Documentation – Tina Jones Neurological Shadow Health assessment
History of Present Illness: Ms. Jones came to the clinic because she has a headache and her neck feels stiff. This started two days after she was in a small car accident. About a week ago, she was in another accident where she was wearing a seatbelt, but it wasn’t serious. She and the driver didn’t go to the hospital and felt okay afterward. But two days later, she started having a headache and neck pain. She feels like her neck might be a bit swollen. She didn’t pass out in the accident and hasn’t felt different since then. She gets a headache every day that lasts for about 1-2 hours. Sometimes she takes Tylenol for it, and it helps. She doesn’t have any other symptoms that usually come with a headache.
Table of Contents
Review of Systems:
– General: She hasn’t had any changes in weight, tiredness, weakness, fever, chills, or night sweats.
– Head: Before these accidents, she didn’t have any head injuries, and she doesn’t have a headache right now.
– Eyes: She doesn’t wear glasses, but her vision has been getting worse slowly over the years. She has trouble seeing clearly after reading for a long time.
– Ears: She can hear fine, and she doesn’t have any ringing in her ears, dizziness, fluid coming out of her ears, or earaches.
– Nose/Sinuses: Her nose isn’t runny, and she doesn’t feel stuffed up, sneezy, itchy, or have any allergies.
– Musculoskeletal: Her muscles aren’t weak, and she doesn’t have any pain, trouble moving, wobbly joints, or swelling.
– Neurologic: She hasn’t lost feeling, feels numb or tingly, shakes, feels weak, can’t move, passed out, had seizures, or had any problems controlling her bladder or bowels. Her concentration, sleep, coordination, and appetite are all normal.
Objective:
– General: Ms. Jones is a friendly 28-year-old woman who is a bit overweight. She looks uncomfortable but is okay. She’s awake and aware. She looked at the doctor while they talked and did what they asked during the exam.
– Head: Her head is normal in size and shape, and there’s no injury.
– Eyes: Both eyes look the same.
– Neurologic: She can smell things normally, and her vision is okay but a bit worse in one eye. Her eye exams show normal results, except for a little bit of a problem in one eye. Her pupils react normally to light. She can move her eyes in all directions, and her facial sensations are normal. She can move her face normally. Other tests for her neck, shoulders, tongue, arms, legs, and balance are all normal.
Assessment:
Ms. Jones has a headache from the car accident she was in.
Plan:
– Ms. Jones should keep an eye on her symptoms and tell the doctor if her headaches get worse.
– She should take ibuprofen pills with food every 8 hours for the next 5 days.
– Using ice or heat on her neck might help too.
– The doctor will teach her some gentle neck stretches.
– She needs to know when to go to the emergency room if she has the worst headache of her life, sudden vision, hearing, or consciousness changes, vomiting with headaches, or new numbness or weakness.
– Ms. Jones should call the doctor in 2 days to talk about how she’s feeling. If her symptoms don’t get better, she might need a CT scan or MRI.
Documentation – Tina Jones Neurological Shadow Health assessment
HPI: Ms. Jones presents to the clinic complaining of a headache and neck stiffness that started 2 days after she was in a minor fender bender. One week ago she states that she was a restrained passenger in an accident in a parking lot and estimates the speed to be approximately 5-10 mph. She and the driver did not seek emergent care and felt fine after the accident. Two days later, however, she developed a bilateral temporal dull ache accompanied by neck ache. She states that she feels as though her neck may be slightly swollen as well. She did not lose consciousness in the accident and denies changes in level of consciousness since that time. She states that she gets a headache every day that lasts approximately 1-2 hours. She occasionally takes 650 mg of over the counter Tylenol with relief of the pain. She denies known associated symptoms.
Review of Systems: General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats.
• Head: Denies history of trauma before this incident. Denies current headache.
• Eyes: She does not wear corrective lenses, but notes that her vision has been worsening over the past few years, but no acute changes. She complains of blurry vision after reading for extended periods. Denies increased tearing or itching.
• Ears: Denies hearing loss, tinnitus, vertigo, discharge, or earache.
• Nose/Sinuses: Denies rhinorrhea. Denies stuffiness, sneezing, itching, previous allergy, epistaxis, or sinus pressure.
• Musculoskeletal: Denies muscle weakness, pain, difficulties with range of motion, joint instability, or swelling.
• Neurologic: Denies loss of sensation, numbness, tingling, tremors, weakness, paralysis, fainting, blackouts, or seizures. Denies bowel or bladder dysfunction. Denies changes in concentration, sleep, coordination, appetite.
|
HPI: Ms. Jones presents to the clinic complaining of a headache and neck stiffness that started 2 days after she was in a minor fender bender. One week ago she states that she was a restrained passenger in an accident in a parking lot and estimates the speed to be approximately 5-10 mph. She and the driver did not seek emergent care and felt fine after the accident. Two days later, however, she developed a bilateral temporal dull ache accompanied by neck ache. She states that she feels as though her neck may be slightly swollen as well. She did not lose consciousness in the accident and denies changes in level of consciousness since that time. She states that she gets a headache every day that lasts approximately 1-2 hours. She occasionally takes 650 mg of over the counter Tylenol with relief of the pain. She denies known associated symptoms. Review of Systems: General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats. • Head: Denies history of trauma before this incident. Denies current headache. • Eyes: She does not wear corrective lenses, but notes that her vision has been worsening over the past few years, but no acute changes. She complains of blurry vision after reading for extended periods. Denies increased tearing or itching. • Ears: Denies hearing loss, tinnitus, vertigo, discharge, or earache. • Nose/Sinuses: Denies rhinorrhea. Denies stuffiness, sneezing, itching, previous allergy, epistaxis, or sinus pressure. • Musculoskeletal: Denies muscle weakness, pain, difficulties with range of motion, joint instability, or swelling. • Neurologic: Denies loss of sensation, numbness, tingling, tremors, weakness, paralysis, fainting, blackouts, or seizures. Denies bowel or bladder dysfunction. Denies changes in concentration, sleep, coordination, appetite. |
|
ObjectiveGeneral: Ms. Jones is a pleasant 28 year old obese african aerican woman seated on a bench at the clinic in no distress. The patient appears uncomformatble but is alert and orineted as she maintained eye contact throughout the interview and cooperated dueing the physical examination. Head: Head is normocephalic and atraumatic Eyes: the eyes are bilateral with equal hair distribution. neurologic: The sense of smell is intact and symmetric Left eye vision: 20/20 Right eye vision:20/40 The results obtainied from the left fundoscopic exam shows sharp disc margin and no hemorrhages while the right fundoscopic exam shows mild retinopathic changes. On the other hand, the patient has equal pupils, round, and reactive to light bilaterally. The extraocular movements atr bilaterally intact with normal convergence. The facial sensatins are intact and the facial features are symmetric. Additionally, the rinne and weber test are bilaterally normal as the gag reflux is intact. The ability to shrug shoulder is symmetric with a scroe of 5 strength againist resistance. The neck has a full range of motion with a 5 strength against resistance. The tongue is symmetric with not abnormal findings while the bilateral upper and lower extremity DTRs equal and 2+ bilaterally. point-to-point movements were smooth ad accurate for finger-to-nose and heal-to-shin. The rapid alternating movements of the upper extremities are intact bilaterally while the gait is steady with continuous symmetric steps. The sensation is intanct to bilateral upper and lower extreamities with a semse of extreamity posistion being intact. Stereognosisand graphethesia intact bilatterally. |
General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress, but appears uncomfortable while sitting in exam chair. She is alert and oriented. She maintains eye contact throughout interview and examination. • Head: Head is normocephalic and atraumatic • Eyes: Bilateral eyes with equal hair distribution. • Neurologic: Sense of smell intact and symmetric. Left eye vision: 20/20. Right eye vision: 20/40. Left fundoscopic exam reveals sharp disc margins, no hemorrhages. Right fundoscopic exam reveals mild retinopathic changes. Pupils equal, round, and reactive to light bilaterally. Extraocular movements intact bilaterally. Normal convergence. Facial sensation intact; facial features and symmetric. Rinne and Weber tests normal bilaterally. Gag reflex intact. Ability to shrug shoulders symmetric; 5 strength against resistance. Neck with full range of motion against resistance; 5 strength against resistance. Tongue symmetric with no abnormal findings. Bilateral upper and lower extremity DTRs equal and 2+ bilaterally. Point-to-point movements smooth and accurate for finger-to-nose and heel-to-shin. Rapid alternating movements of the upper extremities intact bilaterally. Gait steady with continuous, symmetric steps. Sensation intact to bilateral upper and lower extremities; sense of extremity position intact. Stereognosis and graphesthesia intact bilaterally. |
Assessment-Acute post-traumatic headache following a low-speed MVAwhere Ms. Jones was a restrained passenger. |
Acute post-traumatic headache following low-speed MVA where Ms. Jones was a restrained passenger |
Plan-Encouraging Ms. Jones to continue monitoring her symptoms and report any increase in frequency or severity of her headache is essential. -It is important to initiate treatment with ibuprofen 800mg by nmouth every 8 hours a reccommended with food for the next five days. -Adjunt therapy of topical heat or ice per comfort TID-QID is another great treatmet option for Ms. Jones. -Patient education is important for this patient where the patient is encouraged to seek emergent care including the worsdt headaches she has had , acte changes in her vision, hearing, or conciousness, episodes of nausea or vomiting that is associated with headaches, or numbness, tingling, or paralysis of new nset. -For follo-up on Ms. Jones, it is advisable for her t call the office after 2 days to discuss symptoms and if there is no decrease in symptoms, a computerized tomographyscan (CT scan)or magnetic reasoning imaging (MRI) can be used. |
Encourage Ms. Jones to continue to monitor symptoms and report any increase in frequency or severity of her headaches. • Initiate treatment with ibuprofen 800 mg by mouth every 8 hours as needed with food for the next 5 days. • Ms. Jones can also use adjunct therapy of topical heat or ice per comfort TID-QID. • Educate on mild stretches for upper back and neck. • Educate on when to seek emergent care including the worst headache of her life, acute changes in vision, hearing, or consciousness, episodes of nausea or vomiting associated with headache, or numbness, tingling, or paralysis of new onset. • Ask Ms. Jones to call the office in two days to discuss symptoms. If no decrease in symptoms, order a computerized tomography scan or magnetic resonance imaging. |
