Shoshanna Tillman Shadow Health Transcript – assignmenthandlers

Any weight loss?

Question
05/24/23 7:03 PM EDT

Shoshanna Tillman.

Yes, actually.

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How much weight have you lost?

Question
05/24/23 7:03 PM EDT

Shoshanna Tillman.

4 or 5 pounds.

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How has loss of appetite affected your diet? (Clarified to How does your smaller appetite affect your diet?.)

Question
05/24/23 7:07 PM EDT

Shoshanna Tillman.

I haven’t felt like eating much lately. I still eat regular meals, just smaller portions. (Clarified to how my lower appetite affects my diet.)

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Any recent injury?

Question
05/24/23 7:07 PM EDT

Shoshanna Tillman.

No, never been injured, really.

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What are you anxious about?

Question
05/24/23 7:08 PM EDT

Shoshanna Tillman.

I just worry about these symptoms I’ve been having. If they’re going to get worse, and if I’m going to have even more to deal with than I do now.

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Am sorry about that

Empathize
05/24/23 7:09 PM EDT

Shoshanna Tillman.

Thank you, that’s nice.

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What are you sad about?

Question
05/24/23 7:09 PM EDT

Shoshanna Tillman.

Well, I’m still feeling so fatigued and I’m just sad because I feel like it’s not getting any better . . . I just don’t want to feel like this anymore.

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Am sorry about that

Empathize
05/24/23 7:10 PM EDT

Shoshanna Tillman.

Thanks.

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 Inspected both eyes: Normal. Her appearance has no visible abnormal findings, and the site for retractions has no visible abnormal findings

Exam Action
06/01/23 5:27 PM EDT

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 Inspected both eyes: Normal. Her appearance has no visible abnormal findings, and the site for retractions has no visible abnormal findings

Exam Action
06/01/23 5:36 PM EDT

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 Inspected mouth: Oral mucosa is moist and pink

Exam Action
06/01/23 5:36 PM EDT

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 Inspected skin, hair, and nails: No abnormal findings.

Exam Action
06/01/23 5:37 PM EDT

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 Inspected hands and wrists: No visible abnormal findings present

Exam Action
06/01/23 5:37 PM EDT

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 Inspected lower extremities: No visible abnormal findings present Shoshanna Tillman Shadow Health Transcript

Exam Action
06/01/23 5:38 PM EDT

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 Palpated thyroid: No nodules, not enlarged, no irregularities, no tenderness reported

Exam Action
06/01/23 5:38 PM EDT

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 Palpated upper extremities: No abnormal findings present in left or right forearm or left or right upper arms

Exam Action
06/01/23 5:39 PM EDT

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 Palpated lower extremities: No abnormal findings present in left or right calves, left or right ankles, or left or right feet

Exam Action
06/01/23 5:40 PM EDT

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Put your arms out at chest level and keep your hands straight, palm down.

Question
06/01/23 5:42 PM EDT

Shoshanna Tillman.

I can do that.

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 Palpated finger and wrist joints: PIP joints are tender on palpation bilaterally. DIP joints are nontender.

Exam Action
06/01/23 5:42 PM EDT

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Hold your right hand out palm up.

Question
06/01/23 5:51 PM EDT

Shoshanna Tillman.

Sure, yeah.

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 Palpated right radial pulse: Palpated radial pulse was 2+

Exam Action
06/01/23 5:51 PM EDT

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Hold your left hand out palm up

Question
06/01/23 5:51 PM EDT

Shoshanna Tillman.

Sure, yeah.

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 Palpated left radial pulses: Palpated radial pulse was 2+

Exam Action
06/01/23 5:51 PM EDT

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With your write hand make a fist with your thump inside and then bend your wrist towards your little finger.

Question
06/01/23 5:53 PM EDT

Shoshanna Tillman.

I can do that.

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 Performed Finklestein’s test for right hand: No pain elicited over the styloid process of the radius on exam

Exam Action
06/01/23 5:53 PM EDT

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With your left hand make a fist with your thumb inside and then bend your wrist toward your little finger

Question
06/01/23 5:55 PM EDT

Shoshanna Tillman.

I can do that.

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 Performed Finklestein’s test for left hand: No pain elicited over the styloid process of the radius on exam

Exam Action
06/01/23 5:55 PM EDT

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Hold your right hand out palm up

Question
06/01/23 5:56 PM EDT

Shoshanna Tillman.

I can do that.

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 Performed Tinel’s Test on right hand: No paresthesia is elicited into the thumb (1st metacarpal), index finger (2nd metacarpal), or middle/lateral half of the ring finger (4th metacarpal) on exam palpation.

Exam Action
06/01/23 5:56 PM EDT

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Hold your left hand out palm up

Question
06/01/23 5:58 PM EDT

Shoshanna Tillman.

I can do that.

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 Performed Tinel’s Test on left hand: No paresthesia is elicited into the thumb (1st metacarpal), index finger (2nd metacarpal), or middle/lateral half of the ring finger (4th metacarpal) on exam palpation.

Exam Action
06/01/23 5:58 PM EDT

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Press the back of your hands together with your fingers pointing down

Question
06/01/23 6:02 PM EDT

Shoshanna Tillman.

I can do that.

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 Performed Phalen’s Test: No pain or tingling sensation is elicited into the thumb (1st metacarpal), index finger (2nd metacarpal), or middle/lateral half of the ring finger (4th metacarpal) on exam flexion.

Exam Action
06/01/23 6:02 PM EDT

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Touch the tip of your index finger to the tip of your thumb to make an OK sign with your right hand.

Question
06/01/23 6:03 PM EDT

Shoshanna Tillman.

I can do that.

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 Performed OK Sign Test on right hand: Patient is able to make a complete circle with thumb (1st metacarpal and index finger (2nd metacarpal) on exam.

Exam Action
06/01/23 6:04 PM EDT

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Touch the tip of your index finger to the tip of your thumb to make an OK sign with your left hand

Question
06/01/23 6:05 PM EDT

Shoshanna Tillman.

I can do that.

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 Performed OK Sign Test on left hand: Patient is able to make a complete circle with thumb (1st metacarpal and index finger (2nd metacarpal) on exam.

Exam Action
06/01/23 6:05 PM EDT

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Hold your hands out then bend your wrist side to side and up and down.

Question
06/01/23 6:07 PM EDT

Shoshanna Tillman.

I can do that.

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 Tested range of motion of wrists and fingers Shoshanna Tillman Shadow Health Transcript

Exam Action
06/01/23 6:07 PM EDT

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Grasp my fingers and squeeze.

Question
06/01/23 6:08 PM EDT

Shoshanna Tillman.

I can do that.

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 Performed squeezing strength test: All fingers display active movement against full resistance

Exam Action
06/01/23 6:08 PM EDT

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Place your palms to mine and push towards me.

Question
06/01/23 6:09 PM EDT

Shoshanna Tillman.

I can do that.

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 Performed pushing strength test: Performed pushing strength test. All fingers display active movement against full resistance

Exam Action
06/01/23 6:09 PM EDT

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 Tested sensation in both hands: Expected sensation in left and right hand

Exam Action
06/01/23 6:11 PM EDT

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 Tested sensation in both hands: Expected sensation in left and right hand

Exam Action
06/01/23 6:11 PM EDT

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 Tested sensation in both hands: Expected sensation in left and right hand

Exam Action
06/01/23 6:15 PM EDT

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 Tested sensation of both feet: Expected sensation in left and right foot Shoshanna Tillman Shadow Health Transcript

Exam Action
06/01/23 6:15 PM EDT

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