Shadow Health Neurological Transcript

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Neurological shadow health assessment Transcript

Transcript

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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

References

ncbi.gov