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Comprehensive Assessment, Tina Jones shadow health Transcript

Comprehensive Assessment, Tina Jones shadow health Transcript

Tina JonesPatient Information: Patient Name: Tina Jones
Date of Birth: February 17, 1995
Age: 28
Reason for Visit
Chief Complaint:
Required recent physical exam for new job health insurance.
Current Health Status
Current Health Issues:

  • Asthma: Long-standing condition since childhood, currently well-managed.
  • Diabetes: Under control with medication (Metformin).

Employment Information

New Job:

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  • Position: Accounting Clerk at Smith, Stevens, Stewart, Silver & Company.
  • Responsibilities: Assisting an experienced accountant, eventually managing own client list.
  • Start Date: In two weeks.

Medical History

Previous Physical Exams

  • Last check-up: Five months ago, initiated Metformin.
  • Gynecological exam: Normal results, diagnosed with PCOS, started on birth control.

Medications

  • Birth Control: Drospirenone / Ethinyl Estradiol, taken every morning with breakfast.
  • Diabetes Medication: Metformin, 850 mg, taken twice daily.
  • Asthma Inhalers:
    • Daily Inhaler: Flovent, used twice daily.
    • Rescue Inhaler: Albuterol, used occasionally, typically two puffs when needed.

Asthma Management

Triggers and Symptoms

  • Asthma Triggers: Cats, dust, physical exertion (running upstairs).
  • Current Control: No recent asthma attacks since starting daily inhaler and monitoring with peak flow meter.

Peak Flow Meter Use

  • Used in the morning and night, tracked on a chart.

Recent Physical Examination Findings

  • Vital Signs: Pulse oximetry and spirometry performed.
  • Physical Exam:
    • Inspected scalp, mouth, eyes, ears, abdomen, and extremities.
    • No significant findings in lymph nodes or organs; liver slightly palpable.
    • Pulses: All extremity pulses strong and symmetrical.

Additional Health Questions

  • Dizziness: No episodes reported.
  • Overall Health: Patient feels in good health, managing diabetes and stress effectively.

Conclusion

Tina Jones demonstrates effective management of her asthma and diabetes, with all vital signs and physical exam findings within normal limits. Regular monitoring and adherence to medication are crucial for continued health. Follow-up as needed for routine check-ups and any emerging health concerns

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?

Nursing vs. Healthcare Management: Choosing Your Path

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.

Tina Jones Shadow health simulation

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
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 Performed spirometry

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

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

Exam Action
04/29/23 7:38 AM EDT
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 Inspected hair on scalp

Exam Action
04/29/23 7:38 AM EDT
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 Inspected right eyebrow and orbital area

Exam Action
04/29/23 7:39 AM EDT
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 Inspected left eyebrow and orbital area

Exam Action
04/29/23 7:40 AM EDT
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 Inspected mouth: Oral mucosa moist

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

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

Exam Action
04/29/23 7:46 AM EDT
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 Inspected mouth: Oral mucosa moist

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

Exam Action
04/29/23 7:47 AM EDT
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 Tested gag reflex

Exam Action
04/29/23 7:47 AM EDT
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 Inspected upper eyelids

Exam Action
04/29/23 8:22 AM EDT
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 Inspected lower eyelids

Exam Action
04/29/23 8:23 AM EDT
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 Inspected right outer ear

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

Exam Action
04/29/23 8:23 AM EDT
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 Inspected left outer ear

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

Exam Action
04/29/23 8:23 AM EDT
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 Inspected right outer ear

Exam Action
04/29/23 8:23 AM EDT
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 Palpated scalp: no masses

Exam Action
04/29/23 8:23 AM EDT
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 Palpate neck lymph nodes

Exam Action
04/29/23 8:24 AM EDT
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 Palpated supraclavicular lymph nodes: no palpable nodes

Exam Action
04/29/23 8:24 AM EDT
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 Palpated thyroid: smooth without nodules, no goiter

Exam Action
04/29/23 8:25 AM EDT
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 Palpated jaw: no clicks, full ROM

Exam Action
04/29/23 8:25 AM EDT
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 Palpated upper sinus: no pain reported

Exam Action
04/29/23 8:26 AM EDT
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 Palpated lower sinus: no pain reported

Exam Action
04/29/23 8:26 AM EDT
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 Palpated axillary lymph nodes: no palpable nodes

Exam Action
04/29/23 8:26 AM EDT
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 Tested left pupillary light reflex

Exam Action
04/29/23 8:27 AM EDT
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 Tested right pupillary light reflex

Exam Action
04/29/23 8:27 AM EDT
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 Examined fundus of right eye

Exam Action
04/29/23 8:27 AM EDT
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 Examined fundus of left eye

Exam Action
04/29/23 8:28 AM EDT
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 Performed otoscopic exam of right ear

Exam Action
04/29/23 8:29 AM EDT
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 Performed otoscopic exam of left ear

Exam Action
04/29/23 8:30 AM EDT
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 Inspected right naris

Exam Action
04/29/23 8:30 AM EDT
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 Inspected left naris

Exam Action
04/29/23 8:30 AM EDT
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Follow my finger with just your eye

Question
04/29/23 8:30 AM EDT
Tina Jones.
Ok.
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 Tested extraocular movement

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

Exam Action
04/29/23 8:31 AM EDT
Tina Jones.
F P
Tina Jones.
F P
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Tell me when you can no longer see my fingers

Question
04/29/23 8:33 AM EDT
Tina Jones.
Ok, I will.
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 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

Exam Action
04/29/23 8:42 AM EDT
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 Percussed left upper quadrant: tympanic

Exam Action
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+

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04/29/23 8:49 AM EDT
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 Palpated right dorsalis pedis pulse: 2+

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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

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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

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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

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04/29/23 8:53 AM EDT
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 Auscultated pulmonic area with the bell

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04/29/23 8:53 AM EDT
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 Auscultated Erb’s point with the bell

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04/29/23 8:53 AM EDT
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 Auscultated tricuspid area with the bell

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04/29/23 8:53 AM EDT
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 Auscultated mitral area with the bell

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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

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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

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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

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04/29/23 9:09 AM EDT
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 Percussed left middle posterior chest wall: resonant

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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

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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.
Your Avatar.
 Tested left leg proximal light touch

Exam Action
04/29/23 9:29 AM EDT
Tina Jones.
Soft.
Your Avatar.
 Tested left leg distal light touch

Exam Action
04/29/23 9:29 AM EDT
Tina Jones.
Soft.
Your Avatar.
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.
Your Avatar.
 Tested right leg proximal sharp pain

Exam Action
04/29/23 9:31 AM EDT
Tina Jones.
Sharp.
Your Avatar.
 Tested right leg distal sharp pain

Exam Action
04/29/23 9:31 AM EDT
Tina Jones.
Sharp.
Your Avatar.
 Tested left leg proximal sharp pain

Exam Action
04/29/23 9:31 AM EDT
Tina Jones.
Sharp.
Your Avatar.
 Tested left leg distal sharp pain

Exam Action
04/29/23 9:31 AM EDT
Tina Jones.
Sharp.
Your Avatar.
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.
Your Avatar.
 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

Hello. I will be conducting an interview and examination with you.

Greeting
Date: April 29, 2023, 5:28 AM EDT

Hey, can you please tell me your name?

Asking for Name
Date: April 29, 2023, 6:23 AM EDT

I’m Tina Jones. What’s your date of birth?

Asking for Date of Birth
Date: April 29, 2023, 6:23 AM EDT

I was born on February 17th. How old are you?

Asking for Age
Date: April 29, 2023, 6:24 AM EDT

I’m 28 years old. What brings you to the clinic today?

Reason for Clinic Visit
Date: April 29, 2023, 6:24 AM EDT

I’m here because my new job requires a recent physical exam for health insurance. Do you have any current health issues?

Inquiring About Current Health Problems
Date: April 29, 2023, 6:25 AM EDT

I don’t have any specific issues today. I do have asthma and diabetes, but both are well managed. I’m taking good care of my health.

Discussing Health Conditions
Date: April 29, 2023, 6:25 AM EDT

What kind of work will you be doing at your new job?

Asking About New Job
Date: April 29, 2023, 6:27 AM EDT

I’ll be working as an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. I’ll be assisting a more experienced accountant with her clients, and I’ll eventually manage my own clients. I’m starting in two weeks, and I’m excited!

Acknowledging Excitement
Date: April 29, 2023, 6:27 AM EDT

That’s great to hear. When was your last physical exam?

Asking About Last Physical Exam
Date: April 29, 2023, 6:28 AM EDT

Let me think. I had two doctor’s appointments earlier this year. About five months ago, I came in for a check-up and was prescribed metformin. A few weeks later, I saw a gynecologist for a pap smear.

Discussing Recent Medical Appointments
Date: April 29, 2023, 6:28 AM EDT

What did your gynecologist say during the appointment?

Asking About Gynecologist Visit
Date: April 29, 2023, 6:29 AM EDT

She said everything looked good except that I have PCOS, which was also suggested by the nurse here. She started me on birth control, and it seems to be helping.

Discussing Gynecologist’s Diagnosis
Date: April 29, 2023, 6:29 AM EDT

How often do you take your birth control?

Inquiring About Birth Control Usage
Date: April 29, 2023, 6:30 AM EDT

I take it every morning with breakfast.

Discussing Birth Control Routine
Date: April 29, 2023, 6:30 AM EDT

What’s the name of your birth control?

Asking for Birth Control Name
Date: April 29, 2023, 6:31 AM EDT

It’s called drospirenone/ethinyl estradiol.

Naming the Birth Control
Date: April 29, 2023, 6:31 AM EDT

Has your menstrual cycle improved since taking drospirenone?

Asking About Menstrual Cycle
Date: April 29, 2023, 6:32 AM EDT

Now that I’m on the pill, I’m getting my period every month.

Noting Improved Menstrual Cycle
Date: April 29, 2023, 6:32 AM EDT

I’ve had asthma since I was very young.

Discussing Asthma History
Date: April 29, 2023, 6:33 AM EDT

At what age were you diagnosed with asthma?

Inquiring About Age of Asthma Diagnosis
Date: April 29, 2023, 6:34 AM EDT

My doctor told me when I was around two and a half years old. I used to have a lot of asthma attacks back then.

Acknowledging Childhood Asthma Diagnosis
Date: April 29, 2023, 6:34 AM EDT

I appreciate your understanding.

Empathizing with Past Asthma Troubles
Date: April 29, 2023, 6:36 AM EDT

How do you manage your asthma?

Discussing Asthma Management
Date: April 29, 2023, 6:36 AM EDT

I try to avoid triggers that can worsen my breathing, and if my asthma acts up, I use my inhaler.

Explaining Asthma Management
Date: April 29, 2023, 6:36 AM EDT

What are your asthma triggers?

Inquiring About Asthma Triggers
Date: April 29, 2023

, 6:37 AM EDT

Cigarette smoke and cold air are the biggest triggers for me.

Identifying Asthma Triggers
Date: April 29, 2023, 6:37 AM EDT

Is there a history of asthma in your family?

Asking About Family History of Asthma
Date: April 29, 2023, 6:38 AM EDT

Yes, my dad also has asthma.

Confirming Family History
Date: April 29, 2023, 6:38 AM EDT

Now, let’s discuss your diabetes. When were you diagnosed with it?

Asking About Diabetes Diagnosis
Date: April 29, 2023, 6:39 AM EDT

I was diagnosed with type 2 diabetes about four years ago.

Noting Type 2 Diabetes Diagnosis
Date: April 29, 2023, 6:40 AM EDT

How do you manage your diabetes?

Discussing Diabetes Management
Date: April 29, 2023, 6:40 AM EDT

I watch my diet, exercise regularly, and take metformin as prescribed by my doctor.

Explaining Diabetes Management
Date: April 29, 2023, 6:41 AM EDT

What’s your typical diet like?

Inquiring About Diet
Date: April 29, 2023, 6:41 AM EDT

I try to eat a balanced diet with plenty of vegetables, lean protein, and whole grains. I also limit my sugar intake.

Describing Balanced Diet
Date: April 29, 2023, 6:42 AM EDT

That sounds like a healthy approach. How often do you exercise?

Asking About Exercise Routine
Date: April 29, 2023, 6:43 AM EDT

I exercise four to five times a week, usually with a mix of cardio and strength training.

Discussing Exercise Frequency
Date: April 29, 2023, 6:43 AM EDT

That’s great to hear. Do you have any concerns or questions about your upcoming physical exam?

Asking About Concerns or Questions
Date: April 29, 2023, 6:44 AM EDT

I think I’m prepared, but I’d like to know if there’s anything specific I should bring or prepare for the exam.

Discussing Preparation for Physical Exam
Date: April 29, 2023, 6:45 AM EDT

You should bring a list of any medications you’re currently taking, and if you have any recent test results or medical records related to your asthma and diabetes, it’s helpful to have those as well. Other than that, just be ready to discuss your health history and any concerns you might have.

Providing Guidance on Exam Preparation
Date: April 29, 2023, 6:46 AM EDT

Thank you for the information. I’ll make sure to have all of that ready for my appointment.

Expressing Gratitude
Date: April 29, 2023, 6:47 AM EDT

You’re welcome, Tina. If you have any more questions before your appointment, feel free to reach out.

Offering Further Assistance
Date: April 29, 2023, 6:48 AM EDT

Thank you. I’ll do that if I need any more guidance. Have a great day!

Wishing a Good Day
Date: April 29, 2023, 6:48 AM EDT

You too, Tina. Take care.

Saying Goodbye
Date: April 29, 2023, 6:49 AM EDT

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