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neurology shadow health subjective

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  • January 19, 2025
  • 26
  • 2024/2025
  • Other
  • Unknown
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Nursebecky


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

, (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:

Did you lose consciousness during the car accident?



Finding:

Reports low vehicle speed

(Found)

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

Example Question:

How fast was the car going?



Finding:

Reports wearing seatbelt

(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

(Found)

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