Shadow Health Neurological Exam Documentation

Neurological Exam Documentation Document: Provider Notes Student Documentation Model Documentation Subjective 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 states that she was a restrained passenger in an accident in a parking lot and estimates 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 denies 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 with 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 been worsening 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: Denies hearing loss, tinnitus, vertigo, discharge, or Miss Jones is a pleasant 28 year old African American Woman who presents to the clinic with complaints of headaches and neck soreness after getting into a "fender-bender" a week ago. She reports being a front seat passenger in a friend's vehicle when another car rear-ended them at low speed in a grocery store parking lot. She reports wearing a seatbelt and denies loss of consciousness. She states the headaches started two days after the accident, five days ago from today. She Describes headaches as a dull ache in the crown of the head and the back of head, denies any sharp pain. She reports frequency of headaches as everyday for the last five days, typically lasting an hour to two hours. She denies current headache, reports last headache was yesterday afternoon. Denies any cluster headaches, cyclic headaches, or precipitating factors, headaches "seem to happen kind of randomly." She reports taking two regular strength tylenol for headaches and neck pain which has been somewhat effective. She reports symptoms improve with rest, denies using use of home remedies including heat or ice. She reports getting headaches before the accident only when reading or studying for a long time, usually a few times a month. She reports pain in back of neck bilaterally that Student Documentation Model Documentation radiates up into head. She denies any pain that radiates into shoulders, back, or arms. Reports neck pain as constant, rates pain as a 3/10, rates neck pain at its worst as a 4/10. Review of Systems: She denies any scalp tenderness, lacerations, facial pain, or jaw symptoms. She denies any numbness or tingling. She denies any vision changes since the accident or double vision, but reports vision gets blurry when reading a lot, usually for two hours or more, which she has noticed over the past few months. She denies any dizziness, difficulty speaking, or swallowing. She denies any muscle weakness, tremors, problems with balance or coordination.She denies any memory loss, changes in mood or behavior. She denies any history of stroke, meningitis, concussion, or seizure Social History: She denies smoking tobacco, vaping, or any use of illicit drugs, reports history of recreational marijuana use. She reports last drink as a couple weekends ago, typically drinks no more than once or twice a week, no more than 3 beverages in one sitting. She denies family history of headaches or migraines. earache. • Nose/Sinuses: Denies rhinorrhea. Denies stuffiness, sneezing, itching, previous allergy, epistaxis, or sinus pressure. • Musculoskeletal: Denies muscle weakness, pain, difficulties with 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, appetite. Objective Miss Jones is a pleasant, obese 28 year old African American woman in no apparent distress. She is alert and oriented to person, place, and time. She maintains eye contact throughout the interview and examination. She appears wellgroomed, speech is clear and coherent, calm and Cooperative affect. Mental Status: Alert and oriented x3, Head is normocephalic and a traumatic. asbtact thinking intact, thinking both abstract and relevant. Attention span intact, evaluated with serial sevens. Comprehension intact, able to follow one and two step commands. General General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress, but appears uncomfortable while sitting in exam chair. She is alert and oriented. She maintains 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 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 equal, round, and reactive to light bilaterally. Extraocular Student Documentation Model Documentation knowledge and judgement intact. Immediate and remote memory intact, new learning ability intact. Observed vocabulary expected complexity for patients age, education level and general ability. Articulation intact, no problems with pronounciation or expression. Cranial nerves: CN I: Sense of smell intact through both nostrils CN II: Visual acuity intact, PERRL. R eye vision: 20/40, L eye vision: 20/20 Right fundoscopic exam reveals retinopathic changes, Left fundoscopic exam reveals sharp disc margins, no hemorrhages. CN III, IV, VI: EOM's intact bilaterally, normal convergence. CN V: Facial sensation intact to soft, dull and sharp sensation. CN VII: facial features and skull symmetric bilaterally. CN VIII: Rinne and Weber test normal bilaterally CN IX, X: gag reflex intact CN XI: Trapezius muscle 5/5 against resistance bilaterally, neck full range of motion 5/5 R and L against resistance CN XII: Tongue midline, symmetric with no abnormal findings DTRs: bilateral upper and lower extremity deep tendon reflexes equal and 2 + bilaterally Motor Skills: Point-to-point movement smooth and accurate for finger to nose and heel to shin. Rapid alternating movements of the upper extremities intact bilaterally. Gait is steady, no sign of asymmetry or imbalance. Sensory: sensation intact bilaterally to arms and legs. Sensation diminished bilaterally to feet. position sense of fingers and toes intact bilaterally. Stereognosis and graphesthesia intact bilaterally. movements intact bilaterally. Normal convergence. Facial sensation intact; facial features and symmetric. Rinne and Weber tests normal bilaterally. 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 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.