Neurological | Completed | Shadow Health 1.pdf - Neurological Results | Turned In Advanced Health Assessment Spring 2019 NSG516 Online Return to

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Unformatted text preview: Neurological Results | Turned In Advanced Health Assessment - Spring 2019, NSG516 Online Return to Assignment Your Results Overview Reopen Lab Pass Experience Overview Transcript Subjective Data Collection Patient: Tina Jones Student Performance Index 59 out of 61 Objective Data Collection Education & Empathy Documentation Self-Reflection Proficiency Level: Proficient Beginning Digital Clinical Experience Score 100% This score measures your performance on the Student Performance Index in relation to other students in comparable academic programs. Your instructor has chosen to scale your Student Performance Index score so that the average score on the index is a 87.0%. This score may not be your final grade if your instructor chooses to include additional components, such as documentation or time spent. Developing Proficient Students rated as “proficient” demonstrate an entrylevel expertise in advanced practice competencies and clinical reasoning skills. In comparable programs, the top 25% of students perform at the level of a proficient practitioner. Subjective Data Collection Objective Data Collection 37 out of 37 20 out of 20 Education and Empathy 2 out of 4 Time 67 minutes total spent in assignment Interaction with patient Post-exam activities 56 minutes 11 minutes Transcript Started: Feb 14, 2019 | Patient Exam Time: 56 min All Lines (187) Interview Questions (81) Statements (7) Exam Actions (99) Hello Tina. I am Juliana, the nurse practitioner student. I am here to day to interview and examine you. Greet 02/14/19 9:20 AM EST Hey. What brings you in today? Question 02/14/19 9:20 AM EST 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. Oh Tina, I am sorry to hear you got into an accident. Its so scary. I hope it was not too serious! (No matching questions found.) Question 02/14/19 9:21 AM EST Oh Tina, I am sorry to hear you got into an accident. Its so scary. I hope it was not too serious! Empathize 02/14/19 9:21 AM EST I appreciate you saying that. When did the headaches start? Question 02/14/19 9:21 AM EST Five days ago... The headaches started two days after the accident. How often do you get the headaches? Question 02/14/19 9:21 AM EST It's been every day for like, the last five days. Oh, that must make it tough to get things done! Lets see if we can make these headaches go away. Empathize 02/14/19 9:22 AM EST I appreciate you telling me that. How long do the headaches last? About an hour or two. Question 02/14/19 9:22 AM EST Where do you get the headaches? Question 02/14/19 9:22 AM EST The headaches are in the crown of my head, and kind of the back of my head. How severe is the headache? Question 02/14/19 9:22 AM EST The headaches I've been getting aren't horrible, I'm just getting them much more often than I usually do. How do you rate the headaches from 0 to 10? Question 02/14/19 9:22 AM EST It's not horrible or anything, but it's no fun. Maybe a 3. I bet you its no fun! Empathize 02/14/19 9:23 AM EST Thanks. Can you explain the car accident? (No matching questions found.) Question 02/14/19 9:23 AM EST How did the car accident happen? Question 02/14/19 9:23 AM EST We were in my friend's car during the accident. It wasn't serious at all-we were going pretty slowly--but it was still scary. Were you wearing seat belts? Question 02/14/19 9:23 AM EST Yes, I always do. Excellent! Its very important to wear seat belts Empathize 02/14/19 9:24 AM EST Thanks for saying that. Did your head get hit? Question 02/14/19 9:24 AM EST No, I didn't hit my head in the accident or anything. Can you describe the headaches? Question 02/14/19 9:24 AM EST The headaches feel like a dull ache, kind of in the crown of my head, and the back of my head. Does anything make the headache worse? Question 02/14/19 9:24 AM EST Nothing really makes them worse. . . they just sort of start, and eventually they go away. Does anything make the headaches better? Question 02/14/19 9:24 AM EST Yeah, the Tylenol helps a little. How often do you take Tylenol? Question 02/14/19 9:25 AM EST I've been taking it every day since I started getting these headaches. How many Tylenol have you been taking every day? Question 02/14/19 9:25 AM EST I take two of the regular strength kind when I feel a headache coming on, but it's only been once a day. Are you taking other medications? No -- Tylenol is all I've taken recently. Question 02/14/19 9:25 AM EST Do you take prescription medications? Question 02/14/19 9:25 AM EST I have a Flovent inhaler and a Proventil inhaler. Do you have any allergies? Question 02/14/19 9:26 AM EST Yeah, I'm allergic to cats. How do you react to cats? Question 02/14/19 9:26 AM EST Whenever I'm around cats, I start sneezing, my eyes get itchy. . . and my asthma starts to act up. Do you have any allergy to medications? Question 02/14/19 9:26 AM EST Yeah, I'm allergic to penicillin. How do you react to penicillin? Question 02/14/19 9:26 AM EST 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 smoke? Question 02/14/19 9:26 AM EST No. I think it's gross. Good for you! Smoking can cause so many health problems! Thanks for understanding. Empathize 02/14/19 9:26 AM EST Do you drink alcohol? Question 02/14/19 9:27 AM EST I do sometimes, yeah, when I go out with my friends. How many drinks do you have per month? Question 02/14/19 9:27 AM EST Oh, I don't know. Let's see... I might go out every few weeks, so twice a month... and I maybe have 2 or 3 drinks at a time, so maybe 6 drinks a month. Even if I go out more than usual, no more than ten. Do you use recreational drugs? Question 02/14/19 9:27 AM EST No. Does anything relieve the neck pain? Question 02/14/19 9:27 AM EST I haven't been doing anything in particular for my neck. . . just resting and trying not to move it too much. How is your sleep? Question 02/14/19 9:27 AM EST I think I usually get enough sleep. I don't think I have any sleeping problems or anything. [AUDIO COMING SOON] Do you have fever? Question 02/14/19 9:28 AM EST No. Do you have chills? No. Question 02/14/19 9:28 AM EST Have you lost weight? Question 02/14/19 9:28 AM EST I think I've gained a pound or two recently, but I don't weigh myself that often. Do you have fatigue? Question 02/14/19 9:28 AM EST No, not really. Do you have dizziness? Question 02/14/19 9:28 AM EST No, I haven't been feeling dizzy. Do you have changes in sensation? Question 02/14/19 9:28 AM EST No, I don't think so. Do you have numbness? Question 02/14/19 9:28 AM EST Nope. Do you have tingling? Question 02/14/19 9:29 AM EST No, I haven't been tingling at all. Do you have vision problems? 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. Since when you have the vision problems? (Clarified to When did you first notice blurry vision?.) Question 02/14/19 9:29 AM EST Question 02/14/19 9:29 AM EST Hm, I haven't really paid close attention. Maybe over the past few months or so. (Clarified to when the blurry vision began.) Since when do you have these vision problems? Question 02/14/19 9:29 AM EST Well -- first off, my vision's been fine since the car accident. But in general, my vision isn't that great. Sometimes it gets blurry when I read for a long time. How often you have headaches? Question 02/14/19 9:30 AM EST It's been every day for like, the last five days. Do you have problems with hearing? Question 02/14/19 9:30 AM EST No. Did you get headaches before the car accident? Question 02/14/19 9:30 AM EST The only time I got headaches before the accident was when I would read or study for a long time. Do you have a headache right now? Question 02/14/19 9:31 AM EST No, I'm fine right now. Do you have trouble swallowing? Nope. Question 02/14/19 9:31 AM EST Do you have muscle weakness? Question 02/14/19 9:31 AM EST No, I wouldn't say I feel weak. Do you have memory loss? Question 02/14/19 9:31 AM EST Nope. How is your mood? Question 02/14/19 9:31 AM EST I haven't noticed any changes with my mood since the accident. . . I've been about as even-keeled as always. Do you have a family history of headaches? Question 02/14/19 9:32 AM EST No, not that I know of. Do you have a history of seizures? Question 02/14/19 9:32 AM EST No. I've seen somebody have one, though. It's scary. It understand. It can be scary to witness a person having a seizure. Empathize 02/14/19 9:32 AM EST Thanks. May I examine you? Question 02/14/19 9:32 AM EST Sure. What is your name and date of birth? Question 02/14/19 9:33 AM EST My name is Tina Jones, and I was born on February 17th. Evaluated orientation to person What building are you in now? Exam Action 02/14/19 9:33 AM EST Question 02/14/19 9:33 AM EST I'm at the doctor's office. . . it's Shadow Health General Clinic. Evaluated orientation to place What is the date and year? Exam Action 02/14/19 9:33 AM EST Question 02/14/19 9:33 AM EST Um, today's date is [Tina says correct date and year]. Evaluated orientation to time How are apples and oranges alike? Exam Action 02/14/19 9:33 AM EST Question 02/14/19 9:33 AM EST How are they alike? Um.... they're both kinds of fruit. Evaluated abstract thinking: similarities among fruit How are a lake and an ocean alike? Exam Action 02/14/19 9:34 AM EST Question 02/14/19 9:34 AM EST Uh.... they're both bodies of water. Evaluated abstract thinking: similarities among bodies of water Exam Action 02/14/19 9:34 AM EST How are a trumpet and a flute alike? Question 02/14/19 9:34 AM EST They...... they're both musical instruments. Evaluated abstract thinking: similarities among instruments Excellent! Exam Action 02/14/19 9:34 AM EST Empathize 02/14/19 9:34 AM EST Thanks for understanding. Count backwards by 7s from 100 Question 02/14/19 9:34 AM EST Okay. . . 100, 93. . . 86, 79, 72. . . 65. . . 58, 51. . . 44. . . 37, 30, 23, 16. . . 9, and 2. Evaluated attention with serial sevens Exam Action 02/14/19 9:35 AM EST Established one-stage comprehension Exam Action 02/14/19 9:35 AM EST Who was the first president of the United States? Question 02/14/19 9:35 AM EST That's George Washington. Evaluated knowledge of first president Who are the last four presidents of the United States? Well, right now it's Donald Trump. Before him it was Obama. Before *him* we had Bill Clinton and George W. Bush. Exam Action 02/14/19 9:35 AM EST Question 02/14/19 9:35 AM EST Evaluated knowledge of last four presidents Name five large cities in the United States Exam Action 02/14/19 9:35 AM EST Question 02/14/19 9:36 AM EST Let's see. . . New York City. . . and Chicago. . . Detroit. . . Los Angeles. . . and Houston. That's five. Evaluated knowledge of five large cities What would you do if you found a stamped addressed envelope on the sidewalk? Exam Action 02/14/19 9:36 AM EST Question 02/14/19 9:36 AM EST What would I do.... Hmm.. Well, I'd try to figure out who dropped the envelope, but if not... Well, I'd probably just drop it in the first mailbox I saw, if there was one nearby. Evaluated judgment Repeat and remember burger, tulip, nose and tea. Exam Action 02/14/19 9:36 AM EST Question 02/14/19 9:37 AM EST Burger, tulip, nose, and tea. Evaluated immediate memory How did you celebrate your last birthday? Wow. . . it's weird, birthdays were huge for us before Dad died because he would always make a really big deal out of them, like he loved planning these huge celebrations. But the past two birthdays, he hasn't been there, so it's been kind of sad, thinking about what he's missing, and we haven't done huge parties or anything. Last birthday. . . Michael and his fiance came over, and we all had dinner at the house, and I opened presents, and we had a really good cake from this bakery I love. It was nice. Exam Action 02/14/19 9:37 AM EST Question 02/14/19 9:37 AM EST Evaluated remote memory Repeat the four words from before Exam Action 02/14/19 9:38 AM EST Question 02/14/19 9:38 AM EST Burger. . . tulip. . .nose. . . and tea. Evaluated immediate learning Exam Action 02/14/19 9:38 AM EST Observed patient's general vocabulary Exam Action 02/14/19 9:38 AM EST What classes are you taking? Question 02/14/19 9:38 AM EST I'm taking two classes right now, one on auditing and one on managerial accounting Observed patient's general ability to articulate Can you tell me more about school? Exam Action 02/14/19 9:38 AM EST Question 02/14/19 9:38 AM EST 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 02/14/19 9:39 AM EST DEFPOTEC Tested visual acuity of both eyes Exam Action 02/14/19 9:39 AM EST DEFPOTEC Tested visual acuity of left eye Exam Action 02/14/19 9:39 AM EST That's... I can't really tell. Um, that one's kind of blurry. EDEOXF PECFD Tested visual acuity of right eye Exam Action 02/14/19 9:40 AM EST Inspected fundus of right eye Exam Action 02/14/19 9:40 AM EST Inspected fundus of left eye Exam Action 02/14/19 9:40 AM EST Inspected right pupil and tested pupillary light reflex Exam Action 02/14/19 9:41 AM EST Inspected left pupil and tested left pupillary light reflex Exam Action 02/14/19 9:41 AM EST Follow my finger with just your eyes Question 02/14/19 9:41 AM EST Ok. Tested EOM to the upper right Exam Action 02/14/19 9:41 AM EST Tested EOM to the upper center Exam Action 02/14/19 9:41 AM EST Tested EOM to the upper left Exam Action 02/14/19 9:41 AM EST Tested EOM to the lower left Exam Action 02/14/19 9:41 AM EST Tested EOM to the lower center Exam Action 02/14/19 9:41 AM EST Tested EOM to the lower right Exam Action 02/14/19 9:41 AM EST Tested convergence Exam Action 02/14/19 9:41 AM EST Close your eyes and tell me if the touch is sharp, dull or soft. Question 02/14/19 9:42 AM EST Ok. Tested facial sensation: dull stimulus Exam Action 02/14/19 9:42 AM EST Dull. Tested facial sensation: dull stimulus Exam Action 02/14/19 9:42 AM EST Dull. Tested facial sensation: soft stimulus Exam Action 02/14/19 9:42 AM EST Soft. Tested facial sensation: soft stimulus Exam Action 02/14/19 9:42 AM EST Soft. Tested facial sensation: soft stimulus Exam Action 02/14/19 9:42 AM EST Soft. Tested facial sensation: sharp stimulus Exam Action 02/14/19 9:42 AM EST Sharp. Tested facial sensation: sharp stimulus Exam Action 02/14/19 9:42 AM EST Sharp. Tested facial sensation: sharp stimulus Exam Action 02/14/19 9:42 AM EST Sharp. Tested facial sensation: sharp stimulus Exam Action 02/14/19 9:42 AM EST Sharp. Inspected front of face for asymmetry and facial droop Inspected left side of face for asymmetry and facial droop Exam Action 02/14/19 9:43 AM EST Exam Action 02/14/19 9:43 AM EST Inspected back of head for asymmetry Exam Action 02/14/19 9:43 AM EST Inspected right side of face for asymmetry and facial droop Exam Action 02/14/19 9:43 AM EST Inspected front of face for asymmetry and facial droop Exam Action 02/14/19 9:43 AM EST Is the volume the same in both ears or louder in one ear? Question 02/14/19 9:43 AM EST Ok. Same in both ears. Tell me when you no longer hear the ringing Question 02/14/19 9:44 AM EST Ok, I will. Now. Performed Rinne test on right side with tuning fork Exam Action 02/14/19 9:44 AM EST Now. Now. Now. Tested gag reflex Tested trapezius muscle strength against resistance: 5 strength against resistance Exam Action 02/14/19 9:45 AM EST Exam Action 02/14/19 9:45 AM EST Tested sternocleidomastoid muscle strength against resistance head turned to the right: 5 strength against resistance Exam Action 02/14/19 9:46 AM EST Tested sternocleidomastoid muscle strength against resistance head turned to the left: 5 strength against resistance Exam Action 02/14/19 9:46 AM EST Inspected mouth Exam Action 02/14/19 9:46 AM EST Inspected mouth: pushed tongue left with tongue blade Exam Action 02/14/19 9:46 AM EST Inspect mouth: pushed tongue right with tongue blade Exam Action 02/14/19 9:46 AM EST Inspect mouth: lifted tongue with tongue blade Exam Action 02/14/19 9:46 AM EST Inspected mouth: depressed tongue with tongue blade Exam Action 02/14/19 9:46 AM EST Tested reflexes of right triceps: 2+ Exam Action 02/14/19 9:47 AM EST Tested reflexes of left triceps: 2+ Exam Action 02/14/19 9:47 AM EST Tested reflexes of right biceps: 2+ Exam Action 02/14/19 9:47 AM EST Tested reflexes of left biceps: 2+ Exam Action 02/14/19 9:47 AM EST Tested reflexes of right brachioradialis: 2+ Exam Action 02/14/19 9:48 AM EST Tested reflexes of left brachioradialis: 2+ Exam Action 02/14/19 9:48 AM EST Tested reflexes of right patellar tendon: 2+ Exam Action 02/14/19 9:48 AM EST Tested reflexes of right achilles tendon: 2+ Exam Action 02/14/19 9:48 AM EST Tested reflexes of left achilles tendon: 2+ Exam Action 02/14/19 9:49 AM EST Close your eyes and touch your fingers to your nose Question 02/14/19 9:49 AM EST I can do that. Run your right foot down your shin Question 02/14/19 9:49 AM EST Sure. Observed right heel moving to shin Run your left foot down your right shin Exam Action 02/14/19 9:49 AM EST Question 02/14/19 9:50 AM EST Ok. Observed left heel moving to shin Place your hands on your knees and turn them over Exam Action 02/14/19 9:50 AM EST Question 02/14/19 9:50 AM EST Ok, like this? Observed rapid alternating hand movements: Movement is smooth, performed without difficulty Exam Action 02/14/19 9:50 AM EST Observed patient's gait Close your eyes and tell me what I trace on your palm Exam Action 02/14/19 9:50 AM EST Question 02/14/19 9:50 AM EST Ok. That's an "A." Tested left-hand graphesthesia by letter identification Exam Action 02/14/19 9:51 AM EST A figure "8." Tested right-hand graphesthesia by number identification Exam Action 02/14/19 9:51 AM EST Close your eyes and tell me if the touch is sharp, dull, or soft. Question 02/14/19 9:51 AM EST Ok. Tested right arm proximal dull sensation Exam Action 02/14/19 9:51 AM EST Dull. Tested left arm proximal dull sensation Exam Action 02/14/19 9:51 AM EST Dull. Tested right arm distal sharp sensation Exam Action 02/14/19 9:51 AM EST Sharp. Tested left arm distal sharp sensation Exam Action 02/14/19 9:51 AM EST Sharp. Test sensory light chest Exam Action 02/14/19 9:51 AM EST Soft. Close your eyes and tell me if the touch is sharp, dull or soft. Question 02/14/19 9:52 AM EST Ok. Tested right leg proximal dull sensation Exam Action 02/14/19 9:52 AM EST Dull. Tested left leg proximal dull sensation Exam Action 02/14/19 9:52 AM EST Dull. Tested left leg distal light sensation Exam Action 02/14/19 9:52 AM EST Soft. Tested right leg distal light sensation Soft. Exam Action 02/14/19 9:52 AM EST Tested left leg proximal sharp sensation Exam Action 02/14/19 9:52 AM EST Sharp. Tested right leg distal sharp sensation Exam Action 02/14/19 9:52 AM EST Sharp. Close your eyes and tell me when you feel the touch Question 02/14/19 9:53 AM EST Ok, I will. Tested sensation of right heel with monofilament Exam Action 02/14/19 9:53 AM EST Yes. Tested sensation of left ball of foot under small toe with monofilament Tested sensation of right big toe with monofilament Exam Action 02/14/19 9:53 AM EST Exam Action 02/14/19 9:53 AM EST Yes. Tested sensation of right big toe with monofilament Exam Action 02/14/19 9:53 AM EST Tested sensation of left heel with monofilament Exam Action 02/14/19 9:53 AM EST Yes. Tested sensation of left ball of foot under small toe with monofilament Exam Action 02/14/19 9:53 AM EST Tested sensation of left ball of foot under big toe with monofilament Exam Action 02/14/19 9:53 AM EST Tested sensation of left big toe with monofilament Exam Action 02/14/19 9:53 AM EST Close your eyes and tell me if your finger or toe moves up or down Question 02/14/19 9:54 AM EST Ok, I will. Down. Tested positio...
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