Neurological Shadow Health Assessment Transcript

 

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Neurological Tina Shadow Health Assessment Transcript

Your avatar
Hello Tina. Welcome to our clinic. Am Joyce, I will be interviewing you today, and later do a physical examination on you

Greet
03/18/20 10:56 AM PDT

Tina Jones
Hey.
Your avatar
What brings you to the clinic today?

Question
03/18/20 10:57 AM PDT

Tina Jones
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. Neurological shadow health assessment Transcript
Your avatar
Am sorry to hear that you are having headaches

Empathize
03/18/20 10:59 AM PDT

Tina Jones
Thanks for saying that.
Your avatar
Have you had any neck stiffness?

Question
03/18/20 11:00 AM PDT

Tina Jones
Yeah.
Your avatar
When did the neck stiffness begin?

Question
03/18/20 11:01 AM PDT

Tina Jones
My neck started hurting about two days after the accident.
Your avatar
Am sorry that you got an accident (No matching questions found.)

Question
03/18/20 11:02 AM PDT

Your avatar
Am sorry that you got an accident
Neurological shadow health assessment Transcript

Empathize
03/18/20 11:02 AM PDT

Tina Jones
Thanks.
Your avatar
And when did the headaches begin? (Clarified to When did the headache begin?.)

Question
03/18/20 11:03 AM PDT

Tina Jones
It was a few days after the car accident — I noticed a headache creeping up throughout the day. (Clarified to when the headache began.)
Your avatar
Did you lose consciousness after the car accident? (Clarified to Did you lose consciousness during the car accident?.)

Question
03/18/20 11:04 AM PDT

Tina Jones
No, I don’t think I have ever lost consciousness. (Clarified to if I lost consciousness during the car accident.)
Your avatar
How fast was the car going?

Question
03/18/20 11:06 AM PDT

Tina Jones
Oh, it was really slow. We were in a parking lot. Maybe not even fifteen miles an hour.
Your avatar
Were you wearing a seat belt?

Question
03/18/20 11:08 AM PDT

Tina Jones
Yes, I always do.
Your avatar
where in the car were you sitting?

Question
03/18/20 11:10 AM PDT

Tina Jones
I was in the front passenger seat.
Your avatar
Was the driver under the influence of alcohol? (Clarified to Was anyone under the influence of alcohol when the accident occurred?.)

Question
03/18/20 11:12 AM PDT

Tina Jones
No, definitely not. Neither of us had anything to drink. [AUDIO COMING SOON] (Clarified to if anyone was under the influence of alcohol when the accident occurred.)
Your avatar
Great, it’s not advisable to drink under the influence of alcohol

Educate
03/18/20 11:13 AM PDT

Tina Jones
Alright, thanks for letting me know.
Your avatar
How many times have you had the headaches since they started?

Question
03/18/20 11:16 AM PDT

Tina Jones
I’ve had a headache just about once a day since a couple of days after my accident. Once I feel it coming on, I take something for it and it pretty much goes away for the day.
Your avatar
How long does the headache last?

Question
03/18/20 11:18 AM PDT

Tina Jones
About an hour or two.
Your avatar
when was your last headache?

Question
03/18/20 11:19 AM PDT

Tina Jones
Yesterday afternoon.
Your avatar
where are the headaches located?

Question
03/18/20 11:22 AM PDT

Tina Jones
The headaches are in the crown of my head, and kind of the back of my head.
Your avatar
Does the pain radiate?

Question
03/18/20 11:23 AM PDT

Tina Jones
Maybe? The soreness in my neck feels like it goes up into my head. But its just my neck and head that hurt.
Your avatar
how does your neck feel?

Question
03/18/20 11:23 AM PDT

Tina Jones
It has been pretty stiff and a little painful since the accident.
Your avatar
Is your scalp tender?

Question
03/18/20 11:24 AM PDT

Tina Jones
No.
Your avatar
Do you have jaw pain?

Question
03/18/20 11:24 AM PDT

Tina Jones
No, not at all.
Your avatar
Do you have any facial pain?

Question
03/18/20 11:25 AM PDT

Tina Jones
No. My face is fine.
Your avatar
How would you rate your pain?

Question
03/18/20 11:25 AM PDT

Tina Jones
It’s just my neck that hurts right now. . . I guess I’d say it’s a 3 out of 10.
Your avatar
How would you rate your pain at its worst?

Question
03/18/20 11:26 AM PDT

Tina Jones
They probably get up to a 4.
Your avatar
what do your headaches feel like?

Question
03/18/20 11:27 AM PDT

Tina Jones
The headaches feel like a dull ache, kind of in the crown of my head, and the back of my head.
Your avatar
is the headache pain sharp?

Question
03/18/20 11:27 AM PDT

Tina Jones
No, not really.
Your avatar
are your headaches cyclic?

Question
03/18/20 11:28 AM PDT

Tina Jones
No, I don’t think so.
Your avatar
Do your headaches come in clusters?

Question
03/18/20 11:28 AM PDT

Tina Jones
No, definitely not.
Your avatar
do your headaches crescendo?

Question
03/18/20 11:29 AM PDT

Tina Jones
It’s not, like, a sudden, horrible pain, but they don’t worsen gradually either. They just sort of start, and they never get that bad.
Your avatar
What caused your pain?

Question
03/18/20 11:30 AM PDT

Tina Jones
I’m pretty sure it was the car accident. Well, it was really just a fender bender. There was pretty much no damage to the car, and no one got injured, but I guess a sore head and neck can sneak up on you.
Your avatar
Does it hurt to move your head?

Question
03/18/20 11:31 AM PDT

Tina Jones
Yeah, my neck hurts when I move it.
Your avatar
what makes your headache worse?

Question
03/18/20 11:31 AM PDT

Tina Jones
Nothing really makes them worse. . . they just sort of start, and eventually they go away.
Your avatar
have you tried home remedies?

Question
03/18/20 11:32 AM PDT

Tina Jones
I’ve been taking Tylenol. And resting helps, too.
Your avatar
Does your headache get better with rest?

Question
03/18/20 11:33 AM PDT

Tina Jones
I don’t think so. They just come on and eventually go away.
Your avatar
Are you taking any new medications?

Question
03/18/20 11:33 AM PDT

Tina Jones
I’ve been taking more Tylenol for my headaches and my neck.
Your avatar
what dose of Tylenol do you take?

Question
03/18/20 11:36 AM PDT

Tina Jones
I’m not sure of the actual dosage, but I generally take 2 regular-strength pills.
Your avatar
How often do you take the Tylenol?

Question
03/18/20 11:37 AM PDT

Tina Jones
I’ve been taking it every day since I started getting these headaches.
Your avatar
How many times a day? (No matching questions found.)

Question
03/18/20 11:38 AM PDT

Your avatar
Does Tylenol help?

Question
03/18/20 11:38 AM PDT

Tina Jones
Yeah, it has been helping some.
Your avatar
Do you have any new allergies?

Question
03/18/20 11:39 AM PDT

Tina Jones
Well, besides cats, I’m allergic to penicillin.
Your avatar
Do you usually get headaches?

Question
03/18/20 11:40 AM PDT

Tina Jones
The only time I got headaches before the accident was when I would read or study for a long time.
Your avatar
Do you ever get migraines?

Question
03/18/20 11:40 AM PDT

Tina Jones
No, I’m pretty sure my headaches aren’t migraines.
Your avatar
Have you ever had any head trauma?

Question
03/18/20 11:41 AM PDT

Tina Jones
No.
Your avatar
Have you had any seizures?

Question
03/18/20 11:41 AM PDT

Tina Jones
No. I’ve seen somebody have one, though. It’s scary.
Your avatar
Have your sleep habits changed?

Question
03/18/20 11:42 AM PDT

Tina Jones
No.
Your avatar
Have you felt more sleepy?

Question
03/18/20 11:42 AM PDT

Tina Jones
No, I feel about the same as usual.
Your avatar
have you had a fever?

Question
03/18/20 11:43 AM PDT

Tina Jones
No, I don’t think so.
Your avatar
have you had any chills?

Question
03/18/20 11:43 AM PDT

Tina Jones
No.
Your avatar
have you felt fatigued?

Question
03/18/20 11:43 AM PDT

Tina Jones
No, I don’t think so.
Your avatar
have you had nausea?

Question
03/18/20 11:44 AM PDT

Tina Jones
No.
Your avatar
any night sweats?

Question
03/18/20 11:44 AM PDT

Tina Jones
I don’t get sweaty, but sometimes I wake up hot and have to kick off my sheets.
Your avatar
Has one side of your body felt weaker than the other?

Question
03/18/20 11:45 AM PDT

Tina Jones
No, I feel about the same.
Your avatar
Any changes in your gait?

Question
03/18/20 11:45 AM PDT

Tina Jones
No.
Your avatar
Have you felt weak?

Question
03/18/20 11:45 AM PDT

Tina Jones
No.
Your avatar
Have you experienced any auras?

Question
03/18/20 11:46 AM PDT

Tina Jones
No.
Your avatar
have you felt dizzy?

Question
03/18/20 11:47 AM PDT

Tina Jones
No, I haven’t been dizzy.
Your avatar
Any loss of coordination?

Question
03/18/20 11:48 AM PDT

Tina Jones
Not that I’ve noticed.
Your avatar
have you noticed any scotoma?

Question
03/18/20 11:49 AM PDT

Tina Jones
I don’t know what that is, so I guess probably not.
Your avatar
have you felt any tingling?

Question
03/18/20 11:49 AM PDT

Tina Jones
No, I haven’t noticed any tingling.
Your avatar
Has your face been flushed?

Question
03/18/20 11:50 AM PDT

Tina Jones
Nope.
Your avatar
have you felt depressed?

Question
03/18/20 11:50 AM PDT

Tina Jones
No, I’ve been fine.
Your avatar
have you felt more irritable?

Question
03/18/20 11:51 AM PDT

Tina Jones
No, not really.
Your avatar
Have you had any problems concentrating?

Question
03/18/20 11:51 AM PDT

Tina Jones
No, not really.
Your avatar
Have you felt confused?

Question
03/18/20 11:52 AM PDT

Tina Jones
No.

Question
03/18/20 11:52 AM PDT

Your avatar
has your vision changed since the accident?

Question
03/18/20 11:53 AM PDT

Tina Jones
No, my vision hasn’t changed since the accident.
Your avatar
have you ever had a blurred vision?

Question
03/18/20 11:53 AM PDT

Tina Jones
No, my vision hasn’t been blurry since the accident. But, sometimes it gets blurry when I read for too long — that’s been going on for a while.
Your avatar
any vision problems in just one eye?

Question
03/18/20 11:54 AM PDT

Tina Jones
Not that I’ve noticed.
Your avatar
Are you sensitive to light since the accident?

Question
03/18/20 11:55 AM PDT

Tina Jones
No, I’m not sensitive to light. [AUDIO COMING SOON]
Your avatar
have you had any congestion?

Question
03/18/20 11:55 AM PDT

Tina Jones
No, I haven’t been congested.
Your avatar
have you had ringing in your ears?

Question
03/18/20 11:56 AM PDT

Tina Jones
No.
Your avatar
have you had any hearing loss?

Question
03/18/20 11:56 AM PDT

Tina Jones
No.
Your avatar
have you had any difficulty swallowing?

Question
03/18/20 11:57 AM PDT

Tina Jones
Nope.
Your avatar
Any history of migraines in your family? Neurological shadow health assessment Transcript

Question
03/18/20 11:57 AM PDT

Tina Jones
I don’t think so.
Your avatar
Any family history of epilepsy?

Question
03/18/20 11:58 AM PDT

Tina Jones
No.
Your avatar
any history of seizures?

Question
03/18/20 11:58 AM PDT

Tina Jones
No. I’ve seen somebody have one, though. It’s scary.
Your avatar
do you have a family history of Alzheimer’s disease?

Question
03/18/20 11:59 AM PDT

Tina Jones
No.
Your avatar
do you have a family history of Parkinson’s disease?

Question
03/18/20 12:00 PM PDT

Tina Jones
No, I don’t think so.
Your avatar
What is your name and date of birth?

Question
03/18/20 1:29 PM PDT

Tina Jones
My name is Tina Jones, and I was born on February 17th.
Your avatar
 Evaluated orientation to person

Exam Action
03/18/20 1:29 PM PDT

Your avatar
What building are you in now?

Question
03/18/20 1:30 PM PDT

Tina Jones
I’m at the doctor’s office. . . it’s Shadow Health General Clinic.
Your avatar
 Evaluated orientation to place

Exam Action
03/18/20 1:30 PM PDT

Your avatar
What is the date and year?

Question
03/18/20 1:30 PM PDT

Tina Jones
Um, today’s date is [Tina says correct date and year]. Neurological shadow health assessment Transcript
Your avatar
 Evaluated orientation to time

Exam Action
03/18/20 1:30 PM PDT

Your avatar
How are oranges and apples alike?

Question
03/18/20 1:32 PM PDT

Tina Jones
How are they alike? Um…. they’re both kinds of fruit.
Your avatar
 Evaluated abstract thinking: similarities among fruit

Exam Action
03/18/20 1:32 PM PDT

Your avatar
How are a lake and an ocean alike?

Question
03/18/20 1:32 PM PDT

Tina Jones
Uh…. they’re both bodies of water.
Your avatar
 Evaluated abstract thinking: similarities among bodies of water

Exam Action
03/18/20 1:32 PM PDT

Your avatar
How are a trumpet and a flute alike?

Question
03/18/20 1:33 PM PDT

Tina Jones
They…… they’re both musical instruments.
Your avatar
 Evaluated abstract thinking: similarities among instruments

Exam Action
03/18/20 1:33 PM PDT

Your avatar
Count backward by 7s from 100

Question
03/18/20 1:34 PM PDT

Tina Jones
Okay. . . 100, 93. . . 86, 79, 72. . . 65. . . 58, 51. . . 44. . . 37, 30, 23, 16. . . 9, and 2.
Your avatar
 Evaluated attention with serial sevens

Exam Action
03/18/20 1:34 PM PDT

Your avatar
 Established one-stage comprehension

Exam Action
03/18/20 1:36 PM PDT

Your avatar
Who was the first president of the united states?

Question
03/18/20 1:37 PM PDT

Tina Jones
That’s George Washington.
Your avatar
 Evaluated knowledge of the first president

Exam Action
03/18/20 1:37 PM PDT

Your avatar
who are the last four presidents of the united states?

Question
03/18/20 1:37 PM PDT

Tina Jones
Well, right now it’s Donald Trump. Before him it was Obama. Before *him* we had Bill Clinton and George W. Bush.
Your avatar
 Evaluated knowledge of the last four presidents

Exam Action
03/18/20 1:38 PM PDT

Your avatar
name five large cities in the united states

Question
03/18/20 1:38 PM PDT

Tina Jones
Let’s see. . . New York City. . . and Chicago. . . Detroit. . . Los Angeles. . . and Houston. That’s five. Neurological shadow health assessment Transcript
Your avatar
 Evaluated knowledge of five large cities

Exam Action
03/18/20 1:38 PM PDT

Your avatar
What would you do if you found a stamped and addressed envelope on the sidewalk?

Question
03/18/20 1:40 PM PDT

Tina Jones
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.
Your avatar
 Evaluated judgment

Exam Action
03/18/20 1:40 PM PDT

Your avatar
Repeat and remember burger, tulip, nose, and tea

Question
03/18/20 1:41 PM PDT

Tina Jones
Burger, tulip, nose, and tea.
Your avatar
 Evaluated immediate memory

Exam Action
03/18/20 1:41 PM PDT

Your avatar
how did you celebrate your last birthday?

Question
03/18/20 1:41 PM PDT

Tina Jones
Wow. . . it’s weird, birthdays were huge for us before Dad died because he would always make a really big deal out of them like he loved planning these huge celebrations. But the past two birthdays, he hasn’t been there, so it’s been kind of sad, thinking about what he’s missing, and we haven’t done huge parties or anything. Last birthday. . . Michael and his fiance came over, and we all had dinner at the house, and I opened presents, and we had a really good cake from this bakery I love. It was nice.
Your avatar
 Evaluated remote memory

Exam Action
03/18/20 1:42 PM PDT

Your avatar
Repeat the four words from before

Question
03/18/20 1:42 PM PDT

Tina Jones
Burger. . . tulip. . .nose. . . and tea.
Your avatar
 Evaluated immediate learning

Exam Action
03/18/20 1:42 PM PDT

Your avatar
 Observed patient’s general vocabulary

Exam Action
03/18/20 1:43 PM PDT

Your avatar
what classes are you taking?

Question
03/18/20 1:43 PM PDT

Tina Jones
I’m taking two classes right now, one on auditing and one on managerial accounting
Your avatar
 Tested CN I (olfactory nerve) with the smell test

Exam Action
03/18/20 1:45 PM PDT

Tina Jones
F P
Tina Jones
F P
Your avatar
 Inspected right pupil and tested pupillary light reflex

Exam Action
03/18/20 1:49 PM PDT

Your avatar
 Inspected left pupil and tested left pupillary light reflex

Exam Action
03/18/20 1:49 PM PDT

Your avatar
 Inspected fundus of right eye Neurological shadow health assessment Transcript

Exam Action
03/18/20 1:50 PM PDT

Your avatar
 Inspected fundus of the left eye

Exam Action
03/18/20 1:52 PM PDT

Your avatar
Follow my finger with just your eyes

Question
03/18/20 1:54 PM PDT

Tina Jones
Ok.
Your avatar
 Tested EOM to the upper right

Exam Action
03/18/20 1:55 PM PDT

Your avatar
 Tested EOM to the upper left

Exam Action
03/18/20 1:55 PM PDT

Your avatar
 Tested EOM to the lower left

Exam Action
03/18/20 1:55 PM PDT

Your avatar
 Tested convergence

Exam Action
03/18/20 1:55 PM PDT

Your avatar
 Tested EOM to the lower right

Exam Action
03/18/20 1:55 PM PDT

Your avatar
 Tested EOM to the lower center

Exam Action
03/18/20 1:55 PM PDT

Your avatar
 Tested EOM to the upper center

Exam Action
03/18/20 1:55 PM PDT

Your avatar
 Tested EOM to the upper center

Exam Action
03/18/20 1:55 PM PDT

Your avatar
Close your eyes and tell me if the touch is sharp, dull, or soft

Question
03/18/20 1:56 PM PDT

Tina Jones
Ok.
Your avatar
 Tested facial sensation: dull stimulus

Exam Action
03/18/20 1:56 PM PDT

Tina Jones
Dull.
Your avatar
 Tested facial sensation: dull stimulus

Exam Action
03/18/20 1:57 PM PDT

Tina Jones
Dull.
Your avatar
 Tested facial sensation: dull stimulus

Exam Action
03/18/20 1:57 PM PDT

Tina Jones
Dull.
Your avatar
 Tested facial sensation: dull stimulus

Exam Action
03/18/20 1:57 PM PDT

Tina Jones
Dull.
Your avatar
 Tested facial sensation: soft stimulus

Exam Action
03/18/20 1:57 PM PDT

Tina Jones
Soft.
Your avatar
 Tested facial sensation: soft stimulus

Exam Action
03/18/20 1:57 PM PDT

Tina Jones
Soft.
Your avatar
 Tested facial sensation: soft stimulus

Exam Action
03/18/20 1:57 PM PDT

Tina Jones
Soft.
Your avatar
 Tested facial sensation: soft stimulus

Exam Action
03/18/20 1:57 PM PDT

Tina Jones
Soft.
Your avatar
 Tested facial sensation: sharp stimulus

Exam Action
03/18/20 1:57 PM PDT

Tina Jones
Sharp.
Your avatar
 Tested facial sensation: sharp stimulus

Exam Action
03/18/20 1:57 PM PDT

Tina Jones
Sharp.
Your avatar
 Tested facial sensation: sharp stimulus

Exam Action
03/18/20 1:57 PM PDT

Tina Jones
Sharp.
Your avatar
 Tested facial sensation: sharp stimulus Neurological shadow health assessment Transcript

Exam Action
03/18/20 1:57 PM PDT

Tina Jones
Sharp.
Your avatar
 Inspected front of the face for asymmetry and facial droop

Exam Action
03/18/20 1:58 PM PDT

Your avatar
 Inspected right side of the face for asymmetry and facial droop

Exam Action
03/18/20 1:58 PM PDT

Your avatar
 Inspected back of the head for asymmetry

Exam Action
03/18/20 1:58 PM PDT

Your avatar
 Inspected left side of face for asymmetry and facial droop

Exam Action
03/18/20 1:58 PM PDT

Your avatar
 Inspected front of face for asymmetry and facial droop

Exam Action
03/18/20 1:58 PM PDT

Your avatar
 Inspected left side of face for asymmetry and facial droop

Exam Action
03/18/20 1:58 PM PDT

Your avatar
 Inspected front of face for asymmetry and facial droop

Exam Action
03/18/20 1:58 PM PDT

Your avatar
is the volume the same in both ears or louder in one ear

Question
03/18/20 2:00 PM PDT

Tina Jones
Ok.
Tina Jones
Same in both ears.
Your avatar
 Performed Weber test with a tuning fork

Exam Action
03/18/20 2:00 PM PDT

Your avatar
Tell me when you no longer hear the ringing

Question
03/18/20 2:01 PM PDT

Tina Jones
Ok, I will.
Tina Jones
Now.
Your avatar
 Tested gag reflex

Exam Action
03/18/20 2:02 PM PDT

Your avatar
 Tested trapezius muscle strength against resistance: 5 strength against resistance

Exam Action
03/18/20 2:02 PM PDT

Your avatar
 Tested sternocleidomastoid muscle strength against resistance – head turned to the right: 5 strength against resistance

Exam Action
03/18/20 2:03 PM PDT

Your avatar
 Tested sternocleidomastoid muscle strength against resistance – head turned to the left: 5 strength against resistance

Exam Action
03/18/20 2:03 PM PDT

Your avatar
 Inspected mouth

Exam Action
03/18/20 2:04 PM PDT

Your avatar
 Inspected mouth: pushed tongue left with a tongue blade

Exam Action
03/18/20 2:04 PM PDT

Your avatar
 Inspect mouth: pushed tongue right with a tongue blade

Exam Action
03/18/20 2:04 PM PDT

Your avatar
 Inspect mouth: lifted tongue with a tongue blade

Exam Action
03/18/20 2:04 PM PDT

Your avatar
 Inspected mouth: depressed tongue with tongue blade Neurological shadow health assessment Transcript

Exam Action
03/18/20 2:04 PM PDT

Neurological Shadow Health Assessment Transcript
A Sample of Neurological Results Turned

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Frequently Asked Questions (FAQs)

1. What are the 4 neurological assessments?

(1) mental state, (2) cranial nerves, (3) motor system, (4) reflexes, (5) sensory system, (6) coordination, and (7) station and gait are the seven categories of neurological assessments.

2. What are the 3 components of a basic neurological assessment?

Cognitive testing, motor strength and control, sensory function, gait (walking), cranial nerve testing, and balance are all part of a neurological exam.

3. When is a neurological assessment appropriate?

If a person has had a head injury or reports a variety of symptoms such as dizziness, fuzzy vision, disorientation, or difficulties with motor activities, a neuro evaluation is performed. This is done to see whether there is any damage or sickness to the nervous system.

Neurological Shadow Health Assessment Transcript

 

Neurological Shadow Health Assessment Transcript

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