Tina Jones neurological shadow health transcript

neurological shadow health tina jones Transcript

Neurological Shadow Health Transcript

Tina Jones transcript for neurological shadow health

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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