Neurological shadow health Tina Jones Transcript

Tina Jones visited a clinic because she had been experiencing headaches and neck pain since being in a minor car accident a week ago. The healthcare provider greeted her and asked about her symptoms. Tina mentioned that her headaches started two days after the accident and occur about once a day, lasting for about an hour or two each time. She described the headaches as a dull ache in the crown and back of her head. The provider empathized with her situation and asked further questions about her symptoms and medical history.

Tina reported stiffness and some pain in her neck, but no other significant symptoms like loss of consciousness, fever, or nausea. She affirmed wearing a seat belt during the accident and denied any alcohol consumption by herself or the driver. The provider educated her on the importance of wearing seat belts and avoiding driving under the influence of alcohol.

During the interview, the provider also assessed Tina’s neurological status by asking about her sensory perceptions and performing various tests to evaluate her sensory responses, reflexes, and motor functions. Tina mentioned living with her mom and sister and working as a supervisor while completing her Bachelor’s degree. She expressed stress related to school but seemed generally satisfied with her work situation. After the interview, the provider proceeded with a physical assessment to further evaluate Tina’s condition.

Throughout the encounter, the provider demonstrated empathy and reassurance, creating a supportive environment for Tina to discuss her concerns and undergo evaluation.

Transcript of Tina Jones’ Visit to Neurological Shadow Health Clinic

Hello, I’m Tina Jones. Today, I’ll be asking you some questions and later, I’ll be examining you.

Hey there.

Thank you for coming to the clinic.

I’m glad to be here.

What brings you here today?

Well, I was in a minor car accident a week ago, and ever since, I’ve been experiencing headaches and neck pain.

I’m sorry to hear that.

Thank you for your sympathy.

Have you been experiencing any stiffness in your neck?

Yes, I have.

When did the stiffness start?

It began about two days after the accident.

I’m sorry to hear about the accident.

Thank you.

When did the headaches start?

They began about five days ago, two days after the accident.

Did you lose consciousness during the accident?

No, I didn’t.

Were you wearing a seatbelt?

Yes, I always wear one.

It’s important to wear a seatbelt.

I understand.

Where were you seated in the car?

I was in the front passenger seat.

Was anyone intoxicated during the accident?

No, neither of us had been drinking.

It’s crucial not to drive under the influence.

Thank you for mentioning that.

How often do you get these headaches?

I get them about once a day, ever since a couple of days after the accident. Taking something for it usually helps, and they go away for the day.

How long do the headaches usually last?

They last for about an hour or two.

When was your last headache?

Yesterday afternoon.

Where do you feel the headache?

It’s mainly at the crown and the back of my head.

Does the pain spread anywhere else?

Maybe, the soreness in my neck sometimes extends to my head, but the pain is mainly in my neck and head.

I’m sorry to hear that.

Thank you for your understanding.

How does your neck feel?

It’s been stiff and slightly painful since the accident.

Is your scalp tender?

No, it isn’t.

Do you experience any jaw pain?

No, none at all.

Do you have any facial pain?

No, my face feels normal.

On a scale of 0 to 10, how would you rate your current pain?

Right now, I’d say it’s a 3 out of 10.

And at its worst?

It probably reaches a 4.

Can you describe the headaches?

They’re like a dull ache, mainly at the crown and back of my head.

Is the pain sharp?

No, it’s not sharp.

Are the headaches cyclical?

No, I don’t think so.

What do you think caused your pain?

I believe it was the car accident. Though it was just a minor one, the soreness in my head and neck came later.

I’m sorry to hear that.

Thank you for understanding.

Does moving your head exacerbate the pain?

Yes, it does.

What worsens your headaches?

Nothing in particular, they just come and go on their own.

I’m quite sure they’re not migraines.

I’m glad to hear that.

Have you ever experienced head trauma?

No, I haven’t.

Any history of seizures?

No, but I have witnessed someone having one, and it was frightening.

Have your sleeping patterns changed?

No, they haven’t.

Do you have a fever?

No, I don’t.

Any chills?

No chills.

Do you feel fatigued?

Not particularly.

Do you experience nausea?

No, I don’t.

Do you have night sweats?

I don’t sweat excessively, but sometimes I wake up feeling hot and have to remove the covers.

Do you suffer from hypertension?

No, I’ve never been diagnosed with high blood pressure.

That’s good to hear.

Thank you.

Have you noticed any weakness on one side of your body?

No, I feel the same on both sides.

Any changes in your walking pattern?

No, my gait is normal.

Have you experienced dizziness?

No, I haven’t felt dizzy.

Any memory issues?

I believe my memory is normal.

Any changes in your sense of smell?

No, it’s unchanged.

Who do you live with?

I currently live with my mom and my sister.

That’s nice.

Thank you for sharing.

What’s your highest level of education?

I’m completing my Bachelor’s degree.

Do you work?

Yes, I’m a supervisor at Mid-American Copy & Ship. I’ve been there since high school.

Any family history of headaches?

Not that I know of.

Do you experience earaches?

No, I don’t.

Do you have any eye problems?

My vision hasn’t changed recently, but sometimes it gets blurry after a lot of reading.

Do you have a sore throat?

No, my throat is fine.

Any jaw pain?

No, none at all.

Do you have any dental issues?

No, my teeth are fine.

Can you describe your diet?

It’s decent, not overly health-conscious.

Are you physically active?

I don’t go to the gym, but my job keeps me on my feet most of the time.

Do you have trouble swallowing?

No, I don’t.

What’s your current living arrangement?

I live with my

mom and my sister.

Who do you live with?

I currently reside with my mother and sister.

That’s good to know.

Thank you for your time today.

Thank you for seeing me.