Neurological Physical Assessment Assignment Results | Turned In

Overview Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Student Pre-Survey Lifespan Review Questions Self-Reflection Document: Provider Notes Document: Provid ...

Overview Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Student Pre-Survey Lifespan Review Questions Self-Reflection Document: Provider Notes Document: Provider Notes Student Documentation Model Documentation Subjective HPI: Tina Jones comes to the clinic with the chief complaint of headaches and neck stiffness. This occured about five days ago, but the patient was in a minor "fender bender" a week ago. Tina was the passenger and she was wearing a seatbelt. She claims that the accident was at low speed. She did not seek further care after the EMTs looked her over and declared that she was okay. However, two days later, she started to have terrible headaches ad her stiff neck. She also notes that her neck may be swollen. Tina did not lose conciousness, not has she lost conciousness or fainted since. She has been having a headaches daily for the last five days. The headaches last "about an hour or two" and she rates the severity at a 4. She describes the pain as "a dull ache in the corwn of my head and the back of my head." She takes Tylenol to manage the pain as needed. She did not know the dose, but she "generally takes 2 regular strength pills." She denies any other symptoms. Social History: Patient states that she always weras her seatbelt. She claims that she is a safe driver. Her father was in an accident, so she takes it seriously. Patient does not smoke or do drugs. ROS: General: patient denies any fatigue or weakness. Head: patient denies any current headache. patient 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