Objective:Student Documentation Model Documentation
Oriented to person, place and time. Judgement and knowledge intact: Memory intact. no slurred speech Head: symmetrical no lesions, no trauma Weber test intact, rinne test intact, facial sensation intact, gag reflex intact Eyes: Blurry vision with prolong reading: Right eye vision 20/40: retina: with glacoma cupping. Left eye vision 20/20: retina: sharp edges Pupils: PERRL present Point to point intact for finger to nose, heel to shin. Sensation present in extremites except monofilament decreased sensation on foot. Present sensation at heels of both foot. DTR: 2+ for all reflexes Gait: wnl Graphesthesia: able to identify Sterognosis: able to identify
General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress, but appears uncomfortab while sitting in exam chair. She is alert and oriented. She maintai 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 visio 20/20. Right eye vision: 20/40. Left fundoscopic exam reveals sh disc margins, no hemorrhages. Right fundoscopic exam reveals retinopathic changes. Pupils equal, round, and reactive to light bilaterally. Extraocular movements intact bilaterally. Normal convergence. Facial sensation intact; facial features and symmet Rinne and Weber tests normal bilaterally. Gag reflex intact. Ability shrug shoulders symmetric; 5 strength against resistance. Neck full range of motion against resistance; 5 strength against resista 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-to- shin. Rapid alternating movements of the upper extremities intac bilaterally. Gait steady with continuous, symmetric steps. Sensat intact to bilateral upper and lower extremities; sense of extremity position intact. Stereognosis and graphesthesia intact bilaterally.
Assessment
Headache and Neck pain due to s/p slow moving MVA Acute post-traumatic headache following low-speed MVA where Jones was a restrained passenger
Plan
Try Motrin 800mg po every 8 hours prn for headache Offer ice or heat to see if it helps with pain Educate on Warning signs: report any increase headache or worsening headaches, LOC, dizzinees or vomiting Education on exercises for ROM of neck Report to ER if headache is severe, LOC, nausea and vomiting, dizziness. Advise to have someone with her to watch her for the next 2 days if worsening symtoms. Telephone appt in 2 days to follow up with symptoms. Consider neuro consult if symptoms don’t resolve CAT scan if sx worsens or no improvement
Encourage Ms. Jones to continue to monitor symptoms and repo any increase in frequency or severity of her headaches. • Initiate treatment with ibuprofen 800 mg by mouth every 8 hours as nee 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 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 nause vomiting associated with headache, or numbness, tingling, or paralysis of new onset. • Ask Ms. Jones to call the office in two d to discuss symptoms. If no decrease in symptoms, order a computerized tomography scan or magnetic resonance imaging
Comments
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