jones: No.
Your Avatar: Does your mother have any health problems?

Question
11/02/21 7:17 PM EDT
Tina Jones: Mom has high cholesterol and blood pressure, I think. She seems to be doing okay, though.
Your Avatar: Does your father have medical problems?

Question
11/02/21 7:18 PM EDT
Tina Jones: Well, he passed away. But he had a couple of things… Type 2 diabetes, like me, and high cholesterol and blood pressure.
Your Avatar: I’m sorry to

hear that.

Empathize
11/02/21 7:18 PM EDT
Tina Jones: I appreciate you saying that.
Your Avatar: When did your father pass away?

Question
11/02/21 7:18 PM EDT
Tina Jones: It was last year… I guess a little over a year ago.
Your Avatar: How did you cope with your father’s death?

Question
11/02/21 7:19 PM EDT
Tina Jones: Well, right after he died, after the funeral and everything, I just tried to get through that. Mom was having such a hard time, crying a lot, everything made her sad, she was kinda depressed. So I guess at first, I just focused on getting things done – groceries, laundry, insurance papers, and stuff. Knowing that Mom needed me kinda helped me get through day by day. There was about a month where it was hard for us to get to church. Even getting up and ready for church was too overwhelming. But our church family helped us out, and gave us rides to church and brought meals and all that, so they really helped build us back up. Things were only hard like that for a few months.
Your Avatar: You are lucky to have a great support system.

Empathize
11/02/21 7:20 PM EDT
Tina Jones: I appreciate you telling me that.
Your Avatar: What was the cause of your father’s death?

Question
11/02/21 7:21 PM EDT
Tina Jones: He died in a car accident.
Your Avatar: I’m sorry to hear that.

Empathize
11/02/21 7:21 PM EDT
Tina Jones: Thanks for saying that.
Your Avatar: How is your paternal grandfather?

Question
11/02/21 7:22 PM EDT
Tina Jones: Grandpa Jones passed away when I was really little.
Your Avatar: Did Grandpa Jones have medical problems?

Question
11/02/21 7:23 PM EDT
Tina Jones: Grandpa Jones had colon cancer, and that caused all kinds of problems for him. Plus, he had high blood pressure, and… I’m pretty sure he had diabetes.
Your Avatar: Does your paternal grandmother have health problems?

Question
11/02/21 7:23 PM EDT
Tina Jones: She takes some blood pressure pills, and I think she has high cholesterol, but Granny’s doing great for 82.
Your Avatar: That’s great to hear.

Empathize
11/02/21 7:24 PM EDT
Tina Jones: Thanks.
Your Avatar: Your maternal grandfather’s healthy?

Question
11/02/21 7:25 PM EDT
Tina Jones: Well, Poppa died five years ago.
Your Avatar: How old was your maternal grandfather when he passed?

Question
11/02/21 7:25 PM EDT
Tina Jones: He was almost 80, maybe like 78 or 79? (Clarified to how old my maternal grandfather lived to be.)
Your Avatar: Your maternal grandmother’s health?

Question
11/02/21 7:26 PM EDT
Tina Jones: Nana was 73 when she died of a stroke about five years ago. I think she had high blood pressure and cholesterol, too.
Your Avatar: Does your brother have health issues?

Question
11/02/21 7:27 PM EDT
Tina Jones: No, I don’t think so. He’s a little big, maybe.
Your Avatar: Does your sister have health issues?

Question
11/02/21 7:27 PM EDT
Tina Jones: She’s pretty healthy. She has asthma but almost never has attacks.
Your Avatar: Does obesity run in your family?

Question
11/02/21 7:28 PM EDT
Tina Jones: 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.
Your Avatar: Any family history of thyroid problems?

Question
11/02/21 7:29 PM EDT
Tina Jones: No, I don’t think so.
Your Avatar: Any headaches?

Question
11/02/21 7:29 PM EDT
Tina Jones: Yeah, I get them a lot when I’m studying.
Your Avatar: Any loss of consciousness?

Question
11/02/21 7:30 PM EDT
Tina Jones: No.
Your Avatar: Any memory loss?

Question
11/02/21 7:30 PM EDT
Tina Jones: No. I mean, sometimes, I freeze up during a test, but that’s everybody, right? I have a good head for names and directions, stuff like that.
Your Avatar: Any abnormal or excess hair? (Clarified to if I have skin abnormalities.)

Question
11/02/21 7:30 PM EDT
Tina Jones: Well . . . I guess I was noticing the other day that the skin around my neck is looking weird. The skin is getting darker. And my skin’s breaking out, but that’s how it is. (Clarified to if I have skin abnormalities.)
Your Avatar: Any stomach upsets?

Exam Action
11/02/21 7:31 PM EDT
Your Avatar: Measured wound: 2 cm x 1.5 cm, 2.5 mm deep

Exam Action
11/02/21 7:31 PM EDT
Your Avatar: Swabbed wound and sent to lab for C & S

Exam Action
11/02/21 7:31 PM EDT
Your Avatar: Cleansed and irrigated wound with normal saline and applied dry sterile dressing.

Exam Action
11/02/21 7:31 PM EDT
Your Avatar: Measured wound: 2 cm x 1.5 cm, 2.5 mm deep

Exam Action
11/03/21 4:04 AM EDT
Your Avatar: Swabbed wound and sent to lab for C & S

Exam Action
11/03/21 4:04 AM EDT
Your Avatar: Cleansed and irrigated wound with normal saline and applied dry sterile dressing.

Exam Action
11/03/21 4:04 AM EDT