HL HPI
What is your full name & date of birth?
Renee/Rob Cote 3/22/19xx
Tell me about your PMHx; have you been diagnosed with anything?
Child - allergies to pollen/ragweed - sneeze, cough, & sinus congestion problems; frequent ear infections & sore throats
Adult - chronic bronchitis every year & arthritis in multiple joints
What is the SP Arrival time?
7:15am
What brings you in today?
"I am so tired and I can't seem to get my breath."
Are you in a relationship?
Spouse, no family or marital discord.
"I am having some trouble with my hearing."
When was your last doctor's appointment and what was it for?
Last physical exam was 1 yr ago for wellness check & flu shot.
What type of SP feedback?
5 minutes verbal SP feedback only (no CCG)
Tell me more about what brings you in today?
It started 10 days ago with a clear runny nose & scratchy throat, then mid-chest tightness.
What is your diet like?
Normal; eat out occasionally but mostly self or spouse cooks at home.
What does it feel like?
No pain, I just can't hear. Speech sounds garbled, especially when there is background noise.
Have you had any surgeries?
Tonsillectomy as a child.
Name 3 areas for 2nd year verbal feedback.
Summary with opportunity for pt to change/add info.
All ICEE questions asked/discussed - chance to add
Explained any jargon.
Etc.
Have you found anything that makes it feel better?
OTC Primatene Mist inhaler, Loratadine (Claritin) & Halls Throat lozenges have not helped much.
Sitting in front of a fan helps a little.
Do you currently use any alcohol?
Occasionally a glass of wine or beer, 1-2 per month.
Do you have any Associated Symptoms?
I used to have ringing in the R ear on/off, then daily for a couple months. Then, the ringing started in the L ear too, but it has mostly subsided. I'm not sure, but I have also been having a little dizziness if I get up to stand or walk too fast.
Any prescribed medications?
None.
An SP question to ask students during verbal feedback.
Did you have any goals for this session?
If you could do anything differently, what would you change?
How did you feel the communication went?
Can you rate the severity of your symptoms on a scale of 0-10?
About 10 days ago the runny nose & scratchy throat were about a 2/10. Over the past week, symptoms have gotten worse 6/10. Aching in the ribs - 3/10.
What do you do for work?
Postal worker with walking delivery route.
What Concerns do you have?
I'm concerned about losing relationships with family and friends about work. My family & friends say that I don't communicate well with them, don't listen to them, and that I talk too loud too.
Any OTC meds/herbs/vitamins?
OTC Loratadine 10 mg daily during the spring, summer & fall allergies
OTC Ibuprofen 200 mg 2-4 tablets as needed for joint or back pain about every 8 hours depending on the day.
What is your favorite summer activity?
per SP
Do you have any unrelated signs or symptoms?
Not sure. Mid back aches and sore ribs; decreased appetite.
What interests or activities do you do?
Boating, gardening.