ELECTRONIC HEALTH RECORD (ehr) TINA JONES NEUROLOGICAL EXAM

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Documentation / Electronic Health Record

Document: Provider Notes

Student Documentation Model Documentation

Subjective

HPI: Ms. Jones presents to the clinic complaining of a headache and neck stiffness that begun two days after a minor fender bender. One week ago, she was a restrained passenger in a motor vehicle accident. She and the driver never emergent care after the accident. Two days later, she developed bilateral temporal dull ache and a stiff neck. The headaches last 1-2 hours. He has taken OTC 650mg Tylenol for pain relief. General: No weight changes, fatigue, weaknesses, fever, chills, night sweats. HEENT: no head, ear, eye,

Subjective This is what the patient states. Chief Complaint History of Present Illness (PQRSTU) Neurologic Subjective You should ask about headache, head injury, dizziness/vertigo, seizures, tremors, weakness, incoordination, numbness or tingling, difficulty swallowing, difficulty speaking, patient-centered care (past history), environmental/occupational hazards Past Medical History Hospitalizations/Surgical History Social History Family History Current Medications Allergies Substance Use Physical Activity Diet

Objective

Ms. jones is a pleasant 28 year old African American. While she appears uncomfortable, she is alert, well oreinted, and in no distress. he maintained eye contact in the interview: Head: Normocephalic and atraumatic. Eyes: bilateral with equal hair distribution. Neurologic: Intact sense of smell and symmetric left eye. Vision: 20/20 (left), 20/40 (right),. Results from fundoscopic exam shows sharp disc margin and no hemorrhages while right fundoscopic exam shows mild retinopathic changes. Patient has equal pupils. Rinne and Weber tests normal bilaterally. Neck with full ROM

Objective This is what the nurse observes or assesses. Mental Status See Chapter 5 Mental Health. Cranial Nerves See Chapter 24 Neurologic System for objective assessments below: Cranial Nerves 1-XII Motor System Muscles, Cerebellar Function Sensory System Anterolateral Tract, Posterior Column Tract Reflexes DTRs

Assessment

Acute post-traumatic headache following a low-speed motor vehicle accident where the patient was a restrained passenger.

Assessment This is the main problem/concern/nursing diagnosis. Remember, you are in the role of the RN so you do not have to come up with a medical diagnosis or differentials. Problem, Concern, or Nursing Diagnosis What is the problem? Related to Why do they have this problem? As evidenced by What subjective/objective data shows that they have this problem?

Plan

Enourage patient to continue monitoring her symptoms and report any increase in frequency/severity of headaches. Initiate treatment with Ibuprofen 800mg (orally) with food for next 5 days. Adjunt therapy of topical heat/ice per comfort TID-QID. Educate patient on the need for emergent care For follow up, patient should come back to the clinic after two days to discuss the symptoms and have a CT scan or MRI.

Plan List your SMART goal/goals for the patient and list the interventions the patient may need to address the problem listed in the assessment section.

SMART goal/goals

These should be measurable goals for the patient based on the assessment.

Interventions

This should help to achieve the SMART goal/goals listed. This may include medications, treatments, therapy, education, or referrals.

Objective Data Collection: 35.75 of 37 (96.62%)

  •  Correct
  •  Partially correct
  •  Incorrect
  •  Missed
 Confirmed orientation
1 of 1 point
To Person (1/3 point)
  •  Oriented to person
  •  Not oriented to person
To Place (1/3 point)
  •  Oriented to place
  •  Not oriented to place
To Time (1/3 point)
  •  Oriented to time
  •  Not oriented to time
 Evaluated abstract thinking
1 of 1 point
Abstractness (1/2 point)
  •  Abstract
  •  Concrete
Relevance (1/2 point)
  •  Relevant
  •  Not relevant
 Evaluated attention span
1 of 1 point
Serial 7s Test (1/1 point)
  •  Accurate
  •  Not accurate
 Evaluated comprehension
1 of 1 point
Observations (1/1 point)
  •  Able to follow instructions
  •  Unable to follow instructions
 Evaluated general knowledge
1 of 1 point
Accuracy (1/1 point)
  •  Accurate
  •  Not accurate
 Evaluated judgment
1 of 1 point
Observations (1/1 point)
  •  Intact
  •  Not intact
 Evaluated memory
1 of 1 point
Remote Memory (1/3 point)
  •  Intact
  •  Not intact
Immediate Memory (1/3 point)
  •  Intact
  •  Not intact
New Learning Ability (1/3 point)
  •  Accurate
  •  Not accurate
 Observed vocabulary
1 of 1 point
Complexity (1/1 point)
  •  Expected complex for patient’s age, education level, and general ability
  •  Not expected complexity
 Observed articulation
1 of 1 point
Observations (1/1 point)
  •  No observed problems with pronunciation or expression
  •  Imprecise pronunciation of consonants
  •  Slurring
  •  Hesitation
  •  Stutter
 Tested olfactory nerve
1 of 1 point
Sense Of Smell (1/2 point)
  •  Able to discriminate
  •  Not able to discriminate
Symmetric (1/2 point)
  •  Symmetric bilaterally
  •  Asymmetric
 Tested visual acuity (optic nerve)
1 of 1 point
Right (1/2 point)
  •  20/100
  •  20/70
  •  20/50
  •  20/40
  •  20/30
  •  20/25
  •  20/20
  •  20/15
  •  20/13
  •  20/10
Left (1/2 point)
  •  20/100
  •  20/70
  •  20/50
  •  20/40
  •  20/30
  •  20/25
  •  20/20
  •  20/15
  •  20/13
  •  20/10
 Examined retina with ophthalmoscope (optic nerve)
0.75 of 1 point
Right: Fundus (No point)
  •  No visible abnormal findings
  •  Myelinated nerve fibers
  •  Papilledema
  •  Glaucomatous cupping
  •  Drusen bodies
  •  Cotton wool bodies
  •  Hemorrhage
Right: Disc Margin (1/4 point)
  •  Sharp
  •  Blurred
Left: Fundus (1/4 point)
  •  No visible abnormal findings
  •  Myelinated nerve fibers
  •  Papilledema
  •  Glaucomatous cupping
  •  Drusen bodies
  •  Cotton wool bodies
  •  Hemorrhage
Left: Disc Margin (1/4 point)
  •  Sharp
  •  Blurred
 Inspected pupils (optic and oculomotor nerves)
1 of 1 point
Observations With Penlight (1/1 point)
  •  No visible abnormal findings (PERRL)
  •  Unequal
  •  Irregular
  •  Miosis
  •  Mydriasis
  •  Non-reactive to light
 Tested extraocular eye movements (extraocular movements: oculomotor, trochlear, abducens nerves)
1 of 1 point
Cardinal Fields (1/2 point)
  •  No visible abnormal findings
  •  Nystagmus
  •  Fixed pupil
Convergence (1/2 point)
  •  No visible abnormal findings
  •  Unequal bilaterally
  •  Fixed pupil
 Tested facial sensation (trigeminal nerve)
1 of 1 point
Observations (1/1 point)
  •  Intact
  •  Unable to feel dull stimulus
  •  Unable to feel sharp stimulus
  •  Unable to feel soft stimulus
 Inspected head and face (facial nerve)
1 of 1 point
Skull Symmetry (1/2 point)
  •  Symmetric
  •  Asymmetric
Facial Feature Symmetry (1/2 point)
  •  Symmetric
  •  Asymmetric
 Performed Weber test (auditory nerve)
1 of 1 point
Results (1/1 point)
  •  Normal
  •  Conductive or sensorineural loss
 Performed Rinne test (auditory nerve)
1 of 1 point
Right (1/2 point)
  •  Normal
  •  Conductive loss
Left (1/2 point)
  •  Normal
  •  Conductive loss
 Tested gag reflex (glossopharyngeal, vagus nerves)
1 of 1 point
Observations (1/1 point)
  •  Intact
  •  Absent
  •  Hypersensitive
 Tested shoulder shrugging (accessory nerve)
1 of 1 point
Observations (1/2 point)
  •  Symmetric
  •  Asymmetric
Strength (1/2 point)
  •  0 – No evidence of movement
  •  1 – Trace of movement
  •  2 – Full range of motion with passive movement only
  •  3 – Full range of motion against gravity, with no resistance
  •  4 – Full but weak range of motion against gravity, with some resistance
  •  5 – Full range of motion against gravity, with resistance
 Tested neck strength (accessory nerve)
1 of 1 point
Strength (1/1 point)
  •  0 – No evidence of movement
  •  1 – Trace of movement
  •  2 – Full range of motion with passive movement only
  •  3 – Full range of motion against gravity, with no resistance
  •  4 – Full but weak range of motion against gravity, with some resistance
  •  5 – Full range of motion against gravity, with resistance
 Inspected tongue (hypoglossal nerve)
1 of 1 point
Symmetry (1/2 point)
  •  Symmetric
  •  Asymmetric
Observations (1/2 point)
  •  No visible abnormal findings
  •  Fasciculations
  •  Deviation from midline
  •  Atrophy
 Tested deep tendon reflexes in triceps
1 of 1 point
Right (1/2 point)
  •  0 – No response
  •  1 – Diminished
  •  2 – Expected (active)
  •  3 – Hyperactive
  •  4 – Hyperactive, with clonus
Left (1/2 point)
  •  0 – No response
  •  1 – Diminished
  •  2 – Expected (active)
  •  3 – Hyperactive
  •  4 – Hyperactive, with clonus
 Tested deep tendon reflexes in biceps
1 of 1 point
Right (1/2 point)
  •  0 – No response
  •  1 – Diminished
  •  2 – Expected (active)
  •  3 – Hyperactive
  •  4 – Hyperactive, with clonus
Left (1/2 point)
  •  0 – No response
  •  1 – Diminished
  •  2 – Expected (active)
  •  3 – Hyperactive
  •  4 – Hyperactive, with clonus
 Tested deep tendon reflexes in brachioradialis
1 of 1 point
Right (1/2 point)
  •  0 – No response
  •  1 – Diminished
  •  2 – Expected (active)
  •  3 – Hyperactive
  •  4 – Hyperactive, with clonus
Left (1/2 point)
  •  0 – No response
  •  1 – Diminished
  •  2 – Expected (active)
  •  3 – Hyperactive
  •  4 – Hyperactive, with clonus
 Tested deep tendon reflexes in patellar tendon
1 of 1 point
 Tested deep tendon reflexes in Achilles tendon
1 of 1 point
 Tested point-to-point movements: Finger to nose
1 of 1 point
 Tested point-to-point movements: Heel to shin
1 of 1 point
Right (1/2 point)
  •  Smooth and accurate
  •  Jerky
  •  Inaccurate
Left (1/2 point)
  •  Smooth and accurate
  •  Jerky
  •  Inaccurate
 Tested coordination with rapid alternating hand movements
1 of 1 point
Observations (1/1 point)
  •  Able to perform without difficulty
  •  Performs but with difficulty
  •  Unable to perform
 Observed gait
1 of 1 point
Balance (1/2 point)
  •  Steady
  •  Unsteady
Gait (1/2 point)
  •  Continuous, symmetric steps
  •  Discontinuous steps
  •  Asymmetric steps
  •  Stagger
  •  Swaying
  •  Hesitancy due to injury
  •  Use of arms
 Tested graphesthesia
1 of 1 point
Right (1/2 point)
  •  Able to identify
  •  Unable to identify
Left (1/2 point)
  •  Able to identify
  •  Unable to identify
 Tested sensation in arms
1 of 1 point
Right: Dull Touch (1/6 point)
  •  Expected sensation in proximal and distal
  •  Decreased proximal sensation
  •  Decreased distal sensation
Left: Dull Touch (1/6 point)
  •  Expected sensation in proximal and distal
  •  Decreased proximal sensation
  •  Decreased distal sensation
Right: Soft Touch (1/6 point)
  •  Expected sensation in proximal and distal
  •  Decreased proximal sensation
  •  Decreased distal sensation
Left: Soft Touch (1/6 point)
  •  Expected sensation in proximal and distal
  •  Decreased proximal sensation
  •  Decreased distal sensation
Right: Sharp Touch (1/6 point)
  •  Expected sensation in proximal and distal
  •  Decreased proximal sensation
  •  Decreased distal sensation
Left: Sharp Touch (1/6 point)
  •  Expected sensation in proximal and distal
  •  Decreased proximal sensation
  •  Decreased distal sensation
 Tested sensation in legs
1 of 1 point
Right: Dull Touch (1/6 point)
  •  Expected sensation in proximal and distal
  •  Decreased proximal sensation
  •  Decreased distal sensation
Left: Dull Touch (1/6 point)
  •  Expected sensation in proximal and distal
  •  Decreased proximal sensation
  •  Decreased distal sensation
Right: Soft Touch (1/6 point)
  •  Expected sensation in proximal and distal
  •  Decreased proximal sensation
  •  Decreased distal sensation
Left: Soft Touch (1/6 point)
  •  Expected sensation in proximal and distal
  •  Decreased proximal sensation
  •  Decreased distal sensation
Right: Sharp Touch (1/6 point)
  •  Expected sensation in proximal and distal
  •  Decreased proximal sensation
  •  Decreased distal sensation
Left: Sharp Touch (1/6 point)
  •  Expected sensation in proximal and distal
  •  Decreased proximal sensation
  •  Decreased distal sensation
 Tested sensation in feet
0 of 1 point
Right (No point)
  •  Expected sensation
  •  Decreased sensation
Left (No point)
  •  Expected sensation
  •  Decreased sensation
 Tested position sense
1 of 1 point
Fingers (1/2 point)
  •  Intact
  •  Not intact
Toes (1/2 point)
  •  Intact
  •  Not intact
 Tested stereognosis
1 of 1 point
Right (1/2 point)
  •  Able to identify
  •  Unable to identify
Left (1/2 point)
  •  Able to identify
  •  Unable to identify

Subjective Data Collection: 21 of 21 (100.0%)

Hover To Reveal…

Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.

  • Found:

     Indicates an item that you found.

  • Available:

     Indicates an item that is available to be found.

Category

Scored Items

Experts selected these topics as essential components of a strong, thorough interview with this patient.

Patient Data

Not Scored

A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.

Chief Complaint


  • Finding:

    Established chief complaint


  • Finding:

    Reports recent “fender bender”

    (Found)

    Pro Tip: Patients choose to seek treatment for a variety of reasons. Asking why Tina chose to seek treatment today might indicate primary concerns, the severity of her symptoms, or failure to manage symptoms herself.

    Example Question:

    Why are you seeking treatment today?

  • Finding:

    Reports headaches

    (Found)

    Pro Tip: Symptoms often vary from patient to patient. Asking Tina if she’s had headaches specifies the way her individual symptoms and pain manifest.

    Example Question:

    Have you had any headaches?

  • Finding:

    Reports neck symptoms

    (Found)

    Pro Tip: Symptoms often vary from patient to patient. Asking Tina if she’s had neck stiffness specifies the way her individual symptoms and pain manifest.

    Example Question:

    Have you had any neck stiffness?

History of Present Illness


  • Finding:

    Asked about onset of symptoms


  • Finding:

    Reports accident occurred 1 week ago

    (Found)

    Pro Tip: Soliciting a relevant history of Tina’s car accident will allow you to understand the context in which she was injured and the injuries she sustained.

    Example Question:

    When did the accident happen?

  • Finding:

    Reports symptoms began 2 days after accident

    (Found)

    Pro Tip: Symptoms often vary from patient to patient. Asking Tina when the headaches begin specifies the way her individual symptoms and pain manifest.

    Example Question:

    When did the headaches begin?

  • Finding:

    Followed up on details of car accident


  • Finding:

    Denies loss of consciousness

    (Available)

    Pro Tip: Soliciting a relevant history of Tina’s car accident will allow you to understand the context in which she was injured and the injuries she sustained.

    Example Question:

    Did you lose consciousness during the car accident?

  • Finding:

    Reports low vehicle speed

    (Found)

    Pro Tip: Soliciting a relevant history of Tina’s car accident will allow you to understand the context in which she was injured and the injuries she sustained.

    Example Question:

    How fast was the car going?

  • Finding:

    Reports wearing seatbelt

    (Available)

    Pro Tip: Soliciting a relevant history of Tina’s car accident will allow you to understand the context in which she was injured and the injuries she sustained.

    Example Question:

    Were you wearing your seatbelt?

  • Finding:

    Reports sitting in front passenger seat

    (Available)

    Pro Tip: Soliciting a relevant history of Tina’s car accident will allow you to understand the context in which she was injured and the injuries she sustained.

    Example Question:

    Where in the car were you sitting?

  • Finding:

    Reports no alcohol or drug use during accident

    (Available)

    Pro Tip: Soliciting a relevant history of Tina’s car accident will allow you to understand the context in which she was injured and the injuries she sustained.

    Example Question:

    Was anyone in the car under the influence of alcohol?

  • Finding:

    Asked about frequency and duration of symptoms


  • Finding:

    Reports headaches are daily since they began

    (Found)

    Pro Tip: Symptoms often vary from patient to patient. Asking Tina how often she gets headaches specifies the way her individual symptoms and pain manifest.

    Example Question:

    How many days have you had a headache since they started?

  • Finding:

    Reports headaches last 1-2 hours

    (Available)

    Pro Tip: Symptoms often vary from patient to patient. Asking Tina how long the headaches last specifies the way her individual symptoms and pain manifest.

    Example Question:

    How long do the headaches last?

  • Finding:

    Reports last headache was yesterday afternoon

    (Available)

    Pro Tip: Symptoms often vary from patient to patient. Asking Tina when she got her last headaches specifies the way her individual symptoms and pain manifest.

    Example Question:

    When was your last headache?

  • Finding:

    Asked location of pain


  • Finding:

    Reports headache pain in crown and back of head

    (Found)

    Pro Tip: Because symptoms often vary from patient to patient, asking Tina where her headaches are occurring will allow you to most effectively treat her specific symptoms.

    Example Question:

    Where are the headaches located?

  • Finding:

    Reports pain does not radiate into shoulders, back, or arms

    (Available)

    Pro Tip: Symptoms often vary from patient to patient. Asking Tina to describe what her injury feels like specifies the way her symptoms and pain manifest.

    Example Question:

    Does the pain radiate?

  • Finding:

    Reports slight pain in back of neck muscles

    (Found)

    Pro Tip: Because symptoms often vary from patient to patient, asking Tina how her neck feels will allow you to see the ways in which her individual pain manifests.

    Example Question:

    How does your neck feel?

  • Finding:

    Denies scalp tenderness or injury

    (Available)

    Pro Tip: Symptoms often vary from patient to patient. Asking Tina if her scalp is tender specifies the way her individual symptoms and pain manifest.

    Example Question:

    Is your scalp tender?

  • Finding:

    Denies jaw symptoms

    (Available)

    Pro Tip: Symptoms often vary from patient to patient. Asking Tina if her jaw is tender specifies the way her individual symptoms and pain manifest.

    Example Question:

    Do you have jaw pain?

  • Finding:

    Denies facial pain

    (Available)

    Pro Tip: Symptoms often vary from patient to patient. Asking Tina if she is experiencing facial pain specifies the way her individual symptoms and pain manifest.

    Example Question:

    Do you have any facial pain?

  • Finding:

    Asked about severity of pain


  • Finding:

    Rates current head and neck pain severity at 3 out of 10

    (Available)

    Pro Tip: Pain severity might change over time for a variety of reasons. Asking Tina to rate the severity of her current pain on a scale of 1-10 will provide a quantified and relative measurement of her condition.

    Example Question:

    How would you rate your current pain on a scale from 0 to 10?

  • Finding:

    Rates pain severity at its worst is 4 out of 10

    (Available)

    Pro Tip: Pain severity might change over time for a variety of reasons. Asking Tina to rate the severity of her pain when it started on a scale of 1-10 will provide a quantified and relative measurement of her condition.

    Example Question:

    How would you rate your pain at its worst on a scale from 0 to 10?

  • Finding:

    Followed up on headache characteristics


  • Finding:

    Reports headache pain as a dull ache

    (Found)

    Pro Tip: Symptoms often vary from patient to patient. Asking Tina to describe what her headaches feel like specifies the way her individual symptoms and pain manifest.

    Example Question:

    What do your headaches feel like?

  • Finding:

    Denies sharp pain

    (Available)

    Pro Tip: Because symptoms often vary from patient to patient, asking Tina whether her headaches feel sharp will allow you to most effectively treat her specific symptoms.

    Example Question:

    Is the headache pain sharp?

  • Finding:

    Reports headaches not cyclic

    (Available)

    Pro Tip: By understanding the nature of Tina’s pain, you can most effectively treat her. Asking Tina whether her headaches are cyclic will give you a sense for the extent of her pain.

    Example Question:

    Are your headaches cyclic?

  • Finding:

    Reports headaches do not occur in clusters

    (Available)

    Pro Tip: By understanding the nature of Tina’s pain, you can most effectively treat her. Asking Tina whether her headaches come in clusters will give you a sense for the extent of her pain.

    Example Question:

    Do your headaches come in clusters?

  • Finding:

    Reports headaches not rapid in crescendo

    (Available)

    Pro Tip: By understanding the nature of Tina’s pain, you can most effectively treat her. Asking Tina whether her headaches crescendo will give you a sense for the extent of her pain.

    Example Question:

    Do your headaches crescendo?

  • Finding:

    Asked about aggravating factors


  • Finding:

    Reports that car accident seems to be primary cause

    (Available)

    Pro Tip: It’s important to ask the patient if they know the primary cause of an injury.

    Example Question:

    What caused your pain?

  • Finding:

    Reports pain upon head or neck movement

    (Available)

    Pro Tip: Symptoms often vary from patient to patient. Asking Tina if it hurts to move her head specifies the way her individual symptoms and pain manifest.

    Example Question:

    Does it hurt to move your head?

  • Finding:

    Reports headaches don’t have a discernible trigger

    (Found)

    Pro Tip: Pain severity might change for a variety of reasons. Asking Tina what makes her headaches worse might help you to understand sounds, movements, or times that trigger her pain.

    Example Question:

    What makes your headaches worse?

  • Finding:

    Asked about relieving factors for neck pain and headaches


  • Finding:

    Denies home remedies such as heat or cold

    (Found)

    Pro Tip: Finding out the non-medication modalities that a patient is treating her pain with will help you understand the severity of the pain.

    Example Question:

    Have you tried home remedies?

  • Finding:

    Symptoms improve with rest

    (Available)

    Pro Tip: Understanding all of the relieving factors, including how a symptom changes at motion or at rest, can help you understand all of the contributing pain factors.

    Example Question:

    Does the headache get better with rest?

Medical History


  • Finding:

    Confirmed use of medications


  • Finding:

    Confirms medications (no new medications reported)

    (Found)

    Pro Tip: Determining what, if any, medications a patient is taking is a crucial element of a thorough health history and will help you avoid unwanted drug interactions.

    Example Question:

    Are you taking any new medications?

  • Finding:

    Reports increased Tylenol use

    (Found)

    Pro Tip: The amount of pain medication a patient is taking is an important consideration in understanding their level of pain. For a patient who takes pain medication but still experiences pain, it can indicate higher pain severity than she is reporting.

    Example Question:

    Have you been taking Tylenol?

  • Finding:

    Followed up on Tylenol use


  • Finding:

    Unsure of dosage

    (Found)

    Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina how much tylenol she takes will illustrate how effectively OTC medication works for her injury.

    Example Question:

    What dose of tylenol do you take?

  • Finding:

    Takes 2 Tylenol at a time

    (Available)

    Pro Tip: Asking how many pills a patient takes at once time can help you make sure a patient is not taking an unsafe dose.

    Example Question:

    How many Tylenol do you take at a time?

  • Finding:

    Takes Tylenol once a day

    (Found)

    Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina how often she takes tylenol will illustrate how effectively OTC medication works for her injury.

    Example Question:

    How often do you take tylenol?

  • Finding:

    Reports minor relief from Tylenol

    (Found)

    Pro Tip: Asking Tina if the Tylenol helps will allow you to assess the severity of her headaches and whether her current treatment plan is effective.

    Example Question:

    Does the Tylenol help?

  • Finding:

    Confirmed allergies


  • Finding:

    Confirms allergies (no new allergies reported)

    (Found)

    Pro Tip: Asking Tina if she has any new allergies will allow you to understand how, beyond the chief complaint, Tina’s health has been.

    Example Question:

    Do you have any new allergies?

  • Finding:

    Asked about relevant neurological history


  • Finding:

    Reports past frequent headaches

    (Found)

    Pro Tip: Assessing which of Tina’s pain (if any) is “normal” versus caused by the accident will allow you to understand the scope of her injuries.

    Example Question:

    Do you usually get headaches?

  • Finding:

    Denies history of migraine

    (Available)

    Pro Tip: Assessing which of Tina’s pain (if any) is “normal” versus caused by the accident will allow you to understand the scope of her injuries.

    Example Question:

    Do you ever get migraines?

  • Finding:

    Denies head trauma

    (Available)

    Pro Tip: After Tina’s car accident, it is important to establish whether head trauma she might be experiencing predates the accident or, rather, is a result of the crash.

    Example Question:

    Have you ever had any head trauma?

  • Finding:

    Denies history of seizures

    (Available)

    Pro Tip: A car accident can result in a traumatic brain injury (TBI). Asking Tina if she’s had seizures might indicate whether or not she is experiencing symptoms of a traumatic brain injury.

    Example Question:

    Have you had any seizures?

Social History


  • Finding:

    Asked about sleep


  • Finding:

    Denies changes in sleep

    (Available)

    Pro Tip: A car accident can result in a traumatic brain injury (TBI). Asking Tina if her sleep habits have changed lately might indicate whether she is experiencing symptoms of a traumatic brain injury.

    Example Question:

    Have your sleep habits changed?

  • Finding:

    Denies increased sleepiness or yawning

    (Available)

    Pro Tip: A car accident can result in a traumatic brain injury (TBI). Asking Tina if she’s felt more sleepy lately might indicate whether she is experiencing symptoms of a traumatic brain injury.

    Example Question:

    Have you felt more sleepy lately?

Social Determinants of Health


  • Finding:

    Asked about impact of accident on finances


  • Finding:

    Reports having car insurance

    (Available)

    Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.

    Example Question:

    Do you have car insurance?

  • Finding:

    Denies accident places extra burden on her financially

    (Found)

    Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.

    Example Question:

    Is the car accident going to be a financial burden?

Review of Systems


  • Finding:

    Asked about general symptoms


  • Finding:

    Denies fever

    (Available)

    Pro Tip: Following a head injury, asking Tina whether she’s had a fever might indicate if she’s suffered any additional complications to her neck trauma.

    Example Question:

    Have you had a fever?

  • Finding:

    Denies chills

    (Available)

    Pro Tip: Chills after a car accident might indicate shock. Asking Tina if she’s had any chills will reveal whether or not she’s had shock following her accident.

    Example Question:

    Have you had any chills?

  • Finding:

    Denies fatigue or changes in energy level

    (Available)

    Pro Tip: A car accident can result in a traumatic brain injury (TBI). Asking Tina if she’s felt more fatigued lately might indicate whether she is experiencing symptoms of a traumatic brain injury.

    Example Question:

    Have you felt fatigued?

  • Finding:

    Denies nausea or vomiting

    (Available)

    Pro Tip: One symptom of a concussion is nausea. Asking Tina whether she’s felt nausea might reveal that she sustained a concussion in her car accident.

    Example Question:

    Have you had nausea?

  • Finding:

    Denies night sweats

    (Available)

    Pro Tip: One symptom of a concussion is nausea. Asking Tina whether she’s been vomiting might reveal that she sustained a concussion in her car accident.

    Example Question:

    Have you had night sweats?

  • Finding:

    Asked about review of systems for neurological


  • Finding:

    Denies hemiparesis

    (Available)

    Pro Tip: A car accident can result in muscle damage and feeling weak on one side of the body. Asking Tina whether she feels weak on one side of her body can indicate whether she is suffering from muscle damage.

    Example Question:

    Has one side of your body felt weaker than the other?

  • Finding:

    Denies gait disturbance

    (Available)

    Pro Tip: A car accident can result in muscle damage or nerve damage. Asking Tina whether her gait has changed might indicate a muscle or tissue injury that is impacting the way she walks.

    Example Question:

    Have you had any changes in your gait?

  • Finding:

    Denies body weakness

    (Available)

    Pro Tip: A car accident can result in muscle damage and feeling weakness. Asking Tina whether she feels weak can indicate whether or not she is suffering from muscle damage.

    Example Question:

    Have you felt weak?

  • Finding:

    Denies seeing auras or halos

    (Available)

    Pro Tip: After Tina’s car accident, it is important to establish whether neurological problems she might be experiencing predate the accident or, rather, are a result of the crash. Asking Tina if she’s been seeing auras will indicate whether she’s experiencing a neurological disturbance.

    Example Question:

    Have you experienced any auras?

  • Finding:

    Denies dizziness, light-headedness, syncope, or disequilibrium

    (Available)

    Pro Tip: A car accident can result in a traumatic brain injury (TBI). Asking Tina if she’s felt dizzy might indicate whether she is experiencing symptoms of a traumatic brain injury.

    Example Question:

    Have you felt dizzy?

  • Finding:

    Denies loss of coordination

    (Available)

    Pro Tip: People with traumatic brain injuries commonly report loss of coordination. Asking Tina whether she’s lost coordination can indicate that she suffered a traumatic brain injury during her accident.

    Example Question:

    Have you had any loss of coordination?

  • Finding:

    Denies scotoma

    (Available)

    Pro Tip: People with traumatic brain injuries commonly report scotoma. Asking Tina whether she’s noticed any scotoma can indicate that she suffered a traumatic brain injury during her accident.

    Example Question:

    Have you noticed any scotoma?

  • Finding:

    Denies numbness or tingling

    (Available)

    Pro Tip: Tingling sensations after a car accident can suggest a herniated disc. Asking Tina whether she’s experiencing tingling sensations might indicate additional musculoskeletal damage caused by the accident.

    Example Question:

    Have you had any tingling sensations?

  • Finding:

    Denies facial flushing

    (Available)

    Pro Tip: A prolonged flush face can indicate cerebral compression. Asking Tina whether her face has been flushed will indicate if she is suffering from head trauma.

    Example Question:

    Has your face been flushed?

  • Finding:

    Asked about review of systems for psych and behavioral history


  • Finding:

    Denies depression

    (Available)

    Pro Tip: After an accident, it is not uncommon to feel anxious or depressed. Asking Tina whether she’s felt depressed can indicate long-term concerns following her accident.

    Example Question:

    Have you felt depressed?

  • Finding:

    Denies increased irritability

    (Available)

    Pro Tip: One symptom of a concussion is irritability. Asking Tina whether she’s been irritable might reveal that she sustained a concussion in her car accident.

    Example Question:

    Have you felt more irritable?

  • Finding:

    Denies problems with concentration or memory

    (Available)

    Pro Tip: One symptom of a concussion is problems concentrating. Asking Tina whether she’s been experiencing problems concentrating might reveal that she sustained a concussion in her car accident.

    Example Question:

    Have you had any problems concentrating?

  • Finding:

    Denies confusion

    (Available)

    Pro Tip: One symptom of a concussion is confusion. Asking Tina whether she’s felt confusion might reveal that she sustained a concussion in her car accident.

    Example Question:

    Have you felt confused?

  • Finding:

    Asked about review of systems for eyes and vision


  • Finding:

    Denies changes in vision since accident

    (Found)

    Pro Tip: Eye and vision problems are fairly common after a brain injury. Asking Tina whether her vision changed since her accident might indicate that she sustained a head injury.

    Example Question:

    Has your vision changed since the accident?

  • Finding:

    Reports occasional blurry vision (pre-dating accident)

    (Found)

    Pro Tip:

    Example Question:

    Have you ever had blurry vision?

  • Finding:

    Denies unilateral vision disturbance

    (Available)

    Pro Tip: Eye and vision problems are fairly common after a brain injury. Asking Tina whether she’s had vision problems in just one eye since her accident might indicate that she sustained a head injury.

    Example Question:

    Have you had any vision problems in just one eye?

  • Finding:

    Denies sensitivity to light

    (Available)

    Pro Tip: Eye and vision problems are fairly common after a brain injury. Asking Tina whether she is sensitive to light since her accident might indicate that she sustained a head injury.

    Example Question:

    Are you sensitive to light since the accident?

  • Finding:

    Asked about review of systems for ears, nose, and throat


  • Finding:

    Denies nasal congestion or rhinorrhea

    (Found)

    Pro Tip: Whiplash from Tina’s car accident might result in congestion and sinus problems. Asking Tina if she’s been congested can indicate that she suffered from whiplash during the accident.

    Example Question:

    Have you had any congestion?

  • Finding:

    Denies tinnitus

    (Available)

    Pro Tip: Tinnitus, or hearing ringing, can result from the loudness of a car accident. Asking Tina whether she’s hearing ringing can indicate whether she is suffering from Tinnitus.

    Example Question:

    Have you had ringing in your ears?

  • Finding:

    Denies changes in hearing

    (Available)

    Pro Tip: Sudden Sensorineural Hearing Losses can be associated with head trauma caused by car accidents. Asking Tina if she’s experiencing hearing loss can indicate possible head trauma.

    Example Question:

    Have you had any hearing loss?

  • Finding:

    Denies difficulty swallowing

    (Available)

    Pro Tip: Whiplash from Tina’s car accident might result in damage to the soft tissue of her neck. Asking Tina if she is having trouble swallowing might suggest an injury that she sustained in the crash.

    Example Question:

    Have you had any difficulty swallowing?

Family History


  • Finding:

    Asked about relevant family history


  • Finding:

    Denies family history of migraine

    (Found)

    Pro Tip: Some causes of migraines can be inherited, and so it’s important to understand your patient’s risk level.

    Example Question:

    Is there a history of migraines in your family?

  • Finding:

    Denies family history of epilepsy or seizures

    (Available)

    Pro Tip: Epilepsy or other forms of seizures can be inherited, and so it’s important to understand your patient’s risk level.

    Example Question:

    Do you have a family history of epilepsy?

  • Finding:

    Denies family history of Alzheimer’s disease

    (Available)

    Pro Tip: Conditions like Alzheimer’s disease can be inherited, and so it’s important to understand your patient’s risk level.

    Example Question:

    Do you have a family history of Alzheimer’s disease?

  • Finding:

    Denies family history of Parkinson’s disease

Education & Empathy : 2 of 4 (50.0%)

During the patient interview, there are a number of opportunities to provide patient education and empathy. The opportunities listed below are those identified by nursing experts to be of particular importance to this patient. A Model Statement is provided as an example of an appropriate response to each opportunity.

  • Opportunities marked as Not Encountered are opportunities that were not elicited in the interview
  • Opportunities marked as Not Followed Up are missed opportunities that were present in the interview, but where no statements were made
  • Opportunities marked as Followed Up were followed up by students, and include the dialogue between student and patient
 1 Symptoms
Followed Up

 Description: Tina describes the symptoms that have been bothering her.

This is your avatar.

Tell me about any relevant neurological history.

Question
03:15 AM PDT

Tina Jones

Well, since the accident I’ve had these headaches every day. But before that, I would sometimes get headaches from reading for too long.

This is your avatar.

Do you have regular sleep?

Question
03:15 AM PDT

Tina Jones

After Dad died, I had really bad problems sleeping. But it’s getting better. Yeah, I’d say I’m sleeping okay these days.

This is your avatar.

How long do you sleep?

Question
03:16 AM PDT

Tina Jones

I try to be in bed by eleven or midnight, and I get up at seven or eight.

This is your avatar.

The recommended sleep time is 7-9 hours.

Educate
03:16 AM PDT

Tina Jones

That makes sense.

 Model Statement: “I’m sorry to hear that you were in a car accident, and that you’re experiencing pain and headaches. Because car accidents can cause injury to your head and neck, it’s important that I learn about how the injury happened and your symptoms so that we can determine if you need treatment.”

 2 Cause of Injury
Followed Up

 Description: Tina describes her recent “fender bender.”

This is your avatar.

When did the symptoms start?

Question
03:09 AM PDT

Tina Jones

Well, I was in the car accident a week ago, but the headaches and neck stuff started a few days after that.

This is your avatar.

Sorry to hear you were involved in a car accident.

Empathize
03:10 AM PDT

Tina Jones

Thanks for understanding.

 Model Statement: “I’m sorry. Car accidents can be stressful and scary, even if they are minor. I’m glad you are safe.”

 3 Medications
Not Followed Up

 Description: Tina describes her medication regimen, which includes Tylenol for her symptoms.

This is your avatar.

How do you deal with the neck pain? (Clarified to: How are you coping with your pain?)

Question
03:12 AM PDT

Tina Jones

I’ve been taking Tylenol. And resting helps, too. (Clarified to: how I am coping with my pain)

This is your avatar.

How much Tylenol have you been taking?

Question
03:13 AM PDT

Tina Jones

I take two of the regular strength kind when I feel a headache coming on, but it’s only been once a day.

This is your avatar.

Do you have any allergies?

Question
03:13 AM PDT

Tina Jones

Yeah, I’m allergic to cats.

This is your avatar.

What happens when you are around cats?

Question
03:13 AM PDT

Tina Jones

Whenever I’m around cats, I start sneezing, my eyes get itchy. . . and my asthma starts to act up.

 Model Statement: “Thank you for letting me know about the medications you usually take. I will ask you a few questions about how you’re using each medication.”

 4 Vision
Not Followed Up

 Description: Tina describes her eyecare and vision.

This is your avatar.

How do you cope with vision problems? (Clarified to: Can you tell me about your vision problems?)

Question
03:20 AM PDT

Tina Jones

Well — first off, my vision’s been fine since the car accident. But in general, my vision isn’t that great. Sometimes it gets blurry when I read for a long time. (Clarified to: to tell you about my vision problems)

This is your avatar.

Do you wear glasses?

Question
03:21 AM PDT

Tina Jones

I don’t wear glasses–or contacts.

This is your avatar.

Do you have ear problems?

Question
03:21 AM PDT

Tina Jones

No.

This is your avatar.

Do you have nose problems?

Question
03:21 AM PDT

Tina Jones

No, my nose has been fine.

 Model Statement: “Blurry vision can be a sign of eye strain, or changes to the retina caused by conditions like diabetes. I’d like to examine your eyes to determine what might be causing your vision changes.”

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