Neurological Physical Assessment Assignment Results |
Completed
Advanced Health Assessment - Chamberlain, NR509-October-2018
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Your
Turn In Lab Pass
Results
Documentation
Overvie
/ Electronic Health Record
w
Transcri Document: Provider Notes
pt
Subjective Data Document: Provider Notes
Collection Objective
Student Documentation Model Documentation
Data Collection
Subjective Flovent 110mcg, 2
Education & Empathy puffs bid, last
28yo, AA, female used this morning
Documentation CC: Neck pain and headache Albuterol 90mcg
Onset: 2 days after low-inpact car accient MDI, 2 puffs q4h
Student Pre- Location: bilat temporal head, back of head prn shortness of
and neck Duration: headache off and on, breath, last used
Survey Lifespan lasting 1-2 hours everyday x 5 days (2 days 8 months ago
after car accident), neck pain constant starting Ibuprofen 200mg
5 days ago (2 days after car accident) tab, 600mg (3 tabs)
Characteristics: Head 3/10, dull ache, Neck po tid prn
3/10, still and sore. Gradual onset. States menstraul cramps,
last used 8 months
some neck swelling. Denies LOC or other ago
injury
Aggravating Factors: neck pain worse with
movement, no aggravating factors with
headache. Relieving Factors: Rest and not
moving neck much. Tylenol for headache
Treatment: Was evaluated by paramedics
after accident
Allergies:
Cats- sneezing, itchy eyes, asthma
exaceration Penicillin-rash, hives
Dust-asthma exacerbation
Medications:
Tylenol 325mg tab, 650mg (2 tabs) po daily
last taken this morning
, Review of Systems: General: Denies changes
HPI: Ms. Jones presents to the clinic complaining of a headache and neck in weight, fatigue, weakness, fever, chills, and
stiffness that started 2 days after she was in a minor fender bender. One night sweats. • Head: Denies history of
week ago she states that she was a restrained passenger in an accident trauma before this incident. Denies current
in a parking lot and estimates the speed to be approximately 5-10 mph. headache. • Eyes: She does not wear
She and the driver did not seek emergent care and felt fine after the corrective lenses, but notes that her vision
accident. Two days later, however, she developed a bilateral temporal has been worsening over the past few years,
dull ache accompanied by neck ache. She states that she feels as but no acute changes. She complains of blurry
though her neck may be slightly swollen as well. She did not lose vision after reading for extended periods.
consciousness in the accident and denies changes in level of Denies increased tearing or itching. • Ears:
consciousness since that time. She states that she gets a headache Denies hearing loss, tinnitus, vertigo,
every day that lasts approximately 1-2 hours. She occasionally takes 650 discharge, or earache. • Nose/Sinuses: Denies
mg of over the counter Tylenol with relief of the pain. She denies known rhinorrhea. Denies stuffiness, sneezing,
associated symptoms. itching, previous allergy, epistaxis, or sinus
pressure. • Musculoskeletal: Denies muscle
Completed
Advanced Health Assessment - Chamberlain, NR509-October-2018
Return to Assignment
Your
Turn In Lab Pass
Results
Documentation
Overvie
/ Electronic Health Record
w
Transcri Document: Provider Notes
pt
Subjective Data Document: Provider Notes
Collection Objective
Student Documentation Model Documentation
Data Collection
Subjective Flovent 110mcg, 2
Education & Empathy puffs bid, last
28yo, AA, female used this morning
Documentation CC: Neck pain and headache Albuterol 90mcg
Onset: 2 days after low-inpact car accient MDI, 2 puffs q4h
Student Pre- Location: bilat temporal head, back of head prn shortness of
and neck Duration: headache off and on, breath, last used
Survey Lifespan lasting 1-2 hours everyday x 5 days (2 days 8 months ago
after car accident), neck pain constant starting Ibuprofen 200mg
5 days ago (2 days after car accident) tab, 600mg (3 tabs)
Characteristics: Head 3/10, dull ache, Neck po tid prn
3/10, still and sore. Gradual onset. States menstraul cramps,
last used 8 months
some neck swelling. Denies LOC or other ago
injury
Aggravating Factors: neck pain worse with
movement, no aggravating factors with
headache. Relieving Factors: Rest and not
moving neck much. Tylenol for headache
Treatment: Was evaluated by paramedics
after accident
Allergies:
Cats- sneezing, itchy eyes, asthma
exaceration Penicillin-rash, hives
Dust-asthma exacerbation
Medications:
Tylenol 325mg tab, 650mg (2 tabs) po daily
last taken this morning
, Review of Systems: General: Denies changes
HPI: Ms. Jones presents to the clinic complaining of a headache and neck in weight, fatigue, weakness, fever, chills, and
stiffness that started 2 days after she was in a minor fender bender. One night sweats. • Head: Denies history of
week ago she states that she was a restrained passenger in an accident trauma before this incident. Denies current
in a parking lot and estimates the speed to be approximately 5-10 mph. headache. • Eyes: She does not wear
She and the driver did not seek emergent care and felt fine after the corrective lenses, but notes that her vision
accident. Two days later, however, she developed a bilateral temporal has been worsening over the past few years,
dull ache accompanied by neck ache. She states that she feels as but no acute changes. She complains of blurry
though her neck may be slightly swollen as well. She did not lose vision after reading for extended periods.
consciousness in the accident and denies changes in level of Denies increased tearing or itching. • Ears:
consciousness since that time. She states that she gets a headache Denies hearing loss, tinnitus, vertigo,
every day that lasts approximately 1-2 hours. She occasionally takes 650 discharge, or earache. • Nose/Sinuses: Denies
mg of over the counter Tylenol with relief of the pain. She denies known rhinorrhea. Denies stuffiness, sneezing,
associated symptoms. itching, previous allergy, epistaxis, or sinus
pressure. • Musculoskeletal: Denies muscle
