Comprehensive Assessment with Barriers to Care – Tanner Bailey Transcript
Transcript
Started: Mar 25, 2024 | Total Time: 99 min
All Lines (314)Interview Questions (50)Statements (10)Exam Actions (254)
| Hi… my name is Mr. Bui a medical practitioner, and I will be assessing you today. | Greet 03/25/24 10:38 PM MDT | |
| I’m Tanner Bailey. My pronouns are he/him. | ||
| How would you love to be addressed | Question 03/25/24 10:38 PM MDT | |
| Tanners fine. Mr. Bailey if youre feeling formal. | ||
| That’s fine. I will use either. (No matching questions found.) | Question 03/25/24 10:39 PM MDT | |
| How has your day been? | Question 03/25/24 10:39 PM MDT | |
| I guess my day is going OK. I went to a poetry reading this morning where some of my friends performed. | ||
| How did the poetry reading go? | Question 03/25/24 10:40 PM MDT | |
| It went great! One of my friends was super nervous but everyone in the crowd really loved her. | ||
| So Mr. Bailey, you indicated you are here to establish a new primary care provider. I will have to conduct a comprehensive health assessment for you. | Question 03/25/24 10:41 PM MDT | |
| OK, Im up for that. | ||
| During the assessment, one is required to wear a gown or a privacy drape, which one would you prefer? | Question 03/25/24 10:42 PM MDT | |
| I guess Ill go with the privacy drape for my chest. Thanks for asking. | ||
| Is there anything you would like me to know before we proceed? | Question 03/25/24 10:42 PM MDT | |
| Im trans, and Im not super comfortable with people looking at certain parts of my body. So, if you could do your best let me stay as covered as possible while youre doing the assessment, that would help a lot. Also, if you could use the terms chest and genitals when talking about those parts, rather than whatevers on your form, Id appreciate it. Those are just the terms Im more comfortable with. | ||
| Thank you for sharing you concerns. I understand. I will do my best to ensure you have a comfortable exam | Empathize 03/25/24 10:43 PM MDT | |
| Sounds good. Im OK moving forward with the assessment. Thanks for taking the time to talk with me. It really makes me feel more comfortable. | ||
| Mr Bailey, what brings you in today? | Question 03/25/24 10:44 PM MDT | |
| I came in today because I wanted help getting set up with a new provider. And I know you have to give me an assessment before we can get to the next step of that process. | ||
| That is true. It is important to conduct a physical health assessment before establishing care provider relationships. | Educate 03/25/24 10:46 PM MDT | |
| Thanks. That could be really useful. | ||
| Which language are you comfortable using? (No matching questions found.) | Question 03/25/24 10:46 PM MDT | |
| Tell me about your religious and cultural practices | Question 03/25/24 10:47 PM MDT | |
| I can’t think of any cultural or religious considerations that you’d have to worry about. | ||
| Is there language preference (Clarified to Do you have a language preference?.) | Question 03/25/24 10:47 PM MDT | |
| Um, English. It’s funny, I don’t think I’ve ever been asked that question in a clinic before. (Clarified to if I have a language preference.) | ||
| Do you have any current health concerns | Question 03/25/24 10:47 PM MDT | |
| Nope. | ||
| Tell me about your overall health | Question 03/25/24 10:48 PM MDT | |
| I think I’m pretty healthy. | ||
| Tell me about your breast health | Question 03/25/24 10:48 PM MDT | |
| That’s fine. It’s just that, I’d rather you say “chest.” | ||
| Tell me how your chest is | Question 03/25/24 10:48 PM MDT | |
| The binder can be a little uncomfortable, but that’s OK. A lot of healthcare professionals don’t get it, though, and they can end up being kind of pushy about wanting me to get a different one or even stop binding altogether. I don’t have any other kind of chest pain or discomfort. I do my own chest exams every month, and it’s always normal. | ||
| I am sorry to hear about your negative experiences with other health professionals. | Empathize 03/25/24 10:49 PM MDT | |
| Thanks. There’s been so much going on, it’s nice to feel like someone’s in my corner. | ||
| Have you ever had a surgery | Question 03/25/24 10:50 PM MDT | |
| I haven’t had any surgeries. | ||
| When last did you visit a healthcare provider | Question 03/25/24 10:50 PM MDT | |
| My last visit was related to my T prescription, about three months back. That’s when I learned that their practice is closing and that I’d need to get a new provider. And I know how hard it is to find somebody with a trans-affirmative practice. It took me long enough to find the last guy. | ||
| Do you have any current prescription medication | Question 03/25/24 10:50 PM MDT | |
| I have a prescription for the testosterone I take. Delatestryl. | ||
| What dosage of Delatestryl do you take (Clarified to What dose is the testosterone?.) | Question 03/25/24 10:51 PM MDT | |
| The testosterone enanthate I take is 100 milligrams a dose. (Clarified to what dose the testosterone is.) | ||
| When last did you take the testosterone | Question 03/25/24 10:51 PM MDT | |
| I took my weekly dose of testosterone two days ago. | ||
| Have you ever missed a dose of the testosterone | Question 03/25/24 10:52 PM MDT | |
| Nope, never missed a dose. | ||
| Do you take any OTC medications | Question 03/25/24 10:52 PM MDT | |
| I haven’t been taking any over-the-counter medications. | ||
| Do you take any daily vitamins | Question 03/25/24 10:52 PM MDT | |
| I don’t use any vitamins or supplements. No herbal remedies, either. | ||
| Do you have any allergies | Question 03/25/24 10:53 PM MDT | |
| I’ve never had allergies. | ||
| Are you allergic to latex | Question 03/25/24 10:53 PM MDT | |
| I don’t have a latex allergy. | ||
| Are you allergic to any medication | Question 03/25/24 10:53 PM MDT | |
| I don’t have any medication allergies. | ||
| Tell me about your diet | Question 03/25/24 10:53 PM MDT | |
| I eat a lot of lean protein because I want to build muscle. For breakfast I usually have eggs, bacon, and fruit. For lunch it’s some form of chicken or tuna salad and chips. Sometimes I just eat a protein bar if I’m super busy. For dinner, I like chicken or steak, potatoes, veggies . . . I try to keep it balanced. | ||
| That’s great. Taking a balanced diet is important for our health. | Educate 03/25/24 10:54 PM MDT | |
| Yeah, I think maybe that could help. | ||
| Do you take caffeine | Question 03/25/24 10:54 PM MDT | |
| I drink one or two cups of coffee a day. Sometimes swapping a cup out for an espresso shot, if I’m working at the coffee shop. | ||
| That caffeine amount is within the recommended daily intake. Be sure not to exceed that though. | Educate 03/25/24 10:55 PM MDT | |
| Thanks for the help. | ||
| Do you take alcohol | Question 03/25/24 10:55 PM MDT | |
| I drink one or two times a month, with friends. Normally I have a shot or two of whiskey at a time, but I don’t drink much these days. | ||
| Alcohol consumption is not good for health. try as much as possible to reduce your intake further, or better still, eliminate it from your diet. | Educate 03/25/24 10:58 PM MDT | |
| OK, I’ll look into that. | ||
| Do you smoke cigarettes | Question 03/25/24 10:58 PM MDT | |
| Yuck. A lot of my theater crew smokes, but I don’t. | ||
| Do you smoke marijuana | Question 03/25/24 10:58 PM MDT | |
| I’ve never smoked. Not pot, or tobacco, or anything else. I don’t smoke or vape or use a hookah. | ||
| Do you use any recreational drug | Question 03/25/24 10:59 PM MDT | |
| No. I’ve never used drugs. | ||
| Do you exercise | Question 03/25/24 10:59 PM MDT | |
| I work out 6 to 8 hours a week at the gym. | ||
| That’s great. Exercise is good for health. Keep it up. | Educate 03/25/24 11:00 PM MDT | |
| It’s something to consider, definitely. | ||
| Tell me about your mental health status (Clarified to Can you tell me about your psychiatric history?.) | Question 03/25/24 11:00 PM MDT | |
| Not much to tell. Never been diagnosed with anything psychiatric . . . well, gender dysphoria three and a half years ago. At the time, that was technically a mental disorder diagnosis. I prefer the newer term, “gender incongruence.” And, like, it was never great for being trans to be classified as a mental health disorder, and I’m not really thrilled that there’s still a diagnosis for it at all. I mean, it’s not an illness. (Clarified to to tell you about my psychiatric history.) | ||
| Well, it takes time before the mainstream sectors come to pace with certain changes. The good thing is that within the medical field, we all can now get the healthcare services we need. Much needs to be done nonetheless. | Educate 03/25/24 11:03 PM MDT | |
| Thanks for the help. | ||
| How is your sleep patter | Question 03/25/24 11:03 PM MDT | |
| I’ve been sleeping well; no issues there. | ||
| Do you wake up well-rested | Question 03/25/24 11:03 PM MDT | |
| I usually sleep pretty well and feel good the next morning. | ||
| Tell me about your social support system | Question 03/25/24 11:03 PM MDT | |
| I have a few close friends I can call on for support. They’re good people. Aside from them, my brother. And my mom, when she’s sober. | ||
| I am glad to know that you have a good social support support system. It does count for one’s health. | Educate 03/25/24 11:04 PM MDT | |
| Yeah, I think maybe that could help. | ||
| How is your access to healthcare like (Clarified to Is money a barrier to your access to healthcare?.) | Question 03/25/24 11:04 PM MDT | |
| Money can be tight, and it’s really tight right now, but so far, I’ve been able to see providers and get medication, even without health insurance. So I’ve consistently been able to get my testosterone, at least. (Clarified to if I have difficulty accessing healthcare because of finances.) | ||
| Tell me about your mother’s health history | Question 03/25/24 11:05 PM MDT | |
| My mother drinks. She has alcohol use disorder. She’s depressed, too. | ||
| Am sorry to hear that | Empathize 03/25/24 11:05 PM MDT | |
| Things have been pretty stressful lately, so thanks for saying that. | ||
| Tell me about your father’s health history | Question 03/25/24 11:05 PM MDT | |
| My dad’s health is fine. | ||
| Assessed vitals | Exam Action 03/25/24 11:06 PM MDT | |
| Assessed general appearance: patient does appear to be stated age, nutritional status is well developed, posture is upright, no physical deformities present. Mobility is unlimited, facial expression is appropriate for situation, clothing is kempt and grooming is clean. | Exam Action 03/25/24 11:07 PM MDT | |
| what is your date of birth | Question 03/25/24 11:08 PM MDT | |
| My name is Tanner Bailey, and I was born on August 18th. | ||
| Evaluated orientation to person: Oriented to person | Exam Action 03/25/24 11:08 PM MDT | |
| What building are you in now | Question 03/25/24 11:08 PM MDT | |
| I’m at the Shadowville Community Health Center. | ||
| Evaluated orientation to place: Oriented to place | Exam Action 03/25/24 11:08 PM MDT | |
| What is the date and year | Question 03/25/24 11:08 PM MDT | |
| Um, today’s date is . . . [Mr. Bailey reports correct date and year]. | ||
| Evaluated orientation to time: Oriented to time | Exam Action 03/25/24 11:08 PM MDT | |
| Assessed speech: rate of speech and volume are appropriate, no abnormalities with articulation | Exam Action 03/25/24 11:09 PM MDT | |
| Have you experienced any mood changes recently | Question 03/25/24 11:10 PM MDT | |
| I haven’t really had any mood changes. | ||
| Do you feel anxious at times | Question 03/25/24 11:10 PM MDT | |
| I don’t have any mental health disorders. No generalized anxiety, no depression. Sure, I can get anxious about stuff sometimes, but nothing like at the level of a disorder. | ||
| Do you feel angry at times (No matching questions found.) | Question 03/25/24 11:10 PM MDT | |
| Assessed mood and affect: stable mood throughout the interview; full or balanced affect | Exam Action 03/25/24 11:10 PM MDT | |
| Inspected general head and face | Exam Action 03/25/24 11:10 PM MDT | |
| Inspected general head and face | Exam Action 03/25/24 11:11 PM MDT | |
| Inspected general head and face | Exam Action 03/25/24 11:11 PM MDT | |
| Inspected forehead and scalp | Exam Action 03/25/24 11:11 PM MDT | |
| Inspected general head and face | Exam Action 03/25/24 11:11 PM MDT | |
| Inspected general head and face | Exam Action 03/25/24 11:11 PM MDT | |
| Inspected front of neck | Exam Action 03/25/24 11:11 PM MDT | |
| Inspected left side of neck | Exam Action 03/25/24 11:11 PM MDT | |
| Inspected back of neck | Exam Action 03/25/24 11:11 PM MDT | |
| Inspected right side of neck | Exam Action 03/25/24 11:11 PM MDT | |
| Inspected front of neck | Exam Action 03/25/24 11:11 PM MDT | |
| Inspected right side of neck | Exam Action 03/25/24 11:11 PM MDT | |
| Inspected front of neck | Exam Action 03/25/24 11:11 PM MDT | |
| Inspected right orbital area, sclera, and conjunctiva: conjunctiva is moist and pink with no discharge | Exam Action 03/25/24 11:12 PM MDT | |
| Inspected left orbital area, sclera, and conjunctiva: conjunctiva is moist and pink with no discharge | Exam Action 03/25/24 11:12 PM MDT | |
| Inspected mouth: Oral mucosa and lips are moist and pink, teeth have no abnormal findings, gums are pink, tongue is moist and pink, and uvula is midline, intact, and soft palate rises | Exam Action 03/25/24 11:13 PM MDT | |
| Inspected right ear | Exam Action 03/25/24 11:14 PM MDT | |
| Inspected left ear | Exam Action 03/25/24 11:14 PM MDT | |
| Inspected right ear | Exam Action 03/25/24 11:14 PM MDT | |
| Inspected left ear | Exam Action 03/25/24 11:14 PM MDT | |
| Inspected right ear | Exam Action 03/25/24 11:14 PM MDT | |
| Inspected left ear | Exam Action 03/25/24 11:15 PM MDT | |
| Inspected right ear | Exam Action 03/25/24 11:15 PM MDT | |
| Inspected left ear | Exam Action 03/25/24 11:15 PM MDT | |
| Tested corneal light reflex: symmetric and present | Exam Action 03/25/24 11:15 PM MDT | |
| Tested right pupillary reaction with penlight | Exam Action 03/25/24 11:15 PM MDT | |
| Tested left pupillary reaction with penlight | Exam Action 03/25/24 11:16 PM MDT | |
| Tested right pupillary reaction with penlight | Exam Action 03/25/24 11:16 PM MDT | |
| Tested left pupillary reaction with penlight | Exam Action 03/25/24 11:16 PM MDT | |
| Performed otoscopic examination of right naris: naris is patent | Exam Action 03/25/24 11:16 PM MDT | |
| Performed otoscopic examination of left naris: naris is patent | Exam Action 03/25/24 11:16 PM MDT | |
| Tested EOMs, convergence, and confrontation: Cardinal fields and convergence no abnormal findings, visual fields are full by confrontation | Exam Action 03/25/24 11:17 PM MDT | |
| Inspected anterior chest wall: no visible abnormal findings | Exam Action 03/25/24 11:17 PM MDT | |
| Inspected posterior chest wall | Exam Action 03/25/24 11:18 PM MDT | |
| Palpated fremitus in posterior upper chest wall: Present and equal bilaterally, no lumps or tenderness | Exam Action 03/25/24 11:18 PM MDT | |
| Ninety-nine. | ||
| Palpated fremitus in posterior middle chest wall: Present and equal bilaterally, no lumps or tenderness | Exam Action 03/25/24 11:18 PM MDT | |
| Ninety-nine. | ||
| Palpated fremitus in posterior lower chest wall: Present and equal bilaterally, no lumps or tenderness | Exam Action 03/25/24 11:18 PM MDT | |
| Ninety-nine. | ||
| Palpated fremitus in anterior upper chest wall: Present and equal bilaterally, no lumps or tenderness | Exam Action 03/25/24 11:19 PM MDT | |
| Ninety-nine. | ||
| Palpated fremitus in anterior lower chest wall: Present and equal bilaterally, no lumps or tenderness | Exam Action 03/25/24 11:19 PM MDT | |
| Ninety-nine. | ||
| Percussed posterior left upper lobe | Exam Action 03/25/24 11:19 PM MDT | |
| Percussed posterior right upper lobe | Exam Action 03/25/24 11:19 PM MDT | |
| Percussed posterior right mid-back (lower lobe) | Exam Action 03/25/24 11:19 PM MDT | |
| Percussed posterior left mid-back (lower lobe) | Exam Action 03/25/24 11:19 PM MDT | |
| Percussed posterior left lower lobe | Exam Action 03/25/24 11:19 PM MDT | |
| Percussed posterior right lower lobe | Exam Action 03/25/24 11:19 PM MDT | |
| Percussed posterior left lower lobe on side | Exam Action 03/25/24 11:19 PM MDT | |
| Percussed posterior left lower lobe near spine | Exam Action 03/25/24 11:19 PM MDT | |
| Percussed posterior right lower lobe near spine | Exam Action 03/25/24 11:19 PM MDT | |
| Percussed posterior right lower lobe on side | Exam Action 03/25/24 11:19 PM MDT | |
| Percussed anterior right upper lobe | Exam Action 03/25/24 11:20 PM MDT | |
| Percussed anterior left upper lobe | Exam Action 03/25/24 11:20 PM MDT | |
| Percussed anterior right middle lobe | Exam Action 03/25/24 11:20 PM MDT | |
| Percussed anterior left mid-chest (upper lobe) | Exam Action 03/25/24 11:20 PM MDT | |
| Percussed anterior left lower lobe | Exam Action 03/25/24 11:20 PM MDT | |
| Percussed anterior right lower lobe | Exam Action 03/25/24 11:20 PM MDT | |
| Auscultated breath sounds in posterior left upper lobe | Exam Action 03/25/24 11:20 PM MDT | |
| Auscultated breath sounds in posterior right upper lobe | Exam Action 03/25/24 11:20 PM MDT | |
| Auscultated breath sounds in posterior left mid-back (lower lobe) | Exam Action 03/25/24 11:20 PM MDT | |
| Auscultated breath sounds in posterior right mid-back (lower lobe) | Exam Action 03/25/24 11:20 PM MDT | |
| Auscultated breath sounds in posterior left lower lobe | Exam Action 03/25/24 11:20 PM MDT | |
| Auscultated breath sounds in posterior right lower lobe | Exam Action 03/25/24 11:20 PM MDT | |
| Auscultated breath sounds in posterior left lower lobe on side | Exam Action 03/25/24 11:20 PM MDT | |
| Auscultated breath sounds in posterior left lower lobe near spine | Exam Action 03/25/24 11:21 PM MDT | |
| Auscultated breath sounds in posterior right lower lobe near spine | Exam Action 03/25/24 11:21 PM MDT | |
| Auscultated breath sounds in posterior right lower lobe on side | Exam Action 03/25/24 11:21 PM MDT | |
| Auscultated breath sounds in anterior right upper lobe | Exam Action 03/25/24 11:21 PM MDT | |
| Auscultated breath sounds in anterior left upper lobe | Exam Action 03/25/24 11:21 PM MDT | |
| Auscultated breath sounds in anterior right middle lobe | Exam Action 03/25/24 11:21 PM MDT | |
| Auscultated breath sounds in anterior left mid-chest (upper lobe) | Exam Action 03/25/24 11:22 PM MDT | |
| Auscultated breath sounds in anterior right lower lobe | Exam Action 03/25/24 11:22 PM MDT | |
| Auscultated breath sounds in anterior left lower lobe | Exam Action 03/25/24 11:22 PM MDT | |
| Inspected anterior chest wall: no visible abnormal findings | Exam Action 03/25/24 11:31 PM MDT | |
| Palpated right brachial pulse: No thrill, 2+ | Exam Action 03/25/24 11:33 PM MDT | |
| Palpated right radial pulse: No thrill, 2+ | Exam Action 03/25/24 11:33 PM MDT | |
| Palpated left brachial pulse: No thrill, 2+ | Exam Action 03/25/24 11:33 PM MDT | |
| Palpated left radial pulse: No thrill, 2+ | Exam Action 03/25/24 11:33 PM MDT | |
| Palpated chest at PMI: Present at midclavicular line and 5th intercostal space, brisk and tapping, diameter 2 cm | Exam Action 03/25/24 11:33 PM MDT | |
| Palpated right carotid pulse: No thrill, 2+ | Exam Action 03/25/24 11:34 PM MDT | |
| Palpated left carotid pulse: No thrill, 2+ | Exam Action 03/25/24 11:34 PM MDT | |
| Auscultated right carotid pulse | Exam Action 03/25/24 11:34 PM MDT | |
| Auscultated left carotid pulse | Exam Action 03/25/24 11:34 PM MDT | |
| Auscultated aortic area with the bell | Exam Action 03/25/24 11:35 PM MDT | |
| Auscultated pulmonic area with the bell | Exam Action 03/25/24 11:35 PM MDT | |
| Auscultated Erb’s point with the bell | Exam Action 03/25/24 11:35 PM MDT | |
| Auscultated tricuspid area with the bell | Exam Action 03/25/24 11:35 PM MDT | |
| Auscultated mitral area with the bell | Exam Action 03/25/24 11:35 PM MDT | |
| Inspected for jugular venous distension: JVP 1 cm above sternal angle | Exam Action 03/25/24 11:35 PM MDT | |
| Inspected left leg for edema: No edema | Exam Action 03/25/24 11:36 PM MDT | |
| Inspected right leg for edema: No edema | Exam Action 03/25/24 11:36 PM MDT | |
| Palpated all lower peripheral pulses: all pulses no thrill, 2+ | Exam Action 03/25/24 11:36 PM MDT | |
| Checked capillary refill in fingernails: refill time less than 3 seconds | Exam Action 03/25/24 11:37 PM MDT | |
| Checked capillary refill in toes: refill time less than 3 seconds | Exam Action 03/25/24 11:37 PM MDT | |
| Inspected left side of abdomen | Exam Action 03/25/24 11:37 PM MDT | |
| Inspected front of abdomen | Exam Action 03/25/24 11:38 PM MDT | |
| Inspected right side of abdomen | Exam Action 03/25/24 11:38 PM MDT | |
| Palpated right upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension | Exam Action 03/25/24 11:38 PM MDT | |
| Palpated left upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension | Exam Action 03/25/24 11:38 PM MDT | |
| Palpated left lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension | Exam Action 03/25/24 11:38 PM MDT | |
| Palpated right lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension | Exam Action 03/25/24 11:38 PM MDT | |
| Percussed left flank for CVA tenderness | Exam Action 03/25/24 11:39 PM MDT | |
| Percussed right flank for CVA tenderness | Exam Action 03/25/24 11:39 PM MDT | |
| Auscultated right upper quadrant | Exam Action 03/25/24 11:39 PM MDT | |
| Auscultated left upper quadrant | Exam Action 03/25/24 11:39 PM MDT | |
| Auscultated left lower quadrant | Exam Action 03/25/24 11:39 PM MDT | |
| Auscultated right lower quadrant | Exam Action 03/25/24 11:39 PM MDT | |
| Percussed right upper quadrant | Exam Action 03/25/24 11:40 PM MDT | |
| Percussed left upper quadrant | Exam Action 03/25/24 11:40 PM MDT | |
| Percussed left lower quadrant | Exam Action 03/25/24 11:40 PM MDT | |
| Percussed right lower quadrant | Exam Action 03/25/24 11:40 PM MDT | |
| Percussed spleen | Exam Action 03/25/24 11:40 PM MDT | |
| Tested ROM of neck – extension: Expected | Exam Action 03/25/24 11:40 PM MDT | |
| Tested ROM of neck – flexion: Expected | Exam Action 03/25/24 11:41 PM MDT | |
| Tested ROM of neck – lateral bending: Expected | Exam Action 03/25/24 11:41 PM MDT | |
| Tested ROM of neck – rotation: Expected | Exam Action 03/25/24 11:41 PM MDT | |
| Tested spinal ROM – extension: Expected | Exam Action 03/25/24 11:41 PM MDT | |
| Tested spinal ROM – flexion: Expected | Exam Action 03/25/24 11:41 PM MDT | |
| Tested spinal ROM – lateral bending: Expected | Exam Action 03/25/24 11:42 PM MDT | |
| Tested spinal ROM – rotation to the left: Expected | Exam Action 03/25/24 11:42 PM MDT | |
| Tested spinal ROM – rotation to the right: Expected | Exam Action 03/25/24 11:42 PM MDT | |
| Tested ROM of shoulders – adduction: Expected | Exam Action 03/25/24 11:42 PM MDT | |
| Tested ROM of shoulders – extension: Expected | Exam Action 03/25/24 11:42 PM MDT | |
| Tested ROM of shoulders – flexion: Expected | Exam Action 03/25/24 11:43 PM MDT | |
| Tested neck strength: 5/5 | Exam Action 03/25/24 11:43 PM MDT | |
| Tested right and left shoulder strength: 5/5 | Exam Action 03/25/24 11:43 PM MDT | |
| Tested left and right elbow strength during flexion and extension: 5/5 | Exam Action 03/25/24 11:43 PM MDT | |
| Tested ROM of elbows – flexion and extension: Expected | Exam Action 03/25/24 11:44 PM MDT | |
| Tested ROM of elbows – supination and pronation: Expected | Exam Action 03/25/24 11:44 PM MDT | |
| Tested ROM of wrists – ulnar and radial deviation: Expected | Exam Action 03/25/24 11:44 PM MDT | |
| Tested ROM of wrists – extension: Expected | Exam Action 03/25/24 11:44 PM MDT | |
| Tested ROM of wrists – flexion: Expected | Exam Action 03/25/24 11:44 PM MDT | |
| Tested hand and wrist strength: 5/5 | Exam Action 03/25/24 11:45 PM MDT | |
| Tested ROM of hips – abduction: Expected | Exam Action 03/25/24 11:45 PM MDT | |
| Tested ROM of hips – adduction: Expected | Exam Action 03/25/24 11:46 PM MDT | |
| Tested ROM of hips – extension: Expected | Exam Action 03/25/24 11:46 PM MDT | |
| Tested ROM of hips – flexion: Expected | Exam Action 03/25/24 11:46 PM MDT | |
| Tested ROM of knees – extension: Expected | Exam Action 03/25/24 11:46 PM MDT | |
| Tested ROM of knees – flexion: Expected | Exam Action 03/25/24 11:47 PM MDT | |
| Tested ROM of ankles – inversion and eversion: Expected | Exam Action 03/25/24 11:47 PM MDT | |
| Tested ROM of ankles – dorsiflexion and plantar flexion: Expected | Exam Action 03/25/24 11:47 PM MDT | |
| Tested right and left hip strength: 5/5 | Exam Action 03/25/24 11:47 PM MDT | |
| Tested right and left knee strength: 5/5 | Exam Action 03/25/24 11:48 PM MDT | |
| Tested right and left ankle strength: 5/5 | Exam Action 03/25/24 11:48 PM MDT | |
| Tested patient’s shallow knee bend: patient displays full ROM | Exam Action 03/25/24 11:48 PM MDT | |
| Tested patient’s ability to walk heel to toe: patient displays appropriate coordination | Exam Action 03/25/24 11:48 PM MDT | |
| Tested patient’s ability to walk on tiptoes, then walk on heels: patient displays appropriate coordination | Exam Action 03/25/24 11:48 PM MDT | |
| Close your eyes and tell me if the touch is sharp, dull, or soft. | Question 03/25/24 11:49 PM MDT | |
| Ok. | ||
| Tested facial sensation: dull stimulus | Exam Action 03/25/24 11:49 PM MDT | |
| Dull. | ||
| Tested facial sensation: dull stimulus | Exam Action 03/25/24 11:49 PM MDT | |
| Dull. | ||
| Tested facial sensation: dull stimulus | Exam Action 03/25/24 11:49 PM MDT | |
| Dull. | ||
| Tested facial sensation: dull stimulus | Exam Action 03/25/24 11:49 PM MDT | |
| Dull. | ||
| Tested facial sensation: soft stimulus | Exam Action 03/25/24 11:50 PM MDT | |
| Soft. | ||
| Tested facial sensation: soft stimulus | Exam Action 03/25/24 11:50 PM MDT | |
| Soft. | ||
| Tested facial sensation: soft stimulus | Exam Action 03/25/24 11:50 PM MDT | |
| Soft. | ||
| Tested facial sensation: soft stimulus | Exam Action 03/25/24 11:50 PM MDT | |
| Soft. | ||
| Tested facial sensation: sharp stimulus | Exam Action 03/25/24 11:50 PM MDT | |
| Sharp. | ||
| Tested facial sensation: sharp stimulus | Exam Action 03/25/24 11:50 PM MDT | |
| Sharp. | ||
| Tested facial sensation: sharp stimulus | Exam Action 03/25/24 11:50 PM MDT | |
| Sharp. | ||
| Tested facial sensation: sharp stimulus | Exam Action 03/25/24 11:50 PM MDT | |
| Sharp. | ||
| Close your eyes and tell me if the touch is sharp, dull, or soft. | Question 03/25/24 11:51 PM MDT | |
| Ok. | ||
| Tested right arm proximal sharp sensation | Exam Action 03/25/24 11:51 PM MDT | |
| Sharp. | ||
| Tested right arm distal sharp sensation | Exam Action 03/25/24 11:51 PM MDT | |
| Sharp. | ||
| Tested left arm proximal sharp sensation | Exam Action 03/25/24 11:51 PM MDT | |
| Tested left arm proximal sharp sensation | Exam Action 03/25/24 11:51 PM MDT | |
| Sharp. | ||
| Tested left arm distal sharp sensation | Exam Action 03/25/24 11:51 PM MDT | |
| Sharp. | ||
| Tested chest sharp sensation | Exam Action 03/25/24 11:51 PM MDT | |
| Sharp. | ||
| Tested right hand: expected sensation | Exam Action 03/25/24 11:51 PM MDT | |
| Tested left hand: expected sensation | Exam Action 03/25/24 11:51 PM MDT | |
| Tested right arm proximal light sensation | Exam Action 03/25/24 11:51 PM MDT | |
| Soft. | ||
| Tested right arm distal light sensation | Exam Action 03/25/24 11:51 PM MDT | |
| Soft. | ||
| Tested left arm proximal light sensation | Exam Action 03/25/24 11:51 PM MDT | |
| Soft. | ||
| Tested left arm distal light sensation | Exam Action 03/25/24 11:51 PM MDT | |
| Soft. | ||
| Tested chest light sensation | Exam Action 03/25/24 11:51 PM MDT | |
| Soft. | ||
| Tested chest light sensation | Exam Action 03/25/24 11:51 PM MDT | |
| Soft. | ||
| Tested left hand: expected sensation | Exam Action 03/25/24 11:51 PM MDT | |
| Tested right arm proximal dull sensation | Exam Action 03/25/24 11:52 PM MDT | |
| Dull. | ||
| Tested right arm distal dull sensation | Exam Action 03/25/24 11:52 PM MDT | |
| Dull. | ||
| Tested left arm proximal dull sensation | Exam Action 03/25/24 11:52 PM MDT | |
| Dull. | ||
| Tested left arm distal dull sensation | Exam Action 03/25/24 11:52 PM MDT | |
| Tested left arm proximal dull sensation | Exam Action 03/25/24 11:52 PM MDT | |
| Dull. | ||
| Tested chest dull sensation | Exam Action 03/25/24 11:52 PM MDT | |
| Dull. | ||
| Tested left hand: expected sensation | Exam Action 03/25/24 11:52 PM MDT | |
| Close your eyes and tell me if the touch is sharp, dull, or soft. | Question 03/25/24 11:52 PM MDT | |
| Ok. | ||
| Tested right leg proximal dull sensation | Exam Action 03/25/24 11:53 PM MDT | |
| Dull. | ||
| Tested right leg distal dull sensation | Exam Action 03/25/24 11:53 PM MDT | |
| Dull. | ||
| Tested left leg proximal dull sensation | Exam Action 03/25/24 11:53 PM MDT | |
| Dull. | ||
| Tested left leg distal dull sensation | Exam Action 03/25/24 11:53 PM MDT | |
| Dull. | ||
| Tested right leg proximal sharp sensation | Exam Action 03/25/24 11:53 PM MDT | |
| Sharp. | ||
| Tested right leg distal sharp sensation | Exam Action 03/25/24 11:53 PM MDT | |
| Sharp. | ||
| Tested left leg proximal sharp sensation | Exam Action 03/25/24 11:53 PM MDT | |
| Sharp. | ||
| Tested left leg distal sharp sensation | Exam Action 03/25/24 11:53 PM MDT | |
| Sharp. | ||
| Tested right leg proximal light sensation | Exam Action 03/25/24 11:53 PM MDT | |
| Soft. | ||
| Tested right leg distal light sensation | Exam Action 03/25/24 11:53 PM MDT | |
| Soft. | ||
| Tested left leg proximal light sensation | Exam Action 03/25/24 11:53 PM MDT | |
| Soft. | ||
| Tested left leg distal light sensation | Exam Action 03/25/24 11:53 PM MDT | |
| Soft. | ||
| Close your eyes and tell me when you feel the touch | Question 03/25/24 11:54 PM MDT | |
| Ok, I will. | ||
| Tested sensation of right big toe with monofilament | Exam Action 03/25/24 11:54 PM MDT | |
| Yes. | ||
| Tested sensation of left big toe with monofilament | Exam Action 03/25/24 11:54 PM MDT | |
| Yes. | ||
| Tested sensation of left ball of foot under small toe with monofilament | Exam Action 03/25/24 11:54 PM MDT | |
| Yes. | ||
| Tested sensation of right ball of foot with monofilament | Exam Action 03/25/24 11:54 PM MDT | |
| Yes. | ||
| Tested sensation of left heel with monofilament | Exam Action 03/25/24 11:54 PM MDT | |
| Yes. | ||
| Tested sensation of left ball of foot under big toe with monofilament | Exam Action 03/25/24 11:54 PM MDT | |
| Yes. | ||
| Tested sensation of right ball of foot under big toe with monofilament | Exam Action 03/25/24 11:54 PM MDT | |
| Yes. | ||
| Tested sensation of right heel with monofilament | Exam Action 03/25/24 11:54 PM MDT | |
| Yes. | ||
| Tested reflexes of left and right biceps, triceps, and brachioradialis: 2+ | Exam Action 03/25/24 11:55 PM MDT | |
| Tested reflexes of left and right patellar and achilles tendon: 2+ | Exam Action 03/25/24 11:55 PM MDT | |
| Inspected forehead and scalp | Exam Action 03/25/24 11:55 PM MDT | |
| Inspected left and right toenails: no ridges or abnormalities | Exam Action 03/25/24 11:56 PM MDT | |
| Inspected fingernails of left and right hands: no ridges or abnormalities | Exam Action 03/25/24 11:56 PM MDT | |
| Inspected general skin: skin texture is even, skin moisture is moist, and skin temperature is warm | Exam Action 03/25/24 11:56 PM MDT | |
| Inspected left and right feet: no visible abnormal findings | Exam Action 03/25/24 11:56 PM MDT | |
| Inspected front of legs | Exam Action 03/25/24 11:56 PM MDT | |
| Inspected front of ankles | Exam Action 03/25/24 11:56 PM MDT | |
| Inspected front of knees | Exam Action 03/25/24 11:56 PM MDT | |
| Inspected front of hips | Exam Action 03/25/24 11:56 PM MDT | |
| Inspected right leg | Exam Action 03/25/24 11:56 PM MDT | |
| Inspected right knee | Exam Action 03/25/24 11:56 PM MDT | |
| Inspected right side of hips | Exam Action 03/25/24 11:57 PM MDT | |
| Inspected right ankle | Exam Action 03/25/24 11:57 PM MDT | |
| Inspected back of legs | Exam Action 03/25/24 11:57 PM MDT | |
| Inspected back of hips | Exam Action 03/25/24 11:57 PM MDT | |
| Inspected back of knees | Exam Action 03/25/24 11:57 PM MDT | |
| Inspected left leg | Exam Action 03/25/24 11:57 PM MDT | |
| Inspected left side of hips | Exam Action 03/25/24 11:57 PM MDT | |
| Inspected left knee | Exam Action 03/25/24 11:57 PM MDT | |
| Inspected left ankle | Exam Action 03/25/24 11:57 PM MDT | |
| Inspected anterior chest wall: no visible abnormal findings | Exam Action 03/25/24 11:57 PM MDT | |
| Inspected left and right hands | Exam Action 03/25/24 11:57 PM MDT | |
| Inspected left and right arms | Exam Action 03/25/24 11:57 PM MDT | |
| Inspected left side chest wall | Exam Action 03/25/24 11:57 PM MDT | |
| Inspected left shoulder | Exam Action 03/25/24 11:57 PM MDT | |
| Inspected left elbow | Exam Action 03/25/24 11:57 PM MDT | |
| Inspected back | Exam Action 03/25/24 11:57 PM MDT | |
| Inspected upper back and shoulders | Exam Action 03/25/24 11:57 PM MDT | |
| Inspected right side chest wall | Exam Action 03/25/24 11:57 PM MDT | |
| Inspected right shoulder | Exam Action 03/25/24 11:57 PM MDT | |
| Inspected right elbow | Exam Action 03/25/24 11:57 PM MDT | |
| Inspected anterior chest wall: no visible abnormal findings | Exam Action 03/25/24 11:57 PM MDT | |
| Inspected right side chest wall | Exam Action 03/25/24 11:57 PM MDT | |
| Inspected anterior chest wall: no visible abnormal findings | Exam Action 03/25/24 11:57 PM MDT | |
| Inspected general face | Exam Action 03/25/24 11:58 PM MDT | |
| Inspected front of neck | Exam Action 03/25/24 11:58 PM MDT | |
| Inspected right side of face | Exam Action 03/25/24 11:58 PM MDT | |
| Inspected right side of neck | Exam Action 03/25/24 11:58 PM MDT | |
| Inspected back of head | Exam Action 03/25/24 11:58 PM MDT | |
| Inspected back of neck | Exam Action 03/25/24 11:58 PM MDT | |
| Inspected left side of face | Exam Action 03/25/24 11:58 PM MDT | |
| Inspected left side of neck | Exam Action 03/25/24 11:58 PM MDT | |
| Inspected general face | Exam Action 03/25/24 11:59 PM MDT | |
| Inspected left side of face | Exam Action 03/25/24 11:59 PM MDT | |
| Tested skin turgor on forearm | Exam Action 03/25/24 11:59 PM MDT | |
| Tested skin turgor on forearm | Exam Action 03/25/24 11:59 PM MDT |
Comments
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