NR 509 Week 3 Shadow Health Neurological Physical Assessment Assignment

NR 509 Week 3 Shadow Health Neurological Physical Assessment Assignment

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Two days after a minor, low-speed car accident in which Tina was a passenger, she
noticed daily bilateral headaches along with neck stiffness. She reports that it hurts
to move her neck, and she believes her neck might … swollen. She did not lose
consciousness in the accident and denies changes in level of consciousness since that
time. … that she gets a headache every day that lasts approximately 1-2 hours. …
occasionally takes 650 mg of over the counter Tylenol with relief of the pain. This
case study will allow you the opportunity to examine the patient’s optic nerve via use
of the ophthalmoscope as well as assess her visual acuity. You will need to document
your findings using appropriate medical terminology. Be sure to assess for foot
neuropathy using the monofilament test. Reason for visit: Patient presents
complaining of headache.
1 Symptoms
Followed Up
Description: Tina describes the symptoms that have
been bothering her.
Can you describe the pattern of headaches? (Clarified
to: Can you describe the headaches?)
Question
10:26 PM
CDT

The headaches feel like a dull ache, kind of in the
crown of my head, and the back of my head. (Clarified
to: how I would describe my headaches)
It must hurt alot
Empathize
10:27 PM
CDT
Thanks for understanding.
Model Statement: “I’m sorry to hear that you were in
a car accident, and that you’re experiencing pain and
headaches. Because car accidents can cause injury to
your head and neck, it’s important that I learn about
how the injury happened and your symptoms so that
we can determine if you need treatment.”
2 Cause of Injury
Not Followed Up
Description: Tina describes her recent “fender
bender.”
Do you use seatbelts\
Question
11:00 PM
CDT
Yes, I always do.
do you have difficulty concentrating
Question
11:01 PM

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CDT
No, not really.
Do you have any other conditions
Question
11:01 PM
CDT
Um, the only things I know I’m diagnosed with are
diabetes. And asthma.
Model Statement: “I’m sorry. Car accidents can be
stressful and scary, even if they are minor. I’m glad
you are safe.”
3 Medications
Not Followed Up

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