Transcript
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Hello. I will interview and examine you
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Greet |
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Hey.
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What is your name?
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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?
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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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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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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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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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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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It’s Flovent.
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How often do you use flovent?
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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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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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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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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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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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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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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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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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Yeah, I have a peak flow meter at home, and I use it in the morning and at night and keep track of it on a chart.
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It is often advisable to use it as often as prescribed
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Educate |
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Thanks for telling me.
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When was your last asthma attack?
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I haven’t had any asthma problems, really, ever since I started on the daily inhaler. My last breathing problem was three months ago, probably, and it had been months before that.
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Do you feel you are in good health now?
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All of my health stuff is a lot better now. I feel like my diabetes is in control, I’m in better shape. . . I’m eating healthier. I’m less stressed. Things are going really well.
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Any dizziness?
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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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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
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Exam Action |
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Palpate nails
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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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Inspected left chest
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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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Inspected posterior chest
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Exam Action |
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Inspected posterior chest wall
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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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Palpated fremitus: equal bilaterally in upper posterior chest wall
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Exam Action |
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Ninety-nine.
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Palpated fremitus: equal bilaterally in middle posterior chest wall
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Exam Action |
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Ninety-nine.
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Palpated fremitus: equal bilaterally in lower posterior chest wall
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Exam Action |
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Ninety-nine.
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Palpated thoracic expansion: symmetric
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Exam Action |
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Palpated fremitus: equal bilaterally in upper anterior chest wall
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Exam Action |
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Ninety-nine.
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Palpated fremitus: equal bilaterally in lower anterior chest wall
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Exam Action |
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Ninety-nine.
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Percussed left upper posterior chest wall: resonant
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Exam Action |
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Percussed right upper posterior chest wall: resonant
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Exam Action |
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Percussed left middle posterior chest wall: resonant
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Exam Action |
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Percussed right middle posterior chest wall: resonant
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Exam Action |
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Percussed left lower posterior chest wall: resonant
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Exam Action |
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Percussed right lower posterior chest wall: resonant
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Exam Action |
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Percussed left lower posterior chest wall: resonant
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Exam Action |
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Percussed left lower posterior chest wall: resonant
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Exam Action |
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Percussed right lower posterior chest wall: resonant
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Exam Action |
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Percussed right lower posterior chest wall: resonant
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Exam Action |
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Percussed right upper anterior chest wall: resonant
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Exam Action |
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Percussed left upper anterior chest wall: resonant
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Exam Action |
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Percussed right middle anterior chest wall: resonant
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Exam Action |
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Percussed left middle anterior chest wall: resonant
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Exam Action |
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Percussed right lower anterior chest wall: resonant
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Exam Action |
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Percussed left lower anterior chest wall: resonant
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Exam Action |
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Auscultated right upper anterior chest wall
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Exam Action |
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Auscultated left upper anterior chest wall
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Exam Action |
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Auscultated right middle anterior chest wall
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Exam Action |
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Auscultated left middle anterior chest wall
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Exam Action |
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Auscultated right lower anterior chest wall
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Exam Action |
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Auscultated left lower anterior chest wall
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Exam Action |
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Auscultated voice sounds in left lower anterior lungs
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Exam Action |
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Ninety-nine.
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Ninety-nine.
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Auscultated voice sounds in right upper anterior lungs
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Exam Action |
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Ninety-nine.
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Auscultated voice sounds in left upper anterior lungs
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Exam Action |
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Ninety-nine.
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Ninety-nine.
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Auscultated voice sounds in right middle anterior lungs
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Exam Action |
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Ninety-nine.
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Auscultated voice sounds in left middle anterior lungs
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Exam Action |
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Ninety-nine.
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Auscultated voice sounds in right lower anterior lungs
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Exam Action |
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Ninety-nine.
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Auscultated voice sounds in left lower anterior lungs
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Exam Action |
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Ninety-nine.
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Ninety-nine.
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Auscultated upper left posterior chest wall
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Exam Action |
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Auscultated upper right posterior chest wall
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Exam Action |
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Auscultated middle left posterior chest wall
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Exam Action |
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Auscultated middle right posterior chest wall
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Exam Action |
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Auscultated lower left posterior chest wall
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Exam Action |
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Auscultated lower right posterior chest wall
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Exam Action |
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Auscultated lower left posterior chest wall
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Exam Action |
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Auscultated lower left posterior chest wall
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Exam Action |
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Auscultated lower right posterior chest wall
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Exam Action |
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Auscultated lower right posterior chest wall
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Exam Action |
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Performed spirometry
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Exam Action |
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Run your right foot down your shin
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Question |
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Sure.
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Tested right heel moving to shin
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Exam Action |
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Run your left foot down your right shin
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Question |
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Ok.
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Tested left heel moving to shin
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Exam Action |
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Close your eyes and touch your fingers to your nose
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Question |
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I can do that.
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Tested left index finger to nose
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Exam Action |
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Tested right index finger to nose
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Exam Action |
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What is your name and date of birth?
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Question |
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My name is Tina Jones, and I was born on February 17th.
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Discovered orientation to person
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Exam Action |
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What building are you in now?
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Question |
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I’m at the doctor’s office. . . it’s Shadow Health General Clinic.
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Discovered orientation to place
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Exam Action |
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What is the date and year?
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Question |
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Um, today’s date is . . . [Ms. Jones reports correct date and year].
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Confirmed situation orientation
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Exam Action |
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Discovered orientation to time
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Exam Action |
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Place your hands on your knees and turn them over
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Question |
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Ok, like this?
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Tested rapid alternating hand movements
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Exam Action |
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Close your eyes and tell me if the touch is sharp, dull or soft
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Question |
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Ok.
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Tested right leg proximal dull pain
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Exam Action |
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Dull.
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Tested right leg distal dull pain
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Exam Action |
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Dull.
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Tested left leg proximal dull pain
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Exam Action |
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Dull.
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Tested left leg distal dull pain
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Exam Action |
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Dull.
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Tested right leg proximal light touch
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Exam Action |
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Soft.
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Tested right leg proximal light touch
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Exam Action |
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Soft.
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Tested right leg distal light touch
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Exam Action |
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Soft.
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Tested left leg proximal light touch
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Exam Action |
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Soft.
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Tested left leg distal light touch
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Exam Action |
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Soft.
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close your eyes and tell me if the touch is sharp, dull or soft
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Question |
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Ok.
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Tested right leg proximal sharp pain
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Exam Action |
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Sharp.
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Tested right leg distal sharp pain
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Exam Action |
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Sharp.
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Tested left leg proximal sharp pain
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Exam Action |
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Sharp.
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Tested left leg distal sharp pain
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Exam Action |
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Sharp.
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Close your eyes and tell me if the touch is sharp, dull or soft
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Question |
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Ok.
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Tested right arm proximal dull pain
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Exam Action |
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Dull.
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Tested right arm distal dull pain
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Exam Action |