TINA JONES SHADOW HEALTH MEDICAL HISTORY TRANSCRIPTION ON DIAGNOSIS -HEALTH ASSESSMENT HEALTH REPORT

Shadow Health Medical History Transcription On Diagnosis Main Problem a) Physical Examination Nurse: Greetings? My name is Nurse Tina, what is yours? Patient: My name is Ms. Jones Nurse: How old are you? Patient: I am 57 Nurse: Where do you live? Patient: Wisconsin Nurse: Ok. Do you live alone or you have siblings and children? Patient: I am blessed with two kids and I live with my mom who is old at 70 and my younger sister who is 47 b) Health history Nurse: So what is the condition that has led you here? Jones: I have constant headaches that are not stopping and I sweat regularly even when I am doing nothing. Nurse: How long have you had the headaches? Jones: For 2 weeks now? Nurse: Is it the first time you have had this problem and how often does it occur? Jones: It’s not the first time, but this time it is very severe and it occurs when I have just thought of something or when I am about to eat? Nurse: How intense is it and what triggers it often? Jones: It very sharp and its triggered mostly when am stressed about something. Nurse: Do you have any other symptoms? Jones: Yes, I feel cold sometimes but mostly I sweat and general body pains. Past Medical History Nurse: Have you had any hospitalization regarding the condition in the past? Jones: Not really? I was just given some medications and the condition disappeared when last I visited a doctor. Nurse: Did you have any screening tests or exams. Jones: No. Allergies: Nurse: Do you have any allergies to Aspirin and penicillin? Ms. Jones; I have no reaction to the stated drugs. Nurse; Do you have any reaction to cold and any foods? Ms. Jones: I have no medical or environmental reaction to any types of foods Current Medications Nurse: What type of drugs have you been taking since the problem began? Ms. Jones: I was prescribed metformin but the condition seems to persist. Nurse: Any other drug apart from the tablet mentioned? Ms. Jones: Yes, I was given painkillers, Ibrufen to be precise to help cool the fever. Nurse: Other than the drugs, did the doctor mention anything you should do to control the blood pressure? Ms. Jones: The doctor advised that I take enough water and get enough sleep if not possible use sleep tablets but not regularly just to make sure that I am at ease.