Neurological Assignment _ Completed _ Shadow Health:4.pdf - Neurological Assignment | Completed | Shadow Health Transcript Started | Patient Exam Time

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Unformatted text preview: 9/17/2019 Neurological Assignment | Completed | Shadow Health Transcript Started: Sep 16, 2019 | Patient Exam Time: 76 min All Lines (250) Interview Questions (119) Statements (1) Exam Actions (130) hello tina, how are you Greet 09/16/19 11:16 PM CDT Hey. what brings you in today? Question 09/16/19 11:16 PM CDT 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. I'm sorry to hear that Empathize 09/16/19 11:16 PM CDT Thanks for saying that. can you tell me about your headaches ? Question 09/16/19 11:17 PM CDT The headaches feel like a dull ache, kind of in the crown of my head, and the back of my head. how long do they last? Question 09/16/19 11:17 PM CDT Well, it usually takes a minute or two for me to realize I need my inhaler, and then maybe a minute or two for the inhaler to work. So I guess three or four minutes, usually. 1/35 9/17/2019 Neurological Assignment | Completed | Shadow Health How long do your headaches last ? Question 09/16/19 11:18 PM CDT About an hour or two. do you take any medication for them ? (No matching questions found.) Question 09/16/19 11:18 PM CDT are you having any trouble with your vision? Question 09/16/19 11:19 PM CDT 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. do you have any numbness or tingling ? Question 09/16/19 11:20 PM CDT No, I wouldn't say it's a tingling feeling. what kind of feeling is it? (No matching questions found.) Question 09/16/19 11:20 PM CDT are you having any trouble walking Question 09/16/19 11:20 PM CDT Nope. any numbness? Question 09/16/19 11:21 PM CDT Nope. 2/35 9/17/2019 Neurological Assignment | Completed | Shadow Health what is your name and date of birth? Question 09/16/19 11:21 PM CDT My name is Tina Jones, and I was born on February 17th. Evaluated orientation to person what building are you in now ? Exam Action 09/16/19 11:21 PM CDT Question 09/16/19 11:21 PM CDT I'm at the doctor's office. . . it's Shadow Health General Clinic. Evaluated orientation to place What's the date and year? Exam Action 09/16/19 11:21 PM CDT Question 09/16/19 11:22 PM CDT Um, today's date is [Tina says correct date and year]. Evaluated orientation to time how are apples and oranges alike ? Exam Action 09/16/19 11:22 PM CDT Question 09/16/19 11:22 PM CDT How are they alike? Um.... they're both kinds of fruit. Evaluated abstract thinking: similarities among fruit Exam Action 09/16/19 11:22 PM CDT how are lakes and oceans alike 3/35 9/17/2019 Neurological Assignment | Completed | Shadow Health Question 09/16/19 11:23 PM CDT Uh.... they're both bodies of water. Evaluated abstract thinking: similarities among bodies of water how are a trumpet and a flute alike Exam Action 09/16/19 11:23 PM CDT Question 09/16/19 11:24 PM CDT They...... they're both musical instruments. Evaluated abstract thinking: similarities among instruments can you count backward from 100 by 7's Exam Action 09/16/19 11:24 PM CDT Question 09/16/19 11:24 PM CDT Okay. . . 100, 93. . . 86, 79, 72. . . 65. . . 58, 51. . . 44. . . 37, 30, 23, 16. . . 9, and 2. Evaluated attention with serial sevens Exam Action 09/16/19 11:25 PM CDT Established one-stage comprehension Exam Action 09/16/19 11:25 PM CDT Established two-stage comprehension Exam Action 09/16/19 11:26 PM CDT who was the first president of the united states? Question 09/16/19 11:26 PM CDT 4/35 9/17/2019 Neurological Assignment | Completed | Shadow Health That's George Washington. Evaluated knowledge of first president who are the last four presidents of the united states Exam Action 09/16/19 11:26 PM CDT Question 09/16/19 11:27 PM CDT Well, right now it's Donald Trump. Before him it was Obama. Before *him* we had Bill Clinton and George W. Bush. Evaluated knowledge of last four presidents name five large cities in the united states Exam Action 09/16/19 11:27 PM CDT Question 09/16/19 11:27 PM CDT 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 and addressed envelope on the sidewalk? Exam Action 09/16/19 11:27 PM CDT Question 09/16/19 11:28 PM CDT 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 09/16/19 11:28 PM CDT Question 09/16/19 11:29 PM CDT 5/35 9/17/2019 Neurological Assignment | Completed | Shadow Health Burger, tulip, nose, and tea. Evaluated immediate memory Repeat and remember Burger tulip nose and tea Exam Action 09/16/19 11:29 PM CDT Question 09/16/19 11:30 PM CDT Burger, tulip, nose, and tea. Evaluated immediate memory How did you celebrate your last birthday Exam Action 09/16/19 11:30 PM CDT Question 09/16/19 11:30 PM CDT 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. Evaluated remote memory Can you repeat the four words from before Exam Action 09/16/19 11:30 PM CDT Question 09/16/19 11:31 PM CDT Burger. . . tulip. . .nose. . . and tea. Evaluated immediate learning Exam Action 09/16/19 11:31 PM CDT 6/35 9/17/2019 Neurological Assignment | Completed | Shadow Health Observed patient's general vocabulary Exam Action 09/16/19 11:31 PM CDT Observed patient's general ability to articulate Exam Action 09/16/19 11:31 PM CDT Tested CN I (olfactory nerve) with smell test Exam Action 09/16/19 11:31 PM CDT FP FP FP FP FP FP FP Inspected fundus of right eye Exam Action 09/16/19 11:33 PM CDT Inspected fundus of left eye Exam Action 09/16/19 11:34 PM CDT Inspected right pupil and tested pupillary light reflex Exam Action 09/16/19 11:34 PM CDT 7/35 9/17/2019 Neurological Assignment | Completed | Shadow Health Inspected left pupil and tested left pupillary light reflex Follow my finger with just your eyes Exam Action 09/16/19 11:34 PM CDT Question 09/16/19 11:36 PM CDT Ok. Tested EOM to the upper left Exam Action 09/16/19 11:37 PM CDT Tested EOM to the lower left Exam Action 09/16/19 11:37 PM CDT Tested EOM to the lower center Exam Action 09/16/19 11:37 PM CDT Tested EOM to the lower right Exam Action 09/16/19 11:37 PM CDT Tested EOM to the upper right Exam Action 09/16/19 11:37 PM CDT Tested EOM to the upper center Exam Action 09/16/19 11:37 PM CDT Tested convergence Exam Action 09/16/19 11:37 PM CDT Tested convergence Exam Action 09/16/19 11:37 PM CDT Tested EOM to the lower center 8/35 9/17/2019 Neurological Assignment | Completed | Shadow Health Exam Action 09/16/19 11:37 PM CDT Tested EOM to the upper center Exam Action 09/16/19 11:37 PM CDT Tested EOM to the upper left Exam Action 09/16/19 11:37 PM CDT Tested EOM to the lower left Exam Action 09/16/19 11:37 PM CDT Tested EOM to the lower right Exam Action 09/16/19 11:37 PM CDT Tested EOM to the upper right Exam Action 09/16/19 11:37 PM CDT \ Close your eyes and tell me if the touch of Sharp dull or soft Question 09/16/19 11:38 PM CDT Ok. Tested facial sensation: dull stimulus Exam Action 09/16/19 11:38 PM CDT Dull. Tested facial sensation: dull stimulus Exam Action 09/16/19 11:38 PM CDT Dull. 9/35 9/17/2019 Neurological Assignment | Completed | Shadow Health Tested facial sensation: dull stimulus Exam Action 09/16/19 11:38 PM CDT Dull. Tested facial sensation: dull stimulus Exam Action 09/16/19 11:38 PM CDT Dull. Tested facial sensation: soft stimulus Exam Action 09/16/19 11:38 PM CDT Soft. Tested facial sensation: soft stimulus Exam Action 09/16/19 11:38 PM CDT Soft. Tested facial sensation: soft stimulus Exam Action 09/16/19 11:38 PM CDT Soft. Tested facial sensation: soft stimulus Exam Action 09/16/19 11:38 PM CDT Soft. Tested facial sensation: sharp stimulus Exam Action 09/16/19 11:38 PM CDT 10/35 9/17/2019 Neurological Assignment | Completed | Shadow Health Sharp. Tested facial sensation: sharp stimulus Exam Action 09/16/19 11:38 PM CDT Sharp. Tested facial sensation: sharp stimulus Exam Action 09/16/19 11:38 PM CDT Sharp. Tested facial sensation: sharp stimulus Exam Action 09/16/19 11:38 PM CDT Sharp. Inspected front of face for asymmetry and facial droop Exam Action 09/16/19 11:38 PM CDT Inspected right side of face for asymmetry and facial droop Exam Action 09/16/19 11:38 PM CDT Inspected back of head for asymmetry Exam Action 09/16/19 11:39 PM CDT Inspected left side of face for asymmetry and facial droop Exam Action 09/16/19 11:39 PM CDT Inspected front of face for asymmetry and facial droop Exam Action 09/16/19 11:39 PM CDT Is the value in the same in both ears or louder in one 11/35 9/17/2019 Neurological Assignment | Completed | Shadow Health Question 09/16/19 11:41 PM CDT Ok. Same in both ears. Performed Weber test with tuning fork Tell me when you no longer hear the ringing Exam Action 09/16/19 11:41 PM CDT Question 09/16/19 11:42 PM CDT Ok, I will. Now. Performed Rinne test on right side with tuning fork Exam Action 09/16/19 11:42 PM CDT Now. Now. Now. Performed Rinne test on left side with tuning fork when did your symptoms start after the accident Exam Action 09/16/19 11:44 PM CDT Question 09/16/19 11:50 PM CDT 12/35 9/17/2019 Neurological Assignment | Completed | Shadow Health Well, I was in the car accident a week ago, but the headaches and neck stuff started a few days after that. Did you lose Consciousness during the accident Question 09/16/19 11:52 PM CDT No. Was the vehicle moving fast Question 09/16/19 11:52 PM CDT Oh, it was really slow. We were in a parking lot. Maybe not even fifteen miles an hour. Were you wearing a seat belt Question 09/16/19 11:52 PM CDT Yes, I always do. Where were you sitting Question 09/16/19 11:52 PM CDT I was in the front passenger seat. Or drugs or alcohol involved (No matching questions found.) Question 09/16/19 11:52 PM CDT where drugs or alcohol involved (No matching questions found.) Question 09/16/19 11:52 PM CDT where drugs or alcohol involved in the accident (No matching questions found.) Question 09/16/19 11:53 PM CDT 13/35 9/17/2019 Neurological Assignment | Completed | Shadow Health drugs or alcohol involved in the accident (No matching questions found.) Question 09/16/19 11:53 PM CDT drugs or alcohol used in the accident (No matching questions found.) Question 09/16/19 11:53 PM CDT where you drinking Question 09/16/19 11:53 PM CDT I do sometimes, yeah, when I go out with my friends. during the accident Question 09/16/19 11:53 PM CDT My friend was driving. I was in the passenger seat. was your friend drinking (Clarified to Do you friends drink and drive?.) Question 09/16/19 11:54 PM CDT Uh. . . I guess a friend might drive if she's had only a couple of drinks. (Clarified to if my friends drink and drive.) how often are you getting the headaches Question 09/16/19 11:54 PM CDT It's been every day for like, the last five days. when was your last headache Question 09/16/19 11:54 PM CDT Yesterday afternoon. does your pain radiate 14/35 9/17/2019 Neurological Assignment | Completed | Shadow Health Question 09/16/19 11:55 PM CDT Maybe? The soreness in my neck feels like it goes up into my head. But its just my neck and head that hurt. any pain in your neck Question 09/16/19 11:55 PM CDT Yeah, it has been hurting since a couple days after the accident. can you tell me about your neck pain Question 09/16/19 11:55 PM CDT It's just been stiff and sore since a little after the car accident. any jaw pain Question 09/16/19 11:56 PM CDT No, not at all. any facial pain Question 09/16/19 11:56 PM CDT No. My face is fine. can you rate your current pain Question 09/16/19 11:56 PM CDT It's just my neck that hurts right now. . . I guess I'd say it's a 3 out of 10. whats the worst pain 15/35 9/17/2019 Neurological Assignment | Completed | Shadow Health Question 09/16/19 11:56 PM CDT It's really just been the headaches, but my neck is sore, too. can you rate it (Clarified to Can you rate your headache pain?.) Question 09/16/19 11:57 PM CDT It's just my neck that hurts right now. . . I guess I'd say it's a 3 out of 10. (Clarified to how I would rate my headache pain.) can you rate the worst pain Question 09/16/19 11:57 PM CDT They probably get up to a 4. cLuster or cyclic headache (No matching questions found.) Question 09/16/19 11:58 PM CDT are you having cLuster or cyclic headaches Question 09/16/19 11:58 PM CDT No, definitely not. do your headaches move from very painful to minimally painful Question 09/16/19 11:59 PM CDT Maybe? The soreness in my neck feels like it goes up into my head. But its just my neck and head that hurt. do you have multiple headaches Question 09/16/19 11:59 PM CDT 16/35 9/17/2019 Neurological Assignment | Completed | Shadow Health No, it's like one headache a day -- once it starts, I take something for it and it pretty much goes away for the day. what do you take for your headaches? Question 09/17/19 12:00 AM CDT I take Tylenol. how dose it work (No matching questions found.) Question 09/17/19 12:00 AM CDT does the Tylenol work (Clarified to Does the Tylenol help the headaches?.) Question 09/17/19 12:00 AM CDT Yeah, it has been helping some. (Clarified to if Tylenol helps the headaches.) dose anything trigger your headaches (No matching questions found.) Question 09/17/19 12:01 AM CDT what triggers your headaches Question 09/17/19 12:01 AM CDT Well, I'm worried these headaches have something to do with my fender bender -- That's why I came in. But I don't know about any particular triggers. They usually creep up during the day, and then I take something to make them go away. are you using any home remedies (Clarified to Any home remedy use?.) Question 09/17/19 12:01 AM CDT I've been taking Tylenol. And resting helps, too. (Clarified to if I tried any home remedies.) are you using heat or cold (Clarified to Have you tried using heat or ice?.) Question 09/17/19 12:02 AM CDT 17/35 9/17/2019 Neurological Assignment | Completed | Shadow Health No, I haven't tried that. (Clarified to if I have tried heat or ice.) Can you confirm your medication (Clarified to Can you confirm your allergies for me?.) Question 09/17/19 12:02 AM CDT Cats, and penicillin. (Clarified to to confirm my allergies.) Can you confirm your medication (No matching questions found.) Question 09/17/19 12:02 AM CDT What medication are you taking Question 09/17/19 12:03 AM CDT Just some Tylenol for my headaches and my neck... and I use my daily inhaler, too. Are you taking metformin Question 09/17/19 12:03 AM CDT I don't take anything for my diabetes anymore. How often are you using Tylenol Question 09/17/19 12:03 AM CDT I've been taking it every day since I started getting these headaches. How many times a day do you take tylenol Question 09/17/19 12:04 AM CDT I've been taking the Tylenol whenever I get a headache, so it's been about once a day since after the accident. What is the dose of Tylenol you take 18/35 9/17/2019 Neurological Assignment | Completed | Shadow Health Question 09/17/19 12:04 AM CDT I'm not sure the actual dosage, but I generally take 2 regular strength pills. Have you had any Seizures Question 09/17/19 12:23 AM CDT No. I've seen somebody have one, though. It's scary. Have you had headaches before Question 09/17/19 12:24 AM CDT The only time I got headaches before the accident was when I would read or study for a long time. Have you hit your head Question 09/17/19 12:24 AM CDT No, I didn't hit my head in the accident or anything. Have you had any changes in your sleep Question 09/17/19 12:24 AM CDT No. Have you been more tired than usual Question 09/17/19 12:24 AM CDT No, I feel about the same as usual. Have you done excess yawning 19/35 9/17/2019 Neurological Assignment | Completed | Shadow Health Question 09/17/19 12:24 AM CDT No. Have you had any not sure if I'm (No matching questions found.) Question 09/17/19 12:25 AM CDT have you been nausea (Clarified to Have you been vomiting or feeling nauseated?.) Question 09/17/19 12:26 AM CDT No, not at all. (Clarified to if I have had nausea or vomiting.) Any night sweats Question 09/17/19 12:26 AM CDT I don't get sweaty, but sometimes I wake up hot and have to kick off my sheets. Have you been fatigued Question 09/17/19 12:26 AM CDT No, I don't think so. Have you had any fever or chills Question 09/17/19 12:26 AM CDT No, neither of those. [AUDIO COMING SOON] Any dizziness lightheadedness or syncope (Clarified to Do you get dizzy?.) Question 09/17/19 12:26 AM CDT No, I haven't been dizzy. (Clarified to if I get dizzy.) 20/35 9/17/2019 Neurological Assignment | Completed | Shadow Health Any weakness Question 09/17/19 12:27 AM CDT No, I wouldn't say I feel weak. Are you seeing any Halo Question 09/17/19 12:27 AM CDT Nope. Have you been throwing up blood Question 09/17/19 12:27 AM CDT No, I haven't thrown up at all. Have you had any paralysis Question 09/17/19 12:27 AM CDT Definitely not. Has your equilibrium been off (No matching questions found.) Question 09/17/19 12:28 AM CDT Are you having any trouble walking Question 09/17/19 12:28 AM CDT Nope. Have you had any vision changes since the accident Question 09/17/19 12:29 AM CDT No, my vision hasn't changed since the accident. 21/35 9/17/2019 Neurological Assignment | Completed | Shadow Health Do you have any blurry vision Question 09/17/19 12:29 AM CDT No, my vision hasn't been blurry since the accident. But, sometimes it gets blurry when I read for too long -- that's been going on for awhile. Are you having any trouble with your memory Question 09/17/19 12:29 AM CDT I wouldn't say so. I have a pretty normal memory. Are you having any trouble with depression (Clarified to Have you ever been depressed?.) Question 09/17/19 12:29 AM CDT Not really. Things got hard when my dad died, but it's normal to feel sad about that. (Clarified to if I have ever been depressed.) Normal to feel sad about that have you had any confusion (No matching questions found.) Question 09/17/19 12:29 AM CDT Have you had any confusion Question 09/17/19 12:30 AM CDT Nope. Any mood swings Question 09/17/19 12:30 AM CDT I haven't noticed any changes with my mood since the accident. . . I've been about as even-keeled as always. Any light sensitive (Clarified to Have your eyes been sensitive to the light since the accident?.) Question 09/17/19 12:30 AM CDT 22/35 9/17/2019 Neurological Assignment | Completed | Shadow Health No, I'm not sensitive to light. [AUDIO COMING SOON] (Clarified to if my eyes have been sensitive to light since the accident.) Do you have any ringing in your ears Question 09/17/19 12:31 AM CDT No, I don't think so. Any problems hearing Question 09/17/19 12:31 AM CDT My hearing is fine. Any trouble swallowing Question 09/17/19 12:31 AM CDT Nope. Any family history of neurological conditions Question 09/17/19 12:31 AM CDT I don't think so. Any Parkinson or epilepsy (No matching questions found.) Question 09/17/19 12:31 AM CDT Any Parkinson or epilepsy in your family (No matching questions found.) Question 09/17/19 12:32 AM CDT Parkinson or epilepsy in your family history (Clarified to Does anyone in your family have parkinsons?.) Question 09/17/19 12:32 AM CDT 23/35 9/17/2019 Neurological Assignment | Completed | Shadow Health No, I don't think so. (Clarified to if anyone in my family has Parkinson's.) Anyone have a history of epilepsy or seizures (Clarified to Does anyone in your family have epilepsy?.) Question 09/17/19 12:32 AM CDT No. (Clarified to if anyone in my family is epilepti...
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