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 MDTI’m Tanner Bailey. My pronouns are he/him.How would you love to be addressedQuestion
03/25/24 10:38 PM MDTTanners 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 MDTHow has your day been?Question
03/25/24 10:39 PM MDTI 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 MDTIt 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 MDTOK, 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 MDTI 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 MDTIm 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 examEmpathize
03/25/24 10:43 PM MDTSounds 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 MDTI 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 MDTThanks. That could be really useful.Which language are you comfortable using? (No matching questions found.)Question
03/25/24 10:46 PM MDTTell me about your religious and cultural practicesQuestion
03/25/24 10:47 PM MDTI 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 MDTUm, 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 concernsQuestion
03/25/24 10:47 PM MDTNope.Tell me about your overall healthQuestion
03/25/24 10:48 PM MDTI think I’m pretty healthy.Tell me about your breast healthQuestion
03/25/24 10:48 PM MDTThat’s fine. It’s just that, I’d rather you say “chest.”Tell me how your chest isQuestion
03/25/24 10:48 PM MDTThe 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 MDTThanks. There’s been so much going on, it’s nice to feel like someone’s in my corner.Have you ever had a surgeryQuestion
03/25/24 10:50 PM MDTI haven’t had any surgeries.When last did you visit a healthcare providerQuestion
03/25/24 10:50 PM MDTMy 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 medicationQuestion
03/25/24 10:50 PM MDTI 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 MDTThe testosterone enanthate I take is 100 milligrams a dose. (Clarified to what dose the testosterone is.)When last did you take the testosteroneQuestion
03/25/24 10:51 PM MDTI took my weekly dose of testosterone two days ago.Have you ever missed a dose of the testosteroneQuestion
03/25/24 10:52 PM MDTNope, never missed a dose.Do you take any OTC medicationsQuestion
03/25/24 10:52 PM MDTI haven’t been taking any over-the-counter medications.Do you take any daily vitaminsQuestion
03/25/24 10:52 PM MDTI don’t use any vitamins or supplements. No herbal remedies, either.Do you have any allergiesQuestion
03/25/24 10:53 PM MDTI’ve never had allergies.Are you allergic to latexQuestion
03/25/24 10:53 PM MDTI don’t have a latex allergy.Are you allergic to any medicationQuestion
03/25/24 10:53 PM MDTI don’t have any medication allergies.Tell me about your dietQuestion
03/25/24 10:53 PM MDTI 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 MDTYeah, I think maybe that could help.Do you take caffeineQuestion
03/25/24 10:54 PM MDTI 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 MDTThanks for the help.Do you take alcoholQuestion
03/25/24 10:55 PM MDTI 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 MDTOK, I’ll look into that.Do you smoke cigarettesQuestion
03/25/24 10:58 PM MDTYuck. A lot of my theater crew smokes, but I don’t.Do you smoke marijuanaQuestion
03/25/24 10:58 PM MDTI’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 drugQuestion
03/25/24 10:59 PM MDTNo. I’ve never used drugs.Do you exerciseQuestion
03/25/24 10:59 PM MDTI 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 MDTIt’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 MDTNot 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 MDTThanks for the help.How is your sleep patterQuestion
03/25/24 11:03 PM MDTI’ve been sleeping well; no issues there.Do you wake up well-restedQuestion
03/25/24 11:03 PM MDTI usually sleep pretty well and feel good the next morning.Tell me about your social support systemQuestion
03/25/24 11:03 PM MDTI 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 MDTYeah, 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 MDTMoney 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 historyQuestion
03/25/24 11:05 PM MDTMy mother drinks. She has alcohol use disorder. She’s depressed, too.Am sorry to hear thatEmpathize
03/25/24 11:05 PM MDTThings have been pretty stressful lately, so thanks for saying that.Tell me about your father’s health historyQuestion
03/25/24 11:05 PM MDTMy dad’s health is fine. Assessed vitalsExam 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 MDTwhat is your date of birthQuestion
03/25/24 11:08 PM MDTMy name is Tanner Bailey, and I was born on August 18th. Evaluated orientation to person: Oriented to personExam Action
03/25/24 11:08 PM MDTWhat building are you in nowQuestion
03/25/24 11:08 PM MDTI’m at the Shadowville Community Health Center. Evaluated orientation to place: Oriented to placeExam Action
03/25/24 11:08 PM MDTWhat is the date and yearQuestion
03/25/24 11:08 PM MDTUm, today’s date is . . . [Mr. Bailey reports correct date and year]. Evaluated orientation to time: Oriented to timeExam Action
03/25/24 11:08 PM MDT Assessed speech: rate of speech and volume are appropriate, no abnormalities with articulationExam Action
03/25/24 11:09 PM MDTHave you experienced any mood changes recentlyQuestion
03/25/24 11:10 PM MDTI haven’t really had any mood changes.Do you feel anxious at timesQuestion
03/25/24 11:10 PM MDTI 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 affectExam Action
03/25/24 11:10 PM MDT Inspected general head and faceExam Action
03/25/24 11:10 PM MDT Inspected general head and faceExam Action
03/25/24 11:11 PM MDT Inspected general head and faceExam Action
03/25/24 11:11 PM MDT Inspected forehead and scalpExam Action
03/25/24 11:11 PM MDT Inspected general head and faceExam Action
03/25/24 11:11 PM MDT Inspected general head and faceExam Action
03/25/24 11:11 PM MDT Inspected front of neckExam Action
03/25/24 11:11 PM MDT Inspected left side of neckExam Action
03/25/24 11:11 PM MDT Inspected back of neckExam Action
03/25/24 11:11 PM MDT Inspected right side of neckExam Action
03/25/24 11:11 PM MDT Inspected front of neckExam Action
03/25/24 11:11 PM MDT Inspected right side of neckExam Action
03/25/24 11:11 PM MDT Inspected front of neckExam Action
03/25/24 11:11 PM MDT Inspected right orbital area, sclera, and conjunctiva: conjunctiva is moist and pink with no dischargeExam Action
03/25/24 11:12 PM MDT Inspected left orbital area, sclera, and conjunctiva: conjunctiva is moist and pink with no dischargeExam 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 risesExam Action
03/25/24 11:13 PM MDT Inspected right earExam Action
03/25/24 11:14 PM MDT Inspected left earExam Action
03/25/24 11:14 PM MDT Inspected right earExam Action
03/25/24 11:14 PM MDT Inspected left earExam Action
03/25/24 11:14 PM MDT Inspected right earExam Action
03/25/24 11:14 PM MDT Inspected left earExam Action
03/25/24 11:15 PM MDT Inspected right earExam Action
03/25/24 11:15 PM MDT Inspected left earExam Action
03/25/24 11:15 PM MDT Tested corneal light reflex: symmetric and presentExam Action
03/25/24 11:15 PM MDT Tested right pupillary reaction with penlightExam Action
03/25/24 11:15 PM MDT Tested left pupillary reaction with penlightExam Action
03/25/24 11:16 PM MDT Tested right pupillary reaction with penlightExam Action
03/25/24 11:16 PM MDT Tested left pupillary reaction with penlightExam Action
03/25/24 11:16 PM MDT Performed otoscopic examination of right naris: naris is patentExam Action
03/25/24 11:16 PM MDT Performed otoscopic examination of left naris: naris is patentExam 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 confrontationExam Action
03/25/24 11:17 PM MDT Inspected anterior chest wall: no visible abnormal findingsExam Action
03/25/24 11:17 PM MDT Inspected posterior chest wallExam Action
03/25/24 11:18 PM MDT Palpated fremitus in posterior upper chest wall: Present and equal bilaterally, no lumps or tendernessExam Action
03/25/24 11:18 PM MDTNinety-nine. Palpated fremitus in posterior middle chest wall: Present and equal bilaterally, no lumps or tendernessExam Action
03/25/24 11:18 PM MDTNinety-nine. Palpated fremitus in posterior lower chest wall: Present and equal bilaterally, no lumps or tendernessExam Action
03/25/24 11:18 PM MDTNinety-nine. Palpated fremitus in anterior upper chest wall: Present and equal bilaterally, no lumps or tendernessExam Action
03/25/24 11:19 PM MDTNinety-nine. Palpated fremitus in anterior lower chest wall: Present and equal bilaterally, no lumps or tendernessExam Action
03/25/24 11:19 PM MDTNinety-nine. Percussed posterior left upper lobeExam Action
03/25/24 11:19 PM MDT Percussed posterior right upper lobeExam 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 lobeExam Action
03/25/24 11:19 PM MDT Percussed posterior right lower lobeExam Action
03/25/24 11:19 PM MDT Percussed posterior left lower lobe on sideExam Action
03/25/24 11:19 PM MDT Percussed posterior left lower lobe near spineExam Action
03/25/24 11:19 PM MDT Percussed posterior right lower lobe near spineExam Action
03/25/24 11:19 PM MDT Percussed posterior right lower lobe on sideExam Action
03/25/24 11:19 PM MDT Percussed anterior right upper lobeExam Action
03/25/24 11:20 PM MDT Percussed anterior left upper lobeExam Action
03/25/24 11:20 PM MDT Percussed anterior right middle lobeExam 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 lobeExam Action
03/25/24 11:20 PM MDT Percussed anterior right lower lobeExam Action
03/25/24 11:20 PM MDT Auscultated breath sounds in posterior left upper lobeExam Action
03/25/24 11:20 PM MDT Auscultated breath sounds in posterior right upper lobeExam 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 lobeExam Action
03/25/24 11:20 PM MDT Auscultated breath sounds in posterior right lower lobeExam Action
03/25/24 11:20 PM MDT Auscultated breath sounds in posterior left lower lobe on sideExam Action
03/25/24 11:20 PM MDT Auscultated breath sounds in posterior left lower lobe near spineExam Action
03/25/24 11:21 PM MDT Auscultated breath sounds in posterior right lower lobe near spineExam Action
03/25/24 11:21 PM MDT Auscultated breath sounds in posterior right lower lobe on sideExam Action
03/25/24 11:21 PM MDT Auscultated breath sounds in anterior right upper lobeExam Action
03/25/24 11:21 PM MDT Auscultated breath sounds in anterior left upper lobeExam Action
03/25/24 11:21 PM MDT Auscultated breath sounds in anterior right middle lobeExam 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 lobeExam Action
03/25/24 11:22 PM MDT Auscultated breath sounds in anterior left lower lobeExam Action
03/25/24 11:22 PM MDT Inspected anterior chest wall: no visible abnormal findingsExam 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 cmExam 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 pulseExam Action
03/25/24 11:34 PM MDT Auscultated left carotid pulseExam Action
03/25/24 11:34 PM MDT Auscultated aortic area with the bellExam Action
03/25/24 11:35 PM MDT Auscultated pulmonic area with the bellExam Action
03/25/24 11:35 PM MDT Auscultated Erb’s point with the bellExam Action
03/25/24 11:35 PM MDT Auscultated tricuspid area with the bellExam Action
03/25/24 11:35 PM MDT Auscultated mitral area with the bellExam Action
03/25/24 11:35 PM MDT Inspected for jugular venous distension: JVP 1 cm above sternal angleExam Action
03/25/24 11:35 PM MDT Inspected left leg for edema: No edemaExam Action
03/25/24 11:36 PM MDT Inspected right leg for edema: No edemaExam 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 secondsExam Action
03/25/24 11:37 PM MDT Checked capillary refill in toes: refill time less than 3 secondsExam Action
03/25/24 11:37 PM MDT Inspected left side of abdomenExam Action
03/25/24 11:37 PM MDT Inspected front of abdomenExam Action
03/25/24 11:38 PM MDT Inspected right side of abdomenExam Action
03/25/24 11:38 PM MDT Palpated right upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distensionExam Action
03/25/24 11:38 PM MDT Palpated left upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distensionExam Action
03/25/24 11:38 PM MDT Palpated left lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distensionExam Action
03/25/24 11:38 PM MDT Palpated right lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distensionExam Action
03/25/24 11:38 PM MDT Percussed left flank for CVA tendernessExam Action
03/25/24 11:39 PM MDT Percussed right flank for CVA tendernessExam Action
03/25/24 11:39 PM MDT Auscultated right upper quadrantExam Action
03/25/24 11:39 PM MDT Auscultated left upper quadrantExam Action
03/25/24 11:39 PM MDT Auscultated left lower quadrantExam Action
03/25/24 11:39 PM MDT Auscultated right lower quadrantExam Action
03/25/24 11:39 PM MDT Percussed right upper quadrantExam Action
03/25/24 11:40 PM MDT Percussed left upper quadrantExam Action
03/25/24 11:40 PM MDT Percussed left lower quadrantExam Action
03/25/24 11:40 PM MDT Percussed right lower quadrantExam Action
03/25/24 11:40 PM MDT Percussed spleenExam Action
03/25/24 11:40 PM MDT Tested ROM of neck – extension: ExpectedExam Action
03/25/24 11:40 PM MDT Tested ROM of neck – flexion: ExpectedExam Action
03/25/24 11:41 PM MDT Tested ROM of neck – lateral bending: ExpectedExam Action
03/25/24 11:41 PM MDT Tested ROM of neck – rotation: ExpectedExam Action
03/25/24 11:41 PM MDT Tested spinal ROM – extension: ExpectedExam Action
03/25/24 11:41 PM MDT Tested spinal ROM – flexion: ExpectedExam Action
03/25/24 11:41 PM MDT Tested spinal ROM – lateral bending: ExpectedExam Action
03/25/24 11:42 PM MDT Tested spinal ROM – rotation to the left: ExpectedExam Action
03/25/24 11:42 PM MDT Tested spinal ROM – rotation to the right: ExpectedExam Action
03/25/24 11:42 PM MDT Tested ROM of shoulders – adduction: ExpectedExam Action
03/25/24 11:42 PM MDT Tested ROM of shoulders – extension: ExpectedExam Action
03/25/24 11:42 PM MDT Tested ROM of shoulders – flexion: ExpectedExam Action
03/25/24 11:43 PM MDT Tested neck strength: 5/5Exam Action
03/25/24 11:43 PM MDT Tested right and left shoulder strength: 5/5Exam Action
03/25/24 11:43 PM MDT Tested left and right elbow strength during flexion and extension: 5/5Exam Action
03/25/24 11:43 PM MDT Tested ROM of elbows – flexion and extension: ExpectedExam Action
03/25/24 11:44 PM MDT Tested ROM of elbows – supination and pronation: ExpectedExam Action
03/25/24 11:44 PM MDT Tested ROM of wrists – ulnar and radial deviation: ExpectedExam Action
03/25/24 11:44 PM MDT Tested ROM of wrists – extension: ExpectedExam Action
03/25/24 11:44 PM MDT Tested ROM of wrists – flexion: ExpectedExam Action
03/25/24 11:44 PM MDT Tested hand and wrist strength: 5/5Exam Action
03/25/24 11:45 PM MDT Tested ROM of hips – abduction: ExpectedExam Action
03/25/24 11:45 PM MDT Tested ROM of hips – adduction: ExpectedExam Action
03/25/24 11:46 PM MDT Tested ROM of hips – extension: ExpectedExam Action
03/25/24 11:46 PM MDT Tested ROM of hips – flexion: ExpectedExam Action
03/25/24 11:46 PM MDT Tested ROM of knees – extension: ExpectedExam Action
03/25/24 11:46 PM MDT Tested ROM of knees – flexion: ExpectedExam Action
03/25/24 11:47 PM MDT Tested ROM of ankles – inversion and eversion: ExpectedExam Action
03/25/24 11:47 PM MDT Tested ROM of ankles – dorsiflexion and plantar flexion: ExpectedExam Action
03/25/24 11:47 PM MDT Tested right and left hip strength: 5/5Exam Action
03/25/24 11:47 PM MDT Tested right and left knee strength: 5/5Exam Action
03/25/24 11:48 PM MDT Tested right and left ankle strength: 5/5Exam Action
03/25/24 11:48 PM MDT Tested patient’s shallow knee bend: patient displays full ROMExam Action
03/25/24 11:48 PM MDT Tested patient’s ability to walk heel to toe: patient displays appropriate coordinationExam Action
03/25/24 11:48 PM MDT Tested patient’s ability to walk on tiptoes, then walk on heels: patient displays appropriate coordinationExam Action
03/25/24 11:48 PM MDTClose your eyes and tell me if the touch is sharp, dull, or soft.Question
03/25/24 11:49 PM MDTOk. Tested facial sensation: dull stimulusExam Action
03/25/24 11:49 PM MDTDull. Tested facial sensation: dull stimulusExam Action
03/25/24 11:49 PM MDTDull. Tested facial sensation: dull stimulusExam Action
03/25/24 11:49 PM MDTDull. Tested facial sensation: dull stimulusExam Action
03/25/24 11:49 PM MDTDull. Tested facial sensation: soft stimulusExam Action
03/25/24 11:50 PM MDTSoft. Tested facial sensation: soft stimulusExam Action
03/25/24 11:50 PM MDTSoft. Tested facial sensation: soft stimulusExam Action
03/25/24 11:50 PM MDTSoft. Tested facial sensation: soft stimulusExam Action
03/25/24 11:50 PM MDTSoft. Tested facial sensation: sharp stimulusExam Action
03/25/24 11:50 PM MDTSharp. Tested facial sensation: sharp stimulusExam Action
03/25/24 11:50 PM MDTSharp. Tested facial sensation: sharp stimulusExam Action
03/25/24 11:50 PM MDTSharp. Tested facial sensation: sharp stimulusExam Action
03/25/24 11:50 PM MDTSharp.Close your eyes and tell me if the touch is sharp, dull, or soft.Question
03/25/24 11:51 PM MDTOk. Tested right arm proximal sharp sensationExam Action
03/25/24 11:51 PM MDTSharp. Tested right arm distal sharp sensationExam Action
03/25/24 11:51 PM MDTSharp. Tested left arm proximal sharp sensationExam Action
03/25/24 11:51 PM MDT Tested left arm proximal sharp sensationExam Action
03/25/24 11:51 PM MDTSharp. Tested left arm distal sharp sensationExam Action
03/25/24 11:51 PM MDTSharp. Tested chest sharp sensationExam Action
03/25/24 11:51 PM MDTSharp. Tested right hand: expected sensationExam Action
03/25/24 11:51 PM MDT Tested left hand: expected sensationExam Action
03/25/24 11:51 PM MDT Tested right arm proximal light sensationExam Action
03/25/24 11:51 PM MDTSoft. Tested right arm distal light sensationExam Action
03/25/24 11:51 PM MDTSoft. Tested left arm proximal light sensationExam Action
03/25/24 11:51 PM MDTSoft. Tested left arm distal light sensationExam Action
03/25/24 11:51 PM MDTSoft. Tested chest light sensationExam Action
03/25/24 11:51 PM MDTSoft. Tested chest light sensationExam Action
03/25/24 11:51 PM MDTSoft. Tested left hand: expected sensationExam Action
03/25/24 11:51 PM MDT Tested right arm proximal dull sensationExam Action
03/25/24 11:52 PM MDTDull. Tested right arm distal dull sensationExam Action
03/25/24 11:52 PM MDTDull. Tested left arm proximal dull sensationExam Action
03/25/24 11:52 PM MDTDull. Tested left arm distal dull sensationExam Action
03/25/24 11:52 PM MDT Tested left arm proximal dull sensationExam Action
03/25/24 11:52 PM MDTDull. Tested chest dull sensationExam Action
03/25/24 11:52 PM MDTDull. Tested left hand: expected sensationExam Action
03/25/24 11:52 PM MDTClose your eyes and tell me if the touch is sharp, dull, or soft.Question
03/25/24 11:52 PM MDTOk. Tested right leg proximal dull sensationExam Action
03/25/24 11:53 PM MDTDull. Tested right leg distal dull sensationExam Action
03/25/24 11:53 PM MDTDull. Tested left leg proximal dull sensationExam Action
03/25/24 11:53 PM MDTDull. Tested left leg distal dull sensationExam Action
03/25/24 11:53 PM MDTDull. Tested right leg proximal sharp sensationExam Action
03/25/24 11:53 PM MDTSharp. Tested right leg distal sharp sensationExam Action
03/25/24 11:53 PM MDTSharp. Tested left leg proximal sharp sensationExam Action
03/25/24 11:53 PM MDTSharp. Tested left leg distal sharp sensationExam Action
03/25/24 11:53 PM MDTSharp. Tested right leg proximal light sensationExam Action
03/25/24 11:53 PM MDTSoft. Tested right leg distal light sensationExam Action
03/25/24 11:53 PM MDTSoft. Tested left leg proximal light sensationExam Action
03/25/24 11:53 PM MDTSoft. Tested left leg distal light sensationExam Action
03/25/24 11:53 PM MDTSoft.Close your eyes and tell me when you feel the touchQuestion
03/25/24 11:54 PM MDTOk, I will. Tested sensation of right big toe with monofilamentExam Action
03/25/24 11:54 PM MDTYes. Tested sensation of left big toe with monofilamentExam Action
03/25/24 11:54 PM MDTYes. Tested sensation of left ball of foot under small toe with monofilamentExam Action
03/25/24 11:54 PM MDTYes. Tested sensation of right ball of foot with monofilamentExam Action
03/25/24 11:54 PM MDTYes. Tested sensation of left heel with monofilamentExam Action
03/25/24 11:54 PM MDTYes. Tested sensation of left ball of foot under big toe with monofilamentExam Action
03/25/24 11:54 PM MDTYes. Tested sensation of right ball of foot under big toe with monofilamentExam Action
03/25/24 11:54 PM MDTYes. Tested sensation of right heel with monofilamentExam Action
03/25/24 11:54 PM MDTYes. 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 scalpExam Action
03/25/24 11:55 PM MDT Inspected left and right toenails: no ridges or abnormalitiesExam Action
03/25/24 11:56 PM MDT Inspected fingernails of left and right hands: no ridges or abnormalitiesExam Action
03/25/24 11:56 PM MDT Inspected general skin: skin texture is even, skin moisture is moist, and skin temperature is warmExam Action
03/25/24 11:56 PM MDT Inspected left and right feet: no visible abnormal findingsExam Action
03/25/24 11:56 PM MDT Inspected front of legsExam Action
03/25/24 11:56 PM MDT Inspected front of anklesExam Action
03/25/24 11:56 PM MDT Inspected front of kneesExam Action
03/25/24 11:56 PM MDT Inspected front of hipsExam Action
03/25/24 11:56 PM MDT Inspected right legExam Action
03/25/24 11:56 PM MDT Inspected right kneeExam Action
03/25/24 11:56 PM MDT Inspected right side of hipsExam Action
03/25/24 11:57 PM MDT Inspected right ankleExam Action
03/25/24 11:57 PM MDT Inspected back of legsExam Action
03/25/24 11:57 PM MDT Inspected back of hipsExam Action
03/25/24 11:57 PM MDT Inspected back of kneesExam Action
03/25/24 11:57 PM MDT Inspected left legExam Action
03/25/24 11:57 PM MDT Inspected left side of hipsExam Action
03/25/24 11:57 PM MDT Inspected left kneeExam Action
03/25/24 11:57 PM MDT Inspected left ankleExam Action
03/25/24 11:57 PM MDT Inspected anterior chest wall: no visible abnormal findingsExam Action
03/25/24 11:57 PM MDT Inspected left and right handsExam Action
03/25/24 11:57 PM MDT Inspected left and right armsExam Action
03/25/24 11:57 PM MDT Inspected left side chest wallExam Action
03/25/24 11:57 PM MDT Inspected left shoulderExam Action
03/25/24 11:57 PM MDT Inspected left elbowExam Action
03/25/24 11:57 PM MDT Inspected backExam Action
03/25/24 11:57 PM MDT Inspected upper back and shouldersExam Action
03/25/24 11:57 PM MDT Inspected right side chest wallExam Action
03/25/24 11:57 PM MDT Inspected right shoulderExam Action
03/25/24 11:57 PM MDT Inspected right elbowExam Action
03/25/24 11:57 PM MDT Inspected anterior chest wall: no visible abnormal findingsExam Action
03/25/24 11:57 PM MDT Inspected right side chest wallExam Action
03/25/24 11:57 PM MDT Inspected anterior chest wall: no visible abnormal findingsExam Action
03/25/24 11:57 PM MDT Inspected general faceExam Action
03/25/24 11:58 PM MDT Inspected front of neckExam Action
03/25/24 11:58 PM MDT Inspected right side of faceExam Action
03/25/24 11:58 PM MDT Inspected right side of neckExam Action
03/25/24 11:58 PM MDT Inspected back of headExam Action
03/25/24 11:58 PM MDT Inspected back of neckExam Action
03/25/24 11:58 PM MDT Inspected left side of faceExam Action
03/25/24 11:58 PM MDT Inspected left side of neckExam Action
03/25/24 11:58 PM MDT Inspected general faceExam Action
03/25/24 11:59 PM MDT Inspected left side of faceExam Action
03/25/24 11:59 PM MDT Tested skin turgor on forearmExam Action
03/25/24 11:59 PM MDT Tested skin turgor on forearmExam Action
03/25/24 11:59 PM MDT
Comments
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