Hello. I will interview and examine you.
Greet
04/29/23 5:28 AM EDT
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Hey.
Question
04/29/23 6:23 AM EDT
What is your name?
Tina Jones.
Question
04/29/23 6:23 AM EDT
Your date of birth?
February 17th.
Question
04/29/23 6:24 AM EDT
How old are you?
I’m 28. [AUDIO COMING SOON]
Question
04/29/23 6:24 AM EDT
What brought you to the clinic today?
I came in because I’m required to have a recent physical exam for the health insurance at my new job.
Question
04/29/23 6:25 AM EDT
Do you have any current health problems?
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.
Question
04/29/23 6:27 AM EDT
What is your new job?
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!
Empathize
04/29/23 6:27 AM EDT
Alright, thanks.
Question
04/29/23 6:28 AM EDT
When was your last physical examination?
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.
Question
04/29/23 6:29 AM EDT
What did your gynecologist say?
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.
Question
04/29/23 6:30 AM EDT
How often do you take birth control?
I take it every morning, with breakfast.
NURS 6512 Advanced Health Assessment and Diagnostic Reasoning: A.G is a 38-year-old female
Question
04/29/23 6:31 AM EDT
What was the name of the birth control? (Clarified to What is the name of your birth control?.)
It’s drospirenone / ethinyl estradiol. [AUDIO COMING SOON] (Clarified to what the name of my birth control is.)
Question
04/29/23 6:32 AM EDT
Has your menstrual cycle improved since taking drospirenone?
Now that I’m on the pill I’m getting my period every month.
Empathize
04/29/23 6:33 AM EDT
Thanks.
Question
04/29/23 6:33 AM EDT
How long have you had asthma?
I’ve had asthma a long time. . . since I was really little.
Question
04/29/23 6:34 AM EDT
What age were you diagnosed with asthma?
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.
Empathize
04/29/23 6:36 AM EDT
Thanks.
Question
04/29/23 6:36 AM EDT
How do you manage your asthma?
I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler.
Question
04/29/23 6:36 AM EDT
What are your triggers for asthma?
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.
Question
04/29/23 6:37 AM EDT
What happens when you are around dust?
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.
Question
04/29/23 6:38 AM EDT
What daily inhaler do you use?
It’s Flovent.
Question
04/29/23 6:38 AM EDT
How often do you use flovent?
Twice a day.
Question
04/29/23 6:38 AM EDT
When did you most recently use flovent inhaler?
I use my Flovent inhaler two times a day.
Question
04/29/23 6:39 AM EDT
When did you last use inhaler?
I used my Flovent inhaler this morning–I have to take it twice a day. My albuterol, I haven’t had to use in a while.
Empathize
04/29/23 6:39 AM EDT
Thank you for that information.
Question
04/29/23 6:40 AM EDT
How often do you use your albuterol inhaler?
I used to use it a lot more, but lately I haven’t needed it very much. I think I used it maybe once or twice in the past month, and I only had to use it for a couple of days each time. I’ve been doing really well.
Question
04/29/23 6:41 AM EDT
What triggers your asthma attacks?
The worst is definitely being around cats. Like, I love cats, but if I’m around them for too long, I can’t breathe. It’s the worst feeling. I also have to be careful with dusty places, and I try not to push myself too hard if I’m doing something really active, because that can set it off too.
Empathize
04/29/23 6:42 AM EDT
I appreciate your sharing that information.
Question
04/29/23 6:42 AM EDT
How long have you had diabetes?
I found out I had diabetes when I was 20.
Question
04/29/23 6:42 AM EDT
How did you find out you had diabetes?
I had been feeling really thirsty all the time and peeing a lot, so I went to the doctor, and they did some tests. They told me I had diabetes.
Empathize
04/29/23 6:43 AM EDT
I see.
Question
04/29/23 6:43 AM EDT
What type of diabetes do you have?
I have type 2 diabetes.
Question
04/29/23 6:43 AM EDT
How do you manage your diabetes?
I take metformin for it, twice a day.
Question
04/29/23 6:44 AM EDT
When did you start taking metformin?
I started taking metformin about five months ago, when I came in here for my last physical.
Empathize
04/29/23 6:44 AM EDT
Thank you for sharing that.
Question
04/29/23 6:45 AM EDT
How is your blood sugar controlled with metformin?
My blood sugar
is doing pretty well with the metformin. I test it at home, and it’s been mostly within the normal range. I do have days where it’s a little higher than it should be, but I’m working on my diet to try to keep it under control.
Empathize
04/29/23 6:46 AM EDT
I appreciate you sharing that information.
Question
04/29/23 6:46 AM EDT
How often do you check your blood sugar?
I check it at least once a day, usually in the morning. If I have a day where I’m not feeling well or I ate something different, I might check it more often.
Question
04/29/23 6:46 AM EDT
What was your last blood sugar reading?
I checked it this morning and it was 120.
Question
04/29/23 6:47 AM EDT
What is a normal blood sugar reading for you?
The nurse practitioner told me to aim for between 80 and 120, so I’m doing pretty well most of the time.
Empathize
04/29/23 6:47 AM EDT
Thanks for providing that information.
Question
04/29/23 6:48 AM EDT
How do you feel about your diabetes management?
I feel pretty good about it. I know it’s important to stay on top of it, and I’m doing everything I can to keep it under control.
Question
04/29/23 6:49 AM EDT
What challenges do you face in managing your diabetes?
The biggest challenge is probably my diet. I love sweets, and it’s hard for me to resist sometimes. I’ve been trying to find healthier alternatives, though.
Empathize
04/29/23 6:49 AM EDT
Thank you for sharing that.
Question
04/29/23 6:50 AM EDT
What changes have you made to your diet?
I’ve been trying to cut back on sugary snacks and desserts. I’m also eating more fruits and vegetables, and I’ve started cooking at home more instead of ordering takeout.
Question
04/29/23 6:51 AM EDT
How has changing your diet affected your blood sugar?
I’ve noticed that when I eat better, my blood sugar stays more stable. I have fewer days where it’s higher than it should be.
Empathize
04/29/23 6:51 AM EDT
I appreciate you sharing that.
Question
04/29/23 6:51 AM EDT
What exercise do you get regularly?
I try to go for a walk or do some light exercise at least three times a week. I know it’s important for managing my diabetes.
Question
04/29/23 6:52 AM EDT
How does exercise affect your diabetes?
I’ve noticed that when I exercise regularly, my blood sugar tends to stay lower. It also helps me feel more energetic and in control of my health.
Empathize
04/29/23 6:52 AM EDT
Thank you for sharing that.
Question
04/29/23 6:53 AM EDT
Do you smoke?
No, I don’t smoke.
Question
04/29/23 6:53 AM EDT
Have you ever smoked?
I tried it a couple of times in high school, but I never really liked it. I’m not a smoker.
Empathize
04/29/23 6:54 AM EDT
I appreciate your honesty.
Question
04/29/23 6:54 AM EDT
Do you drink alcohol?
I’ll have a drink occasionally, but I’m not a heavy drinker. Maybe once a month or so.
Empathize
04/29/23 6:55 AM EDT
Thank you for sharing that.
Question
04/29/23 6:55 AM EDT
Do you use any recreational drugs?
No, I don’t use any drugs.
Question
04/29/23 6:55 AM EDT
Have you ever used recreational drugs?
No, I’ve never been into that kind of thing.
Empathize
04/29/23 6:56 AM EDT
I appreciate your honesty.
Question
04/29/23 6:56 AM EDT
How would you describe your sleep?
I usually sleep pretty well. I get about 7-8 hours of sleep most nights.
Empathize
04/29/23 6:57 AM EDT
That’s good to hear.
Shoshanna Tillman Follow Up Sick Visit: Musculoskeletal Shadow Health Transcript
Question
04/29/23 6:57 AM EDT
Do you have trouble falling asleep?
Not usually. I might have a night here or there where I have trouble falling asleep, but it’s not a regular thing.
 |
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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Question |
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Tina Jones.
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Your date of birth?
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Question |
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February 17th.
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How old are you?
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Question |
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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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Question |
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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?
|
Question |
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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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Question |
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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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Question |
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Alright, thanks.
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When was your last physical examination?
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Question |
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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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Question |
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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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Question |
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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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Question |
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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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Question |
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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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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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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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Question |
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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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Question |
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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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Exam Action |
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Palpated abdominal left upper quadrant with light pressure: soft, no masses
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Exam Action |
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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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Exam Action |
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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
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Exam Action |
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Inspected left chest
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Exam Action |
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Inspected anterior chest wall
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Exam Action |
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Palpated right brachial pulse: 2+
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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+
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Exam Action |
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Palpated anterior chest: PMI nondisplaced, no heaves or lifts
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Exam Action |
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Palpated right femoral pulse: 2+
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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+
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Exam Action |
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Palpated left popliteal pulse: 2+
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Exam Action |
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Palpated right tibial pulse: 2+
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Exam Action |
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Palpated left tibial pulse: 2+
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Exam Action |
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Palpated right dorsalis pedis pulse: 2+
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Exam Action |
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Palpated left dorsalis pedis pulse: 2+
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Exam Action |
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Palpated right carotid: 2+, no thrill
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Exam Action |
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Palpated right carotid: 2+, no thrill
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Exam Action |
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Palpated left carotid: 2+, no thrill
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Exam Action |
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Auscultated right carotid artery: no bruit
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Exam Action |
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Auscultated left carotid artery: no bruit
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Exam Action |
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Auscultated aorta: no bruit
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Exam Action |
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Auscultated right renal artery: no bruit
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Exam Action |
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Auscultated left renal artery: no bruit
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Exam Action |
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Auscultated right iliac artery: no bruit
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Exam Action |
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Auscultated left iliac artery: no bruit
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Exam Action |
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Auscultated right femoral artery: no bruit
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Exam Action |
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Auscultated left femoral artery: no bruit
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Exam Action |
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Auscultated aortic area with the bell
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Exam Action |
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Auscultated pulmonic area with the bell
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Exam Action |
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Auscultated Erb’s point with the bell
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Exam Action |
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Auscultated tricuspid area with the bell
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Exam Action |
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Auscultated mitral area with the bell
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Exam Action |
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Auscultated mitral area with the diaphragm
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Exam Action |
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Auscultated aortic area with the diaphragm
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Exam Action |
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Auscultated pulmonic area with the diaphragm
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Exam Action |
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Auscultated Erb’s point with the diaphragm
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Exam Action |
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Auscultated tricuspid area with the diaphragm
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Exam Action |
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Auscultated mitral area with the diaphragm
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Exam Action |
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Tested capillary refill
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Exam Action |
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Palpate nails
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Exam Action |
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Tested capillary refill
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Exam Action |
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Palpate nails
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Exam Action |
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Tested capillary refill
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Exam Action |
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Palpate nails
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Exam Action |
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Tested capillary refill
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Exam Action |
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Palpate nails
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Exam Action |
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Tested capillary refill
|
Exam Action |
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Palpate nails
|
Exam Action |
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Inspected anterior chest wall
|
Exam Action |
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Inspected left chest
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Exam Action |
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Inspected anterior chest wall
|
Exam Action |
|
Inspected left chest
|
Exam Action |
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Tested capillary refill
|
Exam Action |
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Palpate nails
|
Exam Action |
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Tested capillary refill
|
Exam Action |
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Palpate nails
|
Exam Action |
|
Inspected posterior chest
|
Exam Action |
|
Inspected posterior chest wall
|
Exam Action |
|
Inspected anterior chest wall
|
Exam Action |
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Inspected left chest
|
Exam Action |
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Palpated fremitus: equal bilaterally in upper posterior chest wall
|
Exam Action |
|
Ninety-nine.
|
|
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Palpated fremitus: equal bilaterally in middle posterior chest wall
|
Exam Action |
|
Ninety-nine.
|
|
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Palpated fremitus: equal bilaterally in lower posterior chest wall
|
Exam Action |
|
Ninety-nine.
|
|
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Palpated thoracic expansion: symmetric
|
Exam Action |
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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.
|
|
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Percussed left upper posterior chest wall: resonant
|
Exam Action |
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Percussed right upper posterior chest wall: resonant
|
Exam Action |
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Percussed left middle posterior chest wall: resonant
|
Exam Action |
|
Percussed right middle posterior chest wall: resonant
|
Exam Action |
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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
|
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