Comprehensive Assessment, Tina Jones shadow health Transcript

Comprehensive Assessment, Tina Jones shadow health Transcript

Hi there. I’m going to talk with you and check how you’re doing.

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

Your Avatar.
Hello. I will interview and examine you

Greet
04/29/23 5:28 AM EDT

Tina Jones.
Hey.
Your Avatar.
What is your name?

Question
04/29/23 6:23 AM EDT

Tina Jones.
Tina Jones.
Your Avatar.
Your date of birth?

Question
04/29/23 6:23 AM EDT

Tina Jones.
February 17th.
Your Avatar.
How old are you?

Question
04/29/23 6:24 AM EDT

Tina Jones.
I’m 28. [AUDIO COMING SOON]
Your Avatar.
What brought you to the clinic today?

Question
04/29/23 6:24 AM EDT

Tina Jones.
I came in because I’m required to have a recent physical exam for the health insurance at my new job.
Your Avatar.
Do you have any current health problems?

Question
04/29/23 6:25 AM EDT

Tina Jones.
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.
Your Avatar.
What is your new job?

Question
04/29/23 6:27 AM EDT

Tina Jones.
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!
Your Avatar.
Thats great.

Question
04/29/23 6:27 AM EDT

Tina Jones.
Alright, thanks.
Your Avatar.
When was your last physical examination?

Question
04/29/23 6:28 AM EDT

Tina Jones.
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.
Your Avatar.
What did your gynecologist say?

Question
04/29/23 6:29 AM EDT

Tina Jones.
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.
Your Avatar.
How often do you take birth control?

Question
04/29/23 6:30 AM EDT

Tina Jones.
I take it every morning, with breakfast.
Your Avatar.
What was the name of the birth control? (Clarified to What is the name of your birth control?.)

Question
04/29/23 6:31 AM EDT

Tina Jones.
It’s drospirenone / ethinyl estradiol. [AUDIO COMING SOON] (Clarified to what the name of my birth control is.)
Your Avatar.
Has your menstrual cycle improved since taking drospirenone?

Question
04/29/23 6:32 AM EDT

Tina Jones.
Now that I’m on the pill I’m getting my period every month.
Your Avatar.
That great

Empathize
04/29/23 6:33 AM EDT

Tina Jones.
Thanks.
Your Avatar.
How long have you had asthma?

Question
04/29/23 6:33 AM EDT

Tina Jones.
I’ve had asthma a long time. . . since I was really little.
Your Avatar.
What age were you diagnosed with asthma?

Question
04/29/23 6:34 AM EDT

Tina Jones.
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.
Your Avatar.
Am sorry about that experience

Empathize
04/29/23 6:36 AM EDT

Tina Jones.
Thanks.
Your Avatar.
How do you manage your asthma

Question
04/29/23 6:36 AM EDT

Tina Jones.
I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler.
Your Avatar.
What are your triggers for asthma?

Question
04/29/23 6:36 AM EDT

Tina Jones.
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.
Your Avatar.
What happens when you are around dust?

Question
04/29/23 6:37 AM EDT

Tina Jones.
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.
Your Avatar.
What daily inhaler do you use?

Question
04/29/23 6:38 AM EDT

Tina Jones.
It’s Flovent.
Your Avatar.
How often do you use flovent?

Question
04/29/23 6:38 AM EDT

Tina Jones.
Twice a day.
Your Avatar.
When did you most recently use flovent inhaler?

Question
04/29/23 6:38 AM EDT

Tina Jones.
I use my Flovent inhaler two times a day.
Your Avatar.
When did you last use inhaler

Question
04/29/23 6:39 AM EDT

Tina Jones.
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.
Your Avatar.
How much albuterol do you use?

Question
04/29/23 6:53 AM EDT

Tina Jones.
I do two puffs of the albuterol inhaler when I need it, but that rarely happens. [AUDIO COMING SOON]
Your Avatar.
How many milligrams of metformin did you take?

Question
04/29/23 6:53 AM EDT

Tina Jones.
It’s 850 mg. And I take one pill, twice a day.
Your Avatar.
When did you last take metformin?

Question
04/29/23 6:53 AM EDT

Tina Jones.
I took it this morning.
Your Avatar.
It is good to adhere to the prescribed dose

Educate
04/29/23 6:54 AM EDT

Tina Jones.
Thanks for telling me.
Your Avatar.
When were you diagnosed with asthma?

Question
04/29/23 6:55 AM EDT

Tina Jones.
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.
Your Avatar.
Are you taking any other medication?

Question
04/29/23 6:55 AM EDT

Tina Jones.
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]
Your Avatar.
Thats good to hear

Empathize
04/29/23 6:55 AM EDT

Tina Jones.
Thanks.
Your Avatar.
Do you feel like your asthma is well controlled?

Question
04/29/23 6:56 AM EDT

Tina Jones.
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.
Your Avatar.
Great am happy to hear that

Empathize
04/29/23 6:57 AM EDT

Tina Jones.
Thanks.
Your Avatar.
How often do you use your peak flow meter?

Question
04/29/23 6:57 AM EDT

Tina Jones.
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.
Your Avatar.
Do you check your peak flow regularly?

Question
04/29/23 6:58 AM EDT

Tina Jones.
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.
Your Avatar.
It is often advisable to use it as often as prescribed

Educate
04/29/23 6:58 AM EDT

Tina Jones.
Thanks for telling me.
Your Avatar.
When was your last asthma attack?

Question
04/29/23 6:59 AM EDT

Tina Jones.
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.
Your Avatar.
Do you feel you are in good health now?

Question
04/29/23 7:01 AM EDT

Tina Jones.
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.
Any dizziness?

Question
04/29/23 7:36 AM EDT

Tina Jones.
I haven’t been getting dizzy at all.
Your Avatar.
 Performed pulse oximetry

Exam Action
04/29/23 7:37 AM EDT

Your Avatar.
 Performed spirometry

Exam Action
04/29/23 7:37 AM EDT

Your Avatar.
 Inspected scalp

Exam Action
04/29/23 7:38 AM EDT

Your Avatar.
 Inspected scalp

Exam Action
04/29/23 7:38 AM EDT

Your Avatar.
 Inspected hair on scalp

Exam Action
04/29/23 7:38 AM EDT

Your Avatar.
 Inspected right eyebrow and orbital area

Exam Action
04/29/23 7:39 AM EDT

Your Avatar.
 Inspected left eyebrow and orbital area

Exam Action
04/29/23 7:40 AM EDT

Your Avatar.
 Inspected mouth: Oral mucosa moist

Exam Action
04/29/23 7:42 AM EDT

Your Avatar.
 Inspect mouth

Exam Action
04/29/23 7:42 AM EDT

Your Avatar.
 Inspect tongue

Exam Action
04/29/23 7:42 AM EDT

Your Avatar.
 Inspected mouth: Oral mucosa moist

Exam Action
04/29/23 7:43 AM EDT

Your Avatar.
 Inspect mouth

Exam Action
04/29/23 7:43 AM EDT

Your Avatar.
 Inspect tongue

Exam Action
04/29/23 7:43 AM EDT

Your Avatar.
 Inspected mouth: Oral mucosa moist

Exam Action
04/29/23 7:44 AM EDT

Your Avatar.
 Inspect mouth

Exam Action
04/29/23 7:44 AM EDT

Your Avatar.
 Inspect tongue

Exam Action
04/29/23 7:44 AM EDT

Your Avatar.
 Inspected mouth: Oral mucosa moist

Exam Action
04/29/23 7:44 AM EDT

Your Avatar.
 Inspect mouth

Exam Action
04/29/23 7:44 AM EDT

Your Avatar.
 Inspect tongue

Exam Action
04/29/23 7:44 AM EDT

Your Avatar.
 Inspected mouth: Oral mucosa moist

Exam Action
04/29/23 7:45 AM EDT

Your Avatar.
 Inspect mouth

Exam Action
04/29/23 7:45 AM EDT

Your Avatar.
 Inspect tongue

Exam Action
04/29/23 7:45 AM EDT

Your Avatar.
 Inspected mouth: Oral mucosa moist

Exam Action
04/29/23 7:45 AM EDT

Your Avatar.
 Inspect mouth

Exam Action
04/29/23 7:45 AM EDT

Your Avatar.
 Inspect tongue

Exam Action
04/29/23 7:45 AM EDT

Your Avatar.
 Inspected mouth: Oral mucosa moist

Exam Action
04/29/23 7:45 AM EDT

Your Avatar.
 Inspect mouth

Exam Action
04/29/23 7:45 AM EDT

Your Avatar.
 Inspect tongue

Exam Action
04/29/23 7:45 AM EDT

Your Avatar.
 Inspected mouth: Oral mucosa moist

Exam Action
04/29/23 7:45 AM EDT

Your Avatar.
 Inspect mouth

Exam Action
04/29/23 7:45 AM EDT

Your Avatar.
 Inspect tongue

Exam Action
04/29/23 7:45 AM EDT

Your Avatar.
 Inspected mouth: Oral mucosa moist

Exam Action
04/29/23 7:46 AM EDT

Your Avatar.
 Inspect mouth

Exam Action
04/29/23 7:46 AM EDT

Your Avatar.
 Inspect tongue

Exam Action
04/29/23 7:46 AM EDT

Your Avatar.
 Inspected mouth: Oral mucosa moist

Exam Action
04/29/23 7:46 AM EDT

Your Avatar.
 Inspect mouth

Exam Action
04/29/23 7:46 AM EDT

Your Avatar.
 Inspect tongue

Exam Action
04/29/23 7:46 AM EDT

Your Avatar.
 Inspected mouth: Oral mucosa moist

Exam Action
04/29/23 7:46 AM EDT

Your Avatar.
 Inspect mouth

Exam Action
04/29/23 7:46 AM EDT

Your Avatar.
 Inspect tongue

Exam Action
04/29/23 7:46 AM EDT

Your Avatar.
 Inspected mouth: Oral mucosa moist

Exam Action
04/29/23 7:47 AM EDT

Your Avatar.
 Inspect mouth

Exam Action
04/29/23 7:47 AM EDT

Your Avatar.
 Tested gag reflex

Exam Action
04/29/23 7:47 AM EDT

Your Avatar.
 Inspected upper eyelids

Exam Action
04/29/23 8:22 AM EDT

Your Avatar.
 Inspected lower eyelids

Exam Action
04/29/23 8:23 AM EDT

Your Avatar.
 Inspected right outer ear

Exam Action
04/29/23 8:23 AM EDT

Your Avatar.
 Inspect ears

Exam Action
04/29/23 8:23 AM EDT

Your Avatar.
 Inspected left outer ear

Exam Action
04/29/23 8:23 AM EDT

Your Avatar.
 Inspect ears

Exam Action
04/29/23 8:23 AM EDT

Your Avatar.
 Inspected right outer ear

Exam Action
04/29/23 8:23 AM EDT

Your Avatar.
 Palpated scalp: no masses

Exam Action
04/29/23 8:23 AM EDT

Your Avatar.
 Palpate neck lymph nodes

Exam Action
04/29/23 8:24 AM EDT

Your Avatar.
 Palpated supraclavicular lymph nodes: no palpable nodes

Exam Action
04/29/23 8:24 AM EDT

Your Avatar.
 Palpated thyroid: smooth without nodules, no goiter

Exam Action
04/29/23 8:25 AM EDT

Your Avatar.
 Palpated jaw: no clicks, full ROM

Exam Action
04/29/23 8:25 AM EDT

Your Avatar.
 Palpated upper sinus: no pain reported

Exam Action
04/29/23 8:26 AM EDT

Your Avatar.
 Palpated lower sinus: no pain reported

Exam Action
04/29/23 8:26 AM EDT

Your Avatar.
 Palpated axillary lymph nodes: no palpable nodes

Exam Action
04/29/23 8:26 AM EDT

Your Avatar.
 Tested left pupillary light reflex

Exam Action
04/29/23 8:27 AM EDT

Your Avatar.
 Tested right pupillary light reflex

Exam Action
04/29/23 8:27 AM EDT

Your Avatar.
 Examined fundus of right eye

Exam Action
04/29/23 8:27 AM EDT

Your Avatar.
 Examined fundus of left eye

Exam Action
04/29/23 8:28 AM EDT

Your Avatar.
 Performed otoscopic exam of right ear

Exam Action
04/29/23 8:29 AM EDT

Your Avatar.
 Performed otoscopic exam of left ear

Exam Action
04/29/23 8:30 AM EDT

Your Avatar.
 Inspected right naris

Exam Action
04/29/23 8:30 AM EDT

Your Avatar.
 Inspected left naris

Exam Action
04/29/23 8:30 AM EDT

Your Avatar.
Follow my finger with just your eye

Question
04/29/23 8:30 AM EDT

Tina Jones.
Ok.
Your Avatar.
 Tested extraocular movement

Exam Action
04/29/23 8:31 AM EDT

Your Avatar.
 Tested convergence

Exam Action
04/29/23 8:31 AM EDT

Tina Jones.
F P
Tina Jones.
F P
Your Avatar.
Tell me when you can no longer see my fingers

Question
04/29/23 8:33 AM EDT

Tina Jones.
Ok, I will.
Your Avatar.
 Tested peripheral vision

Exam Action
04/29/23 8:33 AM EDT

Tina Jones.
Now.
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F.

Question
04/29/23 8:34 AM EDT

Tina Jones.
F.
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Eight

Question
04/29/23 8:34 AM EDT

Tina Jones.
Eight.
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W.

Question
04/29/23 8:34 AM EDT

Tina Jones.
W.
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 Performed whisper test on right ear

Exam Action
04/29/23 8:34 AM EDT

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Four

Question
04/29/23 8:34 AM EDT

Tina Jones.
Four.
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R.

Question
04/29/23 8:34 AM EDT

Tina Jones.
R.
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Nine.

Question
04/29/23 8:34 AM EDT

Tina Jones.
Nine.
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 Performed whisper test on left ear

Exam Action
04/29/23 8:34 AM EDT

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 Inspected left abdomen

Exam Action
04/29/23 8:35 AM EDT

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 Inspected anterior abdomen

Exam Action
04/29/23 8:35 AM EDT

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 Inspected right abdomen

Exam Action
04/29/23 8:35 AM EDT

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 Inspected abdomen

Exam Action
04/29/23 8:35 AM EDT

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 Palpated abdominal right upper quadrant with light pressure: soft, no masses

Exam Action
04/29/23 8:37 AM EDT

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 Palpated abdominal left upper quadrant with light pressure: soft, no masses

Exam Action
04/29/23 8:37 AM EDT

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 Palpated abdominal right lower quadrant with light pressure: soft, no masses

Exam Action
04/29/23 8:37 AM EDT

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 Palpated abdominal left lower quadrant with light pressure: soft, no masses

Exam Action
04/29/23 8:37 AM EDT

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 Liver: palpable 1 cm below right costal margin

Exam Action
04/29/23 8:38 AM EDT

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 Palpated for spleen: not palpable

Exam Action
04/29/23 8:38 AM EDT

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 Palpated for right kidney: not palpable, no masses

Exam Action
04/29/23 8:38 AM EDT

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 Palpated for left kidney: not palpable, no masses

Exam Action
04/29/23 8:38 AM EDT

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 Palpated abdominal right upper quadrant with deep pressure: no masses

Exam Action
04/29/23 8:39 AM EDT

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 Palpated abdominal left upper quadrant with deep pressure: no masses

Exam Action
04/29/23 8:39 AM EDT

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 Palpated abdominal right lower quadrant: with deep pressure: no masses

Exam Action
04/29/23 8:40 AM EDT

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 Palpated abdominal left lower quadrant with deep pressure: no masses

Exam Action
04/29/23 8:40 AM EDT

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 Percussed liver span: 7 cm MCL on percussion

Exam Action
04/29/23 8:40 AM EDT

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 Assessed CVA tenderness on left: none reported

Exam Action
04/29/23 8:41 AM EDT

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 Assessed CVA tenderness on right: none reported

Exam Action
04/29/23 8:41 AM EDT

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 Percussed for spleen: no dullness

Exam Action
04/29/23 8:42 AM EDT

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 Percussed for spleen: no dullness

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04/29/23 8:42 AM EDT

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 Percussed left upper quadrant: tympanic

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04/29/23 8:42 AM EDT

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 Percussed left lower quadrant: tympanic

Exam Action
04/29/23 8:42 AM EDT

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 Percussed right upper quadrant: tympanic

Exam Action
04/29/23 8:42 AM EDT

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 Percussed right lower quadrant: tympanic

Exam Action
04/29/23 8:42 AM EDT

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 Auscultated abdominal right upper quadrant

Exam Action
04/29/23 8:43 AM EDT

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 Auscultated abdominal left upper quadrant

Exam Action
04/29/23 8:43 AM EDT

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 Auscultated abdominal right lower quadrant

Exam Action
04/29/23 8:44 AM EDT

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 Auscultated abdominal left lower quadrant

Exam Action
04/29/23 8:44 AM EDT

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 Inspected left leg: no edema

Exam Action
04/29/23 8:45 AM EDT

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 Inspected right leg: no edema

Exam Action
04/29/23 8:45 AM EDT

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 Inspected anterior chest wall

Exam Action
04/29/23 8:46 AM EDT

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 Inspected left chest

Exam Action
04/29/23 8:46 AM EDT

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 Inspected anterior chest wall

Exam Action
04/29/23 8:46 AM EDT

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 Palpated right brachial pulse: 2+

Exam Action
04/29/23 8:46 AM EDT

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 Palpated right radial pulse: 2+

Exam Action
04/29/23 8:46 AM EDT

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 Palpated brachial pulse, left: 2+

Exam Action
04/29/23 8:46 AM EDT

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 Palpated left radial pulse: 2+

Exam Action
04/29/23 8:46 AM EDT

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 Palpated anterior chest: PMI nondisplaced, no heaves or lifts

Exam Action
04/29/23 8:47 AM EDT

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 Palpated right femoral pulse: 2+

Exam Action
04/29/23 8:48 AM EDT

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 Palpated left femoral pulse: 2+

Exam Action
04/29/23 8:49 AM EDT

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 Palpated right popliteal pulse: 2+

Exam Action
04/29/23 8:49 AM EDT

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 Palpated left popliteal pulse: 2+

Exam Action
04/29/23 8:49 AM EDT

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 Palpated right tibial pulse: 2+

Exam Action
04/29/23 8:49 AM EDT

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 Palpated left tibial pulse: 2+

Exam Action
04/29/23 8:49 AM EDT

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 Palpated right dorsalis pedis pulse: 2+

Exam Action
04/29/23 8:49 AM EDT

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 Palpated left dorsalis pedis pulse: 2+

Exam Action
04/29/23 8:49 AM EDT

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 Palpated right carotid: 2+, no thrill

Exam Action
04/29/23 8:50 AM EDT

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 Palpated right carotid: 2+, no thrill

Exam Action
04/29/23 8:50 AM EDT

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 Palpated left carotid: 2+, no thrill

Exam Action
04/29/23 8:51 AM EDT

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 Auscultated right carotid artery: no bruit

Exam Action
04/29/23 8:51 AM EDT

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 Auscultated left carotid artery: no bruit

Exam Action
04/29/23 8:51 AM EDT

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 Auscultated aorta: no bruit

Exam Action
04/29/23 8:52 AM EDT

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 Auscultated right renal artery: no bruit

Exam Action
04/29/23 8:52 AM EDT

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 Auscultated left renal artery: no bruit

Exam Action
04/29/23 8:52 AM EDT

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 Auscultated right iliac artery: no bruit

Exam Action
04/29/23 8:52 AM EDT

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 Auscultated left iliac artery: no bruit

Exam Action
04/29/23 8:52 AM EDT

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 Auscultated right femoral artery: no bruit

Exam Action
04/29/23 8:52 AM EDT

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 Auscultated left femoral artery: no bruit

Exam Action
04/29/23 8:52 AM EDT

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 Auscultated aortic area with the bell

Exam Action
04/29/23 8:53 AM EDT

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 Auscultated pulmonic area with the bell

Exam Action
04/29/23 8:53 AM EDT

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 Auscultated Erb’s point with the bell

Exam Action
04/29/23 8:53 AM EDT

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 Auscultated tricuspid area with the bell

Exam Action
04/29/23 8:53 AM EDT

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 Auscultated mitral area with the bell

Exam Action
04/29/23 8:53 AM EDT

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 Auscultated mitral area with the diaphragm

Exam Action
04/29/23 8:53 AM EDT

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 Auscultated aortic area with the diaphragm

Exam Action
04/29/23 8:53 AM EDT

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 Auscultated pulmonic area with the diaphragm

Exam Action
04/29/23 8:53 AM EDT

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 Auscultated Erb’s point with the diaphragm

Exam Action
04/29/23 8:53 AM EDT

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 Auscultated tricuspid area with the diaphragm

Exam Action
04/29/23 8:53 AM EDT

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 Auscultated mitral area with the diaphragm

Exam Action
04/29/23 8:53 AM EDT

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 Tested capillary refill

Exam Action
04/29/23 8:54 AM EDT

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 Palpate nails

Exam Action
04/29/23 8:54 AM EDT

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 Tested capillary refill

Exam Action
04/29/23 8:54 AM EDT

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 Palpate nails

Exam Action
04/29/23 8:54 AM EDT

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 Tested capillary refill

Exam Action
04/29/23 8:54 AM EDT

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 Palpate nails

Exam Action
04/29/23 8:54 AM EDT

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 Tested capillary refill

Exam Action
04/29/23 8:55 AM EDT

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 Palpate nails

Exam Action
04/29/23 8:55 AM EDT

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 Tested capillary refill

Exam Action
04/29/23 8:55 AM EDT

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 Palpate nails

Exam Action
04/29/23 8:55 AM EDT

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 Inspected anterior chest wall

Exam Action
04/29/23 8:55 AM EDT

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 Inspected left chest

Exam Action
04/29/23 8:55 AM EDT

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 Inspected anterior chest wall

Exam Action
04/29/23 8:57 AM EDT

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 Inspected left chest

Exam Action
04/29/23 8:57 AM EDT

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 Tested capillary refill

Exam Action
04/29/23 9:02 AM EDT

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 Palpate nails

Exam Action
04/29/23 9:02 AM EDT

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 Tested capillary refill

Exam Action
04/29/23 9:03 AM EDT

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 Palpate nails

Exam Action
04/29/23 9:03 AM EDT

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 Inspected posterior chest

Exam Action
04/29/23 9:05 AM EDT

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 Inspected posterior chest wall

Exam Action
04/29/23 9:05 AM EDT

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 Inspected anterior chest wall

Exam Action
04/29/23 9:06 AM EDT

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 Inspected left chest

Exam Action
04/29/23 9:06 AM EDT

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 Palpated fremitus: equal bilaterally in upper posterior chest wall

Exam Action
04/29/23 9:07 AM EDT

Tina Jones.
Ninety-nine.
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 Palpated fremitus: equal bilaterally in middle posterior chest wall

Exam Action
04/29/23 9:07 AM EDT

Tina Jones.
Ninety-nine.
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 Palpated fremitus: equal bilaterally in lower posterior chest wall

Exam Action
04/29/23 9:07 AM EDT

Tina Jones.
Ninety-nine.
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 Palpated thoracic expansion: symmetric

Exam Action
04/29/23 9:07 AM EDT

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 Palpated fremitus: equal bilaterally in upper anterior chest wall

Exam Action
04/29/23 9:08 AM EDT

Tina Jones.
Ninety-nine.
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 Palpated fremitus: equal bilaterally in lower anterior chest wall

Exam Action
04/29/23 9:08 AM EDT

Tina Jones.
Ninety-nine.
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 Percussed left upper posterior chest wall: resonant

Exam Action
04/29/23 9:09 AM EDT

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 Percussed right upper posterior chest wall: resonant

Exam Action
04/29/23 9:09 AM EDT

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 Percussed left middle posterior chest wall: resonant

Exam Action
04/29/23 9:09 AM EDT

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 Percussed right middle posterior chest wall: resonant

Exam Action
04/29/23 9:09 AM EDT

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 Percussed left lower posterior chest wall: resonant

Exam Action
04/29/23 9:09 AM EDT

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 Percussed right lower posterior chest wall: resonant

Exam Action
04/29/23 9:09 AM EDT

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 Percussed left lower posterior chest wall: resonant

Exam Action
04/29/23 9:09 AM EDT

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 Percussed left lower posterior chest wall: resonant

Exam Action
04/29/23 9:09 AM EDT

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 Percussed right lower posterior chest wall: resonant

Exam Action
04/29/23 9:09 AM EDT

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 Percussed right lower posterior chest wall: resonant

Exam Action
04/29/23 9:09 AM EDT

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 Percussed right upper anterior chest wall: resonant

Exam Action
04/29/23 9:10 AM EDT

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 Percussed left upper anterior chest wall: resonant

Exam Action
04/29/23 9:10 AM EDT

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 Percussed right middle anterior chest wall: resonant

Exam Action
04/29/23 9:10 AM EDT

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 Percussed left middle anterior chest wall: resonant

Exam Action
04/29/23 9:10 AM EDT

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 Percussed right lower anterior chest wall: resonant

Exam Action
04/29/23 9:10 AM EDT

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 Percussed left lower anterior chest wall: resonant

Exam Action
04/29/23 9:11 AM EDT

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 Auscultated right upper anterior chest wall

Exam Action
04/29/23 9:13 AM EDT

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 Auscultated left upper anterior chest wall

Exam Action
04/29/23 9:13 AM EDT

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 Auscultated right middle anterior chest wall

Exam Action
04/29/23 9:13 AM EDT

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 Auscultated left middle anterior chest wall

Exam Action
04/29/23 9:13 AM EDT

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 Auscultated right lower anterior chest wall

Exam Action
04/29/23 9:13 AM EDT

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 Auscultated left lower anterior chest wall

Exam Action
04/29/23 9:13 AM EDT

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 Auscultated voice sounds in left lower anterior lungs

Exam Action
04/29/23 9:15 AM EDT

Tina Jones.
Ninety-nine.
Tina Jones.
Ninety-nine.
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 Auscultated voice sounds in right upper anterior lungs

Exam Action
04/29/23 9:15 AM EDT

Tina Jones.
Ninety-nine.
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 Auscultated voice sounds in left upper anterior lungs

Exam Action
04/29/23 9:15 AM EDT

Tina Jones.
Ninety-nine.
Tina Jones.
Ninety-nine.
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 Auscultated voice sounds in right middle anterior lungs

Exam Action
04/29/23 9:15 AM EDT

Tina Jones.
Ninety-nine.
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 Auscultated voice sounds in left middle anterior lungs

Exam Action
04/29/23 9:15 AM EDT

Tina Jones.
Ninety-nine.
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 Auscultated voice sounds in right lower anterior lungs

Exam Action
04/29/23 9:16 AM EDT

Tina Jones.
Ninety-nine.
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 Auscultated voice sounds in left lower anterior lungs

Exam Action
04/29/23 9:16 AM EDT

Tina Jones.
Ninety-nine.
Tina Jones.
Ninety-nine.
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 Auscultated upper left posterior chest wall

Exam Action
04/29/23 9:17 AM EDT

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 Auscultated upper right posterior chest wall

Exam Action
04/29/23 9:17 AM EDT

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 Auscultated middle left posterior chest wall

Exam Action
04/29/23 9:18 AM EDT

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 Auscultated middle right posterior chest wall

Exam Action
04/29/23 9:18 AM EDT

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 Auscultated lower left posterior chest wall

Exam Action
04/29/23 9:18 AM EDT

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 Auscultated lower right posterior chest wall

Exam Action
04/29/23 9:18 AM EDT

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 Auscultated lower left posterior chest wall

Exam Action
04/29/23 9:18 AM EDT

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 Auscultated lower left posterior chest wall

Exam Action
04/29/23 9:18 AM EDT

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 Auscultated lower right posterior chest wall

Exam Action
04/29/23 9:18 AM EDT

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 Auscultated lower right posterior chest wall

Exam Action
04/29/23 9:18 AM EDT

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 Performed spirometry

Exam Action
04/29/23 9:19 AM EDT

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Run your right foot down your shin

Question
04/29/23 9:21 AM EDT

Tina Jones.
Sure.
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 Tested right heel moving to shin

Exam Action
04/29/23 9:21 AM EDT

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Run your left foot down your right shin

Question
04/29/23 9:21 AM EDT

Tina Jones.
Ok.
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 Tested left heel moving to shin

Exam Action
04/29/23 9:21 AM EDT

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Close your eyes and touch your fingers to your nose

Question
04/29/23 9:23 AM EDT

Tina Jones.
I can do that.
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 Tested left index finger to nose

Exam Action
04/29/23 9:23 AM EDT

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 Tested right index finger to nose

Exam Action
04/29/23 9:23 AM EDT

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What is your name and date of birth?

Question
04/29/23 9:24 AM EDT

Tina Jones.
My name is Tina Jones, and I was born on February 17th.
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 Discovered orientation to person

Exam Action
04/29/23 9:24 AM EDT

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What building are you in now?

Question
04/29/23 9:25 AM EDT

Tina Jones.
I’m at the doctor’s office. . . it’s Shadow Health General Clinic.
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 Discovered orientation to place

Exam Action
04/29/23 9:25 AM EDT

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What is the date and year?

Question
04/29/23 9:25 AM EDT

Tina Jones.
Um, today’s date is . . . [Ms. Jones reports correct date and year].
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 Confirmed situation orientation

Exam Action
04/29/23 9:25 AM EDT

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 Discovered orientation to time

Exam Action
04/29/23 9:25 AM EDT

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Place your hands on your knees and turn them over

Question
04/29/23 9:26 AM EDT

Tina Jones.
Ok, like this?
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 Tested rapid alternating hand movements

Exam Action
04/29/23 9:26 AM EDT

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Close your eyes and tell me if the touch is sharp, dull or soft

Question
04/29/23 9:27 AM EDT

Tina Jones.
Ok.
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 Tested right leg proximal dull pain

Exam Action
04/29/23 9:27 AM EDT

Tina Jones.
Dull.
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 Tested right leg distal dull pain

Exam Action
04/29/23 9:27 AM EDT

Tina Jones.
Dull.
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 Tested left leg proximal dull pain

Exam Action
04/29/23 9:27 AM EDT

Tina Jones.
Dull.
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 Tested left leg distal dull pain

Exam Action
04/29/23 9:27 AM EDT

Tina Jones.
Dull.
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 Tested right leg proximal light touch

Exam Action
04/29/23 9:28 AM EDT

Tina Jones.
Soft.
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 Tested right leg proximal light touch

Exam Action
04/29/23 9:28 AM EDT

Tina Jones.
Soft.
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 Tested right leg distal light touch

Exam Action
04/29/23 9:29 AM EDT

Tina Jones.
Soft.
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 Tested left leg proximal light touch

Exam Action
04/29/23 9:29 AM EDT

Tina Jones.
Soft.
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 Tested left leg distal light touch

Exam Action
04/29/23 9:29 AM EDT

Tina Jones.
Soft.
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close your eyes and tell me if the touch is sharp, dull or soft

Question
04/29/23 9:30 AM EDT

Tina Jones.
Ok.
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 Tested right leg proximal sharp pain

Exam Action
04/29/23 9:31 AM EDT

Tina Jones.
Sharp.
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 Tested right leg distal sharp pain

Exam Action
04/29/23 9:31 AM EDT

Tina Jones.
Sharp.
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 Tested left leg proximal sharp pain

Exam Action
04/29/23 9:31 AM EDT

Tina Jones.
Sharp.
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 Tested left leg distal sharp pain

Exam Action
04/29/23 9:31 AM EDT

Tina Jones.
Sharp.
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Close your eyes and tell me if the touch is sharp, dull or soft

Question
04/29/23 9:32 AM EDT

Tina Jones.
Ok.
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 Tested right arm proximal dull pain

Exam Action
04/29/23 9:33 AM EDT

Tina Jones.
Dull.
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 Tested right arm distal dull pain

Exam Action
04/29/23 9:33 AM EDT