Neurological Results | Turned In Advanced Physical Assessment – March 2020, advanced_physical_assessment__td8__031720__sect1

Neurological Results | Turned In Advanced Physical Assessment – March 2020, advanced_physical_assessment__td8__031720__sect1

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Documentation / Electronic Health Record

Document: Provider Notes

Student Documentation Model Documentation


Ms Jones who is african american pleasant female who presents to the clinic with c/o headache and neck stiffness She was in a slow moving car accident last week, and her symptoms just started two days ago. She was wearing her seat belt. She has a dull headache at the crown of her head and the back is at the back of her neck. She was no loss of consciousness. She takes tylenol which helps, with the pain 3/10. She feels her neck swollen, but has been resolving recently. Moving her neck hurts. ROS: She denies any fatigue, wt loss, fever or chills. Head: NO trauma, or LOC or dizziness,. Eyes: she wears reading glasses, and gets blurry when she reads to much. Ears: no hearing loss or ringing of her ears, no vertigo or earache. Denies any neck stiffnes. Musculoskeletal: denies problems with her ROM Denies any neurological disease or problems. No family hx of neurological disease or problems. Medical hx: Diabetes: no meds Asthma: Medications: Albuterol, proventil, tylenol and advil Allergy med: PCN: hives, and rash

HPI: Ms. Jones presents to the clinic complaining of a headache 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 spee 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 accompan by neck ache. She states that she feels as though her neck may slightly swollen as well. She did not lose consciousness in the accident and denies changes in level of consciousness since tha time. She states that she gets a headache every day that lasts approximately 1-2 hours. She occasionally takes 650 mg of over counter Tylenol with relief of the pain. She denies known associa symptoms. Review of Systems: General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats. • Head: Denies history trauma before this incident. Denies current headache. • Eyes: Sh does not wear corrective lenses, but notes that her vision has be worsening over the past few years, but no acute changes. She complains of blurry vision after reading for extended periods. De increased tearing or itching. • Ears: Denies hearing loss, tinnitus, vertigo, discharge, or earache. • Nose/Sinuses: Denies rhinorrhea Denies stuffiness, sneezing, itching, previous allergy, epistaxis, o sinus pressure. • Musculoskeletal: Denies muscle weakness, pai difficulties with range of motion, joint instability, or swelling. • Neurologic: Denies loss of sensation, numbness, tingling, tremor weakness, paralysis, fainting, blackouts, or seizures. Denies bow or bladder dysfunction. Denies changes in concentration, sleep, coordination, appetite.

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