Hi Ms. Jones, I am LeeAnn and I will be
your nurse today.
Greet
07/17/22
3:41 PM
MDT
Hey.
What bring you in to see us today?
Question
07/17/22
3:41 PM
MDT
My throat has been sore… and itchy. And my
nose won’t stop running. These symptoms are
driving me nuts.
I am sorry to hear that.
Empathize
07/17/22
3:42 PM
MDT
I appreciate you saying that.
how long have you had these symptoms?
Question
07/17/22
3:42 PM
MDT
My itchy eyes, runny nose, and sore throat all
started a week ago. [AUDIO COMING
SOON]
Have you had any other symptoms?
Question
07/17/22
3:43 PM
MDT
Let’s see… I have a lot going on so here’s the
laundry list: sore and itchy throat, runny
nose, itchy eyes.
can you rate your pain for me?
Question
07/17/22
3:48 PM
MDT
It’s like a 4 out of 10, maybe.
what makes it better or worst?
Question
07/17/22
3:48 PM
MDT
Talking to friends or family and going to
church always help me feel less stressed–just
feeling supported and like someone cares.
is the sore throat always there? (Clarified to
How severe is your sore throat?.)
Question
07/17/22
3:49 PM
MDT
It’s not… terrible. I mean, it hurts a little.
Like, mild to moderate. The main thing is
that it won’t go away. (Clarified to how
severe my sore throat is.)
what about the runny nose?
Question
07/17/22
3:49 PM
MDT
It’s really thin and drippy.
what color is the drainage?
Question
07/17/22
3:49 PM
MDT
It’s just clear.
I am sorry you are feeling unwell
Empathize
07/17/22
3:50 PM
MDT
Thanks.
are you coughing?
Question
07/17/22
3:50 PM
MDT
No, I haven’t been coughing.
What other conditions do you have?
Question
07/17/22
3:50 PM
MDT
Um, the only things I know I’m diagnosed
with are diabetes. And asthma.
Have you experience seasonal allergies?
(Clarified to Do you have seasonal
allergies?.)
Question
07/17/22
3:50 PM
MDT
Well, no. I mean, I never had allergies to
pollen or anything outdoors like that. . . But
my nose is acting just like my sister’s right
now, and she’s always had hay fever. I’m
starting to think that this is allergies.
(Clarified to if I have seasonal allergies.)
you have many symptoms that points to
allergy but we will continue to explore and
treat.
Educate
07/17/22
3:51 PM
MDT
That makes sense.
it is possible to develop new allergies as an
adult. We will look into that and try to
determine the cause of your symptoms.
Educate
07/17/22
3:53 PM
MDT
OK, I understand.
does any thing make your sore throat feel
better?
Question
07/17/22
3:53 PM
MDT
All I’ve done is suck on some throat drops.
And I’ve been drinking more water, which
helps.
increasing fluid intake help loosen the
mucous in your throat.
Educate
07/17/22
3:53 PM
MDT
Sure, I think I understand what you mean.
Are you taking any medications for your
symptoms?
Question
07/17/22
3:54 PM
MDT
I’ve been using throat drops, like lozenges,
for my sore throat. Other than that, I just have
my inhaler.
Please tell me the medications that you are
taking (Clarified to What medications do you
take?.)
Question
07/17/22
3:54 PM
MDT
I’ve been taking throat drops. And I have an
inhaler, too. (Clarified to what medications I
am taking.)
do you take any medications for your
diabetes?
Question
07/17/22
3:54 PM
MDT
I don’t take anything for my diabetes
anymore.
How often do you use your inhaler?
Question
07/17/22
3:55 PM
MDT
I don’t use it every day — maybe I use it 2 or
3 times a week. Sometimes not at all.
How is it prescribed to you ? (No matching
questions found.)
Question
07/17/22
3:55 PM
MDT
What is the dose of your inhaler?
Question
07/17/22
3:55 PM
MDT
I think it says to do 2 puffs.
what is the name of your inhaler?
Question
07/17/22
3:55 PM
MDT
It’s just a regular Proventil inhaler.
how long have you been using the inhaler?
Question
07/17/22
3:56 PM
MDT
I’ve had an inhaler since I was two and a half,
when I was diagnosed.
when were you diagnosed with diabetes?
Question
07/17/22
3:56 PM
MDT
I was diagnosed when I was 24.
why did you stop taking medications for your
diabetes?
Question
07/17/22
3:56 PM
MDT
I just got sick of dealing with it!
what was your last blood sugar?
Question
07/17/22
3:56 PM
MDT
…I really don’t know. I don’t really check it.
It is very important to monitor your blood
glucose level.
Educate
07/17/22
3:56 PM
MDT
Alright, thanks for letting me know.
did you discuss stopping your diabetes
medication with your provider? (Clarified to
Did a doctor take you off your diabetes
medication?.)
Question
07/17/22
3:57 PM
MDT
No, I just stopped taking it because I was sick
of dealing with taking it everyday and feeling
gassy all the time. (Clarified to if a doctor
took me off my diabetes medication.)
I can imagine that the side effect is annoying.
Empathize
07/17/22
3:57 PM
MDT
I appreciate you telling me that.
however, diabetes is not something you can
just stop managing. There are many health
consequences to not managing your blood
glucose level.
Educate
07/17/22
3:58 PM
MDT
Thanks for telling me.
What medication were you taking for
diabetes?
Question
07/17/22
3:58 PM
MDT
It was Metformin.
do you remember the dose?
Question
07/17/22
3:58 PM
MDT
Honestly, I don’t remember what the dose
was when I was taking it.
how long has it been since you took it?
Question
07/17/22
3:59 PM
MDT
I haven’t smoked pot since I was twenty or
twenty-one.
when did you stop taking metformin?
Question
07/17/22
3:59 PM
MDT
About three years ago, honestly.
do you have any other symptoms?
Question
07/17/22
4:00 PM
MDT
Let’s see… I have a lot going on so here’s the
laundry list: sore and itchy throat, runny
nose, itchy eyes.
how long have you had itchy eyes?
Question
07/17/22
4:00 PM
MDT
This whole thing started about a week ago.
any headaches?
Question
07/17/22
4:00 PM
MDT
Yeah, I get them a lot when I’m studying.
how often do you get headaches?
Question
07/17/22
4:00 PM
MDT
Maybe once a week? I usually do a lot of my
school work at once, so I’ll study for like, 5
or 6 hours. I usually end up with a headache
by the end of the night.
when was the last time you had your vision
check?
Question
07/17/22
4:00 PM
MDT
I must’ve been… maybe ten the last time the
school nurse checked my vision. You know
how the school nurses do those little checks
every year.
this sounds like the stress on your eyes are
causing some of your headaches.
Educate
07/17/22
4:01 PM
MDT
Sure, I think I understand what you mean.
I understand that it can be difficult to get
regular check ups.
Empathize
07/17/22
4:01 PM
MDT
Thanks for understanding.
However, getting a regular check up of your
eyesearsand dental is important.
Educate
07/17/22
4:02 PM
MDT
Thanks for telling me.
when was the last time you had a dental
exam?
Question
07/17/22
4:02 PM
MDT
Um, I think the last time was a few years ago.
I went twice a year as a kid, though.
what about an ear exam? (No matching
questions found.)
Question
07/17/22
4:03 PM
MDT
any issues with hearing?
Question
07/17/22
4:03 PM
MDT
No.
when was the last time you had your hearing
check?
Question
07/17/22
4:03 PM
MDT
It was when I was a kid.
Do you have health insurance?
Question
07/17/22
4:03 PM
MDT
Work gives me health insurance, fortunately.
That’s great, having a health insurance is a
very good reason to get regular check ups.
Educate
07/17/22
4:04 PM
MDT
OK, I understand.
what do you take for your headaches?
Question
07/17/22
4:04 PM
MDT
I just take some acetaminophen. The gel
kind, 500 mg. [AUDIO COMING SOON]
how often do you take the acetaminophen?
Question
07/17/22
4:04 PM
MDT
I maybe take it once a week. Or less.
is it effective for your headache?
Question
07/17/22
4:04 PM
MDT
It’s kind of behind my forehead.
can you rate the pain?
Question
07/17/22
4:04 PM
MDT
It’s like a 4 out of 10, maybe.
does anything make your headache worst?
(Clarified to Does anything make your
headaches better?.)
Question
07/17/22
4:05 PM
MDT
Yeah. Usually I’ll take a Tylenol and go to
bed, and that’ll get rid of it. (Clarified to if
anything makes my headaches better.)
does anything make your headache worst?
(Clarified to Is there anything that makes
your headaches more severe?.)
Question
07/17/22
4:05 PM
MDT
Usually they get worse if I don’t stop
studying. I try to take a break when they start
most of the time, but if I have a test or
something coming up, I just have to try and
ignore it. (Clarified to if anything makes my
headaches worse.)
I understand that your studies are important
to you.
Empathize
07/17/22
4:06 PM
MDT
Thanks for saying that.
However, I do feel that some of your
symptoms may be related to a decline in your
vision. Let’s keep going with your exam so
we can assess and treat.
Educate
07/17/22
4:06 PM
MDT
That makes sense.
Do you have other eye symptoms?
Question
07/17/22
4:07 PM
MDT
You mean, other than this itchy-eye stuff
going on right now? I guess… my eyes get
blurry sometimes when I read. It seems like
my vision is getting worse over the years.
it sounds like you are getting frequent
headaches.
Empathize
07/17/22
4:07 PM
MDT
Thanks for understanding.
I think we can determine what is causing
these symptoms and try to relieve these for
you.
Educate
07/17/22
4:08 PM
MDT
Alright, thanks for letting me know.
Have you been expose to any allergens?
Question
07/17/22
4:08 PM
MDT
Not lately.
Blurry vision can be a frustrating symptoms.
Empathize
07/17/22
4:09 PM
MDT
Thanks for saying that.
Taking steps toward better eye care like
seeing an eye doctor could improve your
vision and prevent blurriness when you read.
Educate
07/17/22
4:09 PM
MDT
That makes sense.
It would likely help with your headaches too.
(No matching questions found.)
Question
07/17/22
4:09 PM
MDT
It would likely help with your headaches too.
Educate
07/17/22
4:09 PM
MDT
OK, I understand.
do you have any food and drug allergies?
(Clarified to Do you have food allergies?.)
Question
07/17/22
4:10 PM
MDT
Nope, no food allergies that I know of.
(Clarified to if I have food allergies.)
do you have drug allergies?
Question
07/17/22
4:10 PM
MDT
Yeah, I’m allergic to penicillin.
what kind of reaction do you have with
penicillin?
Question
07/17/22
4:11 PM
MDT
I don’t remember that well because the last
time I had penicillin I was pretty little. . . I
think I got a rash, like, hives. The doctor told
me not to take it again after that.
do you have any dental concerns?
Question
07/17/22
4:12 PM
MDT
No, I’ve got good teeth. They don’t give me
any problems.
when was the last time you saw the dentist?
Question
07/17/22
4:13 PM
MDT
Um, I think the last time was a few years ago.
I went twice a year as a kid, though.
it sounds like you have good teeth and
hearing.
Empathize
07/17/22
4:13 PM
MDT
I appreciate you saying that.
Again, I want to stress that a regular check up
is important to maintain your health.
Educate
07/17/22
4:13 PM
MDT
Alright, thanks for letting me know.
how severe is your asthma symptoms?
Question
07/17/22
4:14 PM
MDT
My asthma has been pretty under control. I
use my inhaler a few times a week and it
helps.
have you ever been hospitalized?
Question
07/17/22
4:14 PM
MDT
I used to go to the hospital for asthma
growing up, but I hadn’t been in a while until
about a month ago. . . I had to go to the ER
for my foot.
what is going on with your foot?
Question
07/17/22
4:14 PM
MDT
My foot is doing great. It doesn’t hurt at all,
and the scrape is healed up. I’m glad that’s all
over with.
I am glad your foot is doing better.
Empathize
07/17/22
4:14 PM
MDT
I appreciate you telling me that.
what are you doing to manage your blood
sugar?
Question
07/17/22
4:15 PM
MDT
I just watch what I eat and try to stay away
from sweets.
I am happy to hear that you are managing
your diet.
Empathize
07/17/22
4:15 PM
MDT
Thanks.
How would you know if the effort you are
making is making a difference if you don’t
monitor your blood sugar?
Educate
07/17/22
4:16 PM
MDT
Sure, I think I understand what you mean.
do you a glucometer? (Clarified to Do you
have a glucometer to use?.)
Question
07/17/22
4:16 PM
MDT
I do. I haven’t used it in a while, though.
[AUDIO COMING SOON] (Clarified to if I
use a glucometer.)
why do you not check your blood glucose?
(Clarified to When do you check your blood
sugar?.)
Question
07/17/22
4:16 PM
MDT
I know this is bad, but I haven’t checked it in
a long time. Like… Maybe the last time was
more than a month ago, when I was in the ER
to get my foot looked at. (Clarified to when I
check my blood sugar.)
diabetes can have many complications.
taking medications as prescribed can prevent
cardiovascular problems.
Educate
07/17/22
4:17 PM
MDT
Thanks for telling me.
have you had an xray recently?
Question
07/17/22
4:18 PM
MDT
The last time I went to the hospital for an
asthma attack, when I was still in high
school, they did a chest x-ray.
have you had surgeries?
Question
07/17/22
4:18 PM
MDT
Nope. No surgeries… I’ve been lucky.
did you have any childhood illness?
Question
07/17/22
4:18 PM
MDT
Well, I got the usual stuff, like chicken
pox. . . and I had the asthma, too.
are your vaccines up to date?
Question
07/17/22
4:19 PM
MDT
I’m pretty sure I am, yeah.
do you get the influenza vaccine?
Question
07/17/22
4:19 PM
MDT
No.
As a diabetic, you are at a higher risk for
upper respiratory infections. It is important to
get your seasonal flu vaccines.
Educate
07/17/22
4:20 PM
MDT
Alright, thanks for letting me know.
do you take any herbal supplements?
Question
07/17/22
4:20 PM
MDT
No, I don’t take anything herbal.
what side effect did you get from metformin?
Question
07/17/22
4:20 PM
MDT
I felt sick and gassy all the time. It was really
uncomfortable.
it can be difficult to cope with medication
side effects.
Empathize
07/17/22
4:21 PM
MDT
I appreciate you telling me that.
you should always discuss starting and
stopping medication with your provider.
Educate
07/17/22
4:21 PM
MDT
That makes sense.
do you have any environmental allergies?
Question
07/17/22
4:21 PM
MDT
Well, no. I mean, I never had allergies to
pollen or anything outdoors like that. . . But
my nose is acting just like my sister’s right
now, and she’s always had hay fever. I’m
starting to think that this is allergies.
does anything make your asthma worst?
(Clarified to Is there anything else that
triggers your asthma?.)
Question
07/17/22
4:22 PM
MDT
Being around cats is the worst, but dust and
running up stairs can make my breathing bad,
too. (Clarified to if anything else triggers my
asthma.)
do you use tobacco products?
Question
07/17/22
4:22 PM
MDT
No.
do you consume alcohol?
Question
07/17/22
4:23 PM
MDT
I do sometimes, yeah, when I go out with my
friends.
how much do you consume? (Clarified to
How much alcohol do you drink?.)
Question
07/17/22
4:23 PM
MDT
I only have a few drinks when I go out.
(Clarified to how much alcohol I drink.)
How often do you drink?
Question
07/17/22
4:23 PM
MDT
No more than once or twice a week,
sometimes less.
alcohol have high sugar content.
Educate
07/17/22
4:23 PM
MDT
Sure, I think I understand what you mean.
any history of illicit drug use? (Clarified to
Do you ever use drugs?.)
Question
07/17/22
4:24 PM
MDT
No. (Clarified to if I use illegal drugs.)
are you sexually active?
Question
07/17/22
4:24 PM
MDT
Um, not right now.
do you use any form of birth control?
Question
07/17/22
4:24 PM
MDT
Nope. But I’ve been single for a while so I
haven’t needed to.
how old were you when you were first
sexually active?
Question
07/17/22
4:25 PM
MDT
I was in high school…eighteen.
did you use a condom? (Clarified to Do you
use condoms?.)
Question
07/17/22
4:25 PM
MDT
No, not really. I’m single right now, but
before that I was using the pill. (Clarified to
if I use condoms.)
any history of STDs?
Question
07/17/22
4:25 PM
MDT
No. I’ve never had any symptoms like that.
Have you ever been pregnant?
Question
07/17/22
4:25 PM
MDT
I’ve never been pregnant.
How are your menstrual cycles?
Question
07/17/22
4:26 PM
MDT
No. It’s really only when I read for too long.
when was your last menstrual cycle?
Question
07/17/22
4:26 PM
MDT
My periods are kind of all over the map, so
it’s hard to keep track a lot of the time, but I
just got it a week ago.
irregular cycle can be due to uncontrolled
blood sugar.
Educate
07/17/22
4:26 PM
MDT
Thanks for telling me.
what is your family’s medical history?
Question
07/17/22
4:27 PM
MDT
My mom has some issues, and I think some
of my grandparents did, too.
What health issue does your mom have?
Question
07/17/22
4:27 PM
MDT
Mom has high cholesterol and blood
pressure, I think. She seems to be doing okay
though.
what health issue does your grandmother
have? (Clarified to What health issues do
your grandmothers have?.)
Question
07/17/22
4:27 PM
MDT
Nana passed away awhile ago. My Granny’s
still alive, though, doing well. (Clarified to
what health issues my grandmothers have.)
Is nana your father’s mother?
Question
07/17/22
4:28 PM
MDT
Nana is Mom’s mom. We always called our
other grandma Granny.
I am sorry to hear about nana.
Empathize
07/17/22
4:28 PM
MDT
Thanks for saying that.
many conditions are hereditary, this is the
reason I ask about family health history.
Educate
07/17/22
4:28 PM
MDT
OK, I understand.
how did Nana pass?
Question
07/17/22
4:28 PM
MDT
Nana died of a stroke. It was pretty sudden.
that can be very difficult to manage.
Empathize
07/17/22
4:29 PM
MDT
I appreciate you saying that.
does your mother’s father have any health
concerns?
Question
07/17/22
4:29 PM
MDT
Poppa died of a heart attack when he was
80. . . he had some blood pressure and
cholesterol issues when he was alive, too.
Does Granny have any health issues?
Question
07/17/22
4:29 PM
MDT
She takes some blood pressure pills, and I
think she has high cholesterol, but Granny’s
doing great for 82.
Does your father’s father have any health
issues?
Question
07/17/22
4:30 PM
MDT
Grandpa Jones had colon cancer, and that
caused all kinds of problems for him. Plus, he
had high blood pressure, and…I’m pretty sure
he had diabetes.
it sounds like there are many health concerns
in your family history.
Empathize
07/17/22
4:30 PM
MDT
Thanks for understanding.
with diabetes being so prevelent in your
family. It is very important for you to start
managing your condition.
Educate
07/17/22
4:31 PM
MDT
That makes sense.
Does your father have any health concerns?
Question
07/17/22
4:31 PM
MDT
He passed last year.
this must be so difficult for you.
Empathize
07/17/22
4:31 PM
MDT
Thanks.
It sounds like you have had a rough couple of
years. (No matching questions found.)
Question
07/17/22
4:32 PM
MDT
It sounds like you have had a rough couple of
years.
Empathize
07/17/22
4:32 PM
MDT
I appreciate you saying that.
What is your profession?
Question
07/17/22
4:32 PM
MDT
I’m a supervisor at Mid-American Copy &
Ship. I’ve been working there since high
school, and I’ve just kept moving up.
That’s wonderful, I am happy for you.
Empathize
07/17/22
4:32 PM
MDT
Thanks for understanding.
Have you had any fever?
Question
07/17/22
4:33 PM
MDT
No, I haven’t felt feverish at all this week.
That’s another reason why this seems more
like allergies than a cold.
It sounds like it to me too, but let’s keep
going
Educate
07/17/22
4:33 PM
MDT
OK, I understand.
Is there anything else that is bothering you?
(Clarified to Is there anything else I can do
for you?.)
Question
07/17/22
4:34 PM
MDT
No. (Clarified to if I need anything else from
you.)
Do you have any questions?
Question
07/17/22
4:34 PM
MDT
I don’t have any questions.
Have you travelled outside of the US in the
past two weeks? (Clarified to Do you travel
much?.)
Question
07/17/22
4:34 PM
MDT
I really haven’t travelled that much…I’ve
always wanted to go to France but I’ve never
even been out of the country. I’m always busy
with work or school anyway though. We used
to go on some family vacations when I was
younger, but they were usually just to see
some family in other states. (Clarified to if I
travel much.)
Have you been exposed to any respiratory
illness in the past week?
Question
07/17/22
5:14 PM
MDT
Not lately.
May I examine you?
Question
07/17/22
5:15 PM
MDT
Yeah, that’s fine.
Inspected general face
Exam
Action
07/17/22
5:15 PM
MDT
Inspected forehead and scalp
Exam
Action
07/17/22
5:16 PM
MDT
Inspected nose and mouth
Exam
Action
07/17/22
5:16 PM
MDT
Inspected left side of face
Exam
Action
07/17/22
5:16 PM
MDT
Inspected general face
Exam
Action
07/17/22
5:17 PM
MDT
Inspected right side of face Exam
Action
07/17/22
5:17 PM
MDT
Inspected general face
Exam
Action
07/17/22
5:17 PM
MDT
Inspected forehead and scalp
Exam
Action
07/17/22
5:18 PM
MDT
Inspected nose and mouth
Exam
Action
07/17/22
5:18 PM
MDT
Inspected left orbital area and sclera
Exam
Action
07/17/22
5:21 PM
MDT
Inspected upper conjunctiva
Exam
Action
07/17/22
5:21 PM
MDT
Inspected lower conjunctiva
Exam
Action
07/17/22
5:21 PM
MDT
Inspected upper conjunctiva
Exam
Action
07/17/22
5:22 PM
MDT
Inspected lower conjunctiva
Exam
Action
07/17/22
5:22 PM
MDT
Inspected lower conjunctiva
Exam
Action
07/17/22
5:22 PM
MDT
Performed otoscopic examination of left
naris
Exam
Action
07/17/22
5:22 PM
MDT
Performed otoscopic examination of right
naris
Exam
Action
07/17/22
5:22 PM
MDT
Performed otoscopic examination of left
naris
Exam
Action
07/17/22
5:23 PM
MDT
Performed otoscopic examination of right
ear
Exam
Action
07/17/22
5:23 PM
MDT
Performed otoscopic examination of left ear
Exam
Action
07/17/22
5:26 PM
MDT
Inspected mouth
Exam
Action
07/17/22
5:26 PM
MDT
Inspected front of neck
Exam
Action
07/17/22
5:31 PM
MDT
Inspected general face
Exam
Action
07/17/22
5:32 PM
MDT
Inspected forehead and scalp
Exam
Action
07/17/22
5:32 PM
MDT
Palpated scalp: No balding or thinning hair
distribution, no masses, no tenderness
reported
Exam
Action
07/17/22
5:33 PM
MDT
any tenderness on your head?
Question
07/17/22
5:34 PM
MDT
No.
Palpated scalp: No balding or thinning hair
distribution, no masses, no tenderness
reported
Exam
Action
07/17/22
5:34 PM
MDT
any issues with your hair falling out?
(Clarified to Have you had hair loss?.)
Question
07/17/22
5:34 PM
MDT
Nope. (Clarified to if I have had hair loss.)
Palpated frontal sinuses: No tenderness
reported
Exam
Action
07/17/22
5:34 PM
MDT
Palpated maxillary sinuses: No tenderness
reported
Exam
Action
07/17/22
5:34 PM
MDT
any pain on your face? (Clarified to Does
your face hurt ever?.)
Question
07/17/22
5:35 PM
MDT
No. My face is fine. (Clarified to if I have
facial pain.)
Palpated frontal sinuses: No tenderness
reported
Exam
Action
07/17/22
5:35 PM
MDT
any pressure on your forehead? (Clarified to
Do you feel pressure in your face?.)
Question
07/17/22
5:35 PM
MDT
No, I don’t have any sinus pressure or pain or
anything. (Clarified to if I feel pressure in my
face.)
Palpated temporal arteries bilaterally: Right:
no thrill, 2+ / Left: no thrill, 2+
Exam
Action
07/17/22
5:35 PM
MDT
Palpated left carotid artery: No thrill, 2+
Exam
Action
07/17/22
5:36 PM
MDT
Palpated right carotid artery: No thrill, 2+
Exam
Action
07/17/22
5:36 PM
MDT
Palpated jaw: Full range of motion, no
popping or clicking
Exam
Action
07/17/22
5:37 PM
MDT
Palpated lymph nodes of head and neck: Not
palpable
Exam
Action
07/17/22
5:37 PM
MDT
Palpated supraclavicular lymph nodes: Not
palpable
Exam
Action
07/17/22
5:38 PM
MDT
Palpated axillary lymph nodes: Not palpable
Exam
Action
07/17/22
5:38 PM
MDT
Palpated thyroid gland: No nodules, not
enlarged, no irregularities, no tenderness
reported
Exam
Action
07/17/22
5:38 PM
MDT
Auscultated breath sounds in anterior left
upper lobe
Exam
Action
07/17/22
5:39 PM
MDT
Auscultated breath sounds in anterior left
mid-chest (upper lobe)
Exam
Action
07/17/22
5:39 PM
MDT
Auscultated breath sounds in anterior right
middle lobe
Exam
Action
07/17/22
5:39 PM
MDT
Auscultated breath sounds in anterior right
upper lobe
Exam
Action
07/17/22
5:39 PM
MDT
Auscultated breath sounds in anterior left
lower lobe
Exam
Action
07/17/22
5:39 PM
MDT
Auscultated breath sounds in anterior right
lower lobe
Exam
Action
07/17/22
5:39 PM
MDT
Auscultated breath sounds in posterior left
upper lobe
Exam
Action
07/17/22
5:39 PM
MDT
Auscultated breath sounds in posterior right
upper lobe
Exam
Action
07/17/22
5:39 PM
MDT
Auscultated breath sounds in posterior right
mid-back (lower lobe)
Exam
Action
07/17/22
5:39 PM
MDT
Auscultated breath sounds in posterior left
mid-back (lower lobe)
Exam
Action
07/17/22
5:39 PM
MDT
Auscultated breath sounds in posterior left
lower lobe
Exam
Action
07/17/22
5:39 PM
MDT
Auscultated breath sounds in posterior right
lower lobe
Exam
Action
07/17/22
5:40 PM
MDT
Auscultated breath sounds in posterior right
lower lobe on side
Exam
Action
07/17/22
5:40 PM
MDT
Auscultated breath sounds in posterior right
lower lobe near spine
Exam
Action
07/17/22
5:40 PM
MDT
Auscultated breath sounds in posterior left
lower lobe near spine
Exam
Action
07/17/22
5:40 PM
MDT
Auscultated breath sounds in posterior left
lower lobe on side
Exam
Action
07/17/22
5:40 PM
MDT
Auscultated left temporal pulse
Exam
Action
07/17/22
5:41 PM
MDT
Auscultated right temporal pulse
Exam
Action
07/17/22
5:41 PM
MDT
Auscultated right carotid pulse
Exam
Action
07/17/22
5:41 PM
MDT
Auscultated left carotid pulse
Exam
Action
07/17/22
5:41 PM
MDT
Tested left pupillary reaction with penlight
Exam
Action
07/17/22
5:42 PM
MDT
Tested right pupillary reaction with penlight
Exam
Action
07/17/22
5:42 PM
MDT
Follow my fingers with just your eyes
Question
07/17/22
5:43 PM
MDT
Ok.
Tested convergence to the center
Exam
Action
07/17/22
5:43 PM
MDT
Tested EOM to the upper center
Exam
Action
07/17/22
5:43 PM
MDT
Tested EOM to the upper right
Exam
Action
07/17/22
5:43 PM
MDT
Tested EOM to the upper left
Exam
Action
07/17/22
5:43 PM
MDT
Tested EOM to the lower left
Exam
Action
07/17/22
5:43 PM
MDT
Tested EOM to the lower center
Exam
Action
07/17/22
5:43 PM
MDT
Tested EOM to the lower right
Exam
Action
07/17/22
5:43 PM
MDT
tell me when you can no longer see my
fingers
Question
07/17/22
5:44 PM
MDT
Ok, I will.
Tested peripheral vision
Exam
Action
07/17/22
5:44 PM
MDT
Now.
Examined fundus of left eye with
ophthalmoscope
Exam
Action
07/17/22
5:44 PM
MDT
That’s… I can’t really tell.
Um, that one’s kind of blurry.
E D E O X F
P E C F D
Tested visual acuity of right eye (left eye
covered)
Exam
Action
07/17/22
5:48 PM
MDT
P E C F D
E D F C Z P
F E L O P Z D
D E F P O T E C
Tested visual acuity of left eye (right eye
covered)
Exam
Action
07/17/22
5:49 PM
MDT
I can’t read that line. It’s too little.
is the volume the same in both ears or louder
in one ear?
Question
07/17/22
5:50 PM
MDT
Ok.
Same in both ears.
Performed Weber test with tuning fork
Exam
Action
07/17/22
5:50 PM
MDT
tell me when you no longer hear the ringing
Question
07/17/22
5:51 PM
MDT
Ok, I will.
Now.
tell me when you no longer hear the ringing
Question
07/17/22
5:52 PM
MDT
Ok, I will.
Now.
F.
Question
07/17/22
5:52 PM
MDT
F.
Eight
Question
07/17/22
5:53 PM
MDT
Eight.
W.
Question
07/17/22
5:53 PM
MDT
W.
Performed whisper test in right ear
Exam
Action
07/17/22
5:53 PM
MDT
Four
Question
07/17/22
5:53 PM
MDT
Four.
R.
Question
07/17/22
5:53 PM
MDT
R.
Nine.
Question
07/17/22
5:53 PM
MDT
Nine.
Performed whisper test in left ear
Exam
Action
07/17/22
5:53 PM
MDT
Tested gag reflex with tongue blade
Exam
Action
07/17/22
5:53 PM
MDT
Tested gag reflex with tongue blade
Exam
Action
07/17/22
5:53 PM
MDT
Thank you Ms. Jones (Clarified to Thank
you..)
Question
07/17/22
5:54 PM
MDT
You’re welcome. (Clarified to to say thank
you.)
do you have latex allergy?
Question
07/17/22
6:08 PM
MDT
Nope.
when was your last pap smear?
Question
07/17/22
6:09 PM
MDT
Um, maybe four years ago now?
how old were you when you first started your
period?
Question
07/17/22
6:12 PM
MDT
I think I was eleven.
any concerns with your skin?
Question
07/17/22
6:13 PM
MDT
Well…I guess I was noticing the other day
that the skin around my neck is looking
weird. Like the skin is getting darker. And
my skin’s breaking out, but that’s how it is.
how long have the darkness been around
your neck?
Question
07/17/22
6:14 PM
MDT
I don’t know when I first started to notice it.
Maybe…. maybe it’s been at least a year. I
feel like I notice it more and more lately.
is it painful?
Question
07/17/22
6:14 PM
MDT
No, speaking doesn’t bother my throat too
much. Swallowing does a little, though.
[AUDIO COMING SOON]
does the darkening area around your neck
itch? (Clarified to Does your neck itch?.)
Question
07/17/22
6:15 PM
MDT
No, it’s not itchy. (Clarified to if my neck
itches.)
how long have you had the breaking out?
Question
07/17/22
6:15 PM
MDT
I’ve been getting break-outs since I was in
middle school, I think. Like around the time I
started my period, my skin started to break
out. It went away for a few years in my
twenties, but now I’m getting zits again.
Having skin irritation can be frustrating
Empathize
07/17/22
6:15 PM
MDT
Thanks for saying that.
Is there history of PCOS in your familY?
Educate
07/17/22
6:16 PM
MDT
Sure, I think I understand what you mean.
any moles?
Question
07/17/22
6:18 PM
MDT
I have some, but not too many.
Any hair or nail changes? (Clarified to Have
you had changes with your hair?.)
Question
07/17/22
6:18 PM
MDT
Yeah, I’ve noticed some hairs on my chin that
I have to pluck, and I’m…I guess you can see
that I’m kind of getting a mustache, which I
hate. I’m embarrassed about it. I think I need
to start waxing it… I have some belly hair,
too. (Clarified to if I have had changes with
my hair.)
I am sorry to hear that, facial hair can be
tough for women.
Empathize
07/17/22
6:19 PM
MDT
Thanks for understanding.
do you exercise?
Question
07/17/22
6:20 PM
MDT
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.
what is your living condition?
Question
07/17/22
6:20 PM
MDT
I live at home with my mom and my sister.
It can be tough to find the energy to exercise
when you are on your feet all day
Empathize
07/17/22
6:20 PM
MDT
I appreciate you telling me that.
However, exercise is important for
cardiovascular health.
Educate
07/17/22
6:21 PM
MDT
That makes sense.
what do you eat in a day?
Question
07/17/22
6:21 PM
MDT
Let’s see. . . a muffin or pumpkin bread for
breakfast, a sandwich for lunch, and some
kind of meat with a veggie for dinner.
how is your brother’s health?
Question
07/17/22
6:23 PM
MDT
He’s a healthy guy. Kinda big like me.
anyone in your family with mental disorder?
Question
07/17/22
6:24 PM
MDT
No. They’re crazy, but nobody’s diagnosed
with anything.
alcohol or substance disorder?
Question
07/17/22
6:25 PM
MDT
I do sometimes, yeah, when I go out with my
friends.
is there any history of substance use disorder
in your family? (Clarified to Do you have a
family history of substance abuse?.)
Question
07/17/22
6:25 PM
MDT
One person in the family, my dad’s brother,
has an alcohol problem, but we never see
him. (Clarified to if I have a family history of
substance abuse.)
is there any other family health history?
Question
07/17/22
6:25 PM
MDT
My mom has some issues, and I think some
of my grandparents did, too.
D E F P O T E C
Tested visual acuity with both eyes
Exam
Action
07/17/22
6:46 PM
MDT