Neurological Physical Assessment Assignment | Completed | Shadow Health https://chamberlain.shadowhealth.com/assignment_attempts/4177
Neurological Physical Assessment Assignment Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-October-2018
Return to Assignment
Your Results
m
Overview
Documentation / Electronic Health Record
er as
Transcript
co
eH w
Subjective Data Collection Document: Provider Notes
o.
Objective Data Collection
rs e
ou urc
Education & Empathy Document: Provider Notes
Documentation
Student Documentation Model Documentation
o
Student Pre-Survey
Subjective
aC s
HPI: Ms. Jones presents to the clinic complaining of
Lifespan
vi y re
HPI: Tina Jones comes to the clinic with the chief a headache and neck stiffness that started 2 days
complaint of headaches and neck stiffness. This after she was in a minor fender bender. One week
Review Questions occured about five days ago, but the patient was in a ago she states that she was a restrained passenger
minor "fender bender" a week ago. Tina was the in an accident in a parking lot and estimates the
Self-Reflection passenger and she was wearing a seatbelt. She speed to be approximately 5-10 mph. She and the
ed d
claims that the accident was at low speed. She did driver did not seek emergent care and felt fine after
not seek further care after the EMTs looked her over the accident. Two days later, however, she
ar stu
and declared that she was okay. However, two days developed a bilateral temporal dull ache
later, she started to have terrible headaches ad her accompanied by neck ache. She states that she
stiff neck. She also notes that her neck may be feels as though her neck may be slightly swollen as
swollen. Tina did not lose conciousness, not has she well. She did not lose consciousness in the accident
and denies changes in level of consciousness since
sh is
lost conciousness or fainted since. She has been
having a headaches daily for the last five days. The that time. She states that she gets a headache every
headaches last "about an hour or two" and she rates day that lasts approximately 1-2 hours. She
Th
the severity at a 4. She describes the pain as "a dull occasionally takes 650 mg of over the counter
ache in the corwn of my head and the back of my Tylenol with relief of the pain. She denies known
head." She takes Tylenol to manage the pain as associated symptoms.
needed. She did not know the dose, but she
"generally takes 2 regular strength pills." She denies Review of Systems: General: Denies changes in
any other symptoms. weight, fatigue, weakness, fever, chills, and night
sweats. • Head: Denies history of trauma before this
Social History: Patient states that she always weras incident. Denies current headache. • Eyes: She does
her seatbelt. She claims that she is a safe driver. Her not wear corrective lenses, but notes that her vision
father was in an accident, so she takes it seriously. has been worsening over the past few years, but no
Patient does not smoke or do drugs. acute changes. She complains of blurry vision after
reading for extended periods. Denies increased
ROS: tearing or itching. • Ears: Denies hearing loss,
tinnitus, vertigo, discharge, or earache. •
General: patient denies any fatigue or weakness. Nose/Sinuses: Denies rhinorrhea. Denies stuffiness,
sneezing, itching, previous allergy, epistaxis, or sinus
Head: patient denies any current headache. patient pressure. • Musculoskeletal: Denies muscle
weakness, pain, difficulties with range of motion, joint
© Shadow Health® 2018
https://www.coursehero.com/file/42606658/pdf-16pdf/
https://www.coursehero.com/file/35687602/NR-509-Neurological-Documentation-Shadowpdf/
1 of 4 11/20/2018, 5:53
Neurological Physical Assessment Assignment Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-October-2018
Return to Assignment
Your Results
m
Overview
Documentation / Electronic Health Record
er as
Transcript
co
eH w
Subjective Data Collection Document: Provider Notes
o.
Objective Data Collection
rs e
ou urc
Education & Empathy Document: Provider Notes
Documentation
Student Documentation Model Documentation
o
Student Pre-Survey
Subjective
aC s
HPI: Ms. Jones presents to the clinic complaining of
Lifespan
vi y re
HPI: Tina Jones comes to the clinic with the chief a headache and neck stiffness that started 2 days
complaint of headaches and neck stiffness. This after she was in a minor fender bender. One week
Review Questions occured about five days ago, but the patient was in a ago she states that she was a restrained passenger
minor "fender bender" a week ago. Tina was the in an accident in a parking lot and estimates the
Self-Reflection passenger and she was wearing a seatbelt. She speed to be approximately 5-10 mph. She and the
ed d
claims that the accident was at low speed. She did driver did not seek emergent care and felt fine after
not seek further care after the EMTs looked her over the accident. Two days later, however, she
ar stu
and declared that she was okay. However, two days developed a bilateral temporal dull ache
later, she started to have terrible headaches ad her accompanied by neck ache. She states that she
stiff neck. She also notes that her neck may be feels as though her neck may be slightly swollen as
swollen. Tina did not lose conciousness, not has she well. She did not lose consciousness in the accident
and denies changes in level of consciousness since
sh is
lost conciousness or fainted since. She has been
having a headaches daily for the last five days. The that time. She states that she gets a headache every
headaches last "about an hour or two" and she rates day that lasts approximately 1-2 hours. She
Th
the severity at a 4. She describes the pain as "a dull occasionally takes 650 mg of over the counter
ache in the corwn of my head and the back of my Tylenol with relief of the pain. She denies known
head." She takes Tylenol to manage the pain as associated symptoms.
needed. She did not know the dose, but she
"generally takes 2 regular strength pills." She denies Review of Systems: General: Denies changes in
any other symptoms. weight, fatigue, weakness, fever, chills, and night
sweats. • Head: Denies history of trauma before this
Social History: Patient states that she always weras incident. Denies current headache. • Eyes: She does
her seatbelt. She claims that she is a safe driver. Her not wear corrective lenses, but notes that her vision
father was in an accident, so she takes it seriously. has been worsening over the past few years, but no
Patient does not smoke or do drugs. acute changes. She complains of blurry vision after
reading for extended periods. Denies increased
ROS: tearing or itching. • Ears: Denies hearing loss,
tinnitus, vertigo, discharge, or earache. •
General: patient denies any fatigue or weakness. Nose/Sinuses: Denies rhinorrhea. Denies stuffiness,
sneezing, itching, previous allergy, epistaxis, or sinus
Head: patient denies any current headache. patient pressure. • Musculoskeletal: Denies muscle
weakness, pain, difficulties with range of motion, joint
© Shadow Health® 2018
https://www.coursehero.com/file/42606658/pdf-16pdf/
https://www.coursehero.com/file/35687602/NR-509-Neurological-Documentation-Shadowpdf/
1 of 4 11/20/2018, 5:53
