Shoshanna Tillman Shadow Health Transcript
Shoshanna Tillman Shadow Health Transcript
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Hello…..
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Greet |
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Hi.
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Why are you here today?
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I’m here to follow up on my last visit, about my joint pain, and how tired I’ve been.
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Sorry about that
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Thank you.
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How long have you had joint pain?
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The joint pain started about 3 months ago, now.
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Where is the joint point located? Shoshanna Tillman Shadow Health Transcript
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In my hands and wrists, mainly, but also I have this all-over sort of pain.
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Is your pain like? (Clarified to Can you describe your pain?.)
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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
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What worsens your pain?
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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.
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What relieves your pain?
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Long, hot showers can help a little. Also, the diclofenac has been helping some.
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can you rate your pain on a scale of 1 to ten?
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I still have pain, but since starting the diclofenac, maybe a 2 out of 10. Before it was a 3 or 4.
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How long have you had fatigue
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Going on 3 months now.
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Is your fatigue constant?
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Always, yeah.
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Does your fatigue worsen?
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Yeah, the fatigue feels worse as the day goes on.
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What makes your fatigue worse?
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Nothing, I don’t think . . . but I am pretty stressed regularly.
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I am sorry about that
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I appreciate that.
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Are you able to do your daily activities?
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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.
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What causes your fatigue? Shoshanna Tillman Shadow Health Transcript
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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.
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Any allergies?
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Any weight loss?
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Yes, actually.
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How much weight have you lost?
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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?.)
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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?
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No, never been injured, really.
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What are you anxious about?
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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
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Empathize |
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Thank you, that’s nice.
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What are you sad about?
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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
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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
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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
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Inspected mouth: Oral mucosa is moist and pink
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Inspected skin, hair, and nails: No abnormal findings.
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Inspected hands and wrists: No visible abnormal findings present
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Inspected lower extremities: No visible abnormal findings present Shoshanna Tillman Shadow Health Transcript
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Palpated thyroid: No nodules, not enlarged, no irregularities, no tenderness reported
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Palpated upper extremities: No abnormal findings present in left or right forearm or left or right upper arms
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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
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Put your arms out at chest level and keep your hands straight, palm down.
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I can do that.
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Palpated finger and wrist joints: PIP joints are tender on palpation bilaterally. DIP joints are nontender.
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Hold your right hand out palm up.
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Sure, yeah.
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Palpated right radial pulse: Palpated radial pulse was 2+
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Hold your left hand out palm up
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Sure, yeah.
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Palpated left radial pulses: Palpated radial pulse was 2+
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With your write hand make a fist with your thump inside and then bend your wrist towards your little finger.
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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
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With your left hand make a fist with your thumb inside and then bend your wrist toward your little finger
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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
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Hold your right hand out palm up
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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.
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Hold your left hand out palm up
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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.
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Press the back of your hands together with your fingers pointing down
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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.
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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.
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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.
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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
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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.
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Hold your hands out then bend your wrist side to side and up and down.
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I can do that.
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Tested range of motion of wrists and fingers Shoshanna Tillman Shadow Health Transcript
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Grasp my fingers and squeeze.
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I can do that.
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Performed squeezing strength test: All fingers display active movement against full resistance
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Place your palms to mine and push towards me.
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I can do that.
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Performed pushing strength test: Performed pushing strength test. All fingers display active movement against full resistance
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Tested sensation in both hands: Expected sensation in left and right hand
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Tested sensation in both hands: Expected sensation in left and right hand
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Tested sensation in both hands: Expected sensation in left and right hand
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Tested sensation of both feet: Expected sensation in left and right foot Shoshanna Tillman Shadow Health Transcript
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