Shoshanna Tillman Shadow Health Transcript
Shoshanna Tillman Shadow Health Transcript
Hello…..
Greet
05/24/23 12:15 PM EDT
Hi.
Why are you here today?
Question
05/24/23 12:34 PM EDT
I’m here to follow up on my last visit, about my joint pain, and how tired I’ve been.
Sorry about that
Empathize
05/24/23 12:34 PM EDT
Thank you.
How long have you had joint pain?
Question
05/24/23 12:35 PM EDT
The joint pain started about 3 months ago, now.
Where is the joint point located? Shoshanna Tillman Shadow Health Transcript
Question
05/24/23 12:36 PM EDT
In my hands and wrists, mainly, but also I have this all-over sort of pain.
Is your pain like? (Clarified to Can you describe your pain?.)
Question
05/24/23 12:38 PM EDT
I feel sort of stiff and achy all over. And my hands and wrists are stiff — there’s this dull, throbbing sort of pain. (Clarified to what the pain is like.) Shoshanna Tillman Shadow Health Transcript
What worsens your pain?
Question
05/24/23 12:38 PM EDT
Holding my coffee cup in the morning is tough on my hands and fingers, and my wrists. Also typing and holding my art tools hurts after a while.
What relieves your pain?
Question
05/24/23 12:39 PM EDT
Long, hot showers can help a little. Also, the diclofenac has been helping some.
can you rate your pain on a scale of 1 to ten?
Question
05/24/23 12:40 PM EDT
I still have pain, but since starting the diclofenac, maybe a 2 out of 10. Before it was a 3 or 4.
How long have you had fatigue
Question
05/24/23 12:41 PM EDT
Going on 3 months now.
Is your fatigue constant?
Question
05/24/23 12:41 PM EDT
Always, yeah.
Does your fatigue worsen?
Question
05/24/23 12:42 PM EDT
Yeah, the fatigue feels worse as the day goes on.
What makes your fatigue worse?
Question
05/24/23 12:44 PM EDT
Nothing, I don’t think . . . but I am pretty stressed regularly.
I am sorry about that
Empathize
05/24/23 12:44 PM EDT
I appreciate that.
Are you able to do your daily activities?
Question
05/24/23 12:45 PM EDT
I guess so, yeah. I can do everything I need to. I just take a little longer these days, ’cause I’m so tired. And I sometimes just feel drained after everything.
What causes your fatigue? Shoshanna Tillman Shadow Health Transcript
Question
05/24/23 12:45 PM EDT
I don’t know why I’m so tired. I haven’t noticed anything that makes me particularly tired. Maybe it’s hormones or something. Or stress, I’m very stressed these days.
Any allergies?
Question
05/2
Any weight loss?
Question
05/24/23 7:03 PM EDT
Yes, actually.
How much weight have you lost?
Question
05/24/23 7:03 PM EDT
4 or 5 pounds.
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
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.)
Any recent injury?
Question
05/24/23 7:07 PM EDT
No, never been injured, really.
What are you anxious about?
Question
05/24/23 7:08 PM EDT
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.
Am sorry about that
Empathize
05/24/23 7:09 PM EDT
Thank you, that’s nice.
What are you sad about?
Question
05/24/23 7:09 PM EDT
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.
Am sorry about that
Empathize
05/24/23 7:10 PM EDT
Thanks.
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
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
Inspected mouth: Oral mucosa is moist and pink
Exam Action
06/01/23 5:36 PM EDT
Inspected skin, hair, and nails: No abnormal findings.
Exam Action
06/01/23 5:37 PM EDT
Inspected hands and wrists: No visible abnormal findings present
Exam Action
06/01/23 5:37 PM EDT
Inspected lower extremities: No visible abnormal findings present Shoshanna Tillman Shadow Health Transcript
Exam Action
06/01/23 5:38 PM EDT
Palpated thyroid: No nodules, not enlarged, no irregularities, no tenderness reported
Exam Action
06/01/23 5:38 PM EDT
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
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
Put your arms out at chest level and keep your hands straight, palm down.
Question
06/01/23 5:42 PM EDT
I can do that.
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
Hold your right hand out palm up.
Question
06/01/23 5:51 PM EDT
Sure, yeah.
Palpated right radial pulse: Palpated radial pulse was 2+
Exam Action
06/01/23 5:51 PM EDT
Hold your left hand out palm up
Question
06/01/23 5:51 PM EDT
Sure, yeah.
Palpated left radial pulses: Palpated radial pulse was 2+
Exam Action
06/01/23 5:51 PM EDT
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
I can do that.
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
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
I can do that.
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
Hold your right hand out palm up
Question
06/01/23 5:56 PM EDT
I can do that.
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
Hold your left hand out palm up
Question
06/01/23 5:58 PM EDT
I can do that.
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
Press the back of your hands together with your fingers pointing down
Question
06/01/23 6:02 PM EDT
I can do that.
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
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
I can do that.
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
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
I can do that.
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
Hold your hands out then bend your wrist side to side and up and down.
Question
06/01/23 6:07 PM EDT
I can do that.
Tested range of motion of wrists and fingers Shoshanna Tillman Shadow Health Transcript
Exam Action
06/01/23 6:07 PM EDT
Grasp my fingers and squeeze.
Question
06/01/23 6:08 PM EDT
