Transcript
Started: Jan 26, 2020 | Total Time: 167 min
All Lines (482) Interview Questions (146) Statements (3) Exam Actions (333)
Greet
01/26/20 5:57 PM
MST
Question
A01/26/20 5:57 PM
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...
Transcript
Started: Jan 26, 2020 | Total Time: 167 min
All Lines (482) Interview Questions (146) Statements (3) Exam Actions (333)
Greet
01/26/20 5:57 PM
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Question
A01/26/20 5:57 PM
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Question
01/26/20 5:58 PM
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Question
01/26/20 5:59 PM
Question
01/26/20 6:00 PM
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Question
01/26/20 6:00 PM
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Question
01/26/20 6:01 PM
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01/26/20 6:01 PM
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01/26/20 6:01 PM
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Question
01/26/20 6:03 PM
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01/26/20 6:03 PM
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01/26/20 6:03 PM
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01/26/20 6:03 PM
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01/26/20 6:04 PM
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01/26/20 6:04 PM
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01/26/20 6:04 PM
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01/26/20 6:05 PM
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01/26/20 6:05 PM
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01/26/20 6:05 PM
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01/26/20 6:06 PM
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01/26/20 6:06 PM
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01/26/20 6:06 PM
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01/26/20 6:07 PM
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01/26/20 6:07 PM
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01/26/20 6:08 PM
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01/26/20 6:08 PM
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01/26/20 6:08 PM
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01/26/20 6:09 PM
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01/26/20 6:09 PM
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01/26/20 6:10 PM
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01/26/20 6:10 PM
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01/26/20 6:10 PM
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01/26/20 6:10 PM
Question
01/26/20 6:11 PM
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01/26/20 6:11 PM
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01/26/20 6:12 PM
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01/26/20 6:12 PM
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01/26/20 6:13 PM
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01/26/20 6:14 PM
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01/26/20 6:15 PM
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01/26/20 6:15 PM
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01/26/20 6:15 PM
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01/26/20 6:16 PM
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01/26/20 6:17 PM
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01/26/20 6:17 PM
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01/26/20 6:17 PM
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01/26/20 6:17 PM
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01/26/20 6:18 PM
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01/26/20 6:18 PM
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01/26/20 6:18 PM
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01/26/20 6:19 PM
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01/26/20 6:19 PM
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Question
01/26/20 6:20 PM
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01/26/20 6:20 PM
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01/26/20 6:20 PM
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Question
01/26/20 6:21 PM
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01/26/20 6:21 PM
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01/26/20 6:21 PM
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Question
01/26/20 6:22 PM
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01/26/20 6:23 PM
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01/26/20 6:25 PM
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Question
01/26/20 6:26 PM
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Question
01/26/20 6:27 PM
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01/26/20 6:27 PM
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Question
01/26/20 6:28 PM
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01/26/20 6:29 PM
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01/26/20 6:29 PM
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01/26/20 6:29 PM
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01/26/20 6:29 PM
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01/26/20 6:30 PM
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01/26/20 6:31 PM
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01/26/20 6:31 PM
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01/26/20 6:31 PM
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01/26/20 6:31 PM
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01/26/20 6:32 PM
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01/26/20 6:32 PM
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Question
01/26/20 6:33 PM
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01/26/20 6:33 PM
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01/26/20 6:33 PM
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01/26/20 6:34 PM
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01/26/20 6:34 PM
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01/26/20 6:35 PM
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01/26/20 6:35 PM
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01/26/20 6:35 PM
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01/26/20 6:37 PM
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01/26/20 6:37 PM
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01/26/20 6:38 PM
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01/26/20 6:38 PM
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01/26/20 6:39 PM
Question
01/26/20 6:40 PM
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Question
01/26/20 6:40 PM
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Question
01/26/20 6:41 PM
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Empathize
01/26/20 6:41 PM
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Question
01/26/20 6:42 PM
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Question
01/26/20 6:43 PM
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01/26/20 6:43 PM
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01/26/20 6:44 PM
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01/26/20 6:44 PM
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01/26/20 6:45 PM
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Empathize
01/26/20 6:45 PM
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Question
01/26/20 6:45 PM
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01/26/20 6:45 PM
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01/26/20 6:45 PM
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01/26/20 6:46 PM
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01/26/20 6:46 PM
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01/26/20 6:46 PM
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01/26/20 6:46 PM
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01/26/20 6:47 PM
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01/26/20 6:48 PM
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01/26/20 6:48 PM
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01/26/20 6:48 PM
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01/26/20 6:48 PM
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01/26/20 6:49 PM
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01/26/20 6:49 PM
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01/26/20 6:50 PM
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Question
01/26/20 6:52 PM
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01/26/20 6:52 PM
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Question
01/26/20 6:52 PM
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Question
01/26/20 6:52 PM
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Question
01/26/20 6:55 PM
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Empathize
01/26/20 6:55 PM
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Question
01/26/20 6:55 PM
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Question
01/26/20 6:56 PM
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Question
01/26/20 6:56 PM
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Question
01/26/20 7:04 PM
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01/26/20 7:04 PM
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Question
01/26/20 7:09 PM
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Question
01/26/20 7:10 PM
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Performed pulse oximetry
Performed spirometry
Inspected scalp
Inspected scalp
Exam Action
01/26/20 7:25 PM
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Exam Action
01/26/20 7:25 PM
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Exam Action
01/26/20 7:27 PM
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Exam Action
01/26/20 7:27 PM
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Inspected hair on scalp
Inspected right eyebrow and orbital area
Inspected left eyebrow and orbital area
Inspected mouth: Oral mucosa moist
Inspect mouth
Inspect tongue
Inspected mouth: Oral mucosa moist
Inspect mouth
Exam Action
01/26/20 7:27 PM
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Exam Action
01/26/20 7:27 PM
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Exam Action
01/26/20 7:27 PM
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Exam Action
01/26/20 7:27 PM
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Exam Action
01/26/20 7:27 PM
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Exam Action
01/26/20 7:27 PM
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Exam Action
01/26/20 7:27 PM
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Exam Action
01/26/20 7:27 PM
Inspect tongue
Inspected mouth: Oral mucosa moist
Inspect mouth
Inspect tongue
Inspected mouth: Oral mucosa moist
Inspect mouth
Inspect tongue
Inspected mouth: Oral mucosa moist
Exam Action
01/26/20 7:27 PM
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Exam Action
01/26/20 7:27 PM
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Exam Action
01/26/20 7:27 PM
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Exam Action
01/26/20 7:27 PM
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Exam Action
01/26/20 7:27 PM
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Exam Action
01/26/20 7:27 PM
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Exam Action
01/26/20 7:27 PM
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Exam Action
01/26/20 7:27 PM
Inspect mouth
Tested gag reflex
Inspected upper eyelids
Inspected lower eyelids
Inspected right outer ear
Inspect ears
Inspected left outer ear
Inspect ears
Exam Action
01/26/20 7:27 PM
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Exam Action
01/26/20 7:27 PM
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Exam Action
01/26/20 7:28 PM
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Exam Action
01/26/20 7:28 PM
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Exam Action
01/26/20 7:28 PM
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01/26/20 7:28 PM
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01/26/20 7:28 PM
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01/26/20 7:28 PM
Palpated scalp: no masses
Palpate neck lymph nodes
Palpated supraclavicular lymph nodes: no palpable nodes
Palpated thyroid: smooth without nodules, no goiter
Palpated jaw: no clicks, full ROM
Palpated upper sinus: no pain reported
Palpated lower sinus: no pain reported
Palpated axillary lymph nodes: no palpable nodes
Exam Action
01/26/20 7:28 PM
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Exam Action
01/26/20 7:29 PM
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Exam Action
01/26/20 7:29 PM
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Exam Action
01/26/20 7:29 PM
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Exam Action
01/26/20 7:30 PM
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Exam Action
01/26/20 7:30 PM
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Exam Action
01/26/20 7:30 PM
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Exam Action
01/26/20 7:30 PM
Tested left pupillary light reflex
Tested right pupillary light reflex
Examined fundus of left eye
Examined fundus of right eye
Inspected left naris
Inspected right naris
Performed otoscopic exam of right ear
Performed otoscopic exam of left ear
Exam Action
01/26/20 7:31 PM
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Exam Action
01/26/20 7:31 PM
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Exam Action
01/26/20 7:31 PM
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Exam Action
01/26/20 7:32 PM
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Exam Action
01/26/20 7:32 PM
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Exam Action
01/26/20 7:32 PM
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Exam Action
01/26/20 7:32 PM
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Exam Action
01/26/20 7:32 PM
Question
01/26/20 7:33 PM
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Tested extraocular movement
Tested convergence
Exam Action
01/26/20 7:33 PM
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Exam Action
01/26/20 7:33 PM
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Test both vision
Exam Action
01/26/20 7:34 PM
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Tested visual acuity of left eye with corrective lenses
Exam Action
01/26/20 7:34 PM
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Tested visual acuity of right eye with corrective lenses
Exam Action
01/26/20 7:34 PM
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Question
01/26/20 7:35 PM
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Tested peripheral vision
Exam Action
01/26/20 7:35 PM
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Question
01/26/20 7:35 PM
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Question
01/26/20 7:35 PM
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Question
01/26/20 7:35 PM
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Performed whisper test on left ear
Exam Action
01/26/20 7:35 PM
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Question
01/26/20 7:35 PM
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Question
01/26/20 7:35 PM
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Question
01/26/20 7:35 PM
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Performed whisper test on right ear
Inspected left abdomen
Exam Action
01/26/20 7:35 PM
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Exam Action
01/26/20 7:46 PM
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Inspected anterior abdomen
Inspected right abdomen
Inspected abdomen
Palpated abdominal right upper quadrant with light pressure: soft, no masses
Palpated abdominal left upper quadrant with light pressure: soft, no masses
Palpated abdominal right lower quadrant with light pressure: soft, no masses
Palpated abdominal left lower quadrant with light pressure: soft, no masses
Liver: palpable 1 cm below right costal margin
Exam Action
01/26/20 7:46 PM
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Exam Action
01/26/20 7:46 PM
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Exam Action
01/26/20 7:46 PM
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Exam Action
01/26/20 7:46 PM
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01/26/20 7:46 PM
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Exam Action
01/26/20 7:46 PM
Palpated for spleen: not palpable
Palpated for left kidney: not palpable, no masses
Palpated for right kidney: not palpable, no masses
Palpated abdominal right upper quadrant with deep pressure: no masses
Palpated abdominal left upper quadrant with deep pressure: no masses
Palpated abdominal right lower quadrant: with deep pressure: no masses
Palpated abdominal left lower quadrant with deep pressure: no masses
Percussed liver span: 7 cm MCL on percussion
Exam Action
01/26/20 7:47 PM
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Exam Action
01/26/20 7:48 PM
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Exam Action
01/26/20 7:48 PM
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Exam Action
01/26/20 7:48 PM
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Exam Action
01/26/20 7:48 PM
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01/26/20 7:48 PM
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Exam Action
01/26/20 7:49 PM
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Exam Action
01/26/20 7:49 PM
Assessed CVA tenderness on right: none reported
Assessed CVA tenderness on left: none reported
Percussed for spleen: no dullness
Percussed left upper quadrant: tympanic
Percussed right upper quadrant: tympanic
Percussed right lower quadrant: tympanic
Percussed left lower quadrant: tympanic
Auscultated abdominal left upper quadrant
Exam Action
01/26/20 7:49 PM
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Exam Action
01/26/20 7:49 PM
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Exam Action
01/26/20 7:50 PM
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Exam Action
01/26/20 7:50 PM
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Exam Action
01/26/20 7:50 PM
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Exam Action
01/26/20 7:50 PM
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01/26/20 7:50 PM
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Exam Action
01/26/20 7:50 PM
Auscultated abdominal right upper quadrant
Auscultated abdominal right lower quadrant
Auscultated abdominal left lower quadrant
Inspected left leg: no edema
Inspected right leg: no edema
Inspected anterior chest wall
Inspected left chest
Inspected anterior chest wall
Exam Action
01/26/20 7:50 PM
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Exam Action
01/26/20 7:50 PM
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Exam Action
01/26/20 7:50 PM
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Exam Action
01/26/20 7:51 PM
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Exam Action
01/26/20 7:51 PM
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Exam Action
01/26/20 7:52 PM
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Exam Action
01/26/20 7:52 PM
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Exam Action
01/26/20 7:52 PM
Palpated right brachial pulse: 2+
Palpated brachial pulse, left: 2+
Palpated left radial pulse: 2+
Palpated right radial pulse: 2+
Palpated anterior chest: PMI nondisplaced, no heaves or lifts
Palpated right femoral pulse: 2+
Palpated left femoral pulse: 2+
Palpated left popliteal pulse: 2+
Exam Action
01/26/20 7:52 PM
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Exam Action
01/26/20 7:52 PM
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Exam Action
01/26/20 7:52 PM
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Exam Action
01/26/20 7:52 PM
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Exam Action
01/26/20 7:53 PM
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Exam Action
01/26/20 7:54 PM
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Exam Action
01/26/20 7:54 PM
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Exam Action
01/26/20 7:54 PM
Palpated right popliteal pulse: 2+
Palpated right tibial pulse: 2+
Palpated left tibial pulse: 2+
Palpated left dorsalis pedis pulse: 2+
Palpated right dorsalis pedis pulse: 2+
Palpated right carotid: 2+, no thrill
Palpated left carotid: 2+, no thrill
Auscultated left carotid artery: no bruit
Exam Action
01/26/20 7:54 PM
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Exam Action
01/26/20 7:55 PM
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Exam Action
01/26/20 7:55 PM
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Exam Action
01/26/20 7:55 PM
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Exam Action
01/26/20 7:55 PM
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Exam Action
01/26/20 7:55 PM
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01/26/20 7:55 PM
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Exam Action
01/26/20 7:56 PM
Auscultated right carotid artery: no bruit
Auscultated aorta: no bruit
Auscultated left renal artery: no bruit
Auscultated right renal artery: no bruit
Auscultated right iliac artery: no bruit
Auscultated left iliac artery: no bruit
Auscultated left femoral artery: no bruit
Auscultated right femoral artery: no bruit
Exam Action
01/26/20 7:56 PM
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Exam Action
01/26/20 7:56 PM
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Exam Action
01/26/20 7:56 PM
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Exam Action
01/26/20 7:56 PM
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01/26/20 7:56 PM
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01/26/20 7:56 PM
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Exam Action
01/26/20 7:56 PM
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Exam Action
01/26/20 7:56 PM
Auscultated aortic area with the bell
Auscultated pulmonic area with the bell
Auscultated Erb's point with the bell
Auscultated tricuspid area with the bell
Auscultated mitral area with the bell
Auscultated mitral area with the diaphragm
Auscultated tricuspid area with the diaphragm
Auscultated Erb's point with the diaphragm
Exam Action
01/26/20 7:56 PM
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Exam Action
01/26/20 7:56 PM
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Exam Action
01/26/20 7:57 PM
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Exam Action
01/26/20 7:57 PM
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01/26/20 7:57 PM
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01/26/20 7:57 PM
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Exam Action
01/26/20 7:57 PM
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Exam Action
01/26/20 7:57 PM
Auscultated pulmonic area with the diaphragm
Auscultated aortic area with the diaphragm
Tested capillary refill
Palpate nails
Tested capillary refill
Palpate nails
Tested capillary refill
Palpate nails
Exam Action
01/26/20 7:57 PM
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Exam Action
01/26/20 7:57 PM
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Exam Action
01/26/20 7:57 PM
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Exam Action
01/26/20 7:57 PM
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Exam Action
01/26/20 7:57 PM
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01/26/20 7:57 PM
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Exam Action
01/26/20 7:57 PM
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Exam Action
01/26/20 7:57 PM
Tested capillary refill
Palpate nails
Tested capillary refill
Palpate nails
Inspected posterior chest
Inspected posterior chest wall
Palpated fremitus: equal bilaterally in upper posterior chest wall
Exam Action
01/26/20 7:58 PM
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Exam Action
01/26/20 7:58 PM
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Exam Action
01/26/20 7:58 PM
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Exam Action
01/26/20 7:58 PM
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Exam Action
01/26/20 7:59 PM
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Exam Action
01/26/20 7:59 PM
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Exam Action
01/26/20 8:00 PM
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Palpated fremitus: equal bilaterally in middle posterior chest wall
Exam Action
01/26/20 8:00 PM
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Palpated fremitus: equal bilaterally in lower posterior chest wall
Exam Action
01/26/20 8:00 PM
MST
Palpated thoracic expansion: symmetric
Palpated fremitus: equal bilaterally in upper anterior chest wall
Exam Action
01/26/20 8:00 PM
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Exam Action
01/26/20 8:01 PM
MST
Palpated fremitus: equal bilaterally in lower anterior chest wall
Exam Action
01/26/20 8:01 PM
MST
Percussed right upper posterior chest wall: resonant
Exam Action
01/26/20 8:01 PM
MST
Percussed left upper posterior chest wall: resonant
Percussed left middle posterior chest wall: resonant
Percussed right middle posterior chest wall: resonant
Percussed right lower posterior chest wall: resonant
Percussed left lower posterior chest wall: resonant
Percussed left lower posterior chest wall: resonant
Percussed left lower posterior chest wall: resonant
Percussed right lower posterior chest wall: resonant
Exam Action
01/26/20 8:01 PM
MST
Exam Action
01/26/20 8:01 PM
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Exam Action
01/26/20 8:01 PM
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Exam Action
01/26/20 8:01 PM
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Exam Action
01/26/20 8:01 PM
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Exam Action
01/26/20 8:01 PM
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Exam Action
01/26/20 8:01 PM
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Exam Action
01/26/20 8:01 PM
Percussed left upper anterior chest wall: resonant
Percussed right upper anterior chest wall: resonant
Percussed right middle anterior chest wall: resonant
Percussed left middle anterior chest wall: resonant
Percussed left lower anterior chest wall: resonant
Percussed right lower anterior chest wall: resonant
Auscultated right upper anterior chest wall
Auscultated left upper anterior chest wall
Exam Action
01/26/20 8:02 PM
MST
Exam Action
01/26/20 8:02 PM
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Exam Action
01/26/20 8:02 PM
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Exam Action
01/26/20 8:02 PM
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Exam Action
01/26/20 8:02 PM
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Exam Action
01/26/20 8:02 PM
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Exam Action
01/26/20 8:02 PM
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Exam Action
01/26/20 8:02 PM
Auscultated left middle anterior chest wall
Auscultated right middle anterior chest wall
Auscultated right lower anterior chest wall
Auscultated left lower anterior chest wall
Auscultated upper left posterior chest wall
Auscultated upper right posterior chest wall
Auscultated middle right posterior chest wall
Auscultated middle left posterior chest wall
Exam Action
01/26/20 8:03 PM
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Exam Action
01/26/20 8:03 PM
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Exam Action
01/26/20 8:03 PM
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Exam Action
01/26/20 8:03 PM
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Exam Action
01/26/20 8:04 PM
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Exam Action
01/26/20 8:04 PM
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Exam Action
01/26/20 8:04 PM
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Exam Action
01/26/20 8:04 PM
MST
Auscultated lower left posterior chest wall
Auscultated lower right posterior chest wall
Auscultated lower right posterior chest wall
Auscultated lower right posterior chest wall
Auscultated lower left posterior chest wall
Auscultated lower left posterior chest wall
Performed spirometry
Exam Action
01/26/20 8:04 PM
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Exam Action
01/26/20 8:04 PM
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Exam Action
01/26/20 8:04 PM
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Exam Action
01/26/20 8:04 PM
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Exam Action
01/26/20 8:04 PM
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Exam Action
01/26/20 8:04 PM
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Exam Action
01/26/20 8:04 PM
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Question
01/26/20 8:06 PM
MST
Tested right heel moving to shin
Exam Action
01/26/20 8:06 PM
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Question
01/26/20 8:06 PM
MST
Tested left heel moving to shin
Exam Action
01/26/20 8:07 PM
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Question
01/26/20 8:07 PM
MST
Tested left index finger to nose
Tested right index finger to nose
Exam Action
01/26/20 8:07 PM
MST
Exam Action
01/26/20 8:07 PM
Question
01/26/20 8:08 PM
MST
Discovered orientation to person
Exam Action
01/26/20 8:08 PM
MST
Question
01/26/20 8:08 PM
MST
Discovered orientation to place
Exam Action
01/26/20 8:08 PM
MST
Question
01/26/20 8:08 PM
MST
Confirmed situation orientation
Exam Action
01/26/20 8:08 PM
Discovered orientation to time
Exam Action
01/26/20 8:08 PM
MST
Question
01/26/20 8:09 PM
MST
Tested rapid alternating hand movements
Exam Action
01/26/20 8:09 PM
MST
Question
01/26/20 8:09 PM
MST
Tested right leg proximal dull pain
Exam Action
01/26/20 8:10 PM
MST
Tested left leg proximal dull pain
Exam Action
01/26/20 8:10 PM
MST
Tested left leg distal dull pain
Exam Action
01/26/20 8:10 PM
MST
Tested right leg distal dull pain
Exam Action
01/26/20 8:10 PM
MST
Tested right leg proximal sharp pain
Exam Action
01/26/20 8:10 PM
MST
Tested right leg distal sharp pain
Exam Action
01/26/20 8:10 PM
MST
Tested left leg proximal sharp pain
Exam Action
01/26/20 8:10 PM
MST
Tested left leg distal sharp pain
Exam Action
01/26/20 8:10 PM
MST
Question
01/26/20 8:11 PM
MST
Tested right arm proximal light touch
Exam Action
01/26/20 8:11 PM
MST
Tested right arm distal light touch
Exam Action
01/26/20 8:11 PM
MST
Test sensory light chest
Exam Action
01/26/20 8:11 PM
MST
Tested left arm distal sharp pain
Exam Action
01/26/20 8:11 PM
MST
Tested left arm proximal sharp pain
Exam Action
01/26/20 8:11 PM
MST
Question
01/26/20 8:11 PM
MST
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