Tina Jones neurological shadow health transcript


neurological shadow health tina jones Transcript

Neurological Shadow Health Transcript

Tina Jones transcript for neurological shadow health

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 clinicEmpathize
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 accidentEmpathize
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 beltEducate
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 alcoholEducate
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 thatEmpathize
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 thatEmpathize
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 cyclicQuestion
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. JonesEmpathize
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 hearEmpathize
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 greatEmpathize
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 greatEmpathize
09/08/20 3:02 PM EST
I appreciate you telling me that.
What is your highest level of educationQuestion
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 problemQuestion
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 dietQuestion
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 niceEmpathize
09/08/20 3:12 PM EST
Thanks for understanding.
Thanks for answering my questions Ms. JonesEmpathize
09/08/20 3:13 PM EST
I appreciate you telling me that.
I will now perform the physical assessmentEducate
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 personExam 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 placeExam 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 timeExam 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 fruitExam 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 waterExam 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 testExam 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 eyeExam Action
09/08/20 3:44 PM EST
 Inspected fundus of left eyeExam Action
09/08/20 3:45 PM EST
 Inspected left pupil and tested left pupillary light reflexExam Action
09/08/20 3:46 PM EST
 Inspected right pupil and tested pupillary light reflexExam Action
09/08/20 3:46 PM EST
Follow my finger with just your eyesQuestion
09/08/20 3:48 PM EST
Ok.
 Tested convergenceExam Action
09/08/20 3:48 PM EST
 Tested EOM to the upper leftExam Action
09/08/20 3:48 PM EST
 Tested EOM to the upper centerExam Action
09/08/20 3:49 PM EST
 Tested EOM to the upper rightExam Action
09/08/20 3:49 PM EST
 Tested EOM to the lower rightExam Action
09/08/20 3:49 PM EST
 Tested EOM to the lower centerExam Action
09/08/20 3:49 PM EST
 Tested EOM to the lower leftExam Action
09/08/20 3:49 PM EST
Close your eyes and and tell me if the touch is sharp, dull, or softQuestion
09/08/20 3:50 PM EST
Ok.
 Tested facial sensation: dull stimulusExam Action
09/08/20 3:50 PM EST
Dull.
 Tested facial sensation: dull stimulusExam Action
09/08/20 3:50 PM EST
Dull.
 Tested facial sensation: dull stimulusExam Action
09/08/20 3:50 PM EST
Dull.
 Tested facial sensation: dull stimulusExam Action
09/08/20 3:50 PM EST
Dull.
 Tested facial sensation: dull stimulusExam Action
09/08/20 3:50 PM EST
Dull.
 Tested facial sensation: soft stimulusExam Action
09/08/20 3:51 PM EST
Soft.
 Tested facial sensation: soft stimulusExam Action
09/08/20 3:51 PM EST
Soft.
 Tested facial sensation: soft stimulusExam Action
09/08/20 3:51 PM EST
Soft.
 Tested facial sensation: soft stimulusExam Action
09/08/20 3:51 PM EST
Soft.
 Tested facial sensation: sharp stimulusExam Action
09/08/20 3:52 PM EST
Sharp.
 Tested facial sensation: sharp stimulusExam Action
09/08/20 3:52 PM EST
Sharp.
 Tested facial sensation: sharp stimulusExam Action
09/08/20 3:52 PM EST
Sharp.
 Tested facial sensation: sharp stimulusExam Action
09/08/20 3:52 PM EST
Sharp.
 Tested facial sensation: sharp stimulusExam Action
09/08/20 3:52 PM EST
Sharp.
 Inspected front of face for asymmetry and facial droopExam Action
09/08/20 3:52 PM EST
 Inspected right side of face for asymmetry and facial droopExam Action
09/08/20 3:52 PM EST
 Inspected front of face for asymmetry and facial droopExam Action
09/08/20 3:53 PM EST
 Inspected left side of face for asymmetry and facial droopExam Action
09/08/20 3:53 PM EST
 Inspected back of head for asymmetryExam Action
09/08/20 3:53 PM EST
 Inspected right side of face for asymmetry and facial droopExam Action
09/08/20 3:53 PM EST
 Inspected front of face for asymmetry and facial droopExam 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 forkExam Action
09/08/20 3:55 PM EST
Tell me when you can no longer hear the ringingQuestion
09/08/20 3:55 PM EST
Ok, I will.
Now.
 Tested gag reflexExam Action
09/08/20 3:56 PM EST
 Tested trapezius muscle strength against resistance: 5 strength against resistanceExam Action
09/08/20 3:57 PM EST
 Tested sternocleidomastoid muscle strength against resistance – head turned to the right: 5 strength against resistanceExam Action
09/08/20 3:57 PM EST
 Tested sternocleidomastoid muscle strength against resistance – head turned to the left: 5 strength against resistanceExam Action
09/08/20 3:57 PM EST
 Inspected mouthExam Action
09/08/20 3:58 PM EST
 Inspected mouth: pushed tongue left with tongue bladeExam Action
09/08/20 3:58 PM EST
 Inspect mouth: pushed tongue right with tongue bladeExam Action
09/08/20 3:58 PM EST
 Inspect mouth: lifted tongue with tongue bladeExam Action
09/08/20 3:58 PM EST
 Inspected mouth: depressed tongue with tongue bladeExam 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 noseQuestion
09/08/20 4:04 PM EST
I can do that.
 Observed left index finger to noseExam Action
09/08/20 4:04 PM EST
 Observed right index finger to noseExam Action
09/08/20 4:04 PM EST
Run your right foot down your shinQuestion
09/08/20 4:06 PM EST
Sure.
 Observed right heel moving to shinExam Action
09/08/20 4:06 PM EST
Run your left foot down your shinQuestion
09/08/20 4:06 PM EST
Ok.
 Observed left heel moving to shinExam Action
09/08/20 4:06 PM EST
Place your hands on your knees and turn them overQuestion
09/08/20 4:08 PM EST
Ok, like this?
 Observed rapid alternating hand movements: Movement is smooth, performed without difficultyExam Action
09/08/20 4:08 PM EST
 Observed patient’s gaitExam Action
09/08/20 4:08 PM EST
Close your eyes and tell me what I place in your handQuestion
09/08/20 4:10 PM EST
Ok.
That’s an “A.”
 Tested left-hand graphesthesia by letter identificationExam Action
09/08/20 4:10 PM EST
That’s an “A.”
 Tested left-hand graphesthesia by letter identificationExam Action
09/08/20 4:10 PM EST
 Tested right-hand graphesthesia by number identificationExam Action
09/08/20 4:10 PM EST
A figure “8.”
Close your eyes nd tell me if the touch is sharp, dull or softQuestion
09/08/20 4:12 PM EST
Ok.
 Tested right arm proximal dull sensationExam Action
09/08/20 4:12 PM EST
Dull.
 Tested right arm distal dull sensationExam Action
09/08/20 4:12 PM EST
Dull.
 Tested left arm proximal dull sensationExam Action
09/08/20 4:13 PM EST
Dull.
 Tested left arm distal dull sensationExam Action
09/08/20 4:13 PM EST
Dull.
 Tested left arm distal dull sensationExam Action
09/08/20 4:13 PM EST
Dull.
close your eyes and tell if the touch is sharp, dull, or softQuestion
09/08/20 4:15 PM EST
Ok.
 Test sensory dull chestExam Action
09/08/20 4:15 PM EST
Dull.
 Tested right arm proximal soft sensationExam Action
09/08/20 4:16 PM EST
Soft.
 Tested right arm distal soft sensationExam Action
09/08/20 4:16 PM EST
Soft.
 Tested left arm proximal soft sensationExam Action
09/08/20 4:16 PM EST
Soft.
 Tested left arm proximal soft sensationExam Action
09/08/20 4:16 PM EST
Soft.
 Tested left arm distal soft sensationExam Action
09/08/20 4:16 PM EST
Soft.
 Test sensory light chestExam Action
09/08/20 4:16 PM EST
Soft.
 Tested right arm proximal sharp sensationExam Action
09/08/20 4:17 PM EST
Sharp.
 Tested right arm proximal sharp sensationExam Action
09/08/20 4:17 PM EST
Sharp.
 Tested right arm distal sharp sensationExam Action
09/08/20 4:17 PM EST
Sharp.
 Tested left arm proximal sharp sensationExam Action
09/08/20 4:18 PM EST
Sharp.
 Tested left arm distal sharp sensationExam Action
09/08/20 4:18 PM EST
Sharp.
 Test sensory sharp chestExam Action
09/08/20 4:18 PM EST
Sharp.
Close your eyes and tell me if the touch is sharp, dull, and softQuestion
09/08/20 4:20 PM EST
Ok.
 Tested right leg proximal dull sensationExam Action
09/08/20 4:20 PM EST
Dull.
 Tested right leg distal dull sensationExam Action
09/08/20 4:20 PM EST
Dull.
 Tested left leg proximal dull sensationExam Action
09/08/20 4:21 PM EST
Dull.
 Tested left leg distal dull sensationExam Action
09/08/20 4:21 PM EST
Dull.
 Tested right leg proximal light sensationExam Action
09/08/20 4:21 PM EST
Soft.
 Tested right leg distal light sensationExam Action
09/08/20 4:21 PM EST
Soft.
 Tested left leg proximal light sensationExam Action
09/08/20 4:21 PM EST
Soft.
 Tested left leg distal light sensationExam Action
09/08/20 4:21 PM EST
Soft.
 Tested right leg proximal light sensationExam Action
09/08/20 4:21 PM EST
Soft.
 Tested right leg proximal sharp sensationExam Action
09/08/20 4:22 PM EST
Sharp.
 Tested right leg distal sharp sensationExam Action
09/08/20 4:22 PM EST
Sharp.
 Tested right leg distal sharp sensationExam Action
09/08/20 4:22 PM EST
Sharp.
 Tested left leg proximal sharp sensationExam Action
09/08/20 4:22 PM EST
Sharp.
 Tested left leg distal sharp sensationExam Action
09/08/20 4:22 PM EST
Sharp.
Close your eyes and tell me when you feel the touchQuestion
09/08/20 4:23 PM EST
Ok, I will.
 Tested sensation of right heel with monofilamentExam Action
09/08/20 4:24 PM EST
Yes.
 Tested sensation of left ball of foot under small toe with monofilamentExam Action
09/08/20 4:24 PM EST
 Tested sensation of right big toe with monofilamentExam Action
09/08/20 4:24 PM EST
Yes.
 Tested sensation of right big toe with monofilamentExam Action
09/08/20 4:24 PM EST
 Tested sensation of left big toe with monofilamentExam Action
09/08/20 4:24 PM EST
 Tested sensation of left ball of foot under big toe with monofilamentExam Action
09/08/20 4:24 PM EST
 Tested sensation of left ball of foot under small toe with monofilamentExam Action
09/08/20 4:24 PM EST
 Tested sensation of left ball of foot under small toe with monofilamentExam Action
09/08/20 4:24 PM EST
 Tested sensation of left heel with monofilamentExam Action
09/08/20 4:24 PM EST
Yes.
 Tested sensation of left heel with monofilamentExam Action
09/08/20 4:24 PM EST
Yes.
close your eyes and tell if your finger or toe moves up and downQuestion
09/08/20 4:26 PM EST
Ok, I will.
Down.
 Tested position sense of finger on right handExam Action
09/08/20 4:27 PM EST
Up.
 Tested position sense of finger on left handExam Action
09/08/20 4:27 PM EST
Up.
 Tested position sense of finger on left handExam Action
09/08/20 4:27 PM EST
…I think that was up.
 Tested position sense of toe on right footExam Action
09/08/20 4:27 PM EST
Down.
 Tested position sense of toe on left footExam Action
09/08/20 4:28 PM EST
close your eyes and tell me what I in your handQuestion
09/08/20 4:30 PM EST
Ok, sure.
…Some kind of coin.
 Tested right-hand stereognosis with coinExam Action
09/08/20 4:30 PM EST
 Tested right-hand stereognosis with paper clipExam Action
09/08/20 4:31 PM EST
This is… some wire thing… paperclip?
 Tested right-hand stereognosis with keyExam Action
09/08/20 4:31 PM EST
Um… that feels like a key.
…Some kind of coin.
 Tested left-hand stereognosis with coinExam Action
09/08/20 4:31 PM EST
 Tested left-hand stereognosis with paper clipExam Action
09/08/20 4:31 PM EST
The paperclip again.
Um… that feels like a key.
 Tested left-hand stereognosis with keyExam Action
09/08/20 4:32 PM EST