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Document: Provider Notes

Student Documentation Model Documentation


Ms Jones who is African -American pleasant female who presents to the clinic with c/o headache and neck stiffness She was in a slow moving car accident last week, and her symptoms just started two days ago. She was wearing her seat belt. She has a dull headache at the crown of her head and the back is at the back of her neck. She was no loss of consciousness. She takes Tylenol which helps, with the pain 3/10. She feels her neck swollen, but has been resolving recently. Moving her neck hurts. ROS: She denies any fatigue, wt loss, fever or chills. Head: NO trauma, or LOC or dizziness,. Eyes: she wears reading glasses, and gets blurry when she reads to much. Ears: no hearing loss or ringing of her ears, no vertigo or earache. Denies any neck stiffness. Musculoskeletal: denies problems with her ROM Denies any neurological disease or problems. No family hx of neurological disease or problems. Medical hx: Diabetes: no meds Asthma: Medications: Albuterol, Proventil, tylenols and Advil Allergy med: PCN: hives, and rash

HPI: Ms. Jones presents to the clinic complaining of a headache 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 spee 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 accompan by neck ache. She states that she feels as though her neck may slightly swollen as well. She did not lose consciousness in the accident and denies changes in level of consciousness since tha time. She states that she gets a headache every day that lasts approximately 1-2 hours. She occasionally takes 650 mg of over counter Tylenol with relief of the pain. She denies known associa symptoms. Review of Systems: General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats. • Head: Denies history trauma before this incident. Denies current headache. • Eyes: Sh does not wear corrective lenses, but notes that her vision has be worsening over the past few years, but no acute changes. She complains of blurry vision after reading for extended periods. De increased tearing or itching. • Ears: Denies hearing loss, tinnitus, vertigo, discharge, or earache. • Nose/Sinuses: Denies rhinorrhea Denies stuffiness, sneezing, itching, previous allergy, epistaxis, o sinus pressure. • Musculoskeletal: Denies muscle weakness, pai difficulties with range of motion, joint instability, or swelling. • Neurologic: Denies loss of sensation, numbness, tingling, tremor weakness, paralysis, fainting, blackouts, or seizures. Denies bow or bladder dysfunction. Denies changes in concentration, sleep, coordination, appetite.

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Document: Provider Notes

Student Documentation Model Documentation

Musculoskeletal and Neurological assignments
Musculoskeletal and Neurological assignments


Oriented to person, place and time. Judgement and knowledge intact: Memory intact. no slurred speech Head: symmetrical no lesions, no trauma Weber test intact, rinne test intact, facial sensation intact, gag reflex intact Eyes: Blurry vision with prolong reading: Right eye vision 20/40: retina: with glacoma cupping. Left eye vision 20/20: retina: sharp edges Pupils: PERRL present Point to point intact for finger to nose, heel to shin. Sensation present in extremites except monofilament decreased sensation on foot. Present sensation at heels of both foot. DTR: 2+ for all reflexes Gait: wnl Graphesthesia: able to identify Sterognosis: able to identify

General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress, but appears uncomfortab while sitting in exam chair. She is alert and oriented. She maintai eye contact throughout interview and examination. • Head: Head is normocephalic and atraumatic • Eyes: Bilateral eyes with equal hair distribution. • Neurologic: Sense of smell intact and symmetric. Left eye visio 20/20. Right eye vision: 20/40. Left fundoscopic exam reveals sh disc margins, no hemorrhages. Right fundoscopic exam reveals retinopathic changes. Pupils equal, round, and reactive to light bilaterally. Extraocular movements intact bilaterally. Normal convergence. Facial sensation intact; facial features and symmet Rinne and Weber tests normal bilaterally. Gag reflex intact. Ability shrug shoulders symmetric; 5 strength against resistance. Neck full range of motion against resistance; 5 strength against resista Tongue symmetric with no abnormal findings. Bilateral upper and lower extremity DTRs equal and 2+ bilaterally. Point-to-point movements smooth and accurate for finger-to-nose and heel-to- shin. Rapid alternating movements of the upper extremities intac bilaterally. Gait steady with continuous, symmetric steps. Sensat intact to bilateral upper and lower extremities; sense of extremity position intact. Stereognosis and graphesthesia intact bilaterally.


Headache and Neck pain due to s/p slow moving MVA Acute post-traumatic headache following low-speed MVA where Jones was a restrained passenger


Try Motrin 800mg po every 8 hours prn for headache Offer ice or heat to see if it helps with pain Educate on Warning signs: report any increase headache or worsening headaches, LOC, dizzinees or vomiting Education on exercises for ROM of neck Report to ER if headache is severe, LOC, nausea and vomiting, dizziness. Advise to have someone with her to watch her for the next 2 days if worsening symtoms. Telephone appt in 2 days to follow up with symptoms. Consider neuro consult if symptoms don’t resolve CAT scan if sx worsens or no improvement

Encourage Ms. Jones to continue to monitor symptoms and repo any increase in frequency or severity of her headaches. • Initiate treatment with ibuprofen 800 mg by mouth every 8 hours as nee with food for the next 5 days. • Ms. Jones can also use adjunct therapy of topical heat or ice per comfort TID-QID. • Educate on stretches for upper back and neck. • Educate on when to seek emergent care including the worst headache of her life, acute changes in vision, hearing, or consciousness, episodes of nause vomiting associated with headache, or numbness, tingling, or paralysis of new onset. • Ask Ms. Jones to call the office in two d to discuss symptoms. If no decrease in symptoms, order a computerized tomography scan or magnetic resonance imaging


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