min
All Lines (243)Interview Questions (93)Statements (16)Exam Actions (134)
Hi.I am xx. I will interview you and later examine you. | Greet 09/08/20 1:42 PM EST |
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Hey. | ||
Welcome to the clinic | Empathize 09/08/20 1:51 PM EST |
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I appreciate you saying that. | ||
What brings you to the clinic today? | Question 09/08/20 1:52 PM EST |
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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 |
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I appreciate you telling me that. | ||
Have you had any neck stiffness? | Question 09/08/20 1:55 PM EST |
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Yeah. | ||
When did the neck stiffness begin? | Question 09/08/20 1:55 PM EST |
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My neck started hurting about two days after the accident. | ||
Am sorry about the accident | Empathize 09/08/20 1:57 PM EST |
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Thanks. | ||
When did the headaches begin? | Question 09/08/20 1:58 PM EST |
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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 |
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No. | ||
Were you wearing a seat belt? | Question 09/08/20 2:00 PM EST |
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Yes, I always do. | ||
It is always good to wear a seat belt | Educate 09/08/20 2:01 PM EST |
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Sure, I think I understand what you mean. | ||
Where were you sitting? | Question 09/08/20 2:01 PM EST |
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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 |
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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 |
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Thanks for telling me. | ||
How many times have you had headaches since they started? | Question 09/08/20 2:04 PM EST |
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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 |
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About an hour or two. | ||
When was your last headache? | Question 09/08/20 2:05 PM EST |
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Yesterday afternoon. | ||
Where is the location of the headache? | Question 09/08/20 2:05 PM EST |
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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 |
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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 |
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Thanks for understanding. | ||
How does your neck feel? | Question 09/08/20 2:07 PM EST |
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It has been pretty stiff and a little painful since the accident. | ||
Is your scalp tender? | Question 09/08/20 2:20 PM EST |
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No. | ||
Do you have jaw pain? | Question 09/08/20 2:20 PM EST |
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No, not at all. | ||
Do you have facial pain? | Question 09/08/20 2:20 PM EST |
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No. My face is fine. | ||
How would you rate the pain now? | Question 09/08/20 2:21 PM EST |
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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 |
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They probably get up to a 4. | ||
Describe the headaches? | Question 09/08/20 2:22 PM EST |
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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 |
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Thanks for saying that. | ||
Is the headache pain sharp? | Question 09/08/20 2:23 PM EST |
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No, not really. | ||
Are your headaches cyclic | Question 09/08/20 2:23 PM EST |
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No, I don’t think so. | ||
What caused your pain? | Question 09/08/20 2:24 PM EST |
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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 |
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Thanks for understanding. | ||
Does it hurt to move your head? | Question 09/08/20 2:25 PM EST |
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Yeah, my neck hurts when I move it. | ||
What makes your headache worse? | Question 09/08/20 2:25 PM EST |
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Nothing really makes them worse. . . they just sort of start, and eventually they go away. | ||
Question 09/08/20 2:44 PM EST |
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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 |
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Thanks for saying that. | ||
Have you ever had any head trauma? | Question 09/08/20 2:45 PM EST |
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No. | ||
Any seizures? | Question 09/08/20 2:45 PM EST |
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No. I’ve seen somebody have one, though. It’s scary. | ||
Have your sleep habits changed? | Question 09/08/20 2:47 PM EST |
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No. | ||
Do you have fever? | Question 09/08/20 2:49 PM EST |
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No. | ||
Any chills? | Question 09/08/20 2:50 PM EST |
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No. | ||
Do you have fatigue? | Question 09/08/20 2:50 PM EST |
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No, not really. | ||
Do you have nausea? | Question 09/08/20 2:50 PM EST |
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No. | ||
Any night sweats? | Question 09/08/20 2:50 PM EST |
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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 |
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No, I’ve never been diagnosed with blood pressure problems. | ||
That is great | Empathize 09/08/20 2:51 PM EST |
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Thanks. | ||
Has one side f your body felt weaker? | Question 09/08/20 2:56 PM EST |
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No, I feel about the same. | ||
Any change in your gait? | Question 09/08/20 3:00 PM EST |
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No. | ||
Have you felt dizzy? | Question 09/08/20 3:00 PM EST |
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No, I haven’t been dizzy. | ||
Any memory problems? | Question 09/08/20 3:00 PM EST |
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I wouldn’t say so. I have a pretty normal memory. | ||
Any changes in smell? | Question 09/08/20 3:01 PM EST |
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No. | ||
Who do you live with? | Question 09/08/20 3:01 PM EST |
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Right now I live back at home with my mom and my sister. | ||
That is great | Empathize 09/08/20 3:02 PM EST |
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I appreciate you telling me that. | ||
What is your highest level of education | Question 09/08/20 3:02 PM EST |
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Well, I’m finishing up my Bachelor’s degree right now. | ||
Do you work? | Question 09/08/20 3:02 PM EST |
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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 |
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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 |
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Not really, no. (Clarified to if I get earaches.) | ||
Do you have eye problem | Question 09/08/20 3:05 PM EST |
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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 |
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No, it’s fine. | ||
Any jaw pain? | Question 09/08/20 3:06 PM EST |
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No, not at all. | ||
Any dental concern? | Question 09/08/20 3:06 PM EST |
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Nope, no problems. | ||
Describe your diet | Question 09/08/20 3:06 PM EST |
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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 |
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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 |
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Nope. | ||
What is your current living situation? | Question 09/08/20 3:09 PM EST |
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I live at home with my mom and my sister. | ||
How is your work? | Question 09/08/20 3:09 PM EST |
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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 |
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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 |
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Thanks for understanding. | ||
Thanks for answering my questions Ms. Jones | Empathize 09/08/20 3:13 PM EST |
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I appreciate you telling me that. | ||
I will now perform the physical assessment | Educate 09/08/20 3:13 PM EST |
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OK, I understand. | ||
What is your name and date of birth? | Question 09/08/20 3:28 PM EST |
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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 |
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What building are you in now? | Question 09/08/20 3:28 PM EST |
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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 |
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What is the date and year? | Question 09/08/20 3:29 PM EST |
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Um, today’s date is [Tina says correct date and year]. | ||
Evaluated orientation to time | Exam Action 09/08/20 3:29 PM EST |
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How are apples and orange alike? | Question 09/08/20 3:30 PM EST |
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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 |
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How are a lake and an ocean alike? | Question 09/08/20 3:30 PM EST |
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Uh…. they’re both bodies of water. | ||
Evaluated abstract thinking: similarities among bodies of water | Exam Action 09/08/20 3:31 PM EST |
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How are a trumpet and a flute alike? | Question 09/08/20 3:31 PM EST |
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Can you tell me more about school? | Question 09/08/20 3:41 PM EST |
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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 |
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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 |
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Inspected fundus of left eye | Exam Action 09/08/20 3:45 PM EST |
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Inspected left pupil and tested left pupillary light reflex | Exam Action 09/08/20 3:46 PM EST |
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Inspected right pupil and tested pupillary light reflex | Exam Action 09/08/20 3:46 PM EST |
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Follow my finger with just your eyes | Question 09/08/20 3:48 PM EST |
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Ok. | ||
Tested convergence | Exam Action 09/08/20 3:48 PM EST |
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Tested EOM to the upper left | Exam Action 09/08/20 3:48 PM EST |
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Tested EOM to the upper center | Exam Action 09/08/20 3:49 PM EST |
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Tested EOM to the upper right | Exam Action 09/08/20 3:49 PM EST |
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Tested EOM to the lower right | Exam Action 09/08/20 3:49 PM EST |
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Tested EOM to the lower center | Exam Action 09/08/20 3:49 PM EST |
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Tested EOM to the lower left | Exam Action 09/08/20 3:49 PM EST |
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Close your eyes and and tell me if the touch is sharp, dull, or soft | Question 09/08/20 3:50 PM EST |
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Ok. | ||
Tested facial sensation: dull stimulus | Exam Action 09/08/20 3:50 PM EST |
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Dull. | ||
Tested facial sensation: dull stimulus | Exam Action 09/08/20 3:50 PM EST |
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Dull. | ||
Tested facial sensation: dull stimulus | Exam Action 09/08/20 3:50 PM EST |
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Dull. | ||
Tested facial sensation: dull stimulus | Exam Action 09/08/20 3:50 PM EST |
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Dull. | ||
Tested facial sensation: dull stimulus | Exam Action 09/08/20 3:50 PM EST |
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Dull. | ||
Tested facial sensation: soft stimulus | Exam Action 09/08/20 3:51 PM EST |
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Soft. | ||
Tested facial sensation: soft stimulus | Exam Action 09/08/20 3:51 PM EST |
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Soft. | ||
Tested facial sensation: soft stimulus | Exam Action 09/08/20 3:51 PM EST |
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Soft. | ||
Tested facial sensation: soft stimulus | Exam Action 09/08/20 3:51 PM EST |
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Soft. | ||
Tested facial sensation: sharp stimulus | Exam Action 09/08/20 3:52 PM EST |
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Sharp. | ||
Tested facial sensation: sharp stimulus | Exam Action 09/08/20 3:52 PM EST |
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Sharp. | ||
Tested facial sensation: sharp stimulus | Exam Action 09/08/20 3:52 PM EST |
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Sharp. | ||
Tested facial sensation: sharp stimulus | Exam Action 09/08/20 3:52 PM EST |
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Sharp. | ||
Tested facial sensation: sharp stimulus | Exam Action 09/08/20 3:52 PM EST |
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Sharp. | ||
Inspected front of face for asymmetry and facial droop | Exam Action 09/08/20 3:52 PM EST |
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Inspected right side of face for asymmetry and facial droop | Exam Action 09/08/20 3:52 PM EST |
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Inspected front of face for asymmetry and facial droop | Exam Action 09/08/20 3:53 PM EST |
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Inspected left side of face for asymmetry and facial droop | Exam Action 09/08/20 3:53 PM EST |
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Inspected back of head for asymmetry | Exam Action 09/08/20 3:53 PM EST |
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Inspected right side of face for asymmetry and facial droop | Exam Action 09/08/20 3:53 PM EST |
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Inspected front of face for asymmetry and facial droop | Exam Action 09/08/20 3:53 PM EST |
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Is the volume the same in both ears or louder in one year? | Question 09/08/20 3:54 PM EST |
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Ok. | ||
Same in both ears. | ||
Performed Weber test with tuning fork | Exam Action 09/08/20 3:55 PM EST |
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Tell me when you can no longer hear the ringing | Question 09/08/20 3:55 PM EST |
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Ok, I will. | ||
Now. | ||
Tested gag reflex | Exam Action 09/08/20 3:56 PM EST |
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Tested trapezius muscle strength against resistance: 5 strength against resistance | Exam Action 09/08/20 3:57 PM EST |
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Tested sternocleidomastoid muscle strength against resistance – head turned to the right: 5 strength against resistance | Exam Action 09/08/20 3:57 PM EST |
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Tested sternocleidomastoid muscle strength against resistance – head turned to the left: 5 strength against resistance | Exam Action 09/08/20 3:57 PM EST |
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Inspected mouth | Exam Action 09/08/20 3:58 PM EST |
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Inspected mouth: pushed tongue left with tongue blade | Exam Action 09/08/20 3:58 PM EST |
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Inspect mouth: pushed tongue right with tongue blade | Exam Action 09/08/20 3:58 PM EST |
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Inspect mouth: lifted tongue with tongue blade | Exam Action 09/08/20 3:58 PM EST |
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Inspected mouth: depressed tongue with tongue blade | Exam Action 09/08/20 3:58 PM EST |
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Tested reflexes of right triceps: 2+ | Exam Action 09/08/20 3:59 PM EST |
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Tested reflexes of left triceps: 2+ | Exam Action 09/08/20 3:59 PM EST |
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Tested reflexes of right biceps: 2+ | Exam Action 09/08/20 3:59 PM EST |
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Tested reflexes of left biceps: 2+ | Exam Action 09/08/20 4:00 PM EST |
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Tested reflexes of right brachioradialis: 2+ | Exam Action 09/08/20 4:00 PM EST |
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Tested reflexes of left brachioradialis: 2+ | Exam Action 09/08/20 4:00 PM EST |
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Tested reflexes of right patellar tendon: 2+ | Exam Action 09/08/20 4:01 PM EST |
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Tested reflexes of left patellar tendon: 2+ | Exam Action 09/08/20 4:01 PM EST |
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Tested reflexes of right achilles tendon: 2+ | Exam Action 09/08/20 4:01 PM EST |
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Tested reflexes of right achilles tendon: 2+ | Exam Action 09/08/20 4:02 PM EST |
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Tested reflexes of left achilles tendon: 2+ | Exam Action 09/08/20 4:02 PM EST |
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Close your eyes and touch your fingers to your nose | Question 09/08/20 4:04 PM EST |
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I can do that. | ||
Observed left index finger to nose | Exam Action 09/08/20 4:04 PM EST |
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Observed right index finger to nose | Exam Action 09/08/20 4:04 PM EST |
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Run your right foot down your shin | Question 09/08/20 4:06 PM EST |
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Sure. | ||
Observed right heel moving to shin | Exam Action 09/08/20 4:06 PM EST |
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Run your left foot down your shin | Question 09/08/20 4:06 PM EST |
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Ok. | ||
Observed left heel moving to shin | Exam Action 09/08/20 4:06 PM EST |
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Place your hands on your knees and turn them over | Question 09/08/20 4:08 PM EST |
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Ok, like this? | ||
Observed rapid alternating hand movements: Movement is smooth, performed without difficulty | Exam Action 09/08/20 4:08 PM EST |
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Observed patient’s gait | Exam Action 09/08/20 4:08 PM EST |
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Close your eyes and tell me what I place in your hand | Question 09/08/20 4:10 PM EST |
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Ok. | ||
That’s an “A.” | ||
Tested left-hand graphesthesia by letter identification | Exam Action 09/08/20 4:10 PM EST |
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That’s an “A.” | ||
Tested left-hand graphesthesia by letter identification | Exam Action 09/08/20 4:10 PM EST |
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Tested right-hand graphesthesia by number identification | Exam Action 09/08/20 4:10 PM EST |
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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 |
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Ok. | ||
Tested right arm proximal dull sensation | Exam Action 09/08/20 4:12 PM EST |
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Dull. | ||
Tested right arm distal dull sensation | Exam Action 09/08/20 4:12 PM EST |
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Dull. | ||
Tested left arm proximal dull sensation | Exam Action 09/08/20 4:13 PM EST |
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Dull. | ||
Tested left arm distal dull sensation | Exam Action 09/08/20 4:13 PM EST |
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Dull. | ||
Tested left arm distal dull sensation | Exam Action 09/08/20 4:13 PM EST |
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Dull. | ||
close your eyes and tell if the touch is sharp, dull, or soft | Question 09/08/20 4:15 PM EST |
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Ok. | ||
Test sensory dull chest | Exam Action 09/08/20 4:15 PM EST |
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Dull. | ||
Tested right arm proximal soft sensation | Exam Action 09/08/20 4:16 PM EST |
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Soft. | ||
Tested right arm distal soft sensation | Exam Action 09/08/20 4:16 PM EST |
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Soft. | ||
Tested left arm proximal soft sensation | Exam Action 09/08/20 4:16 PM EST |
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Soft. | ||
Tested left arm proximal soft sensation | Exam Action 09/08/20 4:16 PM EST |
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Soft. | ||
Tested left arm distal soft sensation | Exam Action 09/08/20 4:16 PM EST |
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Soft. | ||
Test sensory light chest | Exam Action 09/08/20 4:16 PM EST |
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Soft. | ||
Tested right arm proximal sharp sensation | Exam Action 09/08/20 4:17 PM EST |
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Sharp. | ||
Tested right arm proximal sharp sensation | Exam Action 09/08/20 4:17 PM EST |
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Sharp. | ||
Tested right arm distal sharp sensation | Exam Action 09/08/20 4:17 PM EST |
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Sharp. | ||
Tested left arm proximal sharp sensation | Exam Action 09/08/20 4:18 PM EST |
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Sharp. | ||
Tested left arm distal sharp sensation | Exam Action 09/08/20 4:18 PM EST |
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Sharp. | ||
Test sensory sharp chest | Exam Action 09/08/20 4:18 PM EST |
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Sharp. | ||
Close your eyes and tell me if the touch is sharp, dull, and soft | Question 09/08/20 4:20 PM EST |
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Ok. | ||
Tested right leg proximal dull sensation | Exam Action 09/08/20 4:20 PM EST |
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Dull. | ||
Tested right leg distal dull sensation | Exam Action 09/08/20 4:20 PM EST |
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Dull. | ||
Tested left leg proximal dull sensation | Exam Action 09/08/20 4:21 PM EST |
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Dull. | ||
Tested left leg distal dull sensation | Exam Action 09/08/20 4:21 PM EST |
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Dull. | ||
Tested right leg proximal light sensation | Exam Action 09/08/20 4:21 PM EST |
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Soft. | ||
Tested right leg distal light sensation | Exam Action 09/08/20 4:21 PM EST |
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Soft. | ||
Tested left leg proximal light sensation | Exam Action 09/08/20 4:21 PM EST |
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Soft. | ||
Tested left leg distal light sensation | Exam Action 09/08/20 4:21 PM EST |
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Soft. | ||
Tested right leg proximal light sensation | Exam Action 09/08/20 4:21 PM EST |
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Soft. | ||
Tested right leg proximal sharp sensation | Exam Action 09/08/20 4:22 PM EST |
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Sharp. | ||
Tested right leg distal sharp sensation | Exam Action 09/08/20 4:22 PM EST |
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Sharp. | ||
Tested right leg distal sharp sensation | Exam Action 09/08/20 4:22 PM EST |
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Sharp. | ||
Tested left leg proximal sharp sensation | Exam Action 09/08/20 4:22 PM EST |
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Sharp. | ||
Tested left leg distal sharp sensation | Exam Action 09/08/20 4:22 PM EST |
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Sharp. | ||
Close your eyes and tell me when you feel the touch | Question 09/08/20 4:23 PM EST |
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Ok, I will. | ||
Tested sensation of right heel with monofilament | Exam Action 09/08/20 4:24 PM EST |
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Yes. | ||
Tested sensation of left ball of foot under small toe with monofilament | Exam Action 09/08/20 4:24 PM EST |
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Tested sensation of right big toe with monofilament | Exam Action 09/08/20 4:24 PM EST |
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Yes. | ||
Tested sensation of right big toe with monofilament | Exam Action 09/08/20 4:24 PM EST |
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Tested sensation of left big toe with monofilament | Exam Action 09/08/20 4:24 PM EST |
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Tested sensation of left ball of foot under big toe with monofilament | Exam Action 09/08/20 4:24 PM EST |
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Tested sensation of left ball of foot under small toe with monofilament | Exam Action 09/08/20 4:24 PM EST |
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Tested sensation of left ball of foot under small toe with monofilament | Exam Action 09/08/20 4:24 PM EST |
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Tested sensation of left heel with monofilament | Exam Action 09/08/20 4:24 PM EST |
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Yes. | ||
Tested sensation of left heel with monofilament | Exam Action 09/08/20 4:24 PM EST |
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Yes. | ||
close your eyes and tell if your finger or toe moves up and down | Question 09/08/20 4:26 PM EST |
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Ok, I will. | ||
Down. | ||
Tested position sense of finger on right hand | Exam Action 09/08/20 4:27 PM EST |
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Up. | ||
Tested position sense of finger on left hand | Exam Action 09/08/20 4:27 PM EST |
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Up. | ||
Tested position sense of finger on left hand | Exam Action 09/08/20 4:27 PM EST |
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…I think that was up. | ||
Tested position sense of toe on right foot | Exam Action 09/08/20 4:27 PM EST |
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Down. | ||
Tested position sense of toe on left foot | Exam Action 09/08/20 4:28 PM EST |
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close your eyes and tell me what I in your hand | Question 09/08/20 4:30 PM EST |
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Ok, sure. | ||
…Some kind of coin. | ||
Tested right-hand stereognosis with coin | Exam Action 09/08/20 4:30 PM EST |
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Tested right-hand stereognosis with paper clip | Exam Action 09/08/20 4:31 PM EST |
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This is… some wire thing… paperclip? | ||
Tested right-hand stereognosis with key | Exam Action 09/08/20 4:31 PM EST |
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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 |
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Tested left-hand stereognosis with paper clip | Exam Action 09/08/20 4:31 PM EST |
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The paperclip again. | ||
Um… that feels like a key. | ||
Tested left-hand stereognosis with key | Exam Action 09/08/20 4:32 PM EST |