Comprehensive Assessment, Tina Jones shadow health Transcript
Hi there. I’m going to talk with you and check how you’re doing.
Table of Contents
Greeting
April 29th, 2023, 5:28 AM EDT
Hey.
What’s your name?
Asking for Name
April 29th, 2023, 6:23 AM EDT
My name is Tina Jones.
When were you born?
Asking for Date of Birth
April 29th, 2023, 6:23 AM EDT
February 17th.
How many years have you lived?
Asking for Age
April 29th, 2023, 6:24 AM EDT
I’m 28 years old.
What brought you to the clinic today?
Asking Reason for Visit
April 29th, 2023, 6:24 AM EDT
I’m here because my new job needs me to have a recent physical for the health insurance.
Do you have any health issues now?
Asking about Current Health Problems
April 29th, 2023, 6:25 AM EDT
Nothing specific today. I have asthma and diabetes, but they’re under control. I’m taking care of my health.
What’s your new job?
Asking about New Job
April 29th, 2023, 6:27 AM EDT
I’m starting as an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. I’ll help an experienced accountant with clients, then get more responsibility later.
That’s wonderful.
April 29th, 2023, 6:27 AM EDT
Okay, thanks.
When did you last get a physical exam?
Asking about Last Physical Examination
April 29th, 2023, 6:28 AM EDT
Let me remember. I had two appointments this year. About five months ago, I had a check-up here. Then, I saw a gynecologist for a pap smear a few weeks later.
What did your gynecologist say?
Asking about Gynecologist Visit
April 29th, 2023, 6:29 AM EDT
She said mostly good things, except I have PCOS. She started me on birth control, and it’s helping.
How often do you take birth control?
Asking about Birth Control Usage
April 29th, 2023, 6:30 AM EDT
I take it every morning with breakfast.
What’s the name of your birth control?
Asking about Birth Control Name
April 29th, 2023, 6:31 AM EDT
It’s drospirenone / ethinyl estradiol.
Has your menstrual cycle improved with it?
Asking about Menstrual Cycle
April 29th, 2023, 6:32 AM EDT
Yes, now I get my period every month.
That’s good.
April 29th, 2023, 6:33 AM EDT
Thank you.
How long have you had asthma?
Asking about Asthma Duration
April 29th, 2023, 6:33 AM EDT
Since I was a child.
When did you find out about it?
Asking about Asthma Diagnosis Age
April 29th, 2023, 6:34 AM EDT
Around two and a half years old. I had many asthma attacks then.
I’m sorry to hear that.
April 29th, 2023, 6:36 AM EDT
Thank you.
How do you handle your asthma?
Asking about Asthma Management
April 29th, 2023, 6:36 AM EDT
I avoid triggers and use my inhaler when needed.
What triggers your asthma?
Asking about Asthma Triggers
April 29th, 2023, 6:36 AM EDT
Cats are the worst, also dust and running upstairs. But it’s been years since I had a severe attack.
What happens around dust?
Asking about Dust Reaction
April 29th, 2023, 6:37 AM EDT
I used to get allergies and asthma from dust, but my daily inhaler stopped that.
Which inhaler do you use?
Asking about Inhaler Type
April 29th, 2023, 6:38 AM EDT
It’s Flovent.
How often do you use it?
Asking about Inhaler Usage Frequency
April 29th, 2023, 6:38 AM EDT
Twice daily.
When did you last use it?
Asking about Last Inhaler Usage
April 29th, 2023, 6:38 AM EDT
This morning. I use it twice a day. My albuterol… I’ve barely needed it since I had asthma issues.
How much albuterol do you use?
Asking about Albuterol Dosage
April 29th, 2023, 6:53 AM EDT
Two puffs when necessary, but rarely.
How many milligrams of metformin do you take?
Asking about Metformin Dosage
April 29th, 2023, 6:53 AM EDT
850 mg, twice a day.
When did you last take it?
Asking about Last Metformin Intake
April 29th, 2023, 6:53 AM EDT
This morning.
Adhering to the prescribed dose is commendable.
April 29th, 2023, 6:54 AM EDT
Thank you for telling me.
When did you learn about your asthma?
Asking about Asthma Diagnosis
April 29th, 2023, 6:55 AM EDT
Around two and a half years old. I had many asthma attacks then.
Are you on any other medications?
Asking about Other Medications
April 29th, 2023, 6:55 AM EDT
Yes, I take several now. I’m on birth control, metformin, and my daily inhaler. I also have albuterol, but I barely use it.
That’s good news.
April 29th, 2023, 6:55 AM EDT
Thank you.
Do you think your asthma is under control?
Asking about Asthma Control
April 29th, 2023, 6:56 AM EDT
Yes, since my daily inhaler and tracking my peak flow, I feel much better.
That’s fantastic to hear.
April 29th, 2023, 6:57 AM EDT
Thank you.
How often do you measure your peak flow?
Asking about Peak Flow Monitoring Frequency
April 29th, 2023, 6:57 AM EDT
I use it morning and night and record it.
Do you check it regularly?
Asking about Peak Flow Monitoring Consistency
April 29th, 2023, 6:58 AM EDT
Yes, morning and night, and I track it.
Using it as prescribed is advisable.
April 29th, 2023, 6:58 AM EDT
Thank you for telling me.
When was your last asthma attack?
Asking about Last Asthma Attack
April 29th, 2023, 6:59 AM EDT
I haven’t had problems since using the daily inhaler. Maybe three months ago was the last time I had trouble.
Do you feel healthy
now?
Asking about Current Health
April 29th, 2023, 7:01 AM EDT
My health is much better now. My diabetes is managed, I’m eating better, and less stressed.
Any dizziness?
Inquiring about Dizziness
April 29th, 2023, 7:36 AM EDT
I haven’t felt dizzy lately.
Performed pulse oximetry
Action
April 29th, 2023, 7:37 AM EDT
Performed spirometry
Action
April 29th, 2023, 7:37 AM EDT
Inspected scalp
Action
April 29th, 2023, 7:38 AM EDT
Inspected scalp
Action
April 29th, 2023, 7:38 AM EDT
Inspected hair on scalp
Action
April 29th, 2023, 7:38 AM EDT
Inspected right eyebrow and orbital area
Action
April 29th, 2023, 7:39 AM EDT
Inspected left eyebrow and orbital area
Action
April 29th, 2023, 7:40 AM EDT
Inspected mouth: Oral mucosa moist
Action
April 29th, 2023, 7:42 AM EDT
Inspect mouth
Action
April 29th, 2023, 7:42 AM EDT
Inspect tongue
Action
April 29th, 2023, 7:42 AM EDT
Inspected mouth: Oral mucosa moist
Action
April 29th, 2023, 7:43 AM EDT
Inspect mouth
Action
April 29th, 2023, 7:43 AM EDT
Inspect tongue
Action
April 29th, 2023, 7:43 AM EDT
Inspected mouth: Oral mucosa moist
Action
April 29th, 2023, 7:44 AM EDT
Inspect mouth
Action
April 29th, 2023, 7:44 AM EDT
Inspect tongue
Action
April 29th, 2023, 7:44 AM EDT
Inspected mouth: Oral mucosa moist
Action
April 29th, 2023, 7:44 AM EDT
Inspect mouth
Action
April 29th, 2023, 7:44 AM EDT
Inspect tongue
Action
April 29th, 2023, 7:44 AM EDT
Inspected mouth: Oral mucosa moist
Action
April 29th, 2023, 7:44 AM EDT
Inspect mouth
Action
April 29th, 2023, 7:44 AM EDT
Inspect tongue
Action
April 29th, 2023, 7:44 AM EDT
Inspected mouth: Oral mucosa moist
Action
April 29th, 2023, 7:44 AM EDT
Inspect mouth
Action
April 29th, 2023, 7:44 AM EDT
Inspect tongue
Action
April 29th, 2023, 7:44 AM EDT
Inspected mouth: Oral mucosa moist
Action
April 29th, 2023, 7:45 AM EDT
Inspect mouth
Action
April 29th, 2023, 7:45 AM EDT
Inspect tongue
Action
April 29th, 2023, 7:45 AM EDT
Inspected mouth: Oral mucosa moist
Action
April 29th, 2023, 7:45 AM EDT
Inspect mouth
Action
April 29th, 2023, 7:45 AM EDT
Inspect tongue
Action
April 29th, 2023, 7:45 AM EDT
Inspected mouth: Oral mucosa moist
Action
April 29th, 2023, 7:45 AM EDT
Inspect mouth
Action
April 29th, 2023, 7:45 AM EDT
Inspect tongue
Action
April 29th, 2023, 7:45 AM EDT
Inspected mouth: Oral mucosa moist
Action
April 29th, 2023, 7:45 AM EDT
Inspect mouth
Action
April 29th, 2023, 7:45 AM EDT
Inspect tongue
Action
April 29th, 2023, 7:45 AM EDT
Inspected mouth: Oral mucosa moist
Action
April 29th, 2023, 7:45 AM EDT
Inspect mouth
Action
April 29th, 2023, 7:45 AM EDT
Inspect tongue
Action
April 29th, 2023, 7:45 AM EDT
Inspected mouth: Oral mucosa moist
Action
April 29th, 2023, 7:45 AM EDT
Inspect mouth
Action
April 29th, 2023, 7:45 AM EDT
Inspect tongue
Action
April 29th, 2023, 7:45 AM EDT
Inspected mouth: Oral mucosa moist
Action
April 29th, 2023, 7:45 AM EDT
Inspect mouth
Action
April 29th, 2023, 7:45 AM EDT
Inspect tongue
Action
April 29th, 2023, 7:45 AM EDT
Inspected mouth: Oral mucosa moist
Action
April 29th, 2023, 7:45 AM EDT
Inspect mouth
Action
April 29th, 2023, 7:45 AM EDT
Inspect tongue
Action
April 29th, 2023, 7:45 AM EDT
Inspected mouth: Oral mucosa moist
Action
April 29th, 2023, 7:45 AM EDT
Inspect mouth
Action
April 29th, 2023, 7:45 AM EDT
Inspect tongue
Action
April 29th, 2023, 7:46 AM EDT
Inspected mouth: Oral mucosa moist
Action
April 29th, 2023, 7:46 AM EDT
Inspect mouth
Action
April 29th, 2023, 7:46 AM EDT
Inspect tongue
Action
April 29th, 2023, 7:46 AM EDT
Inspected mouth: Oral mucosa moist
Action
April 29th, 2023, 7:46 AM EDT
Inspect mouth
Action
April 29th, 2023, 7:46 AM EDT
Inspect tongue
Action
April 29th, 2023, 7:46 AM EDT
Inspected mouth: Oral mucosa moist
Action
April 29th, 2023, 7:46 AM EDT
Inspect mouth
Action
April 29th, 2023, 7:46 AM EDT
Inspect tongue
Action
April 29th, 2023, 7:46 AM EDT
Inspected mouth: Oral mucosa moist
Action
April 29th, 2023, 7:46 AM EDT
Inspect mouth
Action
April 29th, 2023, 7:46 AM EDT
Inspect
Integumentary Felipe Barbosa Sick Visit ShadowHealth Objective Data
Comprehensive Assessment, Tina Jones shadow health Transcript
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Hello. I will interview and examine you
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Greet |
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Hey.
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What is your name?
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Tina Jones.
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Your date of birth?
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February 17th.
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How old are you?
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I’m 28. [AUDIO COMING SOON]
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What brought you to the clinic today?
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I came in because I’m required to have a recent physical exam for the health insurance at my new job.
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Do you have any current health problems?
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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.
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What is your new job?
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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!
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Thats great.
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Alright, thanks.
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When was your last physical examination?
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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.
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What did your gynecologist say?
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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.
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How often do you take birth control?
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I take it every morning, with breakfast.
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What was the name of the birth control? (Clarified to What is the name of your birth control?.)
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It’s drospirenone / ethinyl estradiol. [AUDIO COMING SOON] (Clarified to what the name of my birth control is.)
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Has your menstrual cycle improved since taking drospirenone?
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Question |
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Now that I’m on the pill I’m getting my period every month.
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That great
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Empathize |
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Thanks.
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How long have you had asthma?
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I’ve had asthma a long time. . . since I was really little.
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What age were you diagnosed with asthma?
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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.
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Am sorry about that experience
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Empathize |
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Thanks.
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How do you manage your asthma
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Question |
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I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler.
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What are your triggers for asthma?
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Question |
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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.
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What happens when you are around dust?
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Question |
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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.
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What daily inhaler do you use?
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Question |
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It’s Flovent.
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How often do you use flovent?
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Question |
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Twice a day.
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When did you most recently use flovent inhaler?
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Question |
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I use my Flovent inhaler two times a day.
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When did you last use inhaler
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Question |
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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.
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How much albuterol do you use?
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Question |
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I do two puffs of the albuterol inhaler when I need it, but that rarely happens. [AUDIO COMING SOON]
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How many milligrams of metformin did you take?
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Question |
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It’s 850 mg. And I take one pill, twice a day.
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When did you last take metformin?
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Question |
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I took it this morning.
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It is good to adhere to the prescribed dose
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Educate |
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Thanks for telling me.
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When were you diagnosed with asthma?
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Question |
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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.
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Are you taking any other medication?
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Question |
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Um, I take a lot now, so let me list everything I take . . . I’m taking drospirenone / ethinyl estradiol for birth control, metformin, and my daily inhaler. And I have the albuterol inhaler that I don’t seem to need anymore. [AUDIO COMING SOON]
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Thats good to hear
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Empathize |
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Thanks.
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Do you feel like your asthma is well controlled?
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Question |
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Yeah, ever since I started using my daily inhaler and keeping track of my peak flow I’ve felt much more in control of my breathing.
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Great am happy to hear that
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Empathize |
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Thanks.
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How often do you use your peak flow meter?
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Question |
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Yeah, I have a peak flow meter at home, and I use it in the morning and at night and keep track of it on a chart.
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Do you check your peak flow regularly?
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Question |
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Yeah, I have a peak flow meter at home, and I use it in the morning and at night and keep track of it on a chart.
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It is often advisable to use it as often as prescribed
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Educate |
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Thanks for telling me.
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When was your last asthma attack?
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I haven’t had any asthma problems, really, ever since I started on the daily inhaler. My last breathing problem was three months ago, probably, and it had been months before that.
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Do you feel you are in good health now?
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All of my health stuff is a lot better now. I feel like my diabetes is in control, I’m in better shape. . . I’m eating healthier. I’m less stressed. Things are going really well.
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Any dizziness?
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Question |
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I haven’t been getting dizzy at all.
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Performed pulse oximetry
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Exam Action |
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Performed spirometry
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Exam Action |
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Inspected scalp
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Exam Action |
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Inspected scalp
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Exam Action |
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Inspected hair on scalp
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Exam Action |
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Inspected right eyebrow and orbital area
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Exam Action |
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Inspected left eyebrow and orbital area
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Exam Action |
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Inspected mouth: Oral mucosa moist
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Exam Action |
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Inspect mouth
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Exam Action |
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Inspect tongue
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Exam Action |
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Inspected mouth: Oral mucosa moist
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Exam Action |
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Inspect mouth
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Exam Action |
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Inspect tongue
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Exam Action |
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Inspected mouth: Oral mucosa moist
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Exam Action |
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Inspect mouth
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Exam Action |
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Inspect tongue
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Exam Action |
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Inspected mouth: Oral mucosa moist
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Exam Action |
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Inspect mouth
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Exam Action |
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Inspect tongue
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Exam Action |
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Inspected mouth: Oral mucosa moist
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Exam Action |
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Inspect mouth
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Exam Action |
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Inspect tongue
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Exam Action |
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Inspected mouth: Oral mucosa moist
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Exam Action |
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Inspect mouth
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Exam Action |
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Inspect tongue
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Exam Action |
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Inspected mouth: Oral mucosa moist
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Exam Action |
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Inspect mouth
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Exam Action |
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Inspect tongue
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Exam Action |
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Inspected mouth: Oral mucosa moist
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Exam Action |
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Inspect mouth
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Exam Action |
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Inspect tongue
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Exam Action |
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Inspected mouth: Oral mucosa moist
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Exam Action |
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Inspect mouth
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Exam Action |
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Inspect tongue
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Exam Action |
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Inspected mouth: Oral mucosa moist
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Exam Action |
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Inspect mouth
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Exam Action |
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Inspect tongue
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Exam Action |
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Inspected mouth: Oral mucosa moist
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Exam Action |
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Inspect mouth
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Exam Action |
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Inspect tongue
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Exam Action |
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Inspected mouth: Oral mucosa moist
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Exam Action |
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Inspect mouth
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Exam Action |
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Tested gag reflex
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Exam Action |
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Inspected upper eyelids
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Exam Action |
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Inspected lower eyelids
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Exam Action |
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Inspected right outer ear
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Exam Action |
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Inspect ears
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Exam Action |
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Inspected left outer ear
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Exam Action |
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Inspect ears
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Exam Action |
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Inspected right outer ear
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Exam Action |
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Palpated scalp: no masses
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Exam Action |
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Palpate neck lymph nodes
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Exam Action |
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Palpated supraclavicular lymph nodes: no palpable nodes
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Exam Action |
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Palpated thyroid: smooth without nodules, no goiter
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Exam Action |
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Palpated jaw: no clicks, full ROM
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Exam Action |
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Palpated upper sinus: no pain reported
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Exam Action |
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Palpated lower sinus: no pain reported
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Exam Action |
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Palpated axillary lymph nodes: no palpable nodes
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Exam Action |
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Tested left pupillary light reflex
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Exam Action |
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Tested right pupillary light reflex
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Exam Action |
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Examined fundus of right eye
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Exam Action |
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Examined fundus of left eye
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Exam Action |
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Performed otoscopic exam of right ear
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Exam Action |
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Performed otoscopic exam of left ear
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Exam Action |
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Inspected right naris
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Exam Action |
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Inspected left naris
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Exam Action |
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Follow my finger with just your eye
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Question |
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Ok.
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Tested extraocular movement
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Exam Action |
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Tested convergence
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Exam Action |
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F P
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F P
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Tell me when you can no longer see my fingers
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Question |
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Ok, I will.
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Tested peripheral vision
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Exam Action |
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Now.
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F.
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Question |
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F.
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Eight
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Question |
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Eight.
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W.
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Question |
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W.
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Performed whisper test on right ear
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Exam Action |
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Four
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Question |
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Four.
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R.
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Question |
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R.
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Nine.
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Question |
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Nine.
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Performed whisper test on left ear
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Exam Action |
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Inspected left abdomen
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Exam Action |
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Inspected anterior abdomen
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Exam Action |
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Inspected right abdomen
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Exam Action |
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Inspected abdomen
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Exam Action |
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Palpated abdominal right upper quadrant with light pressure: soft, no masses
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Palpated abdominal left upper quadrant with light pressure: soft, no masses
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Palpated abdominal right lower quadrant with light pressure: soft, no masses
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Exam Action |
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Palpated abdominal left lower quadrant with light pressure: soft, no masses
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Exam Action |
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Liver: palpable 1 cm below right costal margin
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Exam Action |
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Palpated for spleen: not palpable
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Exam Action |
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Palpated for right kidney: not palpable, no masses
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Exam Action |
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Palpated for left kidney: not palpable, no masses
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Exam Action |
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Palpated abdominal right upper quadrant with deep pressure: no masses
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Exam Action |
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Palpated abdominal left upper quadrant with deep pressure: no masses
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Exam Action |
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Palpated abdominal right lower quadrant: with deep pressure: no masses
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Exam Action |
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Palpated abdominal left lower quadrant with deep pressure: no masses
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Exam Action |
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Percussed liver span: 7 cm MCL on percussion
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Exam Action |
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Assessed CVA tenderness on left: none reported
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Assessed CVA tenderness on right: none reported
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Exam Action |
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Percussed for spleen: no dullness
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Exam Action |
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Percussed for spleen: no dullness
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Exam Action |
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Percussed left upper quadrant: tympanic
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Exam Action |
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Percussed left lower quadrant: tympanic
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Exam Action |
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Percussed right upper quadrant: tympanic
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Exam Action |
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Percussed right lower quadrant: tympanic
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Exam Action |
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Auscultated abdominal right upper quadrant
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Exam Action |
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Auscultated abdominal left upper quadrant
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Exam Action |
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Auscultated abdominal right lower quadrant
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Exam Action |
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Auscultated abdominal left lower quadrant
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Exam Action |
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Inspected left leg: no edema
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Exam Action |
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Inspected right leg: no edema
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Exam Action |
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Inspected anterior chest wall
|
Exam Action |
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Inspected left chest
|
Exam Action |
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Inspected anterior chest wall
|
Exam Action |
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Palpated right brachial pulse: 2+
|
Exam Action |
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Palpated right radial pulse: 2+
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Exam Action |
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Palpated brachial pulse, left: 2+
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Exam Action |
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Palpated left radial pulse: 2+
|
Exam Action |
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Palpated anterior chest: PMI nondisplaced, no heaves or lifts
|
Exam Action |
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Palpated right femoral pulse: 2+
|
Exam Action |
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Palpated left femoral pulse: 2+
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Exam Action |
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Palpated right popliteal pulse: 2+
|
Exam Action |
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Palpated left popliteal pulse: 2+
|
Exam Action |
|
Palpated right tibial pulse: 2+
|
Exam Action |
|
Palpated left tibial pulse: 2+
|
Exam Action |
|
Palpated right dorsalis pedis pulse: 2+
|
Exam Action |
|
Palpated left dorsalis pedis pulse: 2+
|
Exam Action |
|
Palpated right carotid: 2+, no thrill
|
Exam Action |
|
Palpated right carotid: 2+, no thrill
|
Exam Action |
|
Palpated left carotid: 2+, no thrill
|
Exam Action |
|
Auscultated right carotid artery: no bruit
|
Exam Action |
|
Auscultated left carotid artery: no bruit
|
Exam Action |
|
Auscultated aorta: no bruit
|
Exam Action |
|
Auscultated right renal artery: no bruit
|
Exam Action |
|
Auscultated left renal artery: no bruit
|
Exam Action |
|
Auscultated right iliac artery: no bruit
|
Exam Action |
|
Auscultated left iliac artery: no bruit
|
Exam Action |
|
Auscultated right femoral artery: no bruit
|
Exam Action |
|
Auscultated left femoral artery: no bruit
|
Exam Action |
|
Auscultated aortic area with the bell
|
Exam Action |
|
Auscultated pulmonic area with the bell
|
Exam Action |
|
Auscultated Erb’s point with the bell
|
Exam Action |
|
Auscultated tricuspid area with the bell
|
Exam Action |
|
Auscultated mitral area with the bell
|
Exam Action |
|
Auscultated mitral area with the diaphragm
|
Exam Action |
|
Auscultated aortic area with the diaphragm
|
Exam Action |
|
Auscultated pulmonic area with the diaphragm
|
Exam Action |
|
Auscultated Erb’s point with the diaphragm
|
Exam Action |
|
Auscultated tricuspid area with the diaphragm
|
Exam Action |
|
Auscultated mitral area with the diaphragm
|
Exam Action |
|
Tested capillary refill
|
Exam Action |
|
Palpate nails
|
Exam Action |
|
Tested capillary refill
|
Exam Action |
|
Palpate nails
|
Exam Action |
|
Tested capillary refill
|
Exam Action |
|
Palpate nails
|
Exam Action |
|
Tested capillary refill
|
Exam Action |
|
Palpate nails
|
Exam Action |
|
Tested capillary refill
|
Exam Action |
|
Palpate nails
|
Exam Action |
|
Inspected anterior chest wall
|
Exam Action |
|
Inspected left chest
|
Exam Action |
|
Inspected anterior chest wall
|
Exam Action |
|
Inspected left chest
|
Exam Action |
|
Tested capillary refill
|
Exam Action |
|
Palpate nails
|
Exam Action |
|
Tested capillary refill
|
Exam Action |
|
Palpate nails
|
Exam Action |
|
Inspected posterior chest
|
Exam Action |
|
Inspected posterior chest wall
|
Exam Action |
|
Inspected anterior chest wall
|
Exam Action |
|
Inspected left chest
|
Exam Action |
|
Palpated fremitus: equal bilaterally in upper posterior chest wall
|
Exam Action |
|
Ninety-nine.
|
|
|
Palpated fremitus: equal bilaterally in middle posterior chest wall
|
Exam Action |
|
Ninety-nine.
|
|
|
Palpated fremitus: equal bilaterally in lower posterior chest wall
|
Exam Action |
|
Ninety-nine.
|
|
|
Palpated thoracic expansion: symmetric
|
Exam Action |
|
Palpated fremitus: equal bilaterally in upper anterior chest wall
|
Exam Action |
|
Ninety-nine.
|
|
|
Palpated fremitus: equal bilaterally in lower anterior chest wall
|
Exam Action |
|
Ninety-nine.
|
|
|
Percussed left upper posterior chest wall: resonant
|
Exam Action |
|
Percussed right upper posterior chest wall: resonant
|
Exam Action |
|
Percussed left middle posterior chest wall: resonant
|
Exam Action |
|
Percussed right middle posterior chest wall: resonant
|
Exam Action |
|
Percussed left lower posterior chest wall: resonant
|
Exam Action |
|
Percussed right lower posterior chest wall: resonant
|
Exam Action |
|
Percussed left lower posterior chest wall: resonant
|
Exam Action |
|
Percussed left lower posterior chest wall: resonant
|
Exam Action |
|
Percussed right lower posterior chest wall: resonant
|
Exam Action |
|
Percussed right lower posterior chest wall: resonant
|
Exam Action |
|
Percussed right upper anterior chest wall: resonant
|
Exam Action |
|
Percussed left upper anterior chest wall: resonant
|
Exam Action |
|
Percussed right middle anterior chest wall: resonant
|
Exam Action |
|
Percussed left middle anterior chest wall: resonant
|
Exam Action |
|
Percussed right lower anterior chest wall: resonant
|
Exam Action |
|
Percussed left lower anterior chest wall: resonant
|
Exam Action |
|
Auscultated right upper anterior chest wall
|
Exam Action |
|
Auscultated left upper anterior chest wall
|
Exam Action |
|
Auscultated right middle anterior chest wall
|
Exam Action |
|
Auscultated left middle anterior chest wall
|
Exam Action |
|
Auscultated right lower anterior chest wall
|
Exam Action |
|
Auscultated left lower anterior chest wall
|
Exam Action |
|
Auscultated voice sounds in left lower anterior lungs
|
Exam Action |
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Auscultated voice sounds in right upper anterior lungs
|
Exam Action |
|
Ninety-nine.
|
|
|
Auscultated voice sounds in left upper anterior lungs
|
Exam Action |
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Auscultated voice sounds in right middle anterior lungs
|
Exam Action |
|
Ninety-nine.
|
|
|
Auscultated voice sounds in left middle anterior lungs
|
Exam Action |
|
Ninety-nine.
|
|
|
Auscultated voice sounds in right lower anterior lungs
|
Exam Action |
|
Ninety-nine.
|
|
|
Auscultated voice sounds in left lower anterior lungs
|
Exam Action |
|
Ninety-nine.
|
|
|
Ninety-nine.
|
|
|
Auscultated upper left posterior chest wall
|
Exam Action |
|
Auscultated upper right posterior chest wall
|
Exam Action |
|
Auscultated middle left posterior chest wall
|
Exam Action |
|
Auscultated middle right posterior chest wall
|
Exam Action |
|
Auscultated lower left posterior chest wall
|
Exam Action |
|
Auscultated lower right posterior chest wall
|
Exam Action |
|
Auscultated lower left posterior chest wall
|
Exam Action |
|
Auscultated lower left posterior chest wall
|
Exam Action |
|
Auscultated lower right posterior chest wall
|
Exam Action |
|
Auscultated lower right posterior chest wall
|
Exam Action |
|
Performed spirometry
|
Exam Action |
|
Run your right foot down your shin
|
Question |
|
Sure.
|
|
|
Tested right heel moving to shin
|
Exam Action |
|
Run your left foot down your right shin
|
Question |
|
Ok.
|
|
|
Tested left heel moving to shin
|
Exam Action |
|
Close your eyes and touch your fingers to your nose
|
Question |
|
I can do that.
|
|
|
Tested left index finger to nose
|
Exam Action |
|
Tested right index finger to nose
|
Exam Action |
|
What is your name and date of birth?
|
Question |
|
My name is Tina Jones, and I was born on February 17th.
|
|
|
Discovered orientation to person
|
Exam Action |
|
What building are you in now?
|
Question |
|
I’m at the doctor’s office. . . it’s Shadow Health General Clinic.
|
|
|
Discovered orientation to place
|
Exam Action |
|
What is the date and year?
|
Question |
|
Um, today’s date is . . . [Ms. Jones reports correct date and year].
|
|
|
Confirmed situation orientation
|
Exam Action |
|
Discovered orientation to time
|
Exam Action |
|
Place your hands on your knees and turn them over
|
Question |
|
Ok, like this?
|
|
|
Tested rapid alternating hand movements
|
Exam Action |
|
Close your eyes and tell me if the touch is sharp, dull or soft
|
Question |
|
Ok.
|
|
|
Tested right leg proximal dull pain
|
Exam Action |
|
Dull.
|
|
|
Tested right leg distal dull pain
|
Exam Action |
|
Dull.
|
|
|
Tested left leg proximal dull pain
|
Exam Action |
|
Dull.
|
|
|
Tested left leg distal dull pain
|
Exam Action |
|
Dull.
|
|
|
Tested right leg proximal light touch
|
Exam Action |
|
Soft.
|
|
|
Tested right leg proximal light touch
|
Exam Action |
|
Soft.
|
|
|
Tested right leg distal light touch
|
Exam Action |
|
Soft.
|
|
|
Tested left leg proximal light touch
|
Exam Action |
|
Soft.
|
|
|
Tested left leg distal light touch
|
Exam Action |
|
Soft.
|
|
|
close your eyes and tell me if the touch is sharp, dull or soft
|
Question |
|
Ok.
|
|
|
Tested right leg proximal sharp pain
|
Exam Action |
|
Sharp.
|
|
|
Tested right leg distal sharp pain
|
Exam Action |
|
Sharp.
|
|
|
Tested left leg proximal sharp pain
|
Exam Action |
|
Sharp.
|
|
|
Tested left leg distal sharp pain
|
Exam Action |
|
Sharp.
|
|
|
Close your eyes and tell me if the touch is sharp, dull or soft
|
Question |
|
Ok.
|
|
|
Tested right arm proximal dull pain
|
Exam Action |
|
Dull.
|
|
|
Tested right arm distal dull pain
|
Exam Action |
