Neurological shadow health tina jones Transcript
Introduction:
– Interviewer (xx): Hi, I’m xx. I’ll be interviewing you and later examining you.
Initial Greeting:
– Patient: Hey.
– Interviewer: Welcome to the clinic.
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Reason for Visit:
– Interviewer: What brings you to the clinic today?
– Patient: Well, I got into a little fender bender a week ago and I’ve been getting these headaches ever since. And my neck is sore too.
– Interviewer: I’m sorry to hear that.
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Neck Stiffness:
– Interviewer: Have you had any neck stiffness?
– Patient: Yeah.
– Interviewer: When did the neck stiffness begin?
– Patient: My neck started hurting about two days after the accident.
– Interviewer: I’m sorry about the accident.
Headaches:
– Interviewer: When did the headaches begin?
– Patient: Five days ago… The headaches started two days after the accident.
– Interviewer: Did you lose consciousness during the accident?
– Patient: No.
– Interviewer: Were you wearing a seat belt?
– Patient: Yes, I always do.
– Interviewer: It’s always good to wear a seat belt.
Frequency and Duration of Headaches:
– Interviewer: How many times have you had headaches since they started?
– Patient: I’ve had a headache just about once a day since a couple of days after my accident. Once I feel it coming on, I take something for it, and it pretty much goes away for the day.
– Interviewer: How long does the headache last?
– Patient: About an hour or two.
– Interviewer: When was your last headache?
– Patient: Yesterday afternoon.
Headache Location and Radiation:
– Interviewer: Where is the location of the headache?
– Patient: The headaches are in the crown of my head and kind of the back of my head.
– Interviewer: Does the pain radiate?
– Patient: Maybe? The soreness in my neck feels like it goes up into my head. But it’s just my neck and head that hurt.
Neck Pain:
– Interviewer: How does your neck feel?
– Patient: It has been pretty stiff and a little painful since the accident.
Additional Symptoms:
– Interviewer: Is your scalp tender?
– Patient: No.
– Interviewer: Do you have jaw pain?
– Patient: No, not at all.
– Interviewer: Do you have facial pain?
– Patient: No. My face is fine.
– Interviewer: How would you rate the pain now?
– Patient: It’s just my neck that hurts right now. I guess I’d say it’s a 3 out of 10.
– Interviewer: How would you rate the pain at its worst?
– Patient: They probably get up to a 4.
Description of Headaches:
– Interviewer: Describe the headaches.
– Patient: The headaches feel like a dull ache, kind of in the crown of my head and the back of my head.
Headache Characteristics:
– Interviewer: Is the headache pain sharp?
– Patient: No, not really.
– Interviewer: Are your headaches cyclic?
– Patient: No, I don’t think so.
Potential Cause of Pain:
– Interviewer: What caused your pain?
– Patient: I’m pretty sure it was the car accident. Well, it was really just a fender bender. There was pretty much no damage to the car, and no one got injured, but I guess a sore head and neck can sneak up on you.
Further Health History:
– Interviewer: Have you ever had any head trauma?
– Patient: No.
– Interviewer: Any seizures?
– Patient: No, I’ve seen somebody have one, though. It’s scary.
– Interviewer: Have your sleep habits changed?
– Patient: No.
– Interviewer: Do you have a fever?
– Patient: No.
– Interviewer: Any chills?
– Patient: No.
– Interviewer: Do you have fatigue?
– Patient: No, not really.
– Interviewer: Do you have nausea?
– Patient: No.
– Interviewer: Any night sweats?
– Patient: I don’t get sweaty, but sometimes I wake up hot and have to kick off my sheets.
– Interviewer: Do you have hypertension?
– Patient: No, I’ve never been diagnosed with blood pressure problems.
Physical Examination:
– Interviewer: Is one side of your body weaker?
– Patient: No, I feel about the same.
– Interviewer: Any change in your gait?
– Patient: No.
– Interviewer: Have you felt dizzy?
– Patient: No, I haven’t been dizzy.
– Interviewer: Any memory problems?
– Patient: I wouldn’t say so. I have a pretty normal memory.
– Interviewer: Any changes in smell?
– Patient: No.
Living Situation:
– Interviewer: Who do you live with?
– Patient: I live by myself.
– Interviewer: What do you do for a living?
– Patient: I work in a bookstore.
– Interviewer: What’s your job at the bookstore?
– Patient: I’m a cashier, so I’m on my feet a lot, but it’s not too tough.
– Interviewer: And what is your relationship status?
– Patient: I’m married, but we’re separated, so it’s just me in the house.
– Interviewer: Who do you have to help you?
– Patient: No one.
Psychological Well-being:
– Interviewer: How are you feeling about things in general?
– Patient: Things are alright. It’s been tough with the separation and all, but I’m getting by.
– Interviewer: Do you have any other medical conditions?
– Patient: No.
– Interviewer: Do you take any medications?
– Patient: Just over-the-counter stuff. Ibuprofen for the headaches, and sometimes I take melatonin to help me sleep.
– Interviewer: Have you taken any over-the-counter pain medications for the headaches?
– Patient: Yeah, I’ve taken ibuprofen. It helps a bit.
– Interviewer: Have you had any surgeries?
– Patient: No.
– Interviewer: Do you have any allergies?
– Patient: No, not that I know of.
– Interviewer: Do you smoke?
– Patient: No.
– Interviewer: Do you use alcohol or recreational drugs?
– Patient: I’ll have a drink now and then, but I’m not a heavy drinker or anything.
– Interviewer: Do you exercise?
– Patient: I used to, but I haven’t been keeping up with it since the accident.
Family History:
– Interviewer: Does your family have any history of medical problems?
– Patient: Not that I know of.
Review of Systems:
– Interviewer: Have you had changes in your vision?
– Patient: No.
– Interviewer: Have you had any changes in your hearing?
– Patient: No.
– Interviewer: Do you have changes in taste or smell?
– Patient: No.
– Interviewer: Do you have difficulty swallowing?
– Patient: No.
– Interviewer: Have you had any trouble with balance?
– Patient: No.
– Interviewer: Do you have difficulty speaking?
– Patient: No.
– Interviewer: Have you had difficulty moving your tongue?
– Patient: No.
– Interviewer: Have you had difficulty
raising your eyebrows?
– Patient: No.
– Interviewer: Have you had difficulty turning your head?
– Patient: No.
– Interviewer: Have you had difficulty swallowing?
– Patient: No.
– Interviewer: Have you had difficulty speaking?
– Patient: No.
Neurologic Examination:
– Interviewer: I’m going to check your reflexes.
– Interviewer (xx): xx: I’m going to check your reflexes.
– Interviewer: First, I’m going to check your biceps reflex.
– Interviewer (xx): xx: First, I’m going to check your biceps reflex.
– Interviewer: You’ll feel a little tap.
– Interviewer (xx): xx: You’ll feel a little tap.
– Interviewer: And again.
– Interviewer (xx): xx: And again.
– Interviewer: Good.
– Interviewer (xx): xx: Good.
– Interviewer: Now I’m going to check your triceps reflex.
– Interviewer (xx): xx: Now I’m going to check your triceps reflex.
– Interviewer: You’ll feel a little tap.
– Interviewer (xx): xx: You’ll feel a little tap.
– Interviewer: And again.
– Interviewer (xx): xx: And again.
– Interviewer: Good.
– Interviewer (xx): xx: Good.
– Interviewer: Now I’m going to check your patellar reflex.
– Interviewer (xx): xx: Now I’m going to check your patellar reflex.
– Interviewer: You’ll feel a little tap.
– Interviewer (xx): xx: You’ll feel a little tap.
– Interviewer: And again.
– Interviewer (xx): xx: And again.
– Interviewer: Good.
– Interviewer (xx): xx: Good.
– Interviewer: Finally, I’m going to check your Achilles reflex.
– Interviewer (xx): xx: Finally, I’m going to check your Achilles reflex.
– Interviewer: You’ll feel a little tap.
– Interviewer (xx): xx: You’ll feel a little tap.
– Interviewer: And again.
– Interviewer (xx): xx: And again.
– Interviewer: Good.
– Interviewer (xx): xx: Good.
Conclusion:
– Interviewer: Thanks for coming in today. I’m going to review my findings with the doctor, and we’ll come up with a plan to help you with your headaches and neck pain.
– Patient: Alright, thank you.
neurological shadow health tina jones Transcript
min
All Lines (243)Interview Questions (93)Statements (16)Exam Actions (134)
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| Hi.I am xx. I will interview you and later examine you. | Greet 09/08/20 1:42 PM EST |
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| Hey. | ||
| Welcome to the clinic | Empathize 09/08/20 1:51 PM EST |
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| I appreciate you saying that. | ||
| What brings you to the clinic today? | Question 09/08/20 1:52 PM EST |
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| Well, I got into a little fender bender a week ago and I’ve been getting these headaches ever since. And my neck is sore too. | ||
| Am sorry to hear that. | Empathize 09/08/20 1:53 PM EST |
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| I appreciate you telling me that. | ||
| Have you had any neck stiffness? | Question 09/08/20 1:55 PM EST |
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| Yeah. | ||
| When did the neck stiffness begin? | Question 09/08/20 1:55 PM EST |
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| My neck started hurting about two days after the accident. | ||
| Am sorry about the accident | Empathize 09/08/20 1:57 PM EST |
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| Thanks. | ||
| When did the headaches begin? | Question 09/08/20 1:58 PM EST |
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| Five days ago… The headaches started two days after the accident. | ||
| Did you lose consciousness during the accident? | Question 09/08/20 1:59 PM EST |
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| No. | ||
| Were you wearing a seat belt? | Question 09/08/20 2:00 PM EST |
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| Yes, I always do. | ||
| It is always good to wear a seat belt | Educate 09/08/20 2:01 PM EST |
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| Sure, I think I understand what you mean. | ||
| Where were you sitting? | Question 09/08/20 2:01 PM EST |
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| I was in the front passenger seat. | ||
| Was anyone under the influence of alcohol when the accident occurred? | Question 09/08/20 2:02 PM EST |
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| No, definitely not. Neither of us had anything to drink. [AUDIO COMING SOON] | ||
| Great. It is not good to drive under the influence of alcohol | Educate 09/08/20 2:03 PM EST |
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| Thanks for telling me. | ||
| How many times have you had headaches since they started? | Question 09/08/20 2:04 PM EST |
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| I’ve had a headache just about once a day since a couple days after my accident. Once I feel it coming on, I take something for it and it pretty much goes away for the day. | ||
| How long does the headache last? | Question 09/08/20 2:04 PM EST |
|
| About an hour or two. | ||
| When was your last headache? | Question 09/08/20 2:05 PM EST |
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| Yesterday afternoon. | ||
| Where is the location of the headache? | Question 09/08/20 2:05 PM EST |
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| The headaches are in the crown of my head, and kind of the back of my head. | ||
| Does the pain radiate? | Question 09/08/20 2:06 PM EST |
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| Maybe? The soreness in my neck feels like it goes up into my head. But its just my neck and head that hurt. | ||
| Sorry about that | Empathize 09/08/20 2:06 PM EST |
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| Thanks for understanding. | ||
| How does your neck feel? | Question 09/08/20 2:07 PM EST |
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| It has been pretty stiff and a little painful since the accident. | ||
| Is your scalp tender? | Question 09/08/20 2:20 PM EST |
|
| No. | ||
| Do you have jaw pain? | Question 09/08/20 2:20 PM EST |
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| No, not at all. | ||
| Do you have facial pain? | Question 09/08/20 2:20 PM EST |
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| No. My face is fine. | ||
| How would you rate the pain now? | Question 09/08/20 2:21 PM EST |
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| It’s just my neck that hurts right now. . . I guess I’d say it’s a 3 out of 10. | ||
| How would you rate the pain at its worst? | Question 09/08/20 2:22 PM EST |
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| They probably get up to a 4. | ||
| Describe the headaches? | Question 09/08/20 2:22 PM EST |
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| The headaches feel like a dull ache, kind of in the crown of my head, and the back of my head. | ||
| Sorry about that | Empathize 09/08/20 2:22 PM EST |
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| Thanks for saying that. | ||
| Is the headache pain sharp? | Question 09/08/20 2:23 PM EST |
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| No, not really. | ||
| Are your headaches cyclic | Question 09/08/20 2:23 PM EST |
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| No, I don’t think so. | ||
| What caused your pain? | Question 09/08/20 2:24 PM EST |
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| I’m pretty sure it was the car accident. Well, it was really just a fender bender. There was pretty much no damage to the car, and no one got injured, but I guess a sore head and neck can sneak up on you. | ||
| Sorry Ms. Jones | Empathize 09/08/20 2:24 PM EST |
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| Thanks for understanding. | ||
| Does it hurt to move your head? | Question 09/08/20 2:25 PM EST |
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| Yeah, my neck hurts when I move it. | ||
| What makes your headache worse? | Question 09/08/20 2:25 PM EST |
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| Nothing really makes them worse. . . they just sort of start, and eventually they go away. | ||
| Question 09/08/20 2:44 PM EST |
||
| No, I’m pretty sure my headaches aren’t migraines. (Clarified to if I get migraines.) | ||
| Good to hear | Empathize 09/08/20 2:45 PM EST |
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| Thanks for saying that. | ||
| Have you ever had any head trauma? | Question 09/08/20 2:45 PM EST |
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| No. | ||
| Any seizures? | Question 09/08/20 2:45 PM EST |
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| No. I’ve seen somebody have one, though. It’s scary. | ||
| Have your sleep habits changed? | Question 09/08/20 2:47 PM EST |
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| No. | ||
| Do you have fever? | Question 09/08/20 2:49 PM EST |
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| No. | ||
| Any chills? | Question 09/08/20 2:50 PM EST |
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| No. | ||
| Do you have fatigue? | Question 09/08/20 2:50 PM EST |
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| No, not really. | ||
| Do you have nausea? | Question 09/08/20 2:50 PM EST |
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| No. | ||
| Any night sweats? | Question 09/08/20 2:50 PM EST |
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| I don’t get sweaty, but sometimes I wake up hot and have to kick off my sheets. | ||
| Do you have hypertension? | Question 09/08/20 2:51 PM EST |
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| No, I’ve never been diagnosed with blood pressure problems. | ||
| That is great | Empathize 09/08/20 2:51 PM EST |
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| Thanks. | ||
| Has one side f your body felt weaker? | Question 09/08/20 2:56 PM EST |
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| No, I feel about the same. | ||
| Any change in your gait? | Question 09/08/20 3:00 PM EST |
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| No. | ||
| Have you felt dizzy? | Question 09/08/20 3:00 PM EST |
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| No, I haven’t been dizzy. | ||
| Any memory problems? | Question 09/08/20 3:00 PM EST |
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| I wouldn’t say so. I have a pretty normal memory. | ||
| Any changes in smell? | Question 09/08/20 3:01 PM EST |
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| No. | ||
| Who do you live with? | Question 09/08/20 3:01 PM EST |
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| Right now I live back at home with my mom and my sister. | ||
| That is great | Empathize 09/08/20 3:02 PM EST |
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| I appreciate you telling me that. | ||
| What is your highest level of education | Question 09/08/20 3:02 PM EST |
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| Well, I’m finishing up my Bachelor’s degree right now. | ||
| Do you work? | Question 09/08/20 3:02 PM EST |
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| I’m a supervisor at Mid-American Copy & Ship. I’ve been working there since high school, and I’ve just kept moving up. | ||
| Do you have a family history of headaches? | Question 09/08/20 3:03 PM EST |
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| No, not that I know of. | ||
| Do you have an earache? (Clarified to Do you have earaches?.) | Question 09/08/20 3:04 PM EST |
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| Not really, no. (Clarified to if I get earaches.) | ||
| Do you have eye problem | Question 09/08/20 3:05 PM EST |
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| Well, no, my vision hasn’t changed recently — not since the accident. But sometimes my vision gets blurry when I do a lot of reading… that’s been going on for awhile. | ||
| Do you have sore throat? | Question 09/08/20 3:05 PM EST |
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| No, it’s fine. | ||
| Any jaw pain? | Question 09/08/20 3:06 PM EST |
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| No, not at all. | ||
| Any dental concern? | Question 09/08/20 3:06 PM EST |
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| Nope, no problems. | ||
| Describe your diet | Question 09/08/20 3:06 PM EST |
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| It’s pretty good, I think. I’m not a huge health nut or anything. | ||
| Are you physically active? | Question 09/08/20 3:07 PM EST |
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| I don’t have the energy to go to a gym or anything after work…I’m pretty exhausted by the end of the day. But I’m on my feet all the time at work so I feel like that’s a little bit of exercise most days at least. | ||
| Any difficulty swallowing? | Question 09/08/20 3:09 PM EST |
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| Nope. | ||
| What is your current living situation? | Question 09/08/20 3:09 PM EST |
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| I live at home with my mom and my sister. | ||
| How is your work? | Question 09/08/20 3:09 PM EST |
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| Mid-American Copy & Ship is a good fit for me, especially while I work on my degree. They have been really understanding of my academic needs. Oh, and I get to do some accounting types of things when I take inventory or prepare orders. | ||
| Has the accident affected your work? (Clarified to Has the car accident had a financial impact on you?.) | Question 09/08/20 3:11 PM EST |
|
| My friend was the one driving, so it was their car that got hit. Thankfully, I don’t have to deal with the repairs. [AUDIO COMING SOON] (Clarified to if the car accident has impacted me financially.) | ||
| ooh that is nice | Empathize 09/08/20 3:12 PM EST |
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| Thanks for understanding. | ||
| Thanks for answering my questions Ms. Jones | Empathize 09/08/20 3:13 PM EST |
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| I appreciate you telling me that. | ||
| I will now perform the physical assessment | Educate 09/08/20 3:13 PM EST |
|
| OK, I understand. | ||
| What is your name and date of birth? | Question 09/08/20 3:28 PM EST |
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| My name is Tina Jones, and I was born on February 17th. | ||
| Evaluated orientation to person | Exam Action 09/08/20 3:28 PM EST |
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| What building are you in now? | Question 09/08/20 3:28 PM EST |
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| I’m at the doctor’s office. . . it’s Shadow Health General Clinic. | ||
| Evaluated orientation to place | Exam Action 09/08/20 3:29 PM EST |
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| What is the date and year? | Question 09/08/20 3:29 PM EST |
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| Um, today’s date is [Tina says correct date and year]. | ||
| Evaluated orientation to time | Exam Action 09/08/20 3:29 PM EST |
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| How are apples and orange alike? | Question 09/08/20 3:30 PM EST |
|
| How are they alike? Um…. they’re both kinds of fruit. | ||
| Evaluated abstract thinking: similarities among fruit | Exam Action 09/08/20 3:30 PM EST |
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| How are a lake and an ocean alike? | Question 09/08/20 3:30 PM EST |
|
| Uh…. they’re both bodies of water. | ||
| Evaluated abstract thinking: similarities among bodies of water | Exam Action 09/08/20 3:31 PM EST |
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| How are a trumpet and a flute alike? | Question 09/08/20 3:31 PM EST |
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| Can you tell me more about school? | Question 09/08/20 3:41 PM EST |
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| School’s good, although it’s a little stressful because I keep thinking about everything I have to do to graduate, and then after that, too. I’m about two months from being done with my last semester. | ||
| Tested CN I (olfactory nerve) with smell test | Exam Action 09/08/20 3:42 PM EST |
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| F P | ||
| F P | ||
| T O Z | ||
| T O Z | ||
| L P E D | ||
| L P E D | ||
| Inspected fundus of right eye | Exam Action 09/08/20 3:44 PM EST |
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| Inspected fundus of left eye | Exam Action 09/08/20 3:45 PM EST |
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| Inspected left pupil and tested left pupillary light reflex | Exam Action 09/08/20 3:46 PM EST |
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| Inspected right pupil and tested pupillary light reflex | Exam Action 09/08/20 3:46 PM EST |
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| Follow my finger with just your eyes | Question 09/08/20 3:48 PM EST |
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| Ok. | ||
| Tested convergence | Exam Action 09/08/20 3:48 PM EST |
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| Tested EOM to the upper left | Exam Action 09/08/20 3:48 PM EST |
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| Tested EOM to the upper center | Exam Action 09/08/20 3:49 PM EST |
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| Tested EOM to the upper right | Exam Action 09/08/20 3:49 PM EST |
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| Tested EOM to the lower right | Exam Action 09/08/20 3:49 PM EST |
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| Tested EOM to the lower center | Exam Action 09/08/20 3:49 PM EST |
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| Tested EOM to the lower left | Exam Action 09/08/20 3:49 PM EST |
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| Close your eyes and and tell me if the touch is sharp, dull, or soft | Question 09/08/20 3:50 PM EST |
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| Ok. | ||
| Tested facial sensation: dull stimulus | Exam Action 09/08/20 3:50 PM EST |
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| Dull. | ||
| Tested facial sensation: dull stimulus | Exam Action 09/08/20 3:50 PM EST |
|
| Dull. | ||
| Tested facial sensation: dull stimulus | Exam Action 09/08/20 3:50 PM EST |
|
| Dull. | ||
| Tested facial sensation: dull stimulus | Exam Action 09/08/20 3:50 PM EST |
|
| Dull. | ||
| Tested facial sensation: dull stimulus | Exam Action 09/08/20 3:50 PM EST |
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| Dull. | ||
| Tested facial sensation: soft stimulus | Exam Action 09/08/20 3:51 PM EST |
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| Soft. | ||
| Tested facial sensation: soft stimulus | Exam Action 09/08/20 3:51 PM EST |
|
| Soft. | ||
| Tested facial sensation: soft stimulus | Exam Action 09/08/20 3:51 PM EST |
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| Soft. | ||
| Tested facial sensation: soft stimulus | Exam Action 09/08/20 3:51 PM EST |
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| Soft. | ||
| Tested facial sensation: sharp stimulus | Exam Action 09/08/20 3:52 PM EST |
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| Sharp. | ||
| Tested facial sensation: sharp stimulus | Exam Action 09/08/20 3:52 PM EST |
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| Sharp. | ||
| Tested facial sensation: sharp stimulus | Exam Action 09/08/20 3:52 PM EST |
|
| Sharp. | ||
| Tested facial sensation: sharp stimulus | Exam Action 09/08/20 3:52 PM EST |
|
| Sharp. | ||
| Tested facial sensation: sharp stimulus | Exam Action 09/08/20 3:52 PM EST |
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| Sharp. | ||
| Inspected front of face for asymmetry and facial droop | Exam Action 09/08/20 3:52 PM EST |
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| Inspected right side of face for asymmetry and facial droop | Exam Action 09/08/20 3:52 PM EST |
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| Inspected front of face for asymmetry and facial droop | Exam Action 09/08/20 3:53 PM EST |
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| Inspected left side of face for asymmetry and facial droop | Exam Action 09/08/20 3:53 PM EST |
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| Inspected back of head for asymmetry | Exam Action 09/08/20 3:53 PM EST |
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| Inspected right side of face for asymmetry and facial droop | Exam Action 09/08/20 3:53 PM EST |
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| Inspected front of face for asymmetry and facial droop | Exam Action 09/08/20 3:53 PM EST |
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| Is the volume the same in both ears or louder in one year? | Question 09/08/20 3:54 PM EST |
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| Ok. | ||
| Same in both ears. | ||
| Performed Weber test with tuning fork | Exam Action 09/08/20 3:55 PM EST |
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| Tell me when you can no longer hear the ringing | Question 09/08/20 3:55 PM EST |
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| Ok, I will. | ||
| Now. | ||
| Tested gag reflex | Exam Action 09/08/20 3:56 PM EST |
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| Tested trapezius muscle strength against resistance: 5 strength against resistance | Exam Action 09/08/20 3:57 PM EST |
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| Tested sternocleidomastoid muscle strength against resistance – head turned to the right: 5 strength against resistance | Exam Action 09/08/20 3:57 PM EST |
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| Tested sternocleidomastoid muscle strength against resistance – head turned to the left: 5 strength against resistance | Exam Action 09/08/20 3:57 PM EST |
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| Inspected mouth | Exam Action 09/08/20 3:58 PM EST |
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| Inspected mouth: pushed tongue left with tongue blade | Exam Action 09/08/20 3:58 PM EST |
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| Inspect mouth: pushed tongue right with tongue blade | Exam Action 09/08/20 3:58 PM EST |
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| Inspect mouth: lifted tongue with tongue blade | Exam Action 09/08/20 3:58 PM EST |
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| Inspected mouth: depressed tongue with tongue blade | Exam Action 09/08/20 3:58 PM EST |
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| Tested reflexes of right triceps: 2+ | Exam Action 09/08/20 3:59 PM EST |
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| Tested reflexes of left triceps: 2+ | Exam Action 09/08/20 3:59 PM EST |
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| Tested reflexes of right biceps: 2+ | Exam Action 09/08/20 3:59 PM EST |
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| Tested reflexes of left biceps: 2+ | Exam Action 09/08/20 4:00 PM EST |
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| Tested reflexes of right brachioradialis: 2+ | Exam Action 09/08/20 4:00 PM EST |
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| Tested reflexes of left brachioradialis: 2+ | Exam Action 09/08/20 4:00 PM EST |
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| Tested reflexes of right patellar tendon: 2+ | Exam Action 09/08/20 4:01 PM EST |
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| Tested reflexes of left patellar tendon: 2+ | Exam Action 09/08/20 4:01 PM EST |
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| Tested reflexes of right achilles tendon: 2+ | Exam Action 09/08/20 4:01 PM EST |
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| Tested reflexes of right achilles tendon: 2+ | Exam Action 09/08/20 4:02 PM EST |
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| Tested reflexes of left achilles tendon: 2+ | Exam Action 09/08/20 4:02 PM EST |
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| Close your eyes and touch your fingers to your nose | Question 09/08/20 4:04 PM EST |
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| I can do that. | ||
| Observed left index finger to nose | Exam Action 09/08/20 4:04 PM EST |
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| Observed right index finger to nose | Exam Action 09/08/20 4:04 PM EST |
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| Run your right foot down your shin | Question 09/08/20 4:06 PM EST |
|
| Sure. | ||
| Observed right heel moving to shin | Exam Action 09/08/20 4:06 PM EST |
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| Run your left foot down your shin | Question 09/08/20 4:06 PM EST |
|
| Ok. | ||
| Observed left heel moving to shin | Exam Action 09/08/20 4:06 PM EST |
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| Place your hands on your knees and turn them over | Question 09/08/20 4:08 PM EST |
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| Ok, like this? | ||
| Observed rapid alternating hand movements: Movement is smooth, performed without difficulty | Exam Action 09/08/20 4:08 PM EST |
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| Observed patient’s gait | Exam Action 09/08/20 4:08 PM EST |
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| Close your eyes and tell me what I place in your hand | Question 09/08/20 4:10 PM EST |
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| Ok. | ||
| That’s an “A.” | ||
| Tested left-hand graphesthesia by letter identification | Exam Action 09/08/20 4:10 PM EST |
|
| That’s an “A.” | ||
| Tested left-hand graphesthesia by letter identification | Exam Action 09/08/20 4:10 PM EST |
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| Tested right-hand graphesthesia by number identification | Exam Action 09/08/20 4:10 PM EST |
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| A figure “8.” | ||
| Close your eyes nd tell me if the touch is sharp, dull or soft | Question 09/08/20 4:12 PM EST |
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| Ok. | ||
| Tested right arm proximal dull sensation | Exam Action 09/08/20 4:12 PM EST |
|
| Dull. | ||
| Tested right arm distal dull sensation | Exam Action 09/08/20 4:12 PM EST |
|
| Dull. | ||
| Tested left arm proximal dull sensation | Exam Action 09/08/20 4:13 PM EST |
|
| Dull. | ||
| Tested left arm distal dull sensation | Exam Action 09/08/20 4:13 PM EST |
|
| Dull. | ||
| Tested left arm distal dull sensation | Exam Action 09/08/20 4:13 PM EST |
|
| Dull. | ||
| close your eyes and tell if the touch is sharp, dull, or soft | Question 09/08/20 4:15 PM EST |
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| Ok. | ||
| Test sensory dull chest | Exam Action 09/08/20 4:15 PM EST |
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| Dull. | ||
| Tested right arm proximal soft sensation | Exam Action 09/08/20 4:16 PM EST |
|
| Soft. | ||
| Tested right arm distal soft sensation | Exam Action 09/08/20 4:16 PM EST |
|
| Soft. | ||
| Tested left arm proximal soft sensation | Exam Action 09/08/20 4:16 PM EST |
|
| Soft. | ||
| Tested left arm proximal soft sensation | Exam Action 09/08/20 4:16 PM EST |
|
| Soft. | ||
| Tested left arm distal soft sensation | Exam Action 09/08/20 4:16 PM EST |
|
| Soft. | ||
| Test sensory light chest | Exam Action 09/08/20 4:16 PM EST |
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| Soft. | ||
| Tested right arm proximal sharp sensation | Exam Action 09/08/20 4:17 PM EST |
|
| Sharp. | ||
| Tested right arm proximal sharp sensation | Exam Action 09/08/20 4:17 PM EST |
|
| Sharp. | ||
| Tested right arm distal sharp sensation | Exam Action 09/08/20 4:17 PM EST |
|
| Sharp. | ||
| Tested left arm proximal sharp sensation | Exam Action 09/08/20 4:18 PM EST |
|
| Sharp. | ||
| Tested left arm distal sharp sensation | Exam Action 09/08/20 4:18 PM EST |
|
| Sharp. | ||
| Test sensory sharp chest | Exam Action 09/08/20 4:18 PM EST |
|
| Sharp. | ||
| Close your eyes and tell me if the touch is sharp, dull, and soft | Question 09/08/20 4:20 PM EST |
|
| Ok. | ||
| Tested right leg proximal dull sensation | Exam Action 09/08/20 4:20 PM EST |
|
| Dull. | ||
| Tested right leg distal dull sensation | Exam Action 09/08/20 4:20 PM EST |
|
| Dull. | ||
| Tested left leg proximal dull sensation | Exam Action 09/08/20 4:21 PM EST |
|
| Dull. | ||
| Tested left leg distal dull sensation | Exam Action 09/08/20 4:21 PM EST |
|
| Dull. | ||
| Tested right leg proximal light sensation | Exam Action 09/08/20 4:21 PM EST |
|
| Soft. | ||
| Tested right leg distal light sensation | Exam Action 09/08/20 4:21 PM EST |
|
| Soft. | ||
| Tested left leg proximal light sensation | Exam Action 09/08/20 4:21 PM EST |
|
| Soft. | ||
| Tested left leg distal light sensation | Exam Action 09/08/20 4:21 PM EST |
|
| Soft. | ||
| Tested right leg proximal light sensation | Exam Action 09/08/20 4:21 PM EST |
|
| Soft. | ||
| Tested right leg proximal sharp sensation | Exam Action 09/08/20 4:22 PM EST |
|
| Sharp. | ||
| Tested right leg distal sharp sensation | Exam Action 09/08/20 4:22 PM EST |
|
| Sharp. | ||
| Tested right leg distal sharp sensation | Exam Action 09/08/20 4:22 PM EST |
|
| Sharp. | ||
| Tested left leg proximal sharp sensation | Exam Action 09/08/20 4:22 PM EST |
|
| Sharp. | ||
| Tested left leg distal sharp sensation | Exam Action 09/08/20 4:22 PM EST |
|
| Sharp. | ||
| Close your eyes and tell me when you feel the touch | Question 09/08/20 4:23 PM EST |
|
| Ok, I will. | ||
| Tested sensation of right heel with monofilament | Exam Action 09/08/20 4:24 PM EST |
|
| Yes. | ||
| Tested sensation of left ball of foot under small toe with monofilament | Exam Action 09/08/20 4:24 PM EST |
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| Tested sensation of right big toe with monofilament | Exam Action 09/08/20 4:24 PM EST |
|
| Yes. | ||
| Tested sensation of right big toe with monofilament | Exam Action 09/08/20 4:24 PM EST |
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| Tested sensation of left big toe with monofilament | Exam Action 09/08/20 4:24 PM EST |
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| Tested sensation of left ball of foot under big toe with monofilament | Exam Action 09/08/20 4:24 PM EST |
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| Tested sensation of left ball of foot under small toe with monofilament | Exam Action 09/08/20 4:24 PM EST |
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| Tested sensation of left ball of foot under small toe with monofilament | Exam Action 09/08/20 4:24 PM EST |
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| Tested sensation of left heel with monofilament | Exam Action 09/08/20 4:24 PM EST |
|
| Yes. | ||
| Tested sensation of left heel with monofilament | Exam Action 09/08/20 4:24 PM EST |
|
| Yes. | ||
| close your eyes and tell if your finger or toe moves up and down | Question 09/08/20 4:26 PM EST |
|
| Ok, I will. | ||
| Down. | ||
| Tested position sense of finger on right hand | Exam Action 09/08/20 4:27 PM EST |
|
| Up. | ||
| Tested position sense of finger on left hand | Exam Action 09/08/20 4:27 PM EST |
|
| Up. | ||
| Tested position sense of finger on left hand | Exam Action 09/08/20 4:27 PM EST |
|
| …I think that was up. | ||
| Tested position sense of toe on right foot | Exam Action 09/08/20 4:27 PM EST |
|
| Down. | ||
| Tested position sense of toe on left foot | Exam Action 09/08/20 4:28 PM EST |
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| close your eyes and tell me what I in your hand | Question 09/08/20 4:30 PM EST |
|
| Ok, sure. | ||
| …Some kind of coin. | ||
| Tested right-hand stereognosis with coin | Exam Action 09/08/20 4:30 PM EST |
|
| Tested right-hand stereognosis with paper clip | Exam Action 09/08/20 4:31 PM EST |
|
| This is… some wire thing… paperclip? | ||
| Tested right-hand stereognosis with key | Exam Action 09/08/20 4:31 PM EST |
|
| Um… that feels like a key. | ||
| …Some kind of coin. | ||
| Tested left-hand stereognosis with coin | Exam Action 09/08/20 4:31 PM EST |
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| Tested left-hand stereognosis with paper clip | Exam Action 09/08/20 4:31 PM EST |
|
| The paperclip again. | ||
| Um… that feels like a key. | ||
| Tested left-hand stereognosis with key | Exam Action 09/08/20 4:32 PM EST |