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Musculoskeletal and Neurological Results | Turned In Advanced Physical Assessment – March 2020, advanced_physical_assessment__td8__031720__sect1

Musculoskeletal and Neurological
Musculoskeletal and Neurological

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Started: Apr 15, 2020 | Total Time: 126 min

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Your Results Lab Pass (/assignment_attempts/6635634/lab_pass.pd

Overview

Transcript

Subjective Data Collection

Objective Data Collection

Education & Empathy

Documentation

All Lines (286) Interview Questions (100) Statements (35) Exam Actions (151)

Hey.

What brings you to the clinic today

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.

Thanks for saying that.

Thanks.

How long has this headache been

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

Where is the pain at

It’s really just been the headaches, but my neck is sore, too.

How long is the pain lasting

About an hour or two.

Can you describe the pain

The headaches feel like a dull ache, kind of in the crown of my head, and the back of my head.https://aspen.shadowhealth.com/assignments/313478/https://aspen.shadowhealth.com/assignment_attempts/6635634/lab_pass.pdf

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Is there anything that makes it feel better (Clarified to Is there anything that makes you feel better?.)

I’ve been taking Tylenol. And resting helps, too. (Clarified to if anything makes me feel better.)

How does it get worse (No matching questions found.)

is your pain any worse (Clarified to Is your pain getting worse?.)

No, it’s stayed about the same. (Clarified to if the pain is getting worse.)

is the pain radiating anywhere

Maybe? The soreness in my neck feels like it goes up into my head. But its just my neck and head that hurt.

Is there any symptoms that goes with it (Clarified to Are there any aggravating factors?.)

Moving my neck definitely makes it hurt more, but I’m not sure what causes the headaches . . . [AUDIO COMING SOON] (Clarified to if there are aggravating factors.)

What is the Pain Scale from 1 to 10 (Clarified to Can you rate your current pain level on a scale of 0 to 10?.)

It’s just my neck that hurts right now. . . I guess I’d say it’s a 3 out of 10. (Clarified to how I would rate my pain on a scale.)

Are you wearing a seatbelt

Yes, I always do.

Can you tell me how fast you were going (Clarified to How fast were you going?.)

Oh, it was really slow. We were in a parking lot. Maybe not even fifteen miles an hour. (Clarified to how fast I was going.)

Do you have any sweating

I don’t get sweaty, but sometimes I wake up hot and have to kick off my sheets.

Is your neck swollen

Yeah. It’s kind of hard to tell but I had a hard time buttoning one of my shirts last week. I think the swelling has gone down a little bit, though.

Did you lose consciousness

No.

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Do you feel tired or wheat

No, not really.

Do you have any fevers or chills

No, neither of those. [AUDIO COMING SOON]

Do you have any vision changes

Well, no, my vision hasn’t changed recently — not since the accident. But sometimes my vision gets blurry when I do a lot of reading… that’s been going on for awhile.

Do you have trouble hearing

My hearing is fine.

Do you feel faint

Nope.

Do you hear ringing of your ears

No, I don’t think so.

Talking to you using pain medication

I’ve been taking Tylenol.

What is your dosage of Tylenol (Clarified to What is the dose of Tylenol?.)

I’m not sure the actual dosage, but I generally take 2 regular strength pills. (Clarified to what dose of Tylenol I take.)

How often are you taking Tylenol

I’ve been taking it every day since I started getting these headaches.

Does it help with the pain (Clarified to Does the pain medication alleviate the pain?.)

Yeah, it has been helping some. (Clarified to if the pain medication helps.)

Do you have difficult range of motion (Clarified to Are you having difficulty moving your neck?.)

I can move my neck fine, but it hurts when I do. (Clarified to if I have a hard time moving my neck.)

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Do you have difficulty breathing (Clarified to Are you having difficulty breathing right now?.)

No, my breathing is fine right now. (Clarified to if I am having difficulty breathing now.)

Are you able to concentrate on task

Yeah, my concentration seems fine

Do you have trouble sleeping

Nope. I’ve been sleeping fine.

Do you have trouble hearing

My hearing is fine.

Do you have trouble walking

Nope.

What is your medical history

I’ve had asthma since I was little, and I have sugar diabetes, too.

Are you taking medication for diabetes

I don’t take anything for my diabetes anymore.

OK, I understand.

Are you taking medications for your asthma (Clarified to Do you use medication for your asthma?.)

I just use my inhaler. (Clarified to if I take anything to control my asthma.)

What medication are you using

Just some Tylenol for my headaches and my neck… and I use my daily inhaler, too.

What is your inhaler medication name

I have a Flovent daily inhaler and a Proventil rescue inhaler.

When was your last asthma attack

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Oh gosh, I guess probably the last time I had to go to the hospital for it, which was when I was sixteen. I definitely haven’t had one since high school.

Are you allergic to any medication

Yeah, I’m allergic to penicillin.

What happens with Penicillin

I don’t remember that well because the last time I had penicillin I was pretty little. . . I think I got a rash, like, hives. The doctor told me not to take it again after that.

What over the counter medication are you taking

Usually I’ll take Tylenol sometimes for a headache, and I take Advil for cramps. Lately I’ve been taking the Tylenol more than usual.

I appreciate you saying that.

Do you have any allergies

Yeah, I’m allergic to cats.

What happens with cats

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

Do you get nosebleeds

No.

Do you have any muscle weakness

No, I wouldn’t say I feel weak.

Do you have trouble concentrating

No, not really.

Do you have trouble sleeping

Nope. I’ve been sleeping fine.

Do you have trouble eating

No, I really try not to worry too much about what I eat.

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Do you have any seizures

No. I’ve seen somebody have one, though. It’s scary.

Do illicit drugs

No.

Any changes in your bladder (Clarified to Have you had a recent change in your energy level?.)

No, I don’t think so. (Clarified to if my energy level has changed.)

Have you had any family history of neurological problems (Clarified to Have you had neurological problems?.)

Definitely not. (Clarified to if I have had neurological problems.)

Do you have any family history of neurological problems

I don’t think so.

Have you had any surgeries

Nope. No surgeries… I’ve been lucky.

Nausea and vomiting

No, not at all.

Have you placed ice on your neck

I just have this weird dark skin there. It’s not like scars or anything… I don’t know what it’s from.

Have you use heat or ice for your neck pain

I haven’t been doing anything in particular for my neck. . . just resting and trying not to move it too much.

Does your neck pain worse when sitting up

Yeah, my neck hurts when I move it.

I appreciate you telling me that.

Thanks for understanding.

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