neurological shadow health tina jones Transcript

neurological shadow health tina jones Transcript

Duration: 243 lines

Interview Questions: 93 lines
Statements: 16 lines
Exam Actions: 134 lines

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“Hi, I’m xx. I will talk to you and then check you.”

“Hey.”
“Welcome to the clinic.”

“I appreciate you saying that.”
“Why are you here today?”

“Well, I had a small car accident a week ago, and I’ve been having headaches since. My neck also hurts.”
“I’m sorry to hear that.”

“I appreciate you telling me.”
“Did your neck get stiff?”

“Yes.”
“When did the neck stiffness start?”

“My neck started hurting about two days after the accident.”
“I’m sorry about the accident.”

“Thanks.”
“When did the headaches start?”

“About five days ago. They began two days after the accident.”
“Did you lose consciousness during the accident?”

“No.”
“Did you wear a seatbelt?”

“Yes, I always do.”
“Wearing a seatbelt is important.”

“Sure, I understand.”
“Where were you seated?”

“I was in the front passenger seat.”
“Was alcohol involved in the accident?”

“No, not at all. Neither of us had any alcohol.”
“That’s good. Driving under the influence is unsafe.”

“Thanks for telling me.”
“How often do you have headaches?”

“I’ve been having a headache almost every day since a few days after the accident. When I feel it coming, I take something for it, and it usually goes away for the day.”
“How long does the headache last?”

“About an hour or two.”
“When did you have your last headache?”

“Yesterday afternoon.”
“Where do you feel the headache?”

“The headaches are at the top of my head and towards the back.”
“Does the pain spread?”

“Maybe. The neck soreness seems to go up to my head. But it’s mainly my neck and head hurting.”
“I’m sorry to hear that.”

“Thanks for understanding.”
“How’s your neck feeling?”

“It’s been stiff and a bit painful since the accident.”
“Does your scalp hurt?”

“No.”
“Do you experience jaw pain?”

“No, not at all.”
“Any facial pain?”

“No, my face is fine.”
“On a scale of 0 to 10, how would you rate the pain?”

“Right now, it’s just my neck that hurts. I’d say it’s around 3 out of 10.”
“At its worst, how intense is the pain?”

“They might reach a 4.”
“Describe the headaches.”

“The headaches feel like a dull ache, mostly at the top and back of my head.”
“I’m sorry about that.”

“Thanks for saying that.”
“Is the headache sharp?”

“No, not really.”
“Are the headaches cyclic?”

“No, I don’t think so.”
“What do you think caused the pain?”

“I’m pretty sure it was the car accident. It was just a minor accident, and there wasn’t much damage to the car. No one got hurt, but I guess a sore head and neck can happen.”
“I’m sorry, Ms. Jones.”

“Thanks for understanding.”
“Does moving your head hurt?”

“Yes, my neck hurts when I move it.”
“What worsens the headache?”

“Nothing really makes them worse. They start and eventually go away on their own.”

“Do you think your headaches are migraines?”

“No, I’m quite certain they’re not migraines.”
“I’m glad to hear that.”

“Thanks for saying that.”
“Have you ever experienced head trauma?”

“No.”
“Any seizures?”

“No. I did witness someone having one, though. It was frightening.”

“Has your sleep pattern changed?”

“No.”
“Do you have a fever?”

“No.”
“Experiencing chills?”

“No.”
“Do you feel fatigued?”

“Not really.”
“Do you feel nauseous?”

“No.”
“Night sweats?”

“I don’t sweat much, but sometimes I wake up feeling hot and need to uncover.”

“Do you have hypertension?”

“No, I haven’t been diagnosed with blood pressure issues.”
“That’s good.”

“Thanks.”
“Have you noticed weakness on one side of your body?”

“No, I feel normal.”
“Any changes in your walk?”

“No.”
“Have you experienced dizziness?”

“No, I haven’t felt dizzy.”
“Any issues with memory?”

“I don’t think so. My memory seems normal.”
“Changes in your sense of smell?”

“No.”
“Who do you live with?”

“I’m living at home with my mom and sister.”
“I appreciate you sharing that.”

“What’s your highest education level?”

“I’m finishing up my Bachelor’s degree.”
“Do you have a job?”

“I’m a supervisor at Mid-American Copy & Ship. I’ve been there since high school and have been promoted.”
“Any family history of headaches?”

“No, not that I know of.”
“Experiencing earaches?”

“Not really.”
“Any problems with your eyes?”

“No, my vision hasn’t changed since the accident. I sometimes get blurry vision from reading, though.”

“Do you have a sore throat?”

“No, my throat is fine.”
“Experiencing jaw pain?”

“No, not at all.”
“Any dental concerns?”

“No, I don’t have any issues.”
“Tell me about your diet.”

“It’s decent. I’m not really a health enthusiast.”

“Are you physically active?”

“I don’t have the energy to go to the gym after work. I’m on my feet at work, so that’s some exercise.”

“Difficulty swallowing?”

“No.”

“Where do you currently live?”

“I’m living with my mom and sister.”
“How’s work?”

“Mid-American Copy & Ship is a good fit, especially as I finish my degree. They’ve been understanding about my studies. I also do some accounting tasks during inventory and orders.”

“Did the accident impact your work?”

“My friend was driving, so the car wasn’t mine. I don’t have to worry about repairs.”

“I appreciate you understanding.”

“Thanks for answering my questions, Ms. Jones.”

“I appreciate you saying that.”
“I’ll now do a physical check.”

“Okay, I understand.”

“What’s your name and birthdate?”

“I’m Tina Jones, born on February 17th.”

“Evaluating your awareness of self.”

“Where are you right now?”

“I’m at the doctor’s office, Shadow Health General Clinic.”

“Evaluating your awareness of location.”

“What’s today’s date and year?”

“Today is [correct date and year].”

“Evaluating your awareness of time.”

“How are apples and oranges similar?”

“Um… They’re both fruits.”

“Evaluating your abstract thinking: similarities between fruits.”

“How are lakes and oceans similar?”

“Uh… They’re both bodies of water.”

“Evaluating your abstract thinking: similarities between bodies of water.”

“How are trumpets and flutes similar?”

“Um… They’re both musical instruments.”

“Evaluating your abstract thinking: similarities between musical instruments.”

“How are bicycles and cars similar?”

“Both bicycles and cars have wheels.”

“Evaluating your abstract thinking: similarities between vehicles.”

“How are houses and apartments similar?”

“They’re both places people live in.”

“Evaluating your abstract thinking: similarities between living spaces.”

“How are mountains and hills similar?”

“Both mountains and hills are elevated land forms.”

“Evaluating your abstract thinking: similarities between land forms.”

“How are birds and butterflies similar?”

“Um… They both fly.”

“Evaluating your abstract thinking: similarities between flying creatures.”

“How are books and movies similar?”

“Both books and movies tell stories.”

“Evaluating your abstract thinking: similarities between storytelling

media.”

“Thanks for answering all my questions, Ms. Jones.”

“I appreciate you telling me.”
“Now I’ll proceed with the physical examination.”

“Okay, I understand.”

neurological shadow health tina jones Transcript

min

All Lines (243)Interview Questions (93)Statements (16)Exam Actions (134)

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

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