neurological shadow health tina jones Transcript

min

All Lines (243)Interview Questions (93)Statements (16)Exam Actions (134)

Hi.I am xx. I will interview you and later examine you. Greet
09/08/20 1:42 PM EST
Hey.
Welcome to the clinic Empathize
09/08/20 1:51 PM EST
I appreciate you saying that.
What brings you to the clinic today? Question
09/08/20 1:52 PM EST
Well, I got into a little fender bender a week ago and I’ve been getting these headaches ever since. And my neck is sore too.
Am sorry to hear that. Empathize
09/08/20 1:53 PM EST
I appreciate you telling me that.
Have you had any neck stiffness? Question
09/08/20 1:55 PM EST
Yeah.
When did the neck stiffness begin? Question
09/08/20 1:55 PM EST
My neck started hurting about two days after the accident.
Am sorry about the accident Empathize
09/08/20 1:57 PM EST
Thanks.
When did the headaches begin? Question
09/08/20 1:58 PM EST
Five days ago… The headaches started two days after the accident.
Did you lose consciousness during the accident? Question
09/08/20 1:59 PM EST
No.
Were you wearing a seat belt? Question
09/08/20 2:00 PM EST
Yes, I always do.
It is always good to wear a seat belt Educate
09/08/20 2:01 PM EST
Sure, I think I understand what you mean.
Where were you sitting? Question
09/08/20 2:01 PM EST
I was in the front passenger seat.
Was anyone under the influence of alcohol when the accident occurred? Question
09/08/20 2:02 PM EST
No, definitely not. Neither of us had anything to drink. [AUDIO COMING SOON]
Great. It is not good to drive under the influence of alcohol Educate
09/08/20 2:03 PM EST
Thanks for telling me.
How many times have you had headaches since they started? Question
09/08/20 2:04 PM EST
I’ve had a headache just about once a day since a couple days after my accident. Once I feel it coming on, I take something for it and it pretty much goes away for the day.
How long does the headache last? Question
09/08/20 2:04 PM EST
About an hour or two.
When was your last headache? Question
09/08/20 2:05 PM EST
Yesterday afternoon.
Where is the location of the headache? Question
09/08/20 2:05 PM EST
The headaches are in the crown of my head, and kind of the back of my head.
Does the pain radiate? Question
09/08/20 2:06 PM EST
Maybe? The soreness in my neck feels like it goes up into my head. But its just my neck and head that hurt.
Sorry about that Empathize
09/08/20 2:06 PM EST
Thanks for understanding.
How does your neck feel? Question
09/08/20 2:07 PM EST
It has been pretty stiff and a little painful since the accident.
Is your scalp tender? Question
09/08/20 2:20 PM EST
No.
Do you have jaw pain? Question
09/08/20 2:20 PM EST
No, not at all.
Do you have facial pain? Question
09/08/20 2:20 PM EST
No. My face is fine.
How would you rate the pain now? Question
09/08/20 2:21 PM EST
It’s just my neck that hurts right now. . . I guess I’d say it’s a 3 out of 10.
How would you rate the pain at its worst? Question
09/08/20 2:22 PM EST
They probably get up to a 4.
Describe the headaches? Question
09/08/20 2:22 PM EST
The headaches feel like a dull ache, kind of in the crown of my head, and the back of my head.
Sorry about that Empathize
09/08/20 2:22 PM EST
Thanks for saying that.
Is the headache pain sharp? Question
09/08/20 2:23 PM EST
No, not really.
Are your headaches cyclic Question
09/08/20 2:23 PM EST
No, I don’t think so.
What caused your pain? Question
09/08/20 2:24 PM EST
I’m pretty sure it was the car accident. Well, it was really just a fender bender. There was pretty much no damage to the car, and no one got injured, but I guess a sore head and neck can sneak up on you.
Sorry Ms. Jones Empathize
09/08/20 2:24 PM EST
Thanks for understanding.
Does it hurt to move your head? Question
09/08/20 2:25 PM EST
Yeah, my neck hurts when I move it.
What makes your headache worse? Question
09/08/20 2:25 PM EST
Nothing really makes them worse. . . they just sort of start, and eventually they go away.
Question
09/08/20 2:44 PM EST
No, I’m pretty sure my headaches aren’t migraines. (Clarified to if I get migraines.)
Good to hear Empathize
09/08/20 2:45 PM EST
Thanks for saying that.
Have you ever had any head trauma? Question
09/08/20 2:45 PM EST
No.
Any seizures? Question
09/08/20 2:45 PM EST
No. I’ve seen somebody have one, though. It’s scary.
Have your sleep habits changed? Question
09/08/20 2:47 PM EST
No.
Do you have fever? Question
09/08/20 2:49 PM EST
No.
Any chills? Question
09/08/20 2:50 PM EST
No.
Do you have fatigue? Question
09/08/20 2:50 PM EST
No, not really.
Do you have nausea? Question
09/08/20 2:50 PM EST
No.
Any night sweats? Question
09/08/20 2:50 PM EST
I don’t get sweaty, but sometimes I wake up hot and have to kick off my sheets.
Do you have hypertension? Question
09/08/20 2:51 PM EST
No, I’ve never been diagnosed with blood pressure problems.
That is great Empathize
09/08/20 2:51 PM EST
Thanks.
Has one side f your body felt weaker? Question
09/08/20 2:56 PM EST
No, I feel about the same.
Any change in your gait? Question
09/08/20 3:00 PM EST
No.
Have you felt dizzy? Question
09/08/20 3:00 PM EST
No, I haven’t been dizzy.
Any memory problems? Question
09/08/20 3:00 PM EST
I wouldn’t say so. I have a pretty normal memory.
Any changes in smell? Question
09/08/20 3:01 PM EST
No.
Who do you live with? Question
09/08/20 3:01 PM EST
Right now I live back at home with my mom and my sister.
That is great Empathize
09/08/20 3:02 PM EST
I appreciate you telling me that.
What is your highest level of education Question
09/08/20 3:02 PM EST
Well, I’m finishing up my Bachelor’s degree right now.
Do you work? Question
09/08/20 3:02 PM EST
I’m a supervisor at Mid-American Copy & Ship. I’ve been working there since high school, and I’ve just kept moving up.
Do you have a family history of headaches? Question
09/08/20 3:03 PM EST
No, not that I know of.
Do you have an earache? (Clarified to Do you have earaches?.) Question
09/08/20 3:04 PM EST
Not really, no. (Clarified to if I get earaches.)
Do you have eye problem Question
09/08/20 3:05 PM EST
Well, no, my vision hasn’t changed recently — not since the accident. But sometimes my vision gets blurry when I do a lot of reading… that’s been going on for awhile.
Do you have sore throat? Question
09/08/20 3:05 PM EST
No, it’s fine.
Any jaw pain? Question
09/08/20 3:06 PM EST
No, not at all.
Any dental concern? Question
09/08/20 3:06 PM EST
Nope, no problems.
Describe your diet Question
09/08/20 3:06 PM EST
It’s pretty good, I think. I’m not a huge health nut or anything.
Are you physically active? Question
09/08/20 3:07 PM EST
I don’t have the energy to go to a gym or anything after work…I’m pretty exhausted by the end of the day. But I’m on my feet all the time at work so I feel like that’s a little bit of exercise most days at least.
Any difficulty swallowing? Question
09/08/20 3:09 PM EST
Nope.
What is your current living situation? Question
09/08/20 3:09 PM EST
I live at home with my mom and my sister.
How is your work? Question
09/08/20 3:09 PM EST
Mid-American Copy & Ship is a good fit for me, especially while I work on my degree. They have been really understanding of my academic needs. Oh, and I get to do some accounting types of things when I take inventory or prepare orders.
Has the accident affected your work? (Clarified to Has the car accident had a financial impact on you?.) Question
09/08/20 3:11 PM EST
My friend was the one driving, so it was their car that got hit. Thankfully, I don’t have to deal with the repairs. [AUDIO COMING SOON] (Clarified to if the car accident has impacted me financially.)
ooh that is nice Empathize
09/08/20 3:12 PM EST
Thanks for understanding.
Thanks for answering my questions Ms. Jones Empathize
09/08/20 3:13 PM EST
I appreciate you telling me that.
I will now perform the physical assessment Educate
09/08/20 3:13 PM EST
OK, I understand.
What is your name and date of birth? Question
09/08/20 3:28 PM EST
My name is Tina Jones, and I was born on February 17th.
 Evaluated orientation to person Exam Action
09/08/20 3:28 PM EST
What building are you in now? Question
09/08/20 3:28 PM EST
I’m at the doctor’s office. . . it’s Shadow Health General Clinic.
 Evaluated orientation to place Exam Action
09/08/20 3:29 PM EST
What is the date and year? Question
09/08/20 3:29 PM EST
Um, today’s date is [Tina says correct date and year].
 Evaluated orientation to time Exam Action
09/08/20 3:29 PM EST
How are apples and orange alike? Question
09/08/20 3:30 PM EST
How are they alike? Um…. they’re both kinds of fruit.
 Evaluated abstract thinking: similarities among fruit Exam Action
09/08/20 3:30 PM EST
How are a lake and an ocean alike? Question
09/08/20 3:30 PM EST
Uh…. they’re both bodies of water.
 Evaluated abstract thinking: similarities among bodies of water Exam Action
09/08/20 3:31 PM EST
How are a trumpet and a flute alike? Question
09/08/20 3:31 PM EST
Can you tell me more about school? Question
09/08/20 3:41 PM EST
School’s good, although it’s a little stressful because I keep thinking about everything I have to do to graduate, and then after that, too. I’m about two months from being done with my last semester.
 Tested CN I (olfactory nerve) with smell test Exam Action
09/08/20 3:42 PM EST
F P
F P
T O Z
T O Z
L P E D
L P E D
 Inspected fundus of right eye Exam Action
09/08/20 3:44 PM EST
 Inspected fundus of left eye Exam Action
09/08/20 3:45 PM EST
 Inspected left pupil and tested left pupillary light reflex Exam Action
09/08/20 3:46 PM EST
 Inspected right pupil and tested pupillary light reflex Exam Action
09/08/20 3:46 PM EST
Follow my finger with just your eyes Question
09/08/20 3:48 PM EST
Ok.
 Tested convergence Exam Action
09/08/20 3:48 PM EST
 Tested EOM to the upper left Exam Action
09/08/20 3:48 PM EST
 Tested EOM to the upper center Exam Action
09/08/20 3:49 PM EST
 Tested EOM to the upper right Exam Action
09/08/20 3:49 PM EST
 Tested EOM to the lower right Exam Action
09/08/20 3:49 PM EST
 Tested EOM to the lower center Exam Action
09/08/20 3:49 PM EST
 Tested EOM to the lower left Exam Action
09/08/20 3:49 PM EST
Close your eyes and and tell me if the touch is sharp, dull, or soft Question
09/08/20 3:50 PM EST
Ok.
 Tested facial sensation: dull stimulus Exam Action
09/08/20 3:50 PM EST
Dull.
 Tested facial sensation: dull stimulus Exam Action
09/08/20 3:50 PM EST
Dull.
 Tested facial sensation: dull stimulus Exam Action
09/08/20 3:50 PM EST
Dull.
 Tested facial sensation: dull stimulus Exam Action
09/08/20 3:50 PM EST
Dull.
 Tested facial sensation: dull stimulus Exam Action
09/08/20 3:50 PM EST
Dull.
 Tested facial sensation: soft stimulus Exam Action
09/08/20 3:51 PM EST
Soft.
 Tested facial sensation: soft stimulus Exam Action
09/08/20 3:51 PM EST
Soft.
 Tested facial sensation: soft stimulus Exam Action
09/08/20 3:51 PM EST
Soft.
 Tested facial sensation: soft stimulus Exam Action
09/08/20 3:51 PM EST
Soft.
 Tested facial sensation: sharp stimulus Exam Action
09/08/20 3:52 PM EST
Sharp.
 Tested facial sensation: sharp stimulus Exam Action
09/08/20 3:52 PM EST
Sharp.
 Tested facial sensation: sharp stimulus Exam Action
09/08/20 3:52 PM EST
Sharp.
 Tested facial sensation: sharp stimulus Exam Action
09/08/20 3:52 PM EST
Sharp.
 Tested facial sensation: sharp stimulus Exam Action
09/08/20 3:52 PM EST
Sharp.
 Inspected front of face for asymmetry and facial droop Exam Action
09/08/20 3:52 PM EST
 Inspected right side of face for asymmetry and facial droop Exam Action
09/08/20 3:52 PM EST
 Inspected front of face for asymmetry and facial droop Exam Action
09/08/20 3:53 PM EST
 Inspected left side of face for asymmetry and facial droop Exam Action
09/08/20 3:53 PM EST
 Inspected back of head for asymmetry Exam Action
09/08/20 3:53 PM EST
 Inspected right side of face for asymmetry and facial droop Exam Action
09/08/20 3:53 PM EST
 Inspected front of face for asymmetry and facial droop Exam Action
09/08/20 3:53 PM EST
Is the volume the same in both ears or louder in one year? Question
09/08/20 3:54 PM EST
Ok.
Same in both ears.
 Performed Weber test with tuning fork Exam Action
09/08/20 3:55 PM EST
Tell me when you can no longer hear the ringing Question
09/08/20 3:55 PM EST
Ok, I will.
Now.
 Tested gag reflex Exam Action
09/08/20 3:56 PM EST
 Tested trapezius muscle strength against resistance: 5 strength against resistance Exam Action
09/08/20 3:57 PM EST
 Tested sternocleidomastoid muscle strength against resistance – head turned to the right: 5 strength against resistance Exam Action
09/08/20 3:57 PM EST
 Tested sternocleidomastoid muscle strength against resistance – head turned to the left: 5 strength against resistance Exam Action
09/08/20 3:57 PM EST
 Inspected mouth Exam Action
09/08/20 3:58 PM EST
 Inspected mouth: pushed tongue left with tongue blade Exam Action
09/08/20 3:58 PM EST
 Inspect mouth: pushed tongue right with tongue blade Exam Action
09/08/20 3:58 PM EST
 Inspect mouth: lifted tongue with tongue blade Exam Action
09/08/20 3:58 PM EST
 Inspected mouth: depressed tongue with tongue blade Exam Action
09/08/20 3:58 PM EST
 Tested reflexes of right triceps: 2+ Exam Action
09/08/20 3:59 PM EST
 Tested reflexes of left triceps: 2+ Exam Action
09/08/20 3:59 PM EST
 Tested reflexes of right biceps: 2+ Exam Action
09/08/20 3:59 PM EST
 Tested reflexes of left biceps: 2+ Exam Action
09/08/20 4:00 PM EST
 Tested reflexes of right brachioradialis: 2+ Exam Action
09/08/20 4:00 PM EST
 Tested reflexes of left brachioradialis: 2+ Exam Action
09/08/20 4:00 PM EST
 Tested reflexes of right patellar tendon: 2+ Exam Action
09/08/20 4:01 PM EST
 Tested reflexes of left patellar tendon: 2+ Exam Action
09/08/20 4:01 PM EST
 Tested reflexes of right achilles tendon: 2+ Exam Action
09/08/20 4:01 PM EST
 Tested reflexes of right achilles tendon: 2+ Exam Action
09/08/20 4:02 PM EST
 Tested reflexes of left achilles tendon: 2+ Exam Action
09/08/20 4:02 PM EST
Close your eyes and touch your fingers to your nose Question
09/08/20 4:04 PM EST
I can do that.
 Observed left index finger to nose Exam Action
09/08/20 4:04 PM EST
 Observed right index finger to nose Exam Action
09/08/20 4:04 PM EST
Run your right foot down your shin Question
09/08/20 4:06 PM EST
Sure.
 Observed right heel moving to shin Exam Action
09/08/20 4:06 PM EST
Run your left foot down your shin Question
09/08/20 4:06 PM EST
Ok.
 Observed left heel moving to shin Exam Action
09/08/20 4:06 PM EST
Place your hands on your knees and turn them over Question
09/08/20 4:08 PM EST
Ok, like this?
 Observed rapid alternating hand movements: Movement is smooth, performed without difficulty Exam Action
09/08/20 4:08 PM EST
 Observed patient’s gait Exam Action
09/08/20 4:08 PM EST
Close your eyes and tell me what I place in your hand Question
09/08/20 4:10 PM EST
Ok.
That’s an “A.”
 Tested left-hand graphesthesia by letter identification Exam Action
09/08/20 4:10 PM EST
That’s an “A.”
 Tested left-hand graphesthesia by letter identification Exam Action
09/08/20 4:10 PM EST
 Tested right-hand graphesthesia by number identification Exam Action
09/08/20 4:10 PM EST
A figure “8.”
Close your eyes nd tell me if the touch is sharp, dull or soft Question
09/08/20 4:12 PM EST
Ok.
 Tested right arm proximal dull sensation Exam Action
09/08/20 4:12 PM EST
Dull.
 Tested right arm distal dull sensation Exam Action
09/08/20 4:12 PM EST
Dull.
 Tested left arm proximal dull sensation Exam Action
09/08/20 4:13 PM EST
Dull.
 Tested left arm distal dull sensation Exam Action
09/08/20 4:13 PM EST
Dull.
 Tested left arm distal dull sensation Exam Action
09/08/20 4:13 PM EST
Dull.
close your eyes and tell if the touch is sharp, dull, or soft Question
09/08/20 4:15 PM EST
Ok.
 Test sensory dull chest Exam Action
09/08/20 4:15 PM EST
Dull.
 Tested right arm proximal soft sensation Exam Action
09/08/20 4:16 PM EST
Soft.
 Tested right arm distal soft sensation Exam Action
09/08/20 4:16 PM EST
Soft.
 Tested left arm proximal soft sensation Exam Action
09/08/20 4:16 PM EST
Soft.
 Tested left arm proximal soft sensation Exam Action
09/08/20 4:16 PM EST
Soft.
 Tested left arm distal soft sensation Exam Action
09/08/20 4:16 PM EST
Soft.
 Test sensory light chest Exam Action
09/08/20 4:16 PM EST
Soft.
 Tested right arm proximal sharp sensation Exam Action
09/08/20 4:17 PM EST
Sharp.
 Tested right arm proximal sharp sensation Exam Action
09/08/20 4:17 PM EST
Sharp.
 Tested right arm distal sharp sensation Exam Action
09/08/20 4:17 PM EST
Sharp.
 Tested left arm proximal sharp sensation Exam Action
09/08/20 4:18 PM EST
Sharp.
 Tested left arm distal sharp sensation Exam Action
09/08/20 4:18 PM EST
Sharp.
 Test sensory sharp chest Exam Action
09/08/20 4:18 PM EST
Sharp.
Close your eyes and tell me if the touch is sharp, dull, and soft Question
09/08/20 4:20 PM EST
Ok.
 Tested right leg proximal dull sensation Exam Action
09/08/20 4:20 PM EST
Dull.
 Tested right leg distal dull sensation Exam Action
09/08/20 4:20 PM EST
Dull.
 Tested left leg proximal dull sensation Exam Action
09/08/20 4:21 PM EST
Dull.
 Tested left leg distal dull sensation Exam Action
09/08/20 4:21 PM EST
Dull.
 Tested right leg proximal light sensation Exam Action
09/08/20 4:21 PM EST
Soft.
 Tested right leg distal light sensation Exam Action
09/08/20 4:21 PM EST
Soft.
 Tested left leg proximal light sensation Exam Action
09/08/20 4:21 PM EST
Soft.
 Tested left leg distal light sensation Exam Action
09/08/20 4:21 PM EST
Soft.
 Tested right leg proximal light sensation Exam Action
09/08/20 4:21 PM EST
Soft.
 Tested right leg proximal sharp sensation Exam Action
09/08/20 4:22 PM EST
Sharp.
 Tested right leg distal sharp sensation Exam Action
09/08/20 4:22 PM EST
Sharp.
 Tested right leg distal sharp sensation Exam Action
09/08/20 4:22 PM EST
Sharp.
 Tested left leg proximal sharp sensation Exam Action
09/08/20 4:22 PM EST
Sharp.
 Tested left leg distal sharp sensation Exam Action
09/08/20 4:22 PM EST
Sharp.
Close your eyes and tell me when you feel the touch Question
09/08/20 4:23 PM EST
Ok, I will.
 Tested sensation of right heel with monofilament Exam Action
09/08/20 4:24 PM EST
Yes.
 Tested sensation of left ball of foot under small toe with monofilament Exam Action
09/08/20 4:24 PM EST
 Tested sensation of right big toe with monofilament Exam Action
09/08/20 4:24 PM EST
Yes.
 Tested sensation of right big toe with monofilament Exam Action
09/08/20 4:24 PM EST
 Tested sensation of left big toe with monofilament Exam Action
09/08/20 4:24 PM EST
 Tested sensation of left ball of foot under big toe with monofilament Exam Action
09/08/20 4:24 PM EST
 Tested sensation of left ball of foot under small toe with monofilament Exam Action
09/08/20 4:24 PM EST
 Tested sensation of left ball of foot under small toe with monofilament Exam Action
09/08/20 4:24 PM EST
 Tested sensation of left heel with monofilament Exam Action
09/08/20 4:24 PM EST
Yes.
 Tested sensation of left heel with monofilament Exam Action
09/08/20 4:24 PM EST
Yes.
close your eyes and tell if your finger or toe moves up and down Question
09/08/20 4:26 PM EST
Ok, I will.
Down.
 Tested position sense of finger on right hand Exam Action
09/08/20 4:27 PM EST
Up.
 Tested position sense of finger on left hand Exam Action
09/08/20 4:27 PM EST
Up.
 Tested position sense of finger on left hand Exam Action
09/08/20 4:27 PM EST
…I think that was up.
 Tested position sense of toe on right foot Exam Action
09/08/20 4:27 PM EST
Down.
 Tested position sense of toe on left foot Exam Action
09/08/20 4:28 PM EST
close your eyes and tell me what I in your hand Question
09/08/20 4:30 PM EST
Ok, sure.
…Some kind of coin.
 Tested right-hand stereognosis with coin Exam Action
09/08/20 4:30 PM EST
 Tested right-hand stereognosis with paper clip Exam Action
09/08/20 4:31 PM EST
This is… some wire thing… paperclip?
 Tested right-hand stereognosis with key Exam Action
09/08/20 4:31 PM EST
Um… that feels like a key.
…Some kind of coin.
 Tested left-hand stereognosis with coin Exam Action
09/08/20 4:31 PM EST
 Tested left-hand stereognosis with paper clip Exam Action
09/08/20 4:31 PM EST
The paperclip again.
Um… that feels like a key.
 Tested left-hand stereognosis with key Exam Action
09/08/20 4:32 PM EST