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Neurological Exam Documentation Document: Provider Notes Student Documentation Model Documentation Subjective Miss Jones is a pleasant 28 year old African American Woman who presents to the clinic with complaints of headaches and neck soreness after getting into a "fender-bender" a week ago. S...

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  • 9 de mayo de 2024
  • 6
  • 2023/2024
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  • neurological exam documentation shadow health

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Neur ological Exam Docume ntation
Document : Provider Notes
Student Documentation Model Documentation
Subjectiv e
Miss Jones is a pleasant 28 year old African American Woman
who presen ts to the clinic with complaints of headac hes and neck soreness after getting into a "fender-bender" a week ago. She reports being a front seat passenger in a friend's vehicle when another car rear-ended them at low speed in a grocery store parking lot. She reports weari ng a seatbelt and
denies loss of consciousness. She states the headaches started two days after the accident, five days ago from today. She Describes headac hes as a dull ache in the crown of the head and the back of head, denies any sharp pain. She reports frequency of headac hes as everyday for the last five days, typically lasting an hour to two hours. She denies current headac he, reports last headac he was yesterday afternoon. Denies any cluster headac hes, cyclic headac hes, or precipitating factors, headac hes "seem to happen kind of randomly." She reports taking two regular strength tylenol for headac hes and neck pain which has been somewh at effective. She reports symptoms improve with rest, denies using use of home remedi es including heat or ice. She reports getting headac hes before the accident only when reading or studying for a long time, usually a few times a month. She reports pain in back of neck bilaterally that HPI: Ms. Jones presen ts to the clinic complaining of a headac he 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 emer gent care and felt fine after the accident. Two days later, however , she developed a
bilateral tempo ral dull ache accompan ied 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 headac he 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, weak ness, fever,
chills, and night sweat s. • Head: Denies history of trauma before this incident. Denies current headac he. • 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

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