Neurological Completed Shadow Health PDF

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Shadow health cardiovascular assignment documentation with description of model documentation...

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10/4/21, 4:35 PM

Neurological | Completed | Shadow Health

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Neurological Results | Turned In Advanced Health Assessment for the APN - Fall 2021, 625 Return to Assignment (/assignments/519380/)

Your Results

Overview

Lab Pass (/assignment_attempts/10764512/lab_pass.

Transcript

Transcript Started: Oct 04, 2021 | Total Time: 79 min Subjective Data Collection All Lines (221)

Interview Questions (92)

Statements (1)

Exam Actions (128)

Objective Data Collection Education & Empathy

Hi my name is Maddie I will be your nurse today

Gre 10/04/21 3:06 PM C

Documentation

Hey.

What brings you in today

Questi 10/04/21 3:07 PM C

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 you're having headaches

Empathi 10/04/21 3:07 PM C

Thanks for understanding.

Have you had any neck stiffness

Questi 10/04/21 3:07 PM C

Yeah.

When did the next stiffness begin (No matching questions found.)

Questi 10/04/21 3:07 PM C

When did the next stiffness begin (No matching questions found.)

Questi 10/04/21 3:07 PM C

When did the neck stiffness begin

Questi 10/04/21 3:08 PM C

My neck started hurting about two days after the accident.

When did the headaches begin

Questi 10/04/21 3:08 PM C

Five days ago... The headaches started two days after the accident.

Did you lose Consciousness after the accident

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Questi PM C

1/19

10/4/21, 4:35 PM

Neurological | Completed | Shadow Health No, I don't think I have ever lost consciousness.

How fast was the car going

Questi 10/04/21 3:08 PM C

Oh, it was really slow. We were in a parking lot. Maybe not even fifteen miles an hour.

Were you wearing your seatbelt

Questi 10/04/21 3:08 PM C

Yes, I always do.

We're in the car were you sitting (Clarified to Where were you sitting in the car when the accident occurred?.)

Questi 10/04/21 3:09 PM C

I was in the front passenger seat. (Clarified to where I was sitting in the car when the accident occurred.)

Where in your head are you having headaches (Clarified to Where do you get headaches?.)

Questi 10/04/21 3:09 PM C

The headaches are in the crown of my head, and kind of the back of my head. (Clarified to where my headache hurts.)

How long do your headaches last

Questi 10/04/21 3:10 PM C

About an hour or two.

What do the headaches feel like

Questi 10/04/21 3:10 PM C

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 headaches worse

Questi 10/04/21 3:10 PM C

Nothing really makes them worse. . . they just sort of start, and eventually they go away.

Anything makes headaches better

Questi 10/04/21 3:10 PM C

Yeah, the Tylenol helps a little.

How often are you taking Tylenol

Questi 10/04/21 3:10 PM C

I've been taking it every day since I started getting these headaches.

What dose of Tylenol are you taking

Questi 10/04/21 3:10 PM C

I'm not sure the actual dosage, but I generally take 2 regular strength pills.

How many times can you had headaches since they started

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Questi 10/04/21 3:11 PM C

2/19

10/4/21, 4:35 PM

Neurological | Completed | Shadow Health I've had a headache just about once a day since a couple days after my accident. Once I feel it coming on, I take something for it and it pretty much goes away for the day.

When was your last headache

Questi 10/04/21 3:11 PM C

Yesterday afternoon.

Does the pain radiate

Questi 10/04/21 3:11 PM C

Maybe? The soreness in my neck feels like it goes up into my head. But its just my neck and head that hurt.

Where is the neck pain

Questi 10/04/21 3:11 PM C

It's the back of my neck that hurts -- both sides.

What does the neck pain feel like

Questi 10/04/21 3:12 PM C

It's just been stiff and sore since a little after the car accident.

Do you take anything for the neck pain

Questi 10/04/21 3:12 PM C

Yeah, the Tylenol I'm taking helps my neck pain.

Is your scalp tender

Questi 10/04/21 3:12 PM C

No.

Do you have any jaw pain

Questi 10/04/21 3:12 PM C

No, not at all.

How would you rate your headache pain

Questi 10/04/21 3:12 PM C

It's just my neck that hurts right now. . . I guess I'd say it's a 3 out of 10.

How would you rate your pain when it's at its worst (Clarified to How would you rate your pain at its worst on a scale from 0 to 10?.)

Questi 10/04/21 3:13 PM C

They probably get up to a 4. (Clarified to how I would rate my pain on a scale at its worst.)

What caused your pain

Questi 10/04/21 3:13 PM C

I'm pretty sure it was the car accident. Well, it was really just a fender bender. There was pretty much no damage to the car, and no one got injured, but I guess a sore head and neck can sneak up on you.

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3/19

10/4/21, 4:35 PM

Neurological | Completed | Shadow Health Do your headaches get better with rest

Questi 10/04/21 3:13 PM C

I don't think so. They just come on and eventually go away.

Are you taking any new medication

Questi 10/04/21 3:13 PM C

I've been taking more Tylenol for my headaches, and my neck.

Do you have any allergies

Questi 10/04/21 3:14 PM C

Yeah, I'm allergic to cats.

Are you allergic to any medication

Questi 10/04/21 3:14 PM C

Yeah, I'm allergic to penicillin.

Did you get headaches before the accident

Questi 10/04/21 3:14 PM C

The only time I got headaches before the accident was when I would read or study for a long time.

Do you ever get migraines

Questi 10/04/21 3:14 PM C

No, I'm pretty sure my headaches aren't migraines.

Have you ever had any head trauma

Questi 10/04/21 3:14 PM C

No.

Have you ever had any seizures

Questi 10/04/21 3:14 PM C

No. I've seen somebody have one, though. It's scary.

Have your sleep habits changed

Questi 10/04/21 3:14 PM C

No.

Have you had a fever

Questi 10/04/21 3:15 PM C

No, I don't think so.

Have you had any chills

Questi 10/04/21 3:15 PM C

No.

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4/19

10/4/21, 4:35 PM

Neurological | Completed | Shadow Health Have you felt fatigued

Questi 10/04/21 3:15 PM C

No, I don't think so.

Have you had nausea

Questi 10/04/21 3:15 PM C

No.

Have you had night sweats

Questi 10/04/21 3:15 PM C

I don't get sweaty, but sometimes I wake up hot and have to kick off my sheets.

His one side of your body felt weaker than the other (Clarified to Has one side of your body felt weaker than the other?.)

Questi 10/04/21 3:15 PM C

No, I feel about the same. (Clarified to if I have felt weaker on one side of my body.)

Have you had any changes in your gait

Questi 10/04/21 3:16 PM C

No.

Have you felt dizzy

Questi 10/04/21 3:16 PM C

No, I haven't been dizzy.

Have you had any loss of coordination

Questi 10/04/21 3:16 PM C

Not that I've noticed.

Have you had any numbness

Questi 10/04/21 3:16 PM C

No, I don't think so.

Have you felt depressed

Questi 10/04/21 3:16 PM C

No, I've been fine.

Have you felt more irritable

Questi 10/04/21 3:16 PM C

No, not really.

Have you had any problems concentrating

Questi 10/04/21 3:16 PM C

No, not really.

https://app.shadowhealth.com/assignment_attempts/10764512

5/19

10/4/21, 4:35 PM

Neurological | Completed | Shadow Health Have you felt confused

Questi 10/04/21 3:16 PM C

No.

Has your vision changed

Questi 10/04/21 3:17 PM C

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.

Are you sensitive to light since the accident

Questi 10/04/21 3:17 PM C

No, I'm not sensitive to light. [AUDIO COMING SOON]

Have you had any congestion

Questi 10/04/21 3:17 PM C

No, I haven't been congested.

Have you had any ringing in your ears

Questi 10/04/21 3:17 PM C

No.

Have you had any hearing loss

Questi 10/04/21 3:17 PM C

No.

Have you had any difficulty swallowing

Questi 10/04/21 3:17 PM C

Nope.

Do you have a history of migraines in your family

Questi 10/04/21 3:17 PM C

I don't think so.

Do you have any family history of epilepsy

Questi 10/04/21 3:18 PM C

No.

What's the driver under the influence of alcohol

Questi 10/04/21 3:18 PM C

No, definitely not. Neither of us had anything to drink. [AUDIO COMING SOON]

Do you have access to health insurance

Questi 10/04/21 3:18 PM C

Yeah, I have car insurance and health insurance. [AUDIO COMING SOON]

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6/19

10/4/21, 4:35 PM

Neurological | Completed | Shadow Health What is your name and date of birth

Questi 10/04/21 3:19 PM C

My name is Tina Jones, and I was born on February 17th.

Evaluated orientation to person

What building are you in now

Exam Actio 10/04/21 3:19 PM C

Questi 10/04/21 3:19 PM C

I'm at the doctor's office. . . it's Shadow Health General Clinic.

Evaluated orientation to place

What is the date in year

Exam Actio 10/04/21 3:19 PM C

Questi 10/04/21 3:19 PM C

Um, today's date is [Tina says correct date and year].

Evaluated orientation to time

Exam Actio 10/04/21 3:19 PM C

How are apples and oranges alike

Questi 10/04/21 3:20 PM C

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 Actio 10/04/21 3:20 PM C

Questi 10/04/21 3:21 PM C

Uh.... they're both bodies of water.

Evaluated abstract thinking: similarities among bodies of water

How are a flute and a trumpet alike

Exam Actio 10/04/21 3:21 PM C

Questi 10/04/21 3:21 PM C

They...... they're both musical instruments.

Evaluated abstract thinking: similarities among instruments

Count backwards by sevens from 100

Exam Actio 10/04/21 3:21 PM C

Questi 10/04/21 3:33 PM C

Okay. . . 100, 93. . . 86, 79, 72. . . 65. . . 58, 51. . . 44. . . 37, 30, 23, 16. . . 9, and 2.

Evaluated attention with serial sevens

Exam Actio 10/04/21 3:34 PM C

Established one-stage comprehension

Exam Actio 10/04/21 3:34 PM C

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7/19

10/4/21, 4:35 PM

Neurological | Completed | Shadow Health Established two-stage comprehension

Who was the first president of the United States

Exam Actio 10/04/21 3:34 PM C

Questi 10/04/21 3:34 PM C

That's George Washington.

Evaluated knowledge of first president

Who are the last four presidents of the United States

Exam Actio 10/04/21 3:34 PM C

Questi 10/04/21 3:35 PM C

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 Actio 10/04/21 3:35 PM C

Questi 10/04/21 3:35 PM C

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 Actio 10/04/21 3:35 PM C

Questi 10/04/21 3:35 PM C

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 Actio 10/04/21 3:36 PM C

Questi 10/04/21 3:36 PM C

Burger, tulip, nose, and tea.

Evaluated immediate memory

How did you celebrate your last birthday

Exam Actio 10/04/21 3:36 PM C

Questi 10/04/21 3:36 PM C

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

Repeat the four words from before

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Exam Actio 10/04/21 3:37 PM C

Questi 10/04/21 3:37 PM C

8/19

10/4/21, 4:35 PM

Neurological | Completed | Shadow Health Burger. . . tulip. . .nose. . . and tea.

Evaluated immediate learning

Exam Actio 10/04/21 3:37 PM C

Observed patient's general vocabulary

Exam Actio 10/04/21 3:37 PM C

What classes are you taking

Questi 10/04/21 3:38 PM C

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 Actio 10/04/21 3:38 PM C

Questi 10/04/21 3:38 PM C

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 Actio 10/04/21 3:39 PM C

TOZ

PECFD

Tested visual acuity of right eye

Exam Actio 10/04/21 3:40 PM C

EDEOXF

PECFD

EDFCZP

FELOPZD

DEFPOTEC

Tested visual acuity of left eye

Exam Actio 10/04/21 3:40 PM C

I can't read that line. It's too little.

Inspected fundus of right eye

Exam Actio 10/04/21 3:41 PM C

Inspected fundus of left eye

Exam Actio 10/04/21 3:43 PM C

Inspected left pupil and tested left pupillary light reflex

Exam Actio 10/04/21 3:44 PM C

https://app.shadowhealth.com/assignment_attempts/10764512

9/19

10/4/21, 4:35 PM

Neurological | Completed | Shadow Health Inspected right pupil and tested pupillary light reflex

Follow my finger with just your eyes

Exam Actio 10/04/21 3:44 PM C

Questi 10/04/21 3:44 PM C

Ok.

Tested EOM to the upper right

Exam Actio 10/04/21 3:44 PM C

Tested EOM to the lower right

Exam Actio 10/04/21 3:44 PM C

Tested EOM to the lower center

Exam Actio 10/04/21 3:45 PM C

Tested EOM to the upper center

Exam Actio 10/04/21 3:45 PM C

Tested EOM to the upper left

Exam Actio 10/04/21 3:45 PM C

Tested EOM to the lower left

Exam Actio 10/04/21 3:45 PM C

Tested convergence

Exam Actio 10/04/21 3:45 PM C

Close your eyes and tell me if the touch a sharp dull or soft

Questi 10/04/21 3:45 PM C

Ok.

Tested facial sensation: dull stimulus

Exam Actio 10/04/21 3:45 PM C

Dull.

Tested facial sensation: dull stimulus

Exam Actio 10/04/21 3:46 PM C

Dull.

Tested facial sensation: dull stimulus

Exam Actio 10/04/21 3:46 PM C

Dull.

Tested facial sensation: dull stimulus

Exam Actio 10/04/21 3:46 PM C

Dull.

Tested facial sensation: soft stimulus

Exam Actio 10/04/21 3:46 PM C

Soft.

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10/19

10/4/21, 4:35 PM

Neurological | Completed | Shadow Health Tested facial sensation: soft stimulus

Exam Actio 10/04/21 3:46 PM C

Soft.

Tested facial sensation: sharp stimulus

Exam Actio 10/04/21 3:46 PM C

Sharp.

Tested facial sensation: sharp stimulus

Exam Actio 10/04/21 3:46 PM C

Sharp.

Tested facial sensation: sharp stimulus

Exam Actio 10/04/21 3:46 PM C

Sharp.

Tested facial sensation: sharp stimulus

Exam Actio 10/04/21 3:46 PM C

Sharp.

Tested facial sensation: soft stimulus

Exam Actio 10/04/21 3:46 PM C

Soft.

Tested facial sensation: soft stimulus

Exam Actio 10/04/21 3:46 PM C

Soft.

Tested facial sensation: soft stimulus

Exam Actio 10/04/21 3:46 PM C

Soft.

Inspected front of face for asymmetry and facial ...