Neurological Shadow Health Assessment Transcript
Transcript
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Hello Tina. Welcome to our clinic. Am Joyce, i will be interviewing you today, and later do a physical examination on you
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Greet |
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Hey.
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What brings you to the clinic today?
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Question |
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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. Neurological shadow health assessment Transcript
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Am sorry to hear that you are having headaches
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Empathize |
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Thanks for saying that.
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Have you had any neck stiffness?
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Yeah.
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When did the neck stiffness begin?
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My neck started hurting about two days after the accident.
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Am sorry that you got an accident (No matching questions found.)
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Am sorry that you got an accident
Neurological shadow health assessment Transcript
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Empathize |
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Thanks.
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And when did the headaches begin? (Clarified to When did the headache begin?.)
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It was a few days after the car accident — I noticed a headache creeping up throughout the day. (Clarified to when the headache began.)
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Did you lose consciousnesses after car accident? (Clarified to Did you lose consciousness during the car accident?.)
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No, I don’t think I have ever lost consciousness. (Clarified to if I lost consciousness during the car accident.)
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How fast was the car going?
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Oh, it was really slow. We were in a parking lot. Maybe not even fifteen miles an hour.
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Were you wearing a seat belt?
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Yes, I always do.
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where in the car were you sitting?
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I was in the front passenger seat.
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Was the driver under the influence of alcohol? (Clarified to Was anyone under the influence of alcohol when the accident occurred?.)
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No, definitely not. Neither of us had anything to drink. [AUDIO COMING SOON] (Clarified to if anyone was under the influence of alcohol when the accident occurred.)
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Great, its not advisable to drink under the influence of alcohol
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Educate |
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Alright, thanks for letting me know.
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How many times have you had the headaches since they started?
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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.
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How long do the headache last?
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About an hour or two.
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when was your last headache?
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Yesterday afternoon.
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where are the headaches located?
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The headaches are in the crown of my head, and kind of the back of my head.
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Does the pain radiate?
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Maybe? The soreness in my neck feels like it goes up into my head. But its just my neck and head that hurt.
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how does your neck feel?
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It has been pretty stiff and a little painful since the accident.
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Is your scalp tender?
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No.
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Do you have jaw pain?
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No, not at all.
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Do you have any facial pain?
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No. My face is fine.
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How would you rate your pain?
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It’s just my neck that hurts right now. . . I guess I’d say it’s a 3 out of 10.
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How would you rate your pain at its worst?
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They probably get up to a 4.
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what do your headaches feel like?
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The headaches feel like a dull ache, kind of in the crown of my head, and the back of my head.
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is the headache pain sharp?
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No, not really.
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are your headaches cyclic?
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No, I don’t think so.
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Do your headaches come in clusters?
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No, definitely not.
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do your headaches crescendo?
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It’s not, like, a sudden, horrible pain, but they don’t worsen gradually either. They just sort of start, and they never get that bad.
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What caused your pain?
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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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Does it hurt to move your head?
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Yeah, my neck hurts when I move it.
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what makes your headache worse?
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Nothing really makes them worse. . . they just sort of start, and eventually they go away.
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have you tried home remedies?
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I’ve been taking Tylenol. And resting helps, too.
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Does your headache get better with rest?
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I don’t think so. They just come on and eventually go away.
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Are you taking any new medications?
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I’ve been taking more Tylenol for my headaches, and my neck.
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what dose of tylenol do you take?
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I’m not sure the actual dosage, but I generally take 2 regular strength pills.
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How often do you take the tylenol?
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I’ve been taking it every day since I started getting these headaches.
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How many times a day? (No matching questions found.)
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Does the tylenol help?
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Yeah, it has been helping some.
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Do you have any new allergies?
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Well, besides cats, I’m allergic to penicillin.
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Do you usually get headaches?
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The only time I got headaches before the accident was when I would read or study for a long time.
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Do you ever get migraines?
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No, I’m pretty sure my headaches aren’t migraines.
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Have you ever had any head trauma?
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No.
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Have you had any seizures?
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No. I’ve seen somebody have one, though. It’s scary.
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Have your sleep habits changed?
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No.
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Have you felt more sleepy?
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No, I feel about the same as usual.
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have you had a fever?
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No, I don’t think so.
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have you had any chills?
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No.
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have you felt fatigued?
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No, I don’t think so.
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have you had nausea?
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No.
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any night sweats?
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I don’t get sweaty, but sometimes I wake up hot and have to kick off my sheets.
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Has one side of your body felt weaker than the other?
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No, I feel about the same.
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Any changes in your gait?
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No.
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Have you felt weak?
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No.
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Have you experienced any auras?
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No.
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have you felt dizzy?
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No, I haven’t been dizzy.
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Any loss of coordination?
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Not that I’ve noticed.
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have you noticed any scotoma?
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I don’t know what that is, so I guess probably not.
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have you felt any tingling?
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No, I haven’t noticed any tingling.
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Has your face been flushed?
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Nope.
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have you felt depressed?
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No, I’ve been fine.
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have you felt more irritable?
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No, not really.
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Have you had any problems concentrating?
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No, not really.
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Have you felt confused?
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No.
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has your vision changed after the accident ? (No matching questions found.)
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has your vision changed since the accident ?
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No, my vision hasn’t changed since the accident.
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have you ever had a blurred vision?
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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.
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any vision problems in just one eye?
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Not that I’ve noticed.
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Are you sensitive to light since the accident?
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No, I’m not sensitive to light. [AUDIO COMING SOON]
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have you had any congestion ?
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No, I haven’t been congested.
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have you had ringing in your ears?
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No.
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have you had any hearing loss?
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No.
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have you had any difficulty swallowing?
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Nope.
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Any history of migraines in your family? Neurological shadow health assessment Transcript
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I don’t think so.
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Any family history of epilepsy?
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No.
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any history of seizures?
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No. I’ve seen somebody have one, though. It’s scary.
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do you have a family history of Alzheimer’s disease?
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No.
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do you have a family history of Parkinson disease ?
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No, I don’t think so.
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What is your name and date of birth?
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My name is Tina Jones, and I was born on February 17th.
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Evaluated orientation to person
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What building are you in now?
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I’m at the doctor’s office. . . it’s Shadow Health General Clinic.
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Evaluated orientation to place
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What is the date and year?
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Um, today’s date is [Tina says correct date and year]. Neurological shadow health assessment Transcript
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Evaluated orientation to time
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Exam Action |
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How are oranges and apples alike?
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How are they alike? Um…. they’re both kinds of fruit.
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Evaluated abstract thinking: similarities among fruit
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How are a lake and an ocean alike?
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Uh…. they’re both bodies of water.
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Evaluated abstract thinking: similarities among bodies of water
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How are a trumpet and a flute alike?
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They…… they’re both musical instruments.
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Evaluated abstract thinking: similarities among instruments
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Exam Action |
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Count backwards by 7s from 100
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Okay. . . 100, 93. . . 86, 79, 72. . . 65. . . 58, 51. . . 44. . . 37, 30, 23, 16. . . 9, and 2.
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Evaluated attention with serial sevens
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Established one-stage comprehension
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Who was the first president of the united states?
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That’s George Washington.
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Evaluated knowledge of first president
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who are the last four presidents of the united states?
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Well, right now it’s Donald Trump. Before him it was Obama. Before *him* we had Bill Clinton and George W. Bush.
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Evaluated knowledge of last four presidents
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name five large cities in the united states
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Let’s see. . . New York City. . . and Chicago. . . Detroit. . . Los Angeles. . . and Houston. That’s five. Neurological shadow health assessment Transcript
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Evaluated knowledge of five large cities
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What would you do if you found a stamped and addressed envelope on the sidewalk?
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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.
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Evaluated judgment
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Repeat and remember burger, tulip, nose and tea
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Burger, tulip, nose, and tea.
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Evaluated immediate memory
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how did you celebrate your last birthday?
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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.
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Evaluated remote memory
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Repeat the four words from before
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Burger. . . tulip. . .nose. . . and tea.
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Evaluated immediate learning
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Observed patient’s general vocabulary
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what classes are you taking?
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I’m taking two classes right now, one on auditing and one on managerial accounting
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Tested CN I (olfactory nerve) with smell test
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F P
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F P
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Inspected right pupil and tested pupillary light reflex
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Inspected left pupil and tested left pupillary light reflex
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Inspected fundus of right eye Neurological shadow health assessment Transcript
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Inspected fundus of left eye
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Follow my finder with just your eyes
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Ok.
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Tested EOM to the upper right
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Tested EOM to the upper left
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Tested EOM to the lower left
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Tested convergence
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Tested EOM to the lower right
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Tested EOM to the lower center
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Tested EOM to the upper center
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Tested EOM to the upper center
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Close your eyes and tell me if the touch is sharp, dull or soft
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Ok.
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Tested facial sensation: dull stimulus
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Dull.
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Tested facial sensation: dull stimulus
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Dull.
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Tested facial sensation: dull stimulus
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Dull.
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Tested facial sensation: dull stimulus
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Dull.
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Tested facial sensation: soft stimulus
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Soft.
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Tested facial sensation: soft stimulus
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Soft.
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Tested facial sensation: soft stimulus
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Exam Action |
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Soft.
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Tested facial sensation: soft stimulus
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Soft.
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Tested facial sensation: sharp stimulus
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Sharp.
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Tested facial sensation: sharp stimulus
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Exam Action |
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Sharp.
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Tested facial sensation: sharp stimulus
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Sharp.
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Tested facial sensation: sharp stimulus Neurological shadow health assessment Transcript
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Sharp.
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Inspected front of face for asymmetry and facial droop
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Inspected right side of face for asymmetry and facial droop
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Inspected back of head for asymmetry
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Inspected left side of face for asymmetry and facial droop
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Inspected front of face for asymmetry and facial droop
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Inspected left side of face for asymmetry and facial droop
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Inspected front of face for asymmetry and facial droop
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is the volume the same in both ears or louder in one ear
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Ok.
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Same in both ears.
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Performed Weber test with tuning fork
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Tell me when you no longer hear the ringing
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Ok, I will.
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Now.
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Tested gag reflex
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Tested trapezius muscle strength against resistance: 5 strength against resistance
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Tested sternocleidomastoid muscle strength against resistance – head turned to the right: 5 strength against resistance
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Tested sternocleidomastoid muscle strength against resistance – head turned to the left: 5 strength against resistance
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Inspected mouth
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Inspected mouth: pushed tongue left with tongue blade
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Inspect mouth: pushed tongue right with tongue blade
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Inspect mouth: lifted tongue with tongue blade
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Inspected mouth: depressed tongue with tongue blade Neurological shadow health assessment Transcript
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Exam Action |