NSG 516 Neurological Shadow Health 5 Complete Solution
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Neurological Results | Turned In
Advanced Health Assessment -
... [Show More] Spring 2019, NSG516 Online
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Experience Overview
Patient: Tina Jones
Digital Clinical Experience Score
100%
Student Performance Index
59 out of 61
Proficiency Level: Proficient
Beginning Developing Proficient
Students rated as “proficient” demonstrate an entrylevel expertise in advanced practice competencies and
clinical reasoning skills. In comparable programs, the
top 25% of students perform at the level of a proficient
practitioner.
This score measures your performance on the Student
Performance Index in relation to other students in
comparable academic programs. Your instructor has
chosen to scale your Student Performance Index score
so that the average score on the index is a 87.0%. This
score may not be your final grade if your instructor
Subjective Data
Collection
20 out of 20
Education and Empathy
2 out of 4
Objective Data Collection
37 out of 37
chooses to include additional components, such as
documentation or time spent. Time
67 minutes total spent in assignment
Interaction with patient
56 minutes
Post-exam activities
11 minutes
Documentation / Electronic Health Record
Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Self-Reflection
Document: Provider Notes
Document: Provider Notes
Student Documentation Model Documentation
Subjective
Ms. Jones is a pleasant, 28 yr old woman.
CHIEF COMPLAINT: I have a headache and my
neck is sore after the car accident.
HPI
Ms. Jones is a 28 yr old African American female
who presented with headaches and a sore neck
resultant from a recent very minor car accident. She
has been experiencing symptoms for the last 5 days
(2 days after the accident). Each episode lasts 1-
2hrs. The pain is dull and present both in the crown
and back of the head. Pt describes it as not horrible
but is worried because it manifests itself often. No
aggravating factors. Tylenol 650mg daily relieves the
pain. She has not tried anything to address nect
discomfort other than resting and not moving it too
much.
Medications:
- Rescue inhaler, Proventil
- Flovent
- Tylenol for headaches
Allergies/Reactions
- Penicillin: rash
- Cats and dust: sneezing, itching
ROS
General: Denies fever, chills, dizziness, weight loss,
fatigue.
Neurological: denies changes in sensation,
numbness, tingling, fainting, memroy problems,
muscle weakness. Denies seizures. Denies sleeping
issues or concentration problems.
Psychological: endorses a stable mood
Head: denies head trauma. Endorses daily
headache and neck soreness.
Eyes: Endorses blurriness (when reading).
Ears: Denies hearing loss.
Nose/Throat: Denies swallowing problems.
Family History:
Denies relevant family history.
Social History:
Alcohol: Social drinker, no more than 10
drinks/month
smoking: Denies
Sleep: endorses adequate sleep
Other drugs: denies current use.
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 instability, or swelling. • Neurologic: Denies loss
of sensation, numbness, tingling, tremors,
weakness, paralysis, fainting, blackouts, or seizures.
Denies bowel or bladder dysfunction. Denies
changes in concentration, sleep, coordination,
appetite.
Objective
Physical exam:
GENERAL: pleasant, overweight young woman (28
yr old) who is relaxed, alert and cooperative. Facial
expression is at rest. Oriented to place, person and
time. Abstract thinking, attention, comprehension,
general knowledge, judgement, memory and
vocabulary are adequate and intact. Pleasant and
easy to engage, able to maintain appropriate eye
contact.
VS: Ht 170 cm, Wt 88Kg, BMI 30.5, BP 139/87, HR
82, RR16, O2sat: 99%. Afebrile (98.9f).
ROS
HEAD: atraumatic, normocephalic.
EYES: eyebrows are full, eye lashes are curvedup,
eyelids positioned normally without pupil overlay.
NEUROLOGIC (Cranial Nerves):
Sense of smell is intact and symmetric bilaterally.
Visual acuity 20/40 right eye and 20/20 left eye.
Right retina: disk margins are sharp, cotton wool
bodies present. Left retina: disk margins sharp.
Pupils are 4mm constricting to 2mmm equally round
and reactive to light and accommodations. EOM
intact: cardinal fields, convergence and peripheral
vision are adequate. Facial sensations intact. Facial
features symmetric. Weber midline. AC>BC. Gag
reflex intact. Symmetric shoulder shrug, 5+ strength
against resistance. Full neck ROM, 5+ strength
against resistance. Tongue is symmetric, without
abnormal findings. Upper and lower extremity deep
tendon reflexes (DTR) 2+ and symmetric bilaterally.
Point-to-point movements (finger to nose, heel to
shin) smooth and accurate bilaterally. Coordination
of rapid hand movements intact bilaterally. Gait is
smooth, steady, continuous, with symmetric steps.
Stereognosis and graphesthesia are intact. Sensory:
pinprick, light touch, position and vibration intact.
Decreased sensation on both right and left feet.
General: Ms. Jones is a pleasant, obese 28-year-old
African American woman in no acute distress, but
appears uncomfortable while sitting in exam chair.
She is alert and oriented. She maintains eye contact
throughout interview and examination.
• Head: Head is normocephalic and atraumatic
• Eyes: Bilateral eyes with equal hair distribution.
• Neurologic: Sense of smell intact and symmetric.
Left eye vision: 20/20. Right eye vision: 20/40. Left
fundoscopic exam reveals sharp disc margins, no
hemorrhages. Right fundoscopic exam reveals mild
retinopathic changes. Pupils equal, round, and
reactive to light bilaterally. Extraocular movements
intact bilaterally. Normal convergence. Facial
sensation intact; facial features and symmetric.
Rinne and Weber tests normal bilaterally. Gag reflex
intact. Ability to shrug shoulders symmetric; 5
strength against resistance. Neck with full range of
motion against resistance; 5 strength against
resistance. Tongue symmetric with no abnormal
findings. Bilateral upper and lower extremity DTRs
equal and 2+ bilaterally. Point-to-point movements
smooth and accurate for finger-to-nose and heel-toshin. Rapid alternating movements of the upper
extremities intact bilaterally. Gait steady with
continuous, symmetric steps. Sensation intact to
bilateral upper and lower extremities; sense of
extremity position intact. Stereognosis and
graphesthesia intact bilaterally.
Assessment
Pt is a 28 yr old African American female who is
pleasant and easy to engage with a PMH of DM and
asthma. She has been assessed for headaches and
a sore neck. These symptoms prompted a
neurological focused assessment.
Her symptoms suggest a diagnosis of headaches
resultant from trauma (minor motor vehicle
accident).
Acute post-traumatic headache following low-speed
MVA where Ms. Jones was a restrained passenger
- Soft tissue therapy to the neck
- Ice/cold compresses as needed (NTE 2 min each
at a time)
Encourage Ms. Jones to continue to monitor
symptoms and report any increase in frequency or
severity of her headaches. • Initiate treatment with
- home stretching program for the upper body and
neck
- NSAID to decrease inflammatory process
- Close monitoring of frequency of headaches and
the need to report to the provider if conditions
worsen
- Education regarding the need to seek emergent
care in the presence of very bad headaches, vision
changes, nausea/vomiting.
- Further testing might be warranted if headaches
dont resolve with suggested interventions.
- Follow up in one week if no relief is obtained
ibuprofen 800 mg by mouth every 8 hours as
needed with food for the next 5 days. • Ms. Jones
can also use adjunct therapy of topical heat or ice
per comfort TID-QID. • Educate on mild stretches
for upper back and neck. • Educate on when to
seek emergent care including the worst headache of
her life, acute changes in vision, hearing, or
consciousness, episodes of nausea or vomiting
associated with headache, or numbness, tingling, or
paralysis of new onset. • Ask Ms. Jones to call the
office in two days to discuss symptoms. If no
decrease in symptoms, order a computerized
tomography scan or magnetic resonance imaging.
Comments
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