Brian Forster Shadow Health Assessment Transcript
Brian Forster Shadow Health Assessment Transcript Transcript
All Lines (307)Interview Questions (138)Statements (8)Exam Actions (161)
| Hello, Mr. Foster. My name is Sarah and I will be taking care of you today. | Greet 04/11/20 9:08 AM MDT | |
| Good morning. | ||
| How are you today? | Question 04/11/20 9:09 AM MDT | |
| I’ve been better. I’ve been experiencing this tight, uncomfortable feeling in my chest every now and then. I’m starting to worry it could be something serious. | ||
| I’m sorry you’re in so much pain. We’ll try to get it under control as soon possible. (No matching questions found.) | Question 04/11/20 9:10 AM MDT | |
| I’m sorry you’re in so much pain. We’ll try to get it under control as soon possible.
| Empathize 04/11/20 9:10 AM MDT | |
| Thanks. I appreciate that. | ||
| Where does your chest hurt? | Question 04/11/20 9:12 AM MDT | |
| When the pain happens, I feel it mostly in the middle of my chest, over my heart. | ||
| Does it radiate to any other part of your body? (No matching questions found.) | Question 04/11/20 9:12 AM MDT | |
| Do you feel the pain in your neck? | Question 04/11/20 9:13 AM MDT | |
| My neck’s been fine. | ||
| Do you feel the pain in your arms? | Question 04/11/20 9:13 AM MDT | |
| No, when I am having the chest pain, it’s mostly just in middle of my chest. | ||
| When did the pain start? | Question 04/11/20 9:14 AM MDT | |
| I first noticed it earlier this month. I thought it might just be heartburn and it passed after about a couple of minutes. | ||
| How long does it last? | Question 04/11/20 9:15 AM MDT | |
| I haven’t noticed any palpitations. | ||
| Can you describe the pain? | Question 04/11/20 9:15 AM MDT | |
| Well, it mostly feels tight and uncomfortable right in the middle of my chest. | ||
| On a scale of 0 to 10, how do you rate the level of pain? (Clarified to How would you rate your chest pain on a scale?.) | Question 04/11/20 9:16 AM MDT | |
| I’d say maybe a . . . 5? It’s just really uncomfortable . . . like there’s nothing I can do about it. Right now it’s like a zero though. (Clarified to how I would rate my chest pain on a scale.) | ||
| Does anything aggravate it? (Clarified to Does anything make the pain worse?.) | Question 04/11/20 9:17 AM MDT | |
| Well, the pain seems to start when I’m doing something physical . . . the first time it happened while I was doing yard work, and the second time . . . I had to take the stairs at work because the elevator broke. Both times it got better if I took a break or sat down to rest. (Clarified to if anything makes the pain worse.) | ||
| How many times have you had the chest pain | Question 04/11/20 9:18 AM MDT | |
| Well, it has happened three times the past month. It usually goes away after about a couple minutes. | ||
| Do you have any other symptoms? | Question 04/11/20 9:19 AM MDT | |
| I don’t think so, it’s mostly been my chest. | ||
| Do you have back pain | Question 04/11/20 9:20 AM MDT | |
| I haven’t had back pain, no. | ||
| Do you have shoulder pain | Question 04/11/20 9:20 AM MDT | |
| No, the pain hasn’t been in my shoulder. | ||
| Does the pain feel the same each episode (No matching questions found.) Brian Forster Shadow Health Assessment Transcript | Question 04/11/20 9:21 AM MDT | |
| Does the pain feel the same each time (No matching questions found.) | Question 04/11/20 9:21 AM MDT | |
| Is the pain the same | Question 04/11/20 9:22 AM MDT | |
| It’s hard to say. Each time it’s happened, the pain has been similar. It’s not even pain so much as an uncomfortable feeling in the middle of my chest that lasts a few minutes. | ||
| Have you taken any medication to relieve the pain | Question 04/11/20 9:23 AM MDT | |
| No, not yet. | ||
| Have you been to the hospital | Question 04/11/20 9:23 AM MDT | |
| I’ve never had to go to the hospital, no. | ||
| Do you get pain when you eat (Clarified to Do you have pain when you eat?.) | Question 04/11/20 9:24 AM MDT | |
| I don’t think eating has anything to do with it. One episode did happen when my wife and I were out for dinner, but it seemed to happen before we even settled. The episodes don’t seem all that related, to be honest. (Clarified to if I have pain with eating.) | ||
| Do you get pain with spicy food | Question 04/11/20 9:27 AM MDT | |
| I don’t think spicy foods have anything to do with it. | ||
| Do you get pain with food | Question 04/11/20 9:27 AM MDT | |
| I don’t think eating has anything to do with it. One episode did happen when my wife and I were out for dinner, but it seemed to happen before we even settled. The episodes don’t seem all that related, to be honest. | ||
| Do you have allergies | Question 04/11/20 9:28 AM MDT | |
| No, well . . . I’ve had a bad reaction to codeine before, but that is all I know of. | ||
| Do you have allergies to food | Question 04/11/20 9:29 AM MDT | |
| No, well . . . I’ve had a bad reaction to codeine before, but that is all I know of. | ||
| Did you feel stressed at dinner (Clarified to Have you been stressed recently?.) | Question 04/11/20 9:29 AM MDT | |
| Honestly, my life is pretty low stress. My job rarely stresses me out, my home life is great, and my kids generally behave. My only stress right now is my concern about this chest pain I keep getting every now and then. (Clarified to if I have been stressed out lately.) Brian Forster Shadow Health Assessment Transcript | ||
| Can you tell me about your medical history | Question 04/11/20 9:30 AM MDT | |
| The doctors told me I have a little bit of high blood pressure and cholesterol, but that’s it. | ||
| When were you diagnosed with high blood pressure | Question 04/11/20 9:32 AM MDT | |
| About one year ago. | ||
| Do you take medications for your high blood pressure | Question 04/11/20 9:32 AM MDT | |
| I take metoprolol, yes. [AUDIO COMING SOON] | ||
| Do you know the dose of your metoprolol (Clarified to What is your dose of Lopressor?.) | Question 04/11/20 9:32 AM MDT | |
| I don’t have it with me but I’m almost positive it’s one hundred milligrams. I take it once a day. (Clarified to how much Lopressor I take.) | ||
| Did you take it today (No matching questions found.) | Question 04/11/20 9:33 AM MDT | |
| Did you take your metoprolol today (Clarified to Did you take metoprolol today?.) | Question 04/11/20 9:33 AM MDT | |
| I haven’t taken it yet. [AUDIO COMING SOON] (Clarified to if I have taken metoprolol today.) | ||
| When were you diagnosed with hyperlipidemia (Clarified to When were you diagnosed with high cholesterol?.) | Question 04/11/20 9:34 AM MDT | |
| About one year ago. (Clarified to when I was diagnosed with high cholesterol.) | ||
| Do you take medication for your high cholesterol | Question 04/11/20 9:34 AM MDT | |
| I take atorvastatin. [AUDIO COMING SOON] | ||
| Do you know the dose (Clarified to What is the dosage of your high cholesterol medication?.) | Question 04/11/20 9:34 AM MDT | |
| It’s 20 mg, once a day. (Clarified to what the dosage of my cholesterol medication is.) | ||
| Do you take any over the counter medications | Question 04/11/20 9:35 AM MDT | |
| Oh, just ibuprofen or Tylenol occasionally for pain. | ||
| Do you take supplements | Question 04/11/20 9:35 AM MDT | |
| I take fish oil, that’s it. | ||
| How much fish oil | Question 04/11/20 9:35 AM MDT | |
| I take it daily. I think it’s 1200 milligrams. Brian Forster Shadow Health Assessment Transcript | ||
| Do you take herbal supplements | Question 04/11/20 9:35 AM MDT | |
| I take fish oil, that’s it. | ||
| It is important for you to take your high blood pressure and cholesterol medications daily. | Educate 04/11/20 9:36 AM MDT | |
| Good to know. Thank you. | ||
| Have you ever had surgery | Question 04/11/20 9:36 AM MDT | |
| I’ve never had any surgeries. | ||
| When was your last tetanus shot | Question 04/11/20 9:37 AM MDT | |
| I’m up to date on my tetanus shot. [AUDIO COMING SOON] | ||
| Do you know the date | Question 04/11/20 9:37 AM MDT | |
| It’s . . . [Mr. Foster says the correct date.] [AUDIO COMING SOON] | ||
| Have you had a flu shot | Question 04/11/20 9:38 AM MDT | |
| Well, I usually get the flu shot. I’ve had one in the past year. [AUDIO COMING SOON] | ||
| Can you tell me about your father (Clarified to Can you tell me about your father’s health?.) | Question 04/11/20 9:40 AM MDT | |
| He really wasn’t doing so great in the last few years. He died when he was 75 of colon cancer, but even before that, his weight and his blood pressure and cholesterol were getting the best of him. It was rough. He didn’t last too long after the cancer diagnosis, unfortunately. I think he was tired of fighting. (Clarified to how my dad’s health was.) | ||
| That must have been a struggle | Empathize 04/11/20 9:41 AM MDT | |
| Thanks. I appreciate that. | ||
| Can you tell me about your mother’s health | Question 04/11/20 9:41 AM MDT | |
| She has type 2 diabetes and some high blood pressure, but I think she’s doing pretty well for 80. | ||
| Do you have siblings | Question 04/11/20 9:41 AM MDT | |
| I have a sister, and I had a brother but he died many years ago. | ||
| How did your brother die | Question 04/11/20 9:41 AM MDT | |
| It was a car accident. He was 24. | ||
| Can you tell me about your sisters health | Question 04/11/20 9:42 AM MDT | |
| She has the same health problems as our mom. Diabetes and hypertension. | ||
| How old is she (Clarified to How old is your sister?.) | Question 04/11/20 9:42 AM MDT | |
| She’s fifty-two. (Clarified to how old is my sister.) | ||
| Can you tell me about your maternal grandmother | Question 04/11/20 9:42 AM MDT | |
| She had breast cancer. She was in her 60s when she died. | ||
| Can you tell me about your maternal grandfather | Question 04/11/20 9:43 AM MDT | |
| My grandfather on my mom’s side died of a heart attack. He was in his mid-fifties. | ||
| Can you tell me about your paternal grandmother’s health | Question 04/11/20 9:43 AM MDT | |
| She died of pneumonia when she was almost 80. 78 or 79, I think. | ||
| Can you tell me about your paternal grandfathers health | Question 04/11/20 9:44 AM MDT | |
| He was healthy right up until he died. He went in his sleep at 85, and we just called it old age. | ||
| How many kids do yo have | Question 04/11/20 9:44 AM MDT | |
| I have a daughter, she’s a freshman in college now, and I have a son who’s an engineer. | ||
| How old are your kids | Question 04/11/20 9:45 AM MDT | |
| Sam is 26 and Allie is 19. [AUDIO COMING SOON] | ||
| Can you tell me about your sons health (No matching questions found.) | Question 04/11/20 9:45 AM MDT | |
| Can you tell me about your son’s health | Question 04/11/20 9:45 AM MDT | |
| The doctors told me I have a little bit of high blood pressure and cholesterol, but that’s it. | ||
| Can you tell me about your daughters health | Question 04/11/20 9:45 AM MDT | |
| My daughter’s name is Allie. [AUDIO COMING SOON] | ||
| Have you ever been diagnosed with chest pain (No matching questions found.) | Question 04/11/20 9:46 AM MDT | |
| Do you have diabetes | Question 04/11/20 9:47 AM MDT | |
| No, I’ve avoided it but my mother and sister both have it. | ||
| Is this the first time you’ve had chest pain | Question 04/11/20 9:47 AM MDT | |
| I’ve felt it a few times this past month. | ||
| How often do you take your blood pressure | Question 04/11/20 9:48 AM MDT | |
| I usually only get it checked when I visit the doctor. | ||
| Monitoring your blood pressure at home is a good way to evaluate if your medication is controlling your high blood pressure. It will give us real-life readings to see how you are doing at home. | Educate 04/11/20 9:50 AM MDT | |
| Good to know. Thank you. | ||
| Do you know your normal blood pressure | Question 04/11/20 9:50 AM MDT | |
| I guess it’s usually somewhat elevated, but no one has ever told me it was bad enough to worry. I’ve taken metoprolol for about a year now. [AUDIO COMING SOON] | ||
| Do you know your typical cholesterol reading | Question 04/11/20 9:51 AM MDT | |
| I’ve been told it’s moderately high. I’ve never noticed any actual symptoms from that though. Brian Forster Shadow Health Assessment Transcript | ||
| Have you had tests for your heart | Question 04/11/20 9:52 AM MDT | |
| I’ve had . . . well, I guess I’ve had the EKG a few times and they give me an annual stress test. | ||
| Do you know the results of your EKG | Question 04/11/20 9:53 AM MDT | |
| I don’t remember the actual results, but as far as I know, it was normal. | ||
| Do you know the results of your stress test | Question 04/11/20 9:53 AM MDT | |
| I’m not sure, all the doctor ever tells me is, “everything looks good.” | ||
| how often do you see your doctor | Question 04/11/20 9:54 AM MDT | |
| I see the doctor every 6 months unless there’s something wrong in between. | ||
| How often do you see your primary care doctor | Question 04/11/20 9:55 AM MDT | |
| I see the doctor every 6 months unless there’s something wrong in between. | ||
| Do you have medical insurance | Question 04/11/20 9:55 AM MDT | |
| We have a PPO with Shadow Mutual. | ||
| When was your last visit with your doctor | Question 04/11/20 9:57 AM MDT | |
| I had a physical about 3 months ago. | ||
| Do you exercise | Question 04/11/20 9:58 AM MDT | |
| Well I used to ride my bike a lot but it got stolen a couple years ago. I guess I haven’t had much regular exercise since then. I want to get a new bike if the doctor says it is OK to exercise with this chest pain I’ve been having. | ||
| You’re right. exercise is important; however, the level of exercise and heart rate should be determined before starting a new exercise regime. | Educate 04/11/20 10:02 AM MDT | |
| Good to know. Thank you. | ||
| Can you tell me your typical diet? | Question 04/11/20 10:03 AM MDT | |
| Um, let’s see . . . For breakfast I usually eat a granola bar and drink an instant breakfast shake. I’ve been doing that a while since it saves time in the morning. Most days for lunch I get a sandwich from the sub shop near work. That’s usually a turkey sub, but sometimes I get a spicy Italian sub. My wife and I grill a lot, and usually have some grilled meat with veggies for dinner. | ||
| How much salt do you eat | Question 04/11/20 10:11 AM MDT | |
| I’m not sure, I don’t really pay attention to it. | ||
| Do you eat sugar | Question 04/11/20 10:12 AM MDT | |
| We don’t really keep sweets in the house. Sometimes I’m tempted into ordering dessert when we go out, though. | ||
| How much water do you drink? | Question 04/11/20 10:15 AM MDT | |
| I usually drink water all day at work. At least four glasses, probably more. [AUDIO COMING SOON] | ||
| It is recommended to drink up to eight glasses of water daily | Educate 04/11/20 10:17 AM MDT | |
| Good to know. Thank you. | ||
| Do you drink cokes | Question 04/11/20 10:17 AM MDT | |
| Once in a blue moon maybe. I avoid it 99% of the time. | ||
| Do you drink soda | Question 04/11/20 10:17 AM MDT | |
| Once in a blue moon maybe. I avoid it 99% of the time. | ||
| Do you have coffee | Question 04/11/20 10:18 AM MDT | |
| Maybe 2 cups on weekdays. Sometimes a whole pot on Sunday mornings, but I’ve cut back a lot in the past few years. | ||
| Do you drink tea | Question 04/11/20 10:19 AM MDT | |
| Well, I drink iced tea sometimes but I’m a coffee man when it comes to hot drinks. My wife is really into her teas though. | ||
| Do you use tobacco | Question 04/11/20 10:19 AM MDT | |
| No. | ||
| have you ever used tobacco | Question 04/11/20 10:20 AM MDT | |
| I don’t smoke at all. Never have. | ||
| Do you use cannabis | Question 04/11/20 10:20 AM MDT | |
| I’ll put it this way: the last time I touched the stuff, Carter was in office. | ||
| Have you used illicit substances | Question 04/11/20 10:21 AM MDT | |
| I tried a few of the usual suspects back in my youth, but I haven’t touched any of that stuff in over 30 years. | ||
| Do you drink alcohol | Question 04/11/20 10:22 AM MDT | |
| Sure, but never more than two or three beers on a weekend. | ||
| Do you have fever | Question 04/11/20 10:24 AM MDT | |
| I haven’t had a fever, no. | ||
| Do you have chills | Question 04/11/20 10:24 AM MDT | |
| I haven’t had chills, no. | ||
| Do you feel tired | Question 04/11/20 10:25 AM MDT | |
| No, I don’t feel any more tired than usual. | ||
| Have you had weight loss | Question 04/11/20 10:25 AM MDT | |
| Not exactly . . . I’ve gained about fifteen to twenty pounds in the last couple years. | ||
| Have you had weight gain | Question 04/11/20 10:26 AM MDT | |
| I’ve gained maybe 20 pounds over the last couple years. I guess I’m getting older . . . my wife doesn’t seem to mind though! Brian Forster Shadow Health Assessment Transcript | ||
| Do you get dizzy | Question 04/11/20 10:27 AM MDT | |
| No, I haven’t felt dizzy. | ||
| have you passed out | Question 04/11/20 10:27 AM MDT | |
| I’ve never passed out. I haven’t even felt dizzy or lightheaded. [AUDIO COMING SOON] | ||
| Any changes in your eyes | Question 04/11/20 10:28 AM MDT | |
| I get my eyes checked every few years. So far, no glasses! | ||
| Any eye pain | Question 04/11/20 10:29 AM MDT | |
| I haven’t had problems with my eyes like that. | ||
| Do you have any changes in hearing | Question 04/11/20 10:29 AM MDT | |
| My hearing’s fine. | ||
| Do you get headaches | Question 04/11/20 10:30 AM MDT | |
| I get headaches once in a blue moon, but it’s never anything that has concerned me. | ||
| How often do you get headaches | Question 04/11/20 10:30 AM MDT | |
| I get headaches once in a blue moon, but it’s never anything that has concerned me. | ||
| do you have sinus problems | Question 04/11/20 10:31 AM MDT | |
| I don’t usually have any sinus trouble. | ||
| Have you had an auditory exam (No matching questions found.) | Question 04/11/20 10:31 AM MDT | |
| Have you had your hearing checked | Question 04/11/20 10:31 AM MDT | |
| Yeah, but it’s been many years now. | ||
| Any issues with your throat | Question 04/11/20 10:32 AM MDT | |
| Nope. | ||
| When was your last dentist appointment | Question 04/11/20 10:32 AM MDT | |
| Um . . . probably about a year ago. | ||
| Do you have trouble swallowing | Question 04/11/20 10:33 AM MDT | |
| I haven’t had any trouble swallowing. | ||
| any changes in the way food tastes | Question 04/11/20 10:35 AM MDT | |
| I can still taste things fine. | ||
| Do you get short of breath | Question 04/11/20 10:36 AM MDT | |
| No, I can usually breathe just fine. Unless I have a cold or something, but that’s rare. | ||
| Have you had heart murmurs | Question 04/11/20 10:37 AM MDT | |
| No, none that I know of. | ||
| Do you have shortness of breath with activity | Question 04/11/20 10:40 AM MDT | |
| Not usually. It depends on how strenuous the activity is. | ||
| Do you have shortness of breath at night | Question 04/11/20 10:41 AM MDT | |
| No, I can breathe just fine. | ||
| Do you cough at night | Question 04/11/20 10:41 AM MDT | |
| I don’t have a cough. | ||
| Do you have swelling in your legs | Question 04/11/20 10:41 AM MDT | |
| I haven’t noticed any swelling. | ||
| Do you have pain in your legs | Question 04/11/20 10:41 AM MDT | |
| I don’t feel any pain in my legs. | ||
| Do you have irregular heart beats | Question 04/11/20 10:42 AM MDT | |
| Not that I know of. | ||
| Do you have heartburn | Question 04/11/20 10:43 AM MDT | |
| No, I’ve never had problems with heartburn. I sure hope that’s all this is, but it’s pretty intense if it’s heartburn. | ||
| Do you have nausea | Question 04/11/20 10:44 AM MDT | |
| No, I haven’t felt nauseous. I just had pain in my chest. | ||
| THe physical exam will help tell us what is causing your pain. I do have a few more questions. Brian Forster Shadow Health Assessment Transcript | Empathize 04/11/20 10:45 AM MDT | |
| Thanks. I appreciate that. | ||
| Have you had vomiting | Question 04/11/20 10:45 AM MDT | |
| No, I haven’t. | ||
| Do you have changes in bowel patterns | Question 04/11/20 10:45 AM MDT | |
| Um . . . no. No problems with that. | ||
| Any changes in urination | Question 04/11/20 10:46 AM MDT | |
| I think I pee a normal amount. Every couple of hours or so. | ||
| Do you have pain when you urinate | Question 04/11/20 10:46 AM MDT | |
| No, it doesn’t hurt. | ||
| Do you have bloating | Question 04/11/20 10:46 AM MDT | |
| Not really, no. | ||
| Have you ever had a sexually transmitted infection | Question 04/11/20 10:47 AM MDT | |
| No, I am clean as a whistle. | ||
| Do you have any joint pain | Question 04/11/20 10:48 AM MDT | |
| My joints don’t give me any trouble. | ||
| Do you get muscle pain | Question 04/11/20 10:48 AM MDT | |
| No muscle problems here. | ||
| Have you had seizures | Question 04/11/20 10:49 AM MDT | |
| No, never. | ||
| Do you have numbness or tingling | Question 04/11/20 10:50 AM MDT | |
| Nope, I haven’t noticed anything. | ||
| Do you have rashes | Question 04/11/20 10:50 AM MDT | |
| I don’t have a rash. [AUDIO COMING SOON] | ||
| Do you have changes in your skin | Question 04/11/20 10:50 AM MDT | |
| I haven’t noticed anything weird with my skin, no. | ||
| Do you have anxiety | Question 04/11/20 10:51 AM MDT | |
| Not usually, but I’m feeling pretty anxious not knowing what’s going on with my chest. | ||
| Do you have depression | Question 04/11/20 10:51 AM MDT | |
| I’ve never had any sort of prolonged depression. | ||
| Any changes in hair | Question 04/11/20 10:52 AM MDT | |
| Not that I’ve noticed. | ||
| Do you feel more thirsty than usual (Clarified to Have you been feeling more thirsty lately?.) | Question 04/11/20 10:53 AM MDT | |
| Not anymore than usual. (Clarified to if I have been more thirsty lately.) | ||
| Do you feel more hungry lately | Question 04/11/20 10:53 AM MDT | |
| I’m not more tired than normal. | ||
| Are you bleeding easily | Question 04/11/20 10:54 AM MDT | |
| No, I sure don’t think so. | ||
| Do you bruise easily | Question 04/11/20 10:54 AM MDT | |
| I don’t bruise easily, no. | ||
| Have you had anemia | Question 04/11/20 10:56 AM MDT | |
| Thankfully, no. | ||
| Have you ever had a blood transfusion | Question 04/11/20 10:56 AM MDT | |
| Thankfully, no. | ||
| Have you notices swollen lymphnodes | Question 04/11/20 10:56 AM MDT | |
| I haven’t noticed any swelling. | ||
| Have you have frequent infections | Question 04/11/20 10:56 AM MDT | |
| No, my ears are fine. | ||
| Do you have asthma | Question 04/11/20 10:56 AM MDT | |
| No, I’ve never had any breathing problems. My daughter has asthma, though. | ||
| OK, we are going to start your physical exam | Educate 04/11/20 10:58 AM MDT | |
| Good to know. Thank you. | ||
| Measured vitals | Exam Action 04/11/20 11:37 AM MDT | |
| Tested blood pressure in left arm with cuff | Exam Action 04/11/20 11:38 AM MDT | |
| Tested blood pressure in right arm with cuff | Exam Action 04/11/20 11:39 AM MDT | |
| Measured vitals | Exam Action 04/11/20 11:40 AM MDT | |
| Inspected face | Exam Action 04/11/20 11:41 AM MDT | |
| Inspected for jugular venous distension: No jugular venous distention; JVP 3 cm above sternal angle. Brian Forster Shadow Health Assessment Transcript | Exam Action 04/11/20 11:43 AM MDT | |
| Inspected for jugular venous distension: No jugular venous distention; JVP 3 cm above sternal angle | Exam Action 04/11/20 11:46 AM MDT | |
| Inspected anterior chest wall | Exam Action 04/11/20 11:47 AM MDT | |
| Inspected left side chest wall | Exam Action 04/11/20 12:09 PM MDT | |
| Inspected posterior chest wall | Exam Action 04/11/20 12:10 PM MDT | |
| Inspected right side chest wall | Exam Action 04/11/20 12:10 PM MDT | |
| Inspected anterior chest wall | Exam Action 04/11/20 12:10 PM MDT | |
| Inspected left side of abdomen | Exam Action 04/11/20 2:20 PM MDT | |
| Inspected front of abdomen | Exam Action 04/11/20 2:21 PM MDT | |
| Inspected right side of abdomen | Exam Action 04/11/20 2:21 PM MDT | |
| Inspected front of abdomen | Exam Action 04/11/20 2:21 PM MDT | |
| Inspected left side of abdomen | Exam Action 04/11/20 2:21 PM MDT | |
| Inspected face | Exam Action 04/11/20 2:33 PM MDT | |
| Inspected right hand: no visible abnormal findings | Exam Action 04/11/20 2:34 PM MDT | |
| Inspected left hand: no visible abnormal findings | Exam Action 04/11/20 2:34 PM MDT | |
| Inspected fingernails of left hand | Exam Action 04/11/20 2:34 PM MDT | |
| Inspected right hand: no visible abnormal findings | Exam Action 04/11/20 2:34 PM MDT | |
| Inspected left hand: no visible abnormal findings | Exam Action 04/11/20 2:34 PM MDT | |
| Inspected fingernails of right hand | Exam Action 04/11/20 2:34 PM MDT | |
| Inspected left leg | Exam Action 04/11/20 2:40 PM MDT | |
| Inspected right leg | Exam Action 04/11/20 2:40 PM MDT | |
| Inspected toenails on left foot | Exam Action 04/11/20 2:40 PM MDT | |
| Inspected toenails on right foot | Exam Action 04/11/20 2:40 PM MDT | |
| Inspected left leg | Exam Action 04/11/20 2:40 PM MDT | |
| Inspected right leg | Exam Action 04/11/20 2:40 PM MDT | |
| Inspected toenails on left foot | Exam Action 04/11/20 2:40 PM MDT | |
| Inspected toenails on right foot | Exam Action 04/11/20 2:40 PM MDT | |
| Inspected toenails on left foot | Exam Action 04/11/20 2:41 PM MDT | |
| Inspected left leg | Exam Action 04/11/20 2:41 PM MDT | |
| Inspected right leg | Exam Action 04/11/20 2:41 PM MDT | |
| Inspected toenails on left foot | Exam Action 04/11/20 2:41 PM MDT | |
| Inspected left leg | Exam Action 04/11/20 2:41 PM MDT | |
| Inspected right leg | Exam Action 04/11/20 2:41 PM MDT | |
| Inspected right leg for edema: No edema | Exam Action 04/11/20 2:45 PM MDT | |
| Inspected left leg for edema: No edema | Exam Action 04/11/20 2:45 PM MDT | |
| Checked capillary refill in fingernails | Exam Action 04/11/20 2:52 PM MDT | |
| Checked capillary refill in fingernails | Exam Action 04/11/20 2:52 PM MDT | |
| Checked capillary refill in fingernails | Exam Action 04/11/20 2:52 PM MDT | |
| Checked capillary refill in fingernails | Exam Action 04/11/20 2:52 PM MDT | |
| Checked capillary refill in fingernails | Exam Action 04/11/20 2:52 PM MDT | |
| Checked capillary refill in fingernails | Exam Action 04/11/20 2:53 PM MDT | |
| Checked capillary refill in fingernails | Exam Action 04/11/20 2:53 PM MDT | |
| Checked capillary refill in fingernails | Exam Action 04/11/20 2:53 PM MDT | |
| Checked capillary refill in fingernails | Exam Action 04/11/20 3:00 PM MDT | |
| Checked capillary refill in fingernails | Exam Action 04/11/20 3:00 PM MDT | |
| Checked capillary refill in toenails | Exam Action 04/11/20 3:02 PM MDT | |
| Checked capillary refill in toenails | Exam Action 04/11/20 3:02 PM MDT | |
| Checked capillary refill in toenails | Exam Action 04/11/20 3:03 PM MDT | |
| Checked capillary refill in toenails | Exam Action 04/11/20 3:03 PM MDT | |
| Checked capillary refill in toenails | Exam Action 04/11/20 3:03 PM MDT | |
| Checked capillary refill in toenails | Exam Action 04/11/20 3:03 PM MDT | |
| Checked capillary refill in toenails | Exam Action 04/11/20 3:03 PM MDT | |
| Checked capillary refill in toenails | Exam Action 04/11/20 3:03 PM MDT | |
| Checked capillary refill in toenails | Exam Action 04/11/20 3:03 PM MDT | |
| Checked capillary refill in toenails | Exam Action 04/11/20 3:04 PM MDT | |
| Checked capillary refill in toenails | Exam Action 04/11/20 3:04 PM MDT | |
| Auscultated right carotid pulse: Bruit present | Exam Action 04/11/20 3:06 PM MDT | |
| Auscultated left carotid pulse | Exam Action 04/11/20 3:07 PM MDT | |
| Auscultated right carotid pulse: Bruit present | Exam Action 04/11/20 3:08 PM MDT | |
| Auscultated aortic area with the bell | Exam Action 04/11/20 3:12 PM MDT | |
| Auscultated aortic area with the diaphragm | Exam Action 04/11/20 3:12 PM MDT | |
| Auscultated aortic area with the bell | Exam Action 04/11/20 3:12 PM MDT | |
| Auscultated aortic area with the diaphragm | Exam Action 04/11/20 3:13 PM MDT | |
| Auscultated aortic area with the bell | Exam Action 04/11/20 3:13 PM MDT | |
| Auscultated pulmonic area with the bell | Exam Action 04/11/20 3:13 PM MDT | |
| Auscultated pulmonic area with the diaphragm | Exam Action 04/11/20 3:13 PM MDT | |
| Auscultated Erb’s point with the diaphragm | Exam Action 04/11/20 3:13 PM MDT | |
| Auscultated Erb’s point with the bell | Exam Action 04/11/20 3:14 PM MDT | |
| Auscultated tricuspid area with the bell | Exam Action 04/11/20 3:14 PM MDT | |
| Auscultated tricuspid area with the diaphragm | Exam Action 04/11/20 3:14 PM MDT | |
| Auscultated mitral area with the diaphragm. Brian Forster Shadow Health Assessment Transcript | Exam Action 04/11/20 3:14 PM MDT | |
| Auscultated mitral area with the bell | Exam Action 04/11/20 3:14 PM MDT | |
| Auscultated aortic area with the bell | Exam Action 04/11/20 3:19 PM MDT | |
| Auscultated aortic area with the diaphragm | Exam Action 04/11/20 3:19 PM MDT | |
| Auscultated pulmonic area with the diaphragm | Exam Action 04/11/20 3:19 PM MDT | |
| Auscultated pulmonic area with the bell | Exam Action 04/11/20 3:19 PM MDT | |
| Auscultated Erb’s point with the bell | Exam Action 04/11/20 3:19 PM MDT | |
| Auscultated Erb’s point with the diaphragm | Exam Action 04/11/20 3:19 PM MDT | |
| Auscultated tricuspid area with the diaphragm | Exam Action 04/11/20 3:19 PM MDT | |
| Auscultated tricuspid area with the bell | Exam Action 04/11/20 3:19 PM MDT | |
| Auscultated mitral area with the bell | Exam Action 04/11/20 3:19 PM MDT | |
| Auscultated mitral area with the diaphragm | Exam Action 04/11/20 3:20 PM MDT | |
| Auscultated mitral area with the bell | Exam Action 04/11/20 3:20 PM MDT | |
| Auscultated aortic area with the bell | Exam Action 04/11/20 3:21 PM MDT | |
| Auscultated aortic area with the diaphragm | Exam Action 04/11/20 3:21 PM MDT | |
| Auscultated breath sounds in anterior right upper lobe | Exam Action 04/11/20 3:29 PM MDT | |
| Auscultated breath sounds in anterior left upper lobe | Exam Action 04/11/20 3:29 PM MDT | |
| Auscultated breath sounds in anterior left mid-chest (upper lobe) | Exam Action 04/11/20 3:30 PM MDT | |
| Auscultated breath sounds in anterior right middle lobe | Exam Action 04/11/20 3:30 PM MDT | |
| Auscultated breath sounds in anterior right lower lobe | Exam Action 04/11/20 3:30 PM MDT | |
| Auscultated breath sounds in anterior left lower lobe | Exam Action 04/11/20 3:30 PM MDT | |
| Auscultated breath sounds in posterior left upper lobe | Exam Action 04/11/20 3:31 PM MDT | |
| Auscultated breath sounds in posterior right upper lobe | Exam Action 04/11/20 3:31 PM MDT | |
| Auscultated breath sounds in posterior right mid-back (lower lobe) | Exam Action 04/11/20 3:31 PM MDT | |
| Auscultated breath sounds in posterior left mid-back (lower lobe) | Exam Action 04/11/20 3:31 PM MDT | |
| Auscultated breath sounds in posterior left lower lobe | Exam Action 04/11/20 3:31 PM MDT | |
| Auscultated breath sounds in posterior right lower lobe | Exam Action 04/11/20 3:31 PM MDT | |
| Auscultated breath sounds in posterior left lower lobe on side | Exam Action 04/11/20 3:32 PM MDT | |
| Auscultated breath sounds in posterior right lower lobe on side | Exam Action 04/11/20 3:32 PM MDT | |
| Auscultated breath sounds in posterior left lower lobe on side | Exam Action 04/11/20 3:35 PM MDT | |
| Auscultated aorta in abdomen | Exam Action 04/11/20 3:39 PM MDT | |
| Auscultated right renal pulse | Exam Action 04/11/20 3:40 PM MDT | |
| Auscultated left renal pulse | Exam Action 04/11/20 3:41 PM MDT | |
| Auscultated left iliac pulse | Exam Action 04/11/20 3:41 PM MDT | |
| Auscultated right iliac pulse | Exam Action 04/11/20 3:41 PM MDT | |
| Auscultated right femoral pulse | Exam Action 04/11/20 3:41 PM MDT | |
| Auscultated left femoral pulse | Exam Action 04/11/20 3:41 PM MDT | |
| Auscultated left upper quadrant | Exam Action 04/11/20 3:42 PM MDT | |
| Auscultated right lower quadrant | Exam Action 04/11/20 9:51 PM MDT | |
| Auscultated right upper quadrant | Exam Action 04/11/20 9:52 PM MDT | |
| Auscultated left upper quadrant | Exam Action 04/11/20 10:39 PM MDT | |
| Auscultated left lower quadrant | Exam Action 04/11/20 10:39 PM MDT | |
| Auscultated over liver | Exam Action 04/11/20 10:41 PM MDT | |
| Auscultated over spleen | Exam Action 04/11/20 10:42 PM MDT | |
| Palpated right carotid pulse: Thrill, 3+ | Exam Action 04/11/20 10:46 PM MDT | |
| Palpated left carotid pulse: No thrill, 2+ | Exam Action 04/11/20 10:47 PM MDT | |
| Palpated PMI: Displaced laterally; brisk and tapping; less than 3 cm. Brian Forster Shadow Health Assessment Transcript | Exam Action 04/11/20 10:49 PM MDT | |
| Palpated right brachial pulse: No thrill, 2+ | Exam Action 04/11/20 10:54 PM MDT | |
| Palpated left brachial pulse: No thrill, 2+ | Exam Action 04/11/20 10:54 PM MDT | |
| Palpated right radial pulse: No thrill, 2+ | Exam Action 04/11/20 10:54 PM MDT | |
| Palpated left radial pulse: No thrill, 2+ | Exam Action 04/11/20 10:54 PM MDT | |
| Palpated right femoral pulse: No thrill, 2+ | Exam Action 04/11/20 10:54 PM MDT | |
| Palpated left femoral pulse: No thrill, 2+ | Exam Action 04/11/20 10:55 PM MDT | |
| Palpated left femoral pulse: No thrill, 2+ | Exam Action 04/11/20 10:55 PM MDT | |
| Palpated right popliteal pulse: No thrill, 1+ | Exam Action 04/11/20 10:55 PM MDT | |
| Palpated left popliteal pulse: No thrill, 1+ | Exam Action 04/11/20 10:55 PM MDT | |
| Palpated right tibial pulse: No thrill, 1+ | Exam Action 04/11/20 10:56 PM MDT | |
| Palpated left tibial pulse: No thrill, 1+ | Exam Action 04/11/20 10:56 PM MDT | |
| Palpated right dorsalis pedis pulse: No thrill, 1+ | Exam Action 04/11/20 10:56 PM MDT | |
| Palpated left dorsalis pedis pulse: No thrill, 1+ | Exam Action 04/11/20 10:56 PM MDT | |
| Palpated right lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension | Exam Action 04/11/20 11:01 PM MDT | |
| Palpated right upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension | Exam Action 04/11/20 11:01 PM MDT | |
| Palpated left upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension | Exam Action 04/11/20 11:01 PM MDT | |
| Palpated left lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension | Exam Action 04/11/20 11:01 PM MDT | |
| Palpated right lower quadrant: with deep pressure: No masses | Exam Action 04/11/20 11:02 PM MDT | |
| Palpated right upper quadrant with deep pressure: No masses | Exam Action 04/11/20 11:02 PM MDT | |
| Palpated left lower quadrant with deep pressure: No masses | Exam Action 04/11/20 11:02 PM MDT | |
| Palpated left lower quadrant with deep pressure: No masses | Exam Action 04/11/20 11:03 PM MDT | |
| Palpated left upper quadrant with deep pressure: No masses | Exam Action 04/11/20 11:03 PM MDT | |
| Palpated liver: Palpable 1 cm below right costal margin | Exam Action 04/11/20 11:06 PM MDT | |
| Palpated for spleen: Not palpable | Exam Action 04/11/20 11:07 PM MDT | |
| Palpated for right kidney: Not palpable | Exam Action 04/11/20 11:07 PM MDT | |
| Palpated for left kidney: Not palpable | Exam Action 04/11/20 11:07 PM MDT | |
| Tested skin turgor | Exam Action 04/11/20 11:08 PM MDT | |
| Percussed right lower quadrant | Exam Action 04/11/20 11:09 PM MDT | |
| Percussed right upper quadrant | Exam Action 04/11/20 11:09 PM MDT | |
| Percussed left upper quadrant | Exam Action 04/11/20 11:09 PM MDT | |
| Percussed left lower quadrant | Exam Action 04/11/20 11:09 PM MDT | |
| Percussed spleen | Exam Action 04/11/20 11:10 PM MDT | |
| Percussed spleen | Exam Action 04/11/20 11:10 PM MDT | |
| Percussed for liver span: 7 cm in the mid-clavicular line | Exam Action 04/11/20 11:10 PM MDT | |
| Percussed spleen | Exam Action 04/11/20 11:11 PM MDT | |
| Percussed for liver span: 7 cm in the mid-clavicular line | Exam Action 04/11/20 11:11 PM MDT | |
| Percussed spleen | Exam Action 04/11/20 11:17 PM MDT | |
| Percussed for liver span: 7 cm in the mid-clavicular line | Exam Action 04/11/20 11:17 PM MDT | |
| Performed EKG | Exam Action 04/11/20 11:20 PM MDT |
Also read: Tina Jones Mental Health Shadow Health Transcript