Tina Jones Shadow Health Neurological Results

Tina Jones Shadow Health Neurological Results

Experience Overview

Patient: Tina Jones

Digital Clinical Experience Score

96.4%

This score measures your performance on the Student Performance Index in relation to other students in comparable academic programs. Your instructor has chosen to scale your Student Performance Index score so that the average score on the index is a 87.0%. This score may not be your final grade if your instructor chooses to include additional components, such as documentation or time spent.

Student Performance Index

59.75  out of 62

Proficiency Level:

Proficient

• Beginning
• Developing
• Proficient

Students rated as “proficient” demonstrate an entry-level expertise in advanced practice competencies and clinical reasoning skills. In comparable programs, the top 25% of students perform at the level of a proficient practitioner.

Subjective Data Collection

21 

out of

21

Objective Data Collection

36.75 

out of

37

Education and Empathy

2 

out of

4

Time

64 minutes total spent in assignment

Interaction with patient

64 minutes

 

Transcript

Started: Apr 27, 2025 | Total Time: 64 min

All Lines (179)Interview Questions (51)Statements (1)Exam Actions (127)

	Hello, my name is Mileidy. I will be your nurse today	Greet 04/27/25 5:55 AM EDT
	Hey.
	What brings you here today?	Question 04/27/25 5:56 AM EDT
	Well, I got into a little fender bender a week ago and I’ve been getting these headaches ever since. And my neck is sore too.
	I am sorry for that	Empathize 04/27/25 5:56 AM EDT
	Thanks for understanding.
	When did the symptoms start?	Question 04/27/25 5:56 AM EDT
	Well, I was in the car accident a week ago, but the headaches and neck stuff started a few days after that.
	Were you wearing seatbelts?	Question 04/27/25 5:57 AM EDT
	Yes, I always do.
	How is the frequency and duration of the symptoms?	Question 04/27/25 5:57 AM EDT
	I’ve had a headache just about once a day since a couple days after my accident. Once I feel it coming on, I take something for it and it pretty much goes away for the day.
	Where is the pain located?	Question 04/27/25 5:58 AM EDT
	It’s really just been the headaches, but my neck is sore, too.
	How severe is the pain?	Question 04/27/25 5:58 AM EDT
	I’ve had worse, but the headaches have gotten bad enough to stop me from what I was doing a couple times.
	How does the headache feels like?	Question 04/27/25 5:58 AM EDT
	The headaches feel like a dull ache, kind of in the crown of my head, and the back of my head.
	What makes the pain worse?	Question 04/27/25 5:59 AM EDT
	I can’t tell if anything makes it worse. It just seems to come and go.
	What relieves the pain?	Question 04/27/25 5:59 AM EDT
	Acetaminophen helps a little. [AUDIO COMING SOON]
	Have you used any medication? (Clarified to Have you been taking any medication?.)	Question 04/27/25 5:59 AM EDT
	Just some acetaminophen for my headaches and my neck. And I use my daily inhaler, too. [AUDIO COMING SOON] (Clarified to if I have been taking any medication.)
	Do you have any allergies?	Question 04/27/25 6:00 AM EDT
	Yeah, I’m allergic to cats.
	Do you have a history of headaches?	Question 04/27/25 6:00 AM EDT
	Yeah, I’ve been getting headaches.
	Do you have a history of migraine?	Question 04/27/25 6:01 AM EDT
	No, I’m pretty sure my headaches aren’t migraines.
	How is your sleep pattern?	Question 04/27/25 6:01 AM EDT
	I try to be in bed by eleven or midnight, and I get up at seven or eight.
	How has the accident affected your finances?	Question 04/27/25 6:02 AM EDT
	My friend was the one driving, so it was their car that got hit. Thankfully, I don’t have to deal with the repairs. [AUDIO COMING SOON]
	Do you have any fever?	Question 04/27/25 6:02 AM EDT
	No.
	Do you have any neurological issue?	Question 04/27/25 6:02 AM EDT
	I don’t think so.
	Do you have stress?	Question 04/27/25 6:03 AM EDT
	I haven’t been particularly stressed lately.
	Do you have depression?	Question 04/27/25 6:03 AM EDT
	No, I’ve been fine.
	How is your vision?	Question 04/27/25 6:03 AM EDT
	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.
	Do you have nasal congestion?	Question 04/27/25 6:04 AM EDT
	No, I haven’t been congested.
	Do you have a family history of migraine?	Question 04/27/25 6:04 AM EDT
	I don’t think so.
	What is your name and date of birth?	Question 04/27/25 6:05 AM EDT
	My name is Tina Jones, and I was born on February 17th.
	Evaluated orientation to person	Exam Action 04/27/25 6:05 AM EDT
	What building are you in now?	Question 04/27/25 6:05 AM EDT
	I’m at the doctor’s office. . . it’s Shadow Health General Clinic.
	Evaluated orientation to place	Exam Action 04/27/25 6:05 AM EDT
	What us the date and year	Question 04/27/25 6:06 AM EDT
	Um, today’s date is . . . [Ms. Jones reports correct date and year].
	Evaluated orientation to time	Exam Action 04/27/25 6:06 AM EDT
	How are apples and oranges alike?	Question 04/27/25 6:06 AM EDT
	How are they alike? Um…. they’re both kinds of fruit.
	Evaluated abstract thinking: similarities among fruit	Exam Action 04/27/25 6:06 AM EDT
	How are a lake and an ocean alike?	Question 04/27/25 6:06 AM EDT
	Uh…. they’re both bodies of water.
	Evaluated abstract thinking: similarities among bodies of water	Exam Action 04/27/25 6:07 AM EDT
	How are a trumpet and a flute alike?	Question 04/27/25 6:07 AM EDT
	They…… they’re both musical instruments.
	Evaluated abstract thinking: similarities among instruments	Exam Action 04/27/25 6:07 AM EDT
	count backwards by 7s from 100	Question 04/27/25 6:09 AM EDT
	Okay. . . 100, 93. . . 86, 79, 72. . . 65. . . 58, 51. . . 44. . . 37, 30, 23, 16. . . 9, and 2.
	Evaluated attention with serial sevens	Exam Action 04/27/25 6:09 AM EDT
	Read and follow these instructions?	Question 04/27/25 6:10 AM EDT
	Established one-stage comprehension	Exam Action 04/27/25 6:10 AM EDT
	Read and follow these instructions	Question 04/27/25 6:10 AM EDT
	Established two-stage comprehension	Exam Action 04/27/25 6:10 AM EDT
	Who was the first president of the united states?	Question 04/27/25 6:10 AM EDT
	That’s George Washington.
	Evaluated knowledge of first president	Exam Action 04/27/25 6:11 AM EDT
	Who are the last four presidents of the united states?	Question 04/27/25 6:11 AM EDT
	Well,.. .[Ms. Jones reports the correct last four presidents.]
	Evaluated knowledge of last four presidents	Exam Action 04/27/25 6:11 AM EDT
	Name five large cities in the united states?	Question 04/27/25 6:11 AM EDT
	Let’s see. . . New York City. . . and Chicago. . . Detroit. . . Los Angeles. . . and Houston. That’s five.
	Evaluated knowledge of five large cities	Exam Action 04/27/25 6:12 AM EDT
	what would you do if you found a stamped and addressed envelope on the sidewalk?	Question 04/27/25 6:12 AM EDT
	What would I do…. Hmm.. Well, I’d try to figure out who dropped the envelope, but if not… Well, I’d probably just drop it in the first mailbox I saw, if there was one nearby.
	Evaluated judgment	Exam Action 04/27/25 6:13 AM EDT
	Repeat and remember burger, tulip, nose, and tea	Question 04/27/25 6:13 AM EDT
	Burger, tulip, nose, and tea.
	Evaluated immediate memory	Exam Action 04/27/25 6:13 AM EDT
	Observed patient’s general vocabulary	Exam Action 04/27/25 6:13 AM EDT
	Observed patient’s general ability to articulate	Exam Action 04/27/25 6:13 AM EDT
	Tested CN I (olfactory nerve) with smell test	Exam Action 04/27/25 6:14 AM EDT
	E D E O X F
	P E C F D
	Tested visual acuity of right eye	Exam Action 04/27/25 6:14 AM EDT
	P E C F D
	E D F C Z P
	F E L O P Z D
	D E F P O T E C
	Tested visual acuity of left eye	Exam Action 04/27/25 6:15 AM EDT
	D E F P O T E C
	Tested visual acuity of both eyes	Exam Action 04/27/25 6:15 AM EDT
	I can’t read that line. It’s too little.
	Inspected fundus of right eye	Exam Action 04/27/25 6:16 AM EDT
	Inspected fundus of left eye	Exam Action 04/27/25 6:16 AM EDT
	Inspected left pupil and tested left pupillary light reflex	Exam Action 04/27/25 6:16 AM EDT
	Inspected right pupil and tested pupillary light reflex	Exam Action 04/27/25 6:16 AM EDT
	Follow my finger with just your eyes	Question 04/27/25 6:17 AM EDT
	Ok.
	Tested EOM to the upper left	Exam Action 04/27/25 6:17 AM EDT
	Tested EOM to the upper center	Exam Action 04/27/25 6:17 AM EDT
	Tested EOM to the upper right	Exam Action 04/27/25 6:17 AM EDT
	Tested convergence	Exam Action 04/27/25 6:17 AM EDT
	Tested EOM to the lower left	Exam Action 04/27/25 6:17 AM EDT
	Tested EOM to the lower center	Exam Action 04/27/25 6:17 AM EDT
	Tested EOM to the lower right	Exam Action 04/27/25 6:17 AM EDT
	Close your eyes and tell me if the touch is sharp, dull or soft	Question 04/27/25 6:18 AM EDT
	Ok.
	Tested facial sensation: dull stimulus	Exam Action 04/27/25 6:18 AM EDT
	Dull.
	Tested facial sensation: dull stimulus	Exam Action 04/27/25 6:18 AM EDT
	Dull.
	Tested facial sensation: dull stimulus	Exam Action 04/27/25 6:18 AM EDT
	Dull.
	Tested facial sensation: dull stimulus	Exam Action 04/27/25 6:18 AM EDT
	Dull.
	Tested facial sensation: soft stimulus	Exam Action 04/27/25 6:18 AM EDT
	Soft.
	Tested facial sensation: soft stimulus	Exam Action 04/27/25 6:18 AM EDT
	Soft.
	Tested facial sensation: soft stimulus	Exam Action 04/27/25 6:18 AM EDT
	Soft.
	Tested facial sensation: soft stimulus	Exam Action 04/27/25 6:18 AM EDT
	Soft.
	Tested facial sensation: sharp stimulus	Exam Action 04/27/25 6:18 AM EDT
	Sharp.
	Tested facial sensation: sharp stimulus	Exam Action 04/27/25 6:18 AM EDT
	Sharp.
	Tested facial sensation: sharp stimulus	Exam Action 04/27/25 6:18 AM EDT
	Sharp.
	Tested facial sensation: sharp stimulus	Exam Action 04/27/25 6:18 AM EDT
	Sharp.
	Inspected front of face for asymmetry and facial droop	Exam Action 04/27/25 6:18 AM EDT
	Inspected right side of face for asymmetry and facial droop	Exam Action 04/27/25 6:18 AM EDT
	Inspected back of head for asymmetry	Exam Action 04/27/25 6:18 AM EDT
	Inspected right side of face for asymmetry and facial droop	Exam Action 04/27/25 6:19 AM EDT
	Inspected front of face for asymmetry and facial droop	Exam Action 04/27/25 6:19 AM EDT
	Inspected left side of face for asymmetry and facial droop	Exam Action 04/27/25 6:19 AM EDT
	Inspected front of face for asymmetry and facial droop	Exam Action 04/27/25 6:19 AM EDT
	Inspected left side of face for asymmetry and facial droop	Exam Action 04/27/25 6:19 AM EDT
	Inspected back of head for asymmetry	Exam Action 04/27/25 6:19 AM EDT
	Inspected left side of face for asymmetry and facial droop	Exam Action 04/27/25 6:19 AM EDT
	Inspected front of face for asymmetry and facial droop	Exam Action 04/27/25 6:19 AM EDT
	is the volume the same in both ears or louder in one ear	Question 04/27/25 6:19 AM EDT
	Ok.
	Same in both ears.
	Performed Weber test with tuning fork	Exam Action 04/27/25 6:19 AM EDT
	Tell me when you no longer hear rhe ringing	Question 04/27/25 6:20 AM EDT
	Ok, I will.
	Now.
	Performed Rinne test on right side with tuning fork	Exam Action 04/27/25 6:21 AM EDT
	Now.
	Now.
	Now.
	Performed Rinne test on left side with tuning fork	Exam Action 04/27/25 6:21 AM EDT
	Tell me when you no longer hear rhe ringing	Question 04/27/25 6:21 AM EDT
	Ok, I will.
	Now.
	Performed Rinne test on left side with tuning fork	Exam Action 04/27/25 6:22 AM EDT
	Now.
	Now.
	Now.
	Performed Rinne test on right side with tuning fork	Exam Action 04/27/25 6:23 AM EDT
	Tested gag reflex	Exam Action 04/27/25 6:23 AM EDT
	Tested trapezius muscle strength against resistance: 5 strength against resistance	Exam Action 04/27/25 6:23 AM EDT
	Tested sternocleidomastoid muscle strength against resistance – head turned to the right: 5 strength against resistance	Exam Action 04/27/25 6:23 AM EDT
	Tested sternocleidomastoid muscle strength against resistance – head turned to the left: 5 strength against resistance	Exam Action 04/27/25 6:24 AM EDT
	Inspected mouth	Exam Action 04/27/25 6:24 AM EDT
	Inspected mouth: pushed tongue left with tongue blade	Exam Action 04/27/25 6:24 AM EDT
	Inspect mouth: pushed tongue right with tongue blade	Exam Action 04/27/25 6:24 AM EDT
	Inspect mouth: lifted tongue with tongue blade	Exam Action 04/27/25 6:24 AM EDT
	Inspected mouth: depressed tongue with tongue blade	Exam Action 04/27/25 6:24 AM EDT
	Tested reflexes of right triceps: 2+	Exam Action 04/27/25 6:25 AM EDT
	Tested reflexes of left triceps: 2+	Exam Action 04/27/25 6:25 AM EDT
	Tested reflexes of right biceps: 2+	Exam Action 04/27/25 6:25 AM EDT
	Tested reflexes of left biceps: 2+	Exam Action 04/27/25 6:25 AM EDT
	Tested reflexes of right brachioradialis: 2+	Exam Action 04/27/25 6:25 AM EDT
	Tested reflexes of left brachioradialis: 2+	Exam Action 04/27/25 6:25 AM EDT
	Tested reflexes of right patellar tendon: 2+	Exam Action 04/27/25 6:26 AM EDT
	Tested reflexes of left patellar tendon: 2+	Exam Action 04/27/25 6:26 AM EDT
	Tested reflexes of right achilles tendon: 2+	Exam Action 04/27/25 6:26 AM EDT
	close your eyes and touch your fingers to your nose	Question 04/27/25 6:26 AM EDT
	I can do that.
	Observed left index finger to nose	Exam Action 04/27/25 6:27 AM EDT
	Observed right index finger to nose	Exam Action 04/27/25 6:27 AM EDT
	run your right foot down your shin	Question 04/27/25 6:27 AM EDT
	Sure.
	Observed right heel moving to shin	Exam Action 04/27/25 6:27 AM EDT
	run your left foot down your right shin	Question 04/27/25 6:28 AM EDT
	Ok.
	Observed left heel moving to shin	Exam Action 04/27/25 6:28 AM EDT
	place your hands on your knees and turn them over	Question 04/27/25 6:28 AM EDT
	Ok, like this?
	Observed rapid alternating hand movements: Movement is smooth, performed without difficulty	Exam Action 04/27/25 6:28 AM EDT
	Observed patient’s gait	Exam Action 04/27/25 6:28 AM EDT
	close your eyes and tell me what I trace on your palm	Question 04/27/25 6:29 AM EDT
	Ok.
	That’s an “A.”
	Tested left-hand graphesthesia by letter identification	Exam Action 04/27/25 6:29 AM EDT
	A figure “8.”
	Tested right-hand graphesthesia by number identification	Exam Action 04/27/25 6:29 AM EDT
	close your eyes and tell me if the touch is sharp, dull or soft	Question 04/27/25 6:30 AM EDT
	Ok.
	Tested right arm proximal dull sensation	Exam Action 04/27/25 6:30 AM EDT
	Dull.
	Tested right arm distal dull sensation	Exam Action 04/27/25 6:30 AM EDT
	Dull.
	Tested left arm proximal dull sensation	Exam Action 04/27/25 6:30 AM EDT
	Dull.
	Tested left arm distal dull sensation	Exam Action 04/27/25 6:30 AM EDT
	Dull.
	Tested right arm proximal soft sensation	Exam Action 04/27/25 6:30 AM EDT
	Soft.
	Tested right arm distal soft sensation	Exam Action 04/27/25 6:30 AM EDT
	Soft.
	Tested left arm proximal soft sensation	Exam Action 04/27/25 6:30 AM EDT
	Soft.
	Tested left arm distal soft sensation	Exam Action 04/27/25 6:30 AM EDT
	Soft.
	Tested right arm proximal sharp sensation	Exam Action 04/27/25 6:30 AM EDT
	Sharp.
	Tested right arm distal sharp sensation	Exam Action 04/27/25 6:30 AM EDT
	Sharp.
	Tested left arm proximal sharp sensation	Exam Action 04/27/25 6:30 AM EDT
	Sharp.
	Tested left arm distal sharp sensation	Exam Action 04/27/25 6:30 AM EDT
	Sharp.
	close your eyes and tell me if the touch is sharp, dull or soft	Question 04/27/25 6:31 AM EDT
	Ok.
	Tested right leg proximal dull sensation	Exam Action 04/27/25 6:31 AM EDT
	Dull.
	Tested right leg distal dull sensation	Exam Action 04/27/25 6:31 AM EDT
	Dull.
	Tested left leg proximal dull sensation	Exam Action 04/27/25 6:31 AM EDT
	Dull.
	Tested left leg distal dull sensation	Exam Action 04/27/25 6:31 AM EDT
	Dull.
	Tested right leg proximal light sensation	Exam Action 04/27/25 6:31 AM EDT
	Soft.
	Tested right leg distal light sensation	Exam Action 04/27/25 6:31 AM EDT
	Soft.
	Tested left leg proximal light sensation	Exam Action 04/27/25 6:31 AM EDT
	Soft.
	Tested left leg distal light sensation	Exam Action 04/27/25 6:31 AM EDT
	Soft.
	Tested right leg proximal sharp sensation	Exam Action 04/27/25 6:31 AM EDT
	Sharp.
	Tested right leg distal sharp sensation	Exam Action 04/27/25 6:31 AM EDT
	Sharp.
	Tested left leg proximal sharp sensation	Exam Action 04/27/25 6:31 AM EDT
	Sharp.
	Tested left leg distal sharp sensation	Exam Action 04/27/25 6:31 AM EDT
	Sharp.
	close your eyes and tell me when you feel the touch	Question 04/27/25 6:32 AM EDT
	Ok, I will.
	Tested sensation of right big toe with monofilament	Exam Action 04/27/25 6:32 AM EDT
	Tested sensation of left big toe with monofilament	Exam Action 04/27/25 6:32 AM EDT
	Tested sensation of left ball of foot under big toe with monofilament	Exam Action 04/27/25 6:32 AM EDT
	Tested sensation of right ball of foot under big toe with monofilament	Exam Action 04/27/25 6:32 AM EDT
	Yes.
	Tested sensation of right ball of foot under small toe with monofilament	Exam Action 04/27/25 6:32 AM EDT
	Tested sensation of right heel with monofilament	Exam Action 04/27/25 6:32 AM EDT
	Yes.
	Tested sensation of left heel with monofilament	Exam Action 04/27/25 6:32 AM EDT
	Yes.
	Tested sensation of left ball of foot under small toe with monofilament	Exam Action 04/27/25 6:32 AM EDT
	close your eyes and tell me if your finger or toe moves up or down	Question 04/27/25 6:33 AM EDT
	Ok, I will.
	Down.
	Tested position sense of finger on right hand	Exam Action 04/27/25 6:33 AM EDT
	Up.
	Tested position sense of finger on left hand	Exam Action 04/27/25 6:33 AM EDT
	…I think that was up.
	Tested position sense of toe on right foot	Exam Action 04/27/25 6:33 AM EDT
	Down.
	Tested position sense of toe on left foot	Exam Action 04/27/25 6:34 AM EDT
	close your eyes and tell me what I put in your hand	Question 04/27/25 6:34 AM EDT
	Ok, sure.
	Tested right-hand stereognosis with coin	Exam Action 04/27/25 6:34 AM EDT
	…Some kind of coin.
	This is… some wire thing… paperclip?
	Tested right-hand stereognosis with paper clip	Exam Action 04/27/25 6:34 AM EDT
	Um… that feels like a key.
	Tested right-hand stereognosis with key	Exam Action 04/27/25 6:35 AM EDT
	…Some kind of coin.
	Tested left-hand stereognosis with coin	Exam Action 04/27/25 6:35 AM EDT
	Tested left-hand stereognosis with paper clip	Exam Action 04/27/25 6:35 AM EDT
	The paperclip again.
	Um… that feels like a key.
	Tested left-hand stereognosis with key	Exam Action 04/27/25 6:35 AM EDT

 

 

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

(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:

How fast was the car going?

Finding:

Reports wearing seatbelt

(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:

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

(Available)

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 acetaminophen 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 acetaminophen?

Finding:

Followed up on acetaminophen use

Finding:

Unsure of dosage

(Available)

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

Example Question:

What dose of acetaminophen do you take?

Finding:

Takes 2 acetaminophen 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 much acetaminophen do you take at a time?

Finding:

Takes acetaminophen once a day

(Available)

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

Example Question:

How often do you take acetaminophen?

Finding:

Reports minor relief from acetaminophen

(Found)

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

Example Question:

Does acetaminophen 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

(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 usually get headaches?

Finding:

Denies history of migraine

(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 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

(Found)

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

(Found)

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

 

Objective Data Collection: 36.75 of 37 (99.32%)

•  Correct
•  Partially correct

•  Incorrect
•  Missed

 Confirmed orientation

1 of 1 point

 

To Person (1/3 point)

•  Oriented to person

To Place (1/3 point)

•  Oriented to place

To Time (1/3 point)

•  Oriented to time

 Evaluated abstract thinking

1 of 1 point

 

Abstractness (1/2 point)

•  Abstract

Relevance (1/2 point)

•  Relevant

 Evaluated attention span

1 of 1 point

 

Serial 7s Test (1/1 point)

•  Accurate

 Evaluated comprehension

1 of 1 point

 

Observations (1/1 point)

•  Able to follow instructions

 Evaluated general knowledge

1 of 1 point

 

Accuracy (1/1 point)

•  Accurate

 Evaluated judgment

1 of 1 point

 

Observations (1/1 point)

•  Intact

 Evaluated memory

1 of 1 point

 

Remote Memory (1/3 point)

•  Intact

Immediate Memory (1/3 point)

•  Intact

New Learning Ability (1/3 point)

•  Accurate

 Observed vocabulary

1 of 1 point

 

Complexity (1/1 point)

•  Expected complex for patient’s age, education level, and general ability

 Observed articulation

1 of 1 point

 

Observations (1/1 point)

•  No observed problems with pronunciation or expression

 Tested olfactory nerve

1 of 1 point

 

Sense Of Smell (1/2 point)

•  Able to discriminate

Symmetric (1/2 point)

•  Symmetric bilaterally

 Tested visual acuity (optic nerve)

1 of 1 point

 

Right (1/2 point)

•  20/40

Left (1/2 point)

•  20/20

 Examined retina with ophthalmoscope (optic nerve)

0.75 of 1 point

 

Right: Fundus (1/4 point)

•  Cotton wool bodies

Right: Disc Margin (1/4 point)

•  Sharp

Left: Fundus (1/4 point)

•  No visible abnormal findings

Left: Disc Margin (1/4 point)

•  Sharp

 Inspected pupils (optic and oculomotor nerves)

1 of 1 point

 

Observations With Penlight (1/1 point)

•  No visible abnormal findings (PERRL)

 Tested extraocular eye movements (extraocular movements: oculomotor, trochlear, abducens nerves)

1 of 1 point

 

Cardinal Fields (1/2 point)

•  No visible abnormal findings

Convergence (1/2 point)

•  No visible abnormal findings

 Tested facial sensation (trigeminal nerve)

1 of 1 point

 

Observations (1/1 point)

•  Intact

 Inspected head and face (facial nerve)

1 of 1 point

 

Skull Symmetry (1/2 point)

•  Symmetric

Facial Feature Symmetry (1/2 point)

•  Symmetric

 Performed Weber test (auditory nerve)

1 of 1 point

 

Results (1/1 point)

•  Normal

 Performed Rinne test (auditory nerve)

1 of 1 point

 

Right (1/2 point)

•  Normal

Left (1/2 point)

•  Normal

 Tested gag reflex (glossopharyngeal, vagus nerves)

1 of 1 point

 

Observations (1/1 point)

•  Intact

 Tested shoulder shrugging (accessory nerve)

1 of 1 point

 

Observations (1/2 point)

•  Symmetric

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)

•  5 – Full range of motion against gravity, with resistance

 Inspected tongue (hypoglossal nerve)

1 of 1 point

 

Symmetry (1/2 point)

•  Symmetric

Observations (1/2 point)

•  No visible abnormal findings

 Tested deep tendon reflexes in triceps

1 of 1 point

 

Right (1/2 point)

•  2 – Expected (active)

Left (1/2 point)

•  2 – Expected (active)

 Tested deep tendon reflexes in biceps

1 of 1 point

 

Right (1/2 point)

•  2 – Expected (active)

Left (1/2 point)

•  2 – Expected (active)

 Tested deep tendon reflexes in brachioradialis

1 of 1 point

 

Right (1/2 point)

•  2 – Expected (active)

Left (1/2 point)

•  2 – Expected (active)

 Tested deep tendon reflexes in patellar tendon

1 of 1 point

 

Right (1/2 point)

•  2 – Expected (active)

Left (1/2 point)

•  2 – Expected (active)

 Tested deep tendon reflexes in Achilles tendon

1 of 1 point

 

Right (1/2 point)

•  2 – Expected (active)

Left (1/2 point)

•  2 – Expected (active)

 Tested point-to-point movements: Finger to nose

1 of 1 point

 

Right (1/2 point)

•  Smooth and accurate

Left (1/2 point)

•  Smooth and accurate

 Tested point-to-point movements: Heel to shin

1 of 1 point

 

Right (1/2 point)

•  Smooth and accurate

Left (1/2 point)

•  Smooth and accurate

 Tested coordination with rapid alternating hand movements

1 of 1 point

 

Observations (1/1 point)

•  Able to perform without difficulty

 Observed gait

1 of 1 point

 

Balance (1/2 point)

•  Steady

Gait (1/2 point)

•  Continuous, symmetric steps

 Tested graphesthesia

1 of 1 point

 

Right (1/2 point)

•  Able to identify

Left (1/2 point)

•  Able to identify

 Tested sensation in arms

1 of 1 point

 

Right: Dull Touch (1/6 point)

•  Expected sensation in proximal and distal

Left: Dull Touch (1/6 point)

•  Expected sensation in proximal and distal

Right: Soft Touch (1/6 point)

•  Expected sensation in proximal and distal

Left: Soft Touch (1/6 point)

•  Expected sensation in proximal and distal
•  Right: Sharp Touch (1/6 point)

•  Expected sensation in proximal and distal

Left: Sharp Touch (1/6 point)

•  Expected sensation in proximal and distal

 Tested sensation in legs

1 of 1 point

 

Right: Dull Touch (1/6 point)

•  Expected sensation in proximal and distal

Left: Dull Touch (1/6 point)

•  Expected sensation in proximal and distal

Right: Soft Touch (1/6 point)

•  Expected sensation in proximal and distal

Left: Soft Touch (1/6 point)

•  Expected sensation in proximal and distal

Right: Sharp Touch (1/6 point)

•  Expected sensation in proximal and distal

Left: Sharp Touch (1/6 point)

•  Expected sensation in proximal and distal

 Tested sensation in feet

1 of 1 point

 

Right (1/2 point)

•  Decreased sensation

Left (1/2 point)

•  Decreased sensation

 Tested position sense

1 of 1 point

 

Fingers (1/2 point)

•  Intact

Toes (1/2 point)

•  Intact

 Tested stereognosis

1 of 1 point

 

Right (1/2 point)

•  Able to identify

Left (1/2 point)

•  Able to identify

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.
	What brings you here today?	Question 05:56 AM EDT
	Well, I got into a little fender bender a week ago and I’ve been getting these headaches ever since. And my neck is sore too.
	I am sorry for that	Empathize 05:56 AM EDT
	Thanks for understanding.
	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.”
	What brings you here today?	Question 05:56 AM EDT
	Well, I got into a little fender bender a week ago and I’ve been getting these headaches ever since. And my neck is sore too.
	I am sorry for that	Empathize 05:56 AM EDT
	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.
	What relieves the pain?	Question 05:59 AM EDT
	Acetaminophen helps a little. [AUDIO COMING SOON]
	Have you used any medication? (Clarified to: Have you been taking any medication?)	Question 05:59 AM EDT
	Just some acetaminophen for my headaches and my neck. And I use my daily inhaler, too. [AUDIO COMING SOON] (Clarified to: if I have been taking any medication)
	Do you have any allergies?	Question 06:00 AM EDT
	Yeah, I’m allergic to cats.
	Do you have a history of headaches?	Question 06:00 AM EDT
	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.
	How is your vision?	Question 06:03 AM EDT
	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.
	Do you have nasal congestion?	Question 06:04 AM EDT
	No, I haven’t been congested.
	Do you have a family history of migraine?	Question 06:04 AM EDT
	I don’t think so.
	My name is Tina Jones, and I was born on February 17th.
	I’m at the doctor’s office. . . it’s Shadow Health General Clinic.
	Um, today’s date is . . . [Ms. Jones reports correct date and year].
	How are they alike? Um…. they’re both kinds of fruit.
	Uh…. they’re both bodies of water.
	They…… they’re both musical instruments.
	Okay. . . 100, 93. . . 86, 79, 72. . . 65. . . 58, 51. . . 44. . . 37, 30, 23, 16. . . 9, and 2.
	That’s George Washington.
	Well,.. .[Ms. Jones reports the correct last four presidents.]
	Let’s see. . . New York City. . . and Chicago. . . Detroit. . . Los Angeles. . . and Houston. That’s five.
	What would I do…. Hmm.. Well, I’d try to figure out who dropped the envelope, but if not… Well, I’d probably just drop it in the first mailbox I saw, if there was one nearby.
	Burger, tulip, nose, and tea.
	E D E O X F
	P E C F D
	P E C F D
	E D F C Z P
	F E L O P Z D
	D E F P O T E C
	D E F P O T E C
	I can’t read that line. It’s too little.
	Ok.
	Ok.
	Dull.
	Dull.
	Dull.
	Dull.
	Soft.
	Soft.
	Soft.
	Soft.
	Sharp.
	Sharp.
	Sharp.
	Sharp.
	Ok.
	Same in both ears.
	Ok, I will.
	Now.
	Now.
	Now.
	Now.
	Ok, I will.
	Now.
	Now.
	Now.
	Now.
	I can do that.
	Sure.
	Ok.
	Ok, like this?
	Ok.
	That’s an “A.”
	A figure “8.”
	Ok.
	Dull.
	Dull.
	Dull.
	Dull.
	Soft.
	Soft.
	Soft.
	Soft.
	Sharp.
	Sharp.
	Sharp.
	Sharp.
	Ok.
	Dull.
	Dull.
	Dull.
	Dull.
	Soft.
	Soft.
	Soft.
	Soft.
	Sharp.
	Sharp.
	Sharp.
	Sharp.
	Ok, I will.
	Yes.
	Yes.
	Yes.
	Ok, I will.
	Down.
	Up.
	…I think that was up.
	Down.
	Ok, sure.
	…Some kind of coin.
	This is… some wire thing… paperclip?
	Um… that feels like a key.
	…Some kind of coin.
	The paperclip again.
	Um… that feels like a key.
	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.”

 

Documentation / Electronic Health Record

• Document: Provider Notes

Document: Provider Notes

Student Documentation	Model Documentation
Subjective Ms. Jones presents to the clinic complaining of neck stiffness that started 2 days ago after a car accident on the parking lot. She gets headaches daily since the accident. She states she has soreness in the neck that radiaes to the head. The neck hurts on both sides. She rates the pain a 3 on scale of 0-10. No allergies No fever, chills, night sweats, nausea and vomiting No fatigue Fells dizzy, numbness or tingling No vision changes	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 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 Ms. Jones is a pleasant woman in no acute distress. She is alert and oriented. Eyes: Bilateral Neurologic: Sense of smell intact, right eye vision 20/40	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 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.
Assessment Acute post-traumatic headache following an accident where the patient was a passenger	Acute post-traumatic headache following low-speed MVA where Ms. Jones was a restrained passenger
Plan Continue monitoring the headaches Ibuprofen 800 mg every 8hrs for the next 5 days Educate on how to relieve the neck pain through nexk stretches Educate on when to seek emergent care Observe changes in vision, nausea or vomiting	Encourage Ms. Jones to continue to monitor symptoms and report any increase in frequency or severity of her headaches. • Initiate treatment with ibuprofen 800 mg by mouth every 8 hours as needed 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 mild 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 nausea or vomiting associated with headache, or numbness, tingling, or paralysis of new onset. • Ask Ms. Jones to call the office in two days to discuss symptoms. If no decrease in symptoms, order a computerized tomography scan or magnetic resonance imaging.

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