Neurological shadow health assessment Transcript
Neurological shadow health assessment Transcript
Neurological shadow health assessment Transcript
Transcript
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.
WE ARE THE SHADOW HEALTH EXPERTS,
CHAT US TO PLACE OUR ORDER AND SCORE 100%
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
