NR 509 Neurological Documentation Shadow Health

Subjective

HPI: Tina Jones comes to the clinic with the chief complaint of headaches and neck stiffness. This occurred about five days ago, but the patient was in a minor “fender bender” a week ago. Tina was the passenger, and she was wearing a seatbelt.

She claims that the accident was at low speed. She did not seek further care after the EMTs looked her over and declared that she was okay. However, two days later, she started to have terrible headaches ad a stiff neck. She also notes that her neck may be swollen. Tina did not lose consciousness, nor has she lost consciousness or fainted since. She has had headaches daily for the last five days.

The headaches last “about an hour or two,” and she rates the severity at a 4. She describes the pain as “a dull ache in the crown of my head and the back of my head.”

She takes Tylenol to manage the pain as needed. She did not know the dose but “generally takes 2 regular strength pills.” She denies any other symptoms.

Social History: The patient states that she always wears her seat belt. She claims that she is a safe driver. Her father was in an accident, so she takes it seriously. The patient does not smoke or do drugs.

Denies any trauma before the car accident. Eyes: The patient does not wear corrective lenses. The patient states that her vision becomes blurry when she reads for extended periods. She says that her dream is worsening. The patient denies eye pain or itching. 

  • Ear: patient denies any ear pain or ringing in the ears.
  • Nose: Patient denies any congestion and sneezing. The patient does not have an allergy to cats and mold that can cause sneezes.
  • Musculoskeletal: The patient denies any muscle pain or weakness anywhere other than her neck. Patient notes possible swelling in the neck but nowhere else.
  • Neurologic: Patient denies any weakness or dizziness. The patient denies fainting. The patient denies any tingling or tremors. The patient notes no changes in the bladder or bowels. The patient denies any changes in concentration or sleep.

Objective

General: Ms. Jones is a pleasant and agreeable 28-year-old African American female. She is dressed nicely and answers questions during the exam fully. She stayed alert the entire time.

Mental Status: confirmed orientation to person, place, and time. Patients could successfully think abstractly and relevantly.

I tested the patient’s attention span with a serial 7 test and she completed it accurately. Patient’s comprehension was evaluated and she was able to follow instructions. Patient could accurately answer general knowledge questions.

The patient’s judgment is intact. Patient’s remote memory, immediate memory, and new learning ability are intact and accurate. Patient’s observed vocabulary was to be expected for the patient’s age and ability, and there were no problems with her articulation or pronunciation.

Cranial Nerves: Olfactory nerve intact as patient could discriminate smell and it was also symmetric bilaterally. Visual acuity: right eye 20/40, left eye 20/20. Fundoscopic exam reveals sharp right disc margin with cotton wool bodies. Left eye had sharp disc margin with no abnormal findings.

Observed pupils with penlight: PEERL. Extraocular eye movements: cardinal fields and convergence revealed no abnormal findings. Facial sensations to dull, soft, and sharp were intact. Skull and facial features were symmetric. The Weber test was normal. Rinne tests normal on both sides. Gag reflex intact. Accessory nerves in the shoulders and neck were tested against resistance with a grade of 5 meaning full range of motion.

Tongue was symmetric with no abnormal findings.

ROS:

  • General: patient denies any fatigue or weakness. Head: patient denies any current headache. patient

Model Documentation

HPI: Ms. Jones presents to the clinic complaining of a headache and neck stiffness that started 2 days after she was in a minor fender bender. One week ago she stated that she was a restrained passenger in an accident in a parking lot and estimated the speed to 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 accompanied by neck ache. She states that she feels as though her neck may be slightly swollen as well.

She did not lose consciousness in the accident and denied changes in level of consciousness since that time. She states that she gets a headache every day that lasts approximately 1-2 hours. She occasionally takes 650 mg of over-the-counter Tylenol for relief of the pain. She denies known associated symptoms.

Review of Systems: General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats.

  • Head: Denies history of trauma before this incident. Denies current headache.
  • Eyes: She does not wear corrective lenses but notes that her vision has worsened over the past few years, but no acute changes. She complains of blurry vision after reading for extended periods. Denies increased tearing or itching: ears refuse hearing loss, tinnitus, vertigo, discharge, or earache.
  • Nose/Sinuses: Denies rhinorrhea. Denies stuffiness, sneezing, itching, previous allergy, epistaxis, or sinus pressure. • Musculoskeletal: Denies muscle weakness, pain, difficulties with a range of motion, joint Instability, or swelling.
  • Neurologic: Denies loss of sensation, numbness, tingling, tremors, weakness, paralysis, fainting, blackouts, or seizures. Denies bowel or bladder dysfunction. Denies changes in concentration, sleep, coordination, and appetite.

Objective

General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress, but appears uncomfortable sitting in an exam chair. She is alert and oriented. She maintains eye contact throughout the interview and examination.

  • Head: Head is normocephalic and atraumatic
  • Eyes: Bilateral eyes with equal hair

Neurologic: Sense of smell intact and symmetric. Left eye vision: 20/20. Right eye vision: 20/40. Left fundoscopic exam reveals sharp disc margins, no hemorrhages. Right fundoscopic exam reveals mild retinopathic changes. Pupils are equal, round, and reactive to light bilaterally.

  • Extraocular movements are intact bilaterally. Normal convergence. Facial sensation intact; facial features and symmetric. Rinne and Weber tested normal Gag reflex intact. Ability to shrug shoulders symmetric; 5 strength against resistance.
  • Neck with full range of motion against resistance; 5 strength against resistance. Tongue symmetric with no abnormal findings. Bilateral upper and lower extremity DTRs equal and 2+ bilaterally. Point-to-point movements are smooth and accurate for finger-to-nose and heel-to- shin.
  • Rapid alternating movements of the upper extremities intact bilaterally. Gait steady with continuous, symmetric steps. Sensation intact to bilateral upper and lower extremities; sense of extremity position intact. Stereognosis and graphesthesia intact bilaterally.