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Neurological Results | Turned In
Advanced Health Assessment - January 2025, 11041.202510
Return to Assignment (/assignments/1128416/)
Your
Lab Pass (/assignment_attempts/18712875/lab_pass.pdf)
Results
Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Document: Provider Notes
Collection
Objective Data
Collection Education Document: Provider Notes
& Empathy Student Documentation Model Documentation
Documentation
Subjective HPI: Ms. Jones presents to the clinic complaining of
Video Tutorial a headache and neck stiffness that started 2 days
Tina Jones presents to the clinic, complaining of after she was in a minor fender bender. One week
headaches and sore neck after getting into a fender ago she states that she was a restrained passenger
bender a week ago. She reports that she was a a in an accident in a parking lot and estimates the
restrained front- seat passenger in her firend's car speed to be approximately 5- 10 mph. She and the
when another care hit them at a low speed of about driver did not seek emergent care and felt fine
5-10 mph from the rear in the parking lot. Both her after the accident. Two days later, however, she
and the driver were fine after the accident, and did developed a bilateral temporal dull ache
not seek emergency care. She did not lose accompanied by neck ache. She states that she
concsiousness. Two days later, she developed feels as though her neck may be slightly swollen as
bitemporal dull headache and necka soreness. She well. She did not lose consciousness in the accident
feels as if her neck is also swollen. Since then, she and denies changes in level of consciousness since
reports gettign a headache every day that lasts for that time. She states that she gets a headache
1-2 hrs, for which she occassionally takes 650mg of every day that lasts approximately 1-2 hours. She
OTC Tylenol. She also reports pain in the back of her occasionally takes 650 mg of over the counter
neck bilaterally that radiates to into her head. The Tylenol with relief of the pain. She denies known
pain is constant, severity 3/10 and at 4/10 worst. associated symptoms.
Last headache yesterday afternoon, no current
headache. Symptoms improve with rest. She Review of Systems: General: Denies changes in
reports getting heacahes before the accident only weight, fatigue, weakness, fever, chills, and night
when reading for a long time, often a few times a sweats. • Head: Denies history of trauma before
month. this incident. Denies current headache. • Eyes: She
does not wear corrective lenses, but notes that her
ROS vision has been worsening over the past few years,
General but no acute changes. She complains of blurry
Head; Denies history of trauma, or current vision after reading for extended periods. Denies
headache Eyes; No acute vision changes, reports increased tearing or itching. • Ears: Denies hearing
progressive worsenign of vision over years. loss, tinnitus, vertigo, discharge, or earache. •
Ears; Denies tinnitus, hearing loss, vertigo, Nose/Sinuses: Denies rhinorrhea. Denies stuffiness,
discharge, or pain. sneezing, itching, previous allergy, epistaxis, or
Nose; Denies epistaxis, rhinorrhea, stuffiness, sinus sinus pressure. • Musculoskeletal: Denies muscle
pressure, or sneezing. weakness, pain, difficulties with range of motion,
Neurological; Denies numbness, tingling, wekaness, joint instability, or swelling.
seizures, paralysis, or LOC
be disabled. Thank you for helping us to improve your Shadow Health experience!
Neurological Results | Turned In
Advanced Health Assessment - January 2025, 11041.202510
Return to Assignment (/assignments/1128416/)
Your
Lab Pass (/assignment_attempts/18712875/lab_pass.pdf)
Results
Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Document: Provider Notes
Collection
Objective Data
Collection Education Document: Provider Notes
& Empathy Student Documentation Model Documentation
Documentation
Subjective HPI: Ms. Jones presents to the clinic complaining of
Video Tutorial a headache and neck stiffness that started 2 days
Tina Jones presents to the clinic, complaining of after she was in a minor fender bender. One week
headaches and sore neck after getting into a fender ago she states that she was a restrained passenger
bender a week ago. She reports that she was a a in an accident in a parking lot and estimates the
restrained front- seat passenger in her firend's car speed to be approximately 5- 10 mph. She and the
when another care hit them at a low speed of about driver did not seek emergent care and felt fine
5-10 mph from the rear in the parking lot. Both her after the accident. Two days later, however, she
and the driver were fine after the accident, and did developed a bilateral temporal dull ache
not seek emergency care. She did not lose accompanied by neck ache. She states that she
concsiousness. Two days later, she developed feels as though her neck may be slightly swollen as
bitemporal dull headache and necka soreness. She well. She did not lose consciousness in the accident
feels as if her neck is also swollen. Since then, she and denies changes in level of consciousness since
reports gettign a headache every day that lasts for that time. She states that she gets a headache
1-2 hrs, for which she occassionally takes 650mg of every day that lasts approximately 1-2 hours. She
OTC Tylenol. She also reports pain in the back of her occasionally takes 650 mg of over the counter
neck bilaterally that radiates to into her head. The Tylenol with relief of the pain. She denies known
pain is constant, severity 3/10 and at 4/10 worst. associated symptoms.
Last headache yesterday afternoon, no current
headache. Symptoms improve with rest. She Review of Systems: General: Denies changes in
reports getting heacahes before the accident only weight, fatigue, weakness, fever, chills, and night
when reading for a long time, often a few times a sweats. • Head: Denies history of trauma before
month. this incident. Denies current headache. • Eyes: She
does not wear corrective lenses, but notes that her
ROS vision has been worsening over the past few years,
General but no acute changes. She complains of blurry
Head; Denies history of trauma, or current vision after reading for extended periods. Denies
headache Eyes; No acute vision changes, reports increased tearing or itching. • Ears: Denies hearing
progressive worsenign of vision over years. loss, tinnitus, vertigo, discharge, or earache. •
Ears; Denies tinnitus, hearing loss, vertigo, Nose/Sinuses: Denies rhinorrhea. Denies stuffiness,
discharge, or pain. sneezing, itching, previous allergy, epistaxis, or
Nose; Denies epistaxis, rhinorrhea, stuffiness, sinus sinus pressure. • Musculoskeletal: Denies muscle
pressure, or sneezing. weakness, pain, difficulties with range of motion,
Neurological; Denies numbness, tingling, wekaness, joint instability, or swelling.
seizures, paralysis, or LOC
