Permalink:https://thestudycorp.com/shadow-health-neurological-transcript/
Neurological shadow health assessment Transcript
Transcript
As you continue reading remember that StudyCorp.com has the top and most qualified writers to help with any of your assignments. All you need to do is place an order with us.
All Lines (155)Interview Questions (94)Statements (3)Exam Actions (58)
 | Hello Tina. Welcome to our clinic. Am Joyce, i will be interviewing you today, and later do a physical examination on you | Greet 03/18/20 10:56 AM PDT |
 | Hey. | |
| What brings you to the clinic today? | Question 03/18/20 10:57 AM PDT |
| 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. Neurological shadow health assessment Transcript | |
| Am sorry to hear that you are having headaches | Empathize 03/18/20 10:59 AM PDT |
| Thanks for saying that. | |
| Have you had any neck stiffness? | Question 03/18/20 11:00 AM PDT |
| Yeah. | |
| When did the neck stiffness begin? | Question 03/18/20 11:01 AM PDT |
| My neck started hurting about two days after the accident. | |
| Am sorry that you got an accident (No matching questions found.) | Question 03/18/20 11:02 AM PDT |
| Am sorry that you got an accident Neurological shadow health assessment Transcript | Empathize 03/18/20 11:02 AM PDT |
| Thanks. | |
| And when did the headaches begin? (Clarified to When did the headache begin?.) | Question 03/18/20 11:03 AM PDT |
| It was a few days after the car accident — I noticed a headache creeping up throughout the day. (Clarified to when the headache began.) | |
| Did you lose consciousnesses after car accident? (Clarified to Did you lose consciousness during the car accident?.) | Question 03/18/20 11:04 AM PDT |
| No, I don’t think I have ever lost consciousness. (Clarified to if I lost consciousness during the car accident.) | |
| How fast was the car going? | Question 03/18/20 11:06 AM PDT |
| Oh, it was really slow. We were in a parking lot. Maybe not even fifteen miles an hour. | |
| Were you wearing a seat belt? | Question 03/18/20 11:08 AM PDT |
| Yes, I always do. | |
| where in the car were you sitting? | Question 03/18/20 11:10 AM PDT |
| I was in the front passenger seat. | |
| Was the driver under the influence of alcohol? (Clarified to Was anyone under the influence of alcohol when the accident occurred?.) | Question 03/18/20 11:12 AM PDT |
| No, definitely not. Neither of us had anything to drink. [AUDIO COMING SOON] (Clarified to if anyone was under the influence of alcohol when the accident occurred.) | |
| Great, its not advisable to drink under the influence of alcohol | Educate 03/18/20 11:13 AM PDT |
| Alright, thanks for letting me know. | |
| How many times have you had the headaches since they started? | Question 03/18/20 11:16 AM PDT |
| 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 do the headache last? | Question 03/18/20 11:18 AM PDT |
| About an hour or two. | |
| when was your last headache? | Question 03/18/20 11:19 AM PDT |
| Yesterday afternoon. | |
| where are the headaches located? | Question 03/18/20 11:22 AM PDT |
| The headaches are in the crown of my head, and kind of the back of my head. | |
| Does the pain radiate? | Question 03/18/20 11:23 AM PDT |
| Maybe? The soreness in my neck feels like it goes up into my head. But its just my neck and head that hurt. | |
| how does your neck feel? | Question 03/18/20 11:23 AM PDT |
| It has been pretty stiff and a little painful since the accident. | |
| Is your scalp tender? | Question 03/18/20 11:24 AM PDT |
| No. | |
| Do you have jaw pain? | Question 03/18/20 11:24 AM PDT |
| No, not at all. | |
| Do you have any facial pain? | Question 03/18/20 11:25 AM PDT |
| No. My face is fine. | |
| How would you rate your pain? | Question 03/18/20 11:25 AM PDT |
| 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 your pain at its worst? | Question 03/18/20 11:26 AM PDT |
| They probably get up to a 4. | |
| what do your headaches feel like? | Question 03/18/20 11:27 AM PDT |
| The headaches feel like a dull ache, kind of in the crown of my head, and the back of my head. | |
| is the headache pain sharp? | Question 03/18/20 11:27 AM PDT |
| No, not really. | |
| are your headaches cyclic? | Question 03/18/20 11:28 AM PDT |
| No, I don’t think so. | |
| Do your headaches come in clusters? | Question 03/18/20 11:28 AM PDT |
| No, definitely not. | |
| do your headaches crescendo? | Question 03/18/20 11:29 AM PDT |
| It’s not, like, a sudden, horrible pain, but they don’t worsen gradually either. They just sort of start, and they never get that bad. | |
| What caused your pain? | Question 03/18/20 11:30 AM PDT |
| 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. | |
| Does it hurt to move your head? | Question 03/18/20 11:31 AM PDT |
| Yeah, my neck hurts when I move it. | |
| what makes your headache worse? | Question 03/18/20 11:31 AM PDT |
| Nothing really makes them worse. . . they just sort of start, and eventually they go away. | |
| have you tried home remedies? | Question 03/18/20 11:32 AM PDT |
| I’ve been taking Tylenol. And resting helps, too. | |
| Does your headache get better with rest? | Question 03/18/20 11:33 AM PDT |
| I don’t think so. They just come on and eventually go away. | |
| Are you taking any new medications? | Question 03/18/20 11:33 AM PDT |
| I’ve been taking more Tylenol for my headaches, and my neck. | |
| what dose of tylenol do you take? | Question 03/18/20 11:36 AM PDT |
| I’m not sure the actual dosage, but I generally take 2 regular strength pills. | |
| How often do you take the tylenol? | Question 03/18/20 11:37 AM PDT |
| I’ve been taking it every day since I started getting these headaches. | |
| How many times a day? (No matching questions found.) | Question 03/18/20 11:38 AM PDT |
| Does the tylenol help? | Question 03/18/20 11:38 AM PDT |
| Yeah, it has been helping some. | |
| Do you have any new allergies? | Question 03/18/20 11:39 AM PDT |
| Well, besides cats, I’m allergic to penicillin. | |
| Do you usually get headaches? | Question 03/18/20 11:40 AM PDT |
| The only time I got headaches before the accident was when I would read or study for a long time. | |
| Do you ever get migraines? | Question 03/18/20 11:40 AM PDT |
| No, I’m pretty sure my headaches aren’t migraines. | |
| Have you ever had any head trauma? | Question 03/18/20 11:41 AM PDT |
| No. | |
| Have you had any seizures? | Question 03/18/20 11:41 AM PDT |
| No. I’ve seen somebody have one, though. It’s scary. | |
| Have your sleep habits changed? | Question 03/18/20 11:42 AM PDT |
| No. | |
| Have you felt more sleepy? | Question 03/18/20 11:42 AM PDT |
| No, I feel about the same as usual. | |
| have you had a fever? | Question 03/18/20 11:43 AM PDT |
| No, I don’t think so. | |
| have you had any chills? | Question 03/18/20 11:43 AM PDT |
| No. | |
| have you felt fatigued? | Question 03/18/20 11:43 AM PDT |
| No, I don’t think so. | |
| have you had nausea? | Question 03/18/20 11:44 AM PDT |
| No. | |
| any night sweats? | Question 03/18/20 11:44 AM PDT |
| I don’t get sweaty, but sometimes I wake up hot and have to kick off my sheets. | |
| Has one side of your body felt weaker than the other? | Question 03/18/20 11:45 AM PDT |
| No, I feel about the same. | |
| Any changes in your gait? | Question 03/18/20 11:45 AM PDT |
| No. | |
| Have you felt weak? | Question 03/18/20 11:45 AM PDT |
| No. | |
| Have you experienced any auras? | Question 03/18/20 11:46 AM PDT |
| No. | |
| have you felt dizzy? | Question 03/18/20 11:47 AM PDT |
| No, I haven’t been dizzy. | |
| Any loss of coordination? | Question 03/18/20 11:48 AM PDT |
| Not that I’ve noticed. | |
| have you noticed any scotoma? | Question 03/18/20 11:49 AM PDT |
| I don’t know what that is, so I guess probably not. | |
| have you felt any tingling? | Question 03/18/20 11:49 AM PDT |
| No, I haven’t noticed any tingling. | |
| Has your face been flushed? | Question 03/18/20 11:50 AM PDT |
| Nope. | |
| have you felt depressed? | Question 03/18/20 11:50 AM PDT |
| No, I’ve been fine. | |
| have you felt more irritable? | Question 03/18/20 11:51 AM PDT |
| No, not really. | |
| Have you had any problems concentrating? | Question 03/18/20 11:51 AM PDT |
| No, not really. | |
| Have you felt confused? | Question 03/18/20 11:52 AM PDT |
| No. | |
| has your vision changed after the accident ? (No matching questions found.) | Question 03/18/20 11:52 AM PDT |
| has your vision changed since the accident ? | Question 03/18/20 11:53 AM PDT |
| No, my vision hasn’t changed since the accident. | |
| have you ever had a blurred vision? | Question 03/18/20 11:53 AM PDT |
| No, my vision hasn’t been blurry since the accident. But, sometimes it gets blurry when I read for too long — that’s been going on for awhile. | |
| any vision problems in just one eye? | Question 03/18/20 11:54 AM PDT |
| Not that I’ve noticed. | |
| Are you sensitive to light since the accident? | Question 03/18/20 11:55 AM PDT |
| No, I’m not sensitive to light. [AUDIO COMING SOON] | |
| have you had any congestion ? | Question 03/18/20 11:55 AM PDT |
| No, I haven’t been congested. | |
| have you had ringing in your ears? | Question 03/18/20 11:56 AM PDT |
| No. | |
| have you had any hearing loss? | Question 03/18/20 11:56 AM PDT |
| No. | |
| have you had any difficulty swallowing? | Question 03/18/20 11:57 AM PDT |
| Nope. | |
| Any history of migraines in your family? Neurological shadow health assessment Transcript | Question 03/18/20 11:57 AM PDT |
| I don’t think so. | |
| Any family history of epilepsy? | Question 03/18/20 11:58 AM PDT |
| No. | |
| any history of seizures? | Question 03/18/20 11:58 AM PDT |
| No. I’ve seen somebody have one, though. It’s scary. | |
| do you have a family history of Alzheimer’s disease? | Question 03/18/20 11:59 AM PDT |
| No. | |
| do you have a family history of Parkinson disease ? | Question 03/18/20 12:00 PM PDT |
| No, I don’t think so. | |
| What is your name and date of birth? | Question 03/18/20 1:29 PM PDT |
| My name is Tina Jones, and I was born on February 17th. | |
| Evaluated orientation to person | Exam Action 03/18/20 1:29 PM PDT |
| What building are you in now? | Question 03/18/20 1:30 PM PDT |
| I’m at the doctor’s office. . . it’s Shadow Health General Clinic. | |
| Evaluated orientation to place | Exam Action 03/18/20 1:30 PM PDT |
| What is the date and year? | Question 03/18/20 1:30 PM PDT |
| Um, today’s date is [Tina says correct date and year]. Neurological shadow health assessment Transcript | |
| Evaluated orientation to time | Exam Action 03/18/20 1:30 PM PDT |
| How are oranges and apples alike? | Question 03/18/20 1:32 PM PDT |
| How are they alike? Um…. they’re both kinds of fruit. | |
| Evaluated abstract thinking: similarities among fruit | Exam Action 03/18/20 1:32 PM PDT |
| How are a lake and an ocean alike? | Question 03/18/20 1:32 PM PDT |
| Uh…. they’re both bodies of water. | |
| Evaluated abstract thinking: similarities among bodies of water | Exam Action 03/18/20 1:32 PM PDT |
| How are a trumpet and a flute alike? | Question 03/18/20 1:33 PM PDT |
| They…… they’re both musical instruments. | |
| Evaluated abstract thinking: similarities among instruments | Exam Action 03/18/20 1:33 PM PDT |
| Count backwards by 7s from 100 | Question 03/18/20 1:34 PM PDT |
| Okay. . . 100, 93. . . 86, 79, 72. . . 65. . . 58, 51. . . 44. . . 37, 30, 23, 16. . . 9, and 2. | |
| Evaluated attention with serial sevens | Exam Action 03/18/20 1:34 PM PDT |
| Established one-stage comprehension | Exam Action 03/18/20 1:36 PM PDT |
| Who was the first president of the united states? | Question 03/18/20 1:37 PM PDT |
| That’s George Washington. | |
| Evaluated knowledge of first president | Exam Action 03/18/20 1:37 PM PDT |
| who are the last four presidents of the united states? | Question 03/18/20 1:37 PM PDT |
| Well, right now it’s Donald Trump. Before him it was Obama. Before *him* we had Bill Clinton and George W. Bush. | |
| Evaluated knowledge of last four presidents | Exam Action 03/18/20 1:38 PM PDT |
| name five large cities in the united states | Question 03/18/20 1:38 PM PDT |
| Let’s see. . . New York City. . . and Chicago. . . Detroit. . . Los Angeles. . . and Houston. That’s five. Neurological shadow health assessment Transcript | |
| Evaluated knowledge of five large cities | Exam Action 03/18/20 1:38 PM PDT |
| What would you do if you found a stamped and addressed envelope on the sidewalk? | Question 03/18/20 1:40 PM PDT |
| What would I do…. Hmm.. Well, I’d try to figure out who dropped the envelope, but if not… Well, I’d probably just drop it in the first mailbox I saw, if there was one nearby. | |
| Evaluated judgment | Exam Action 03/18/20 1:40 PM PDT |
| Repeat and remember burger, tulip, nose and tea | Question 03/18/20 1:41 PM PDT |
| Burger, tulip, nose, and tea. | |
| Evaluated immediate memory | Exam Action 03/18/20 1:41 PM PDT |
| how did you celebrate your last birthday? | Question 03/18/20 1:41 PM PDT |
| Wow. . . it’s weird, birthdays were huge for us before Dad died because he would always make a really big deal out of them, like he loved planning these huge celebrations. But the past two birthdays, he hasn’t been there, so it’s been kind of sad, thinking about what he’s missing, and we haven’t done huge parties or anything. Last birthday. . . Michael and his fiance came over, and we all had dinner at the house, and I opened presents, and we had a really good cake from this bakery I love. It was nice. | |
| Evaluated remote memory | Exam Action 03/18/20 1:42 PM PDT |
| Repeat the four words from before | Question 03/18/20 1:42 PM PDT |
| Burger. . . tulip. . .nose. . . and tea. | |
| Evaluated immediate learning | Exam Action 03/18/20 1:42 PM PDT |
| Observed patient’s general vocabulary | Exam Action 03/18/20 1:43 PM PDT |
| what classes are you taking? | Question 03/18/20 1:43 PM PDT |
| I’m taking two classes right now, one on auditing and one on managerial accounting | |
| Tested CN I (olfactory nerve) with smell test | Exam Action 03/18/20 1:45 PM PDT |
| F P | |
| F P | |
| Inspected right pupil and tested pupillary light reflex | Exam Action 03/18/20 1:49 PM PDT |
| Inspected left pupil and tested left pupillary light reflex | Exam Action 03/18/20 1:49 PM PDT |
| Inspected fundus of right eye Neurological shadow health assessment Transcript | Exam Action 03/18/20 1:50 PM PDT |
| Inspected fundus of left eye | Exam Action 03/18/20 1:52 PM PDT |
| Follow my finder with just your eyes | Question 03/18/20 1:54 PM PDT |
| Ok. | |
| Tested EOM to the upper right | Exam Action 03/18/20 1:55 PM PDT |
| Tested EOM to the upper left | Exam Action 03/18/20 1:55 PM PDT |
| Tested EOM to the lower left | Exam Action 03/18/20 1:55 PM PDT |
| Tested convergence | Exam Action 03/18/20 1:55 PM PDT |
| Tested EOM to the lower right | Exam Action 03/18/20 1:55 PM PDT |
| Tested EOM to the lower center | Exam Action 03/18/20 1:55 PM PDT |
| Tested EOM to the upper center | Exam Action 03/18/20 1:55 PM PDT |
| Tested EOM to the upper center | Exam Action 03/18/20 1:55 PM PDT |
| Close your eyes and tell me if the touch is sharp, dull or soft | Question 03/18/20 1:56 PM PDT |
| Ok. | |
| Tested facial sensation: dull stimulus | Exam Action 03/18/20 1:56 PM PDT |
| Dull. | |
| Tested facial sensation: dull stimulus | Exam Action 03/18/20 1:57 PM PDT |
| Dull. | |
| Tested facial sensation: dull stimulus | Exam Action 03/18/20 1:57 PM PDT |
| Dull. | |
| Tested facial sensation: dull stimulus | Exam Action 03/18/20 1:57 PM PDT |
| Dull. | |
| Tested facial sensation: soft stimulus | Exam Action 03/18/20 1:57 PM PDT |
| Soft. | |
| Tested facial sensation: soft stimulus | Exam Action 03/18/20 1:57 PM PDT |
| Soft. | |
| Tested facial sensation: soft stimulus | Exam Action 03/18/20 1:57 PM PDT |
| Soft. | |
| Tested facial sensation: soft stimulus | Exam Action 03/18/20 1:57 PM PDT |
| Soft. | |
| Tested facial sensation: sharp stimulus | Exam Action 03/18/20 1:57 PM PDT |
| Sharp. | |
| Tested facial sensation: sharp stimulus | Exam Action 03/18/20 1:57 PM PDT |
| Sharp. | |
| Tested facial sensation: sharp stimulus | Exam Action 03/18/20 1:57 PM PDT |
| Sharp. | |
| Tested facial sensation: sharp stimulus Neurological shadow health assessment Transcript | Exam Action 03/18/20 1:57 PM PDT |
| Sharp. | |
| Inspected front of face for asymmetry and facial droop | Exam Action 03/18/20 1:58 PM PDT |
| Inspected right side of face for asymmetry and facial droop | Exam Action 03/18/20 1:58 PM PDT |
| Inspected back of head for asymmetry | Exam Action 03/18/20 1:58 PM PDT |
| Inspected left side of face for asymmetry and facial droop | Exam Action 03/18/20 1:58 PM PDT |
| Inspected front of face for asymmetry and facial droop | Exam Action 03/18/20 1:58 PM PDT |
| Inspected left side of face for asymmetry and facial droop | Exam Action 03/18/20 1:58 PM PDT |
| Inspected front of face for asymmetry and facial droop | Exam Action 03/18/20 1:58 PM PDT |
| is the volume the same in both ears or louder in one ear | Question 03/18/20 2:00 PM PDT |
| Ok. | |
| Same in both ears. | |
| Performed Weber test with tuning fork | Exam Action 03/18/20 2:00 PM PDT |
| Tell me when you no longer hear the ringing | Question 03/18/20 2:01 PM PDT |
| Ok, I will. | |
| Now. | |
| Tested gag reflex | Exam Action 03/18/20 2:02 PM PDT |
| Tested trapezius muscle strength against resistance: 5 strength against resistance | Exam Action 03/18/20 2:02 PM PDT |
| Tested sternocleidomastoid muscle strength against resistance – head turned to the right: 5 strength against resistance | Exam Action 03/18/20 2:03 PM PDT |
| Tested sternocleidomastoid muscle strength against resistance – head turned to the left: 5 strength against resistance | Exam Action 03/18/20 2:03 PM PDT |
| Inspected mouth | Exam Action 03/18/20 2:04 PM PDT |
| Inspected mouth: pushed tongue left with tongue blade | Exam Action 03/18/20 2:04 PM PDT |
| Inspect mouth: pushed tongue right with tongue blade | Exam Action 03/18/20 2:04 PM PDT |
| Inspect mouth: lifted tongue with tongue blade | Exam Action 03/18/20 2:04 PM PDT |
| Inspected mouth: depressed tongue with tongue blade Neurological shadow health assessment Transcript | Exam Action 03/18/20 2:04 PM PDT |
