Tina Jones Neurological Shadow Health assessment

HPI: Ms. Jones came to the clinic with complaints of a headache and neck stiffness that started two days after a minor car accident. A week ago, she was a restrained passenger in a parking lot accident, estimating the speed at 5-10 mph. She didn’t seek immediate care and felt fine after the accident. However, two days later, she developed bilateral temporal dull aches with neck discomfort. She also mentioned a slight swelling sensation in her neck. She didn’t lose consciousness and denies any changes in consciousness since the accident. She experiences daily headaches lasting 1-2 hours and occasionally takes 650 mg Tylenol for relief. No other associated symptoms reported.

Table of Contents

Review of Systems:
– General: Denies changes in weight, fatigue, weakness, fever, chills, or night sweats.
– Head: Denies any previous history of trauma before this incident and denies current headache.
– Eyes: No corrective lenses, but her vision has worsened over the years without acute changes. Complains of blurry vision after reading for extended periods. No increased tearing or itching.
– Ears: Denies hearing loss, tinnitus, vertigo, discharge, or earache.
– Nose/Sinuses: Denies rhinorrhea, stuffiness, sneezing, itching, previous allergies, epistaxis, or sinus pressure.
– Musculoskeletal: Denies muscle weakness, pain, difficulty with range of motion, joint instability, or swelling.
– Neurologic: Denies loss of sensation, numbness, tingling, tremors, weakness, paralysis, fainting, blackouts, or seizures. No bowel or bladder dysfunction. No changes in concentration, sleep, coordination, or appetite.

Objective:

General: Ms. Jones, a pleasant 28-year-old obese African American woman, appears uncomfortable but is in no distress. She is alert, oriented, and maintains eye contact throughout the interview and examination.
Head: Head is normocephalic and atraumatic.
Eyes: Bilateral eyes with equal hair distribution.
Neurologic: Sense of smell intact and symmetric. Left eye vision: 20/20, Right eye vision: 20/40. Left fundoscopic exam reveals sharp disc margins with no hemorrhages. Right fundoscopic exam shows mild retinopathic changes. Pupils equal, round, and reactive to light bilaterally. Extraocular movements intact bilaterally. Normal convergence. Facial sensation intact with symmetric facial features. Rinne and Weber tests normal bilaterally. Gag reflex intact. Ability to shrug shoulders symmetrically with a 5 strength against resistance. Neck has a full range of motion with 5 strength against resistance. Tongue is symmetric with no abnormal findings. Bilateral upper and lower extremity DTRs equal and 2+ bilaterally. Point-to-point movements smooth and accurate for finger-to-nose and heel-to-shin. Rapid alternating movements of the upper extremities intact bilaterally. Gait steady with continuous, symmetric steps. Sensation intact to bilateral upper and lower extremities with a sense of extremity position being intact. Stereognosis and graphesthesia intact bilaterally.

Assessment:

Acute post-traumatic headache following a low-speed motor vehicle accident where Ms. Jones was a restrained passenger.

Plan:

– Encourage Ms. Jones to continue monitoring her symptoms and report any increase in frequency or severity of her headaches.
– Initiate treatment with ibuprofen 800mg by mouth every 8 hours as needed with food for the next five days.
– Adjunct therapy of topical heat or ice per comfort TID-QID is another great treatment option for Ms. Jones.
– Patient education is important, encouraging her to seek emergent care if she experiences the worst headaches she has had, acute changes in vision, hearing, or consciousness, episodes of nausea or vomiting associated with headaches, or numbness, tingling, or paralysis of new onset.
– For follow-up, Ms. Jones is advised to call the office after two days to discuss symptoms, and if there is no decrease in symptoms, a computerized tomography scan (CT scan) or magnetic resonance imaging (MRI) can be considered.

HPI: Ms. Jones presents to the clinic complaining of a headache 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 emergent care and felt fine after the accident. Two days later, however, she developed a bilateral temporal dull ache accompanied 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 headache 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, weakness, fever, chills, and night sweats. • Head: Denies history of trauma before this incident. Denies current headache. • 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 earache. • Nose/Sinuses: Denies rhinorrhea. Denies stuffiness, sneezing, itching, previous allergy, epistaxis, or sinus pressure. • Musculoskeletal: Denies muscle weakness, pain, difficulties with range of motion, joint instability, or swelling. • Neurologic: Denies loss of sensation, numbness, tingling, tremors, weakness, paralysis, fainting, blackouts, or seizures. Denies bowel or bladder dysfunction. Denies changes in concentration, sleep, coordination, appetite.

HPI: Ms. Jones presents to the clinic complaining of a headache 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 emergent care and felt fine after the accident. Two days later, however, she developed a bilateral temporal dull ache accompanied 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 headache 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, weakness, fever, chills, and night sweats. • Head: Denies history of trauma before this incident. Denies current headache. • 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 earache. • Nose/Sinuses: Denies rhinorrhea. Denies stuffiness, sneezing, itching, previous allergy, epistaxis, or sinus pressure. • Musculoskeletal: Denies muscle weakness, pain, difficulties with range of motion, joint instability, or swelling. • Neurologic: Denies loss of sensation, numbness, tingling, tremors, weakness, paralysis, fainting, blackouts, or seizures. Denies bowel or bladder dysfunction. Denies changes in concentration, sleep, coordination, appetite.
Objective General: Ms. Jones is a pleasant 28 year old obese african aerican woman seated on a bench at the clinic in no distress. The patient appears uncomformatble but is alert and orineted as she maintained eye contact throughout the interview and cooperated dueing the physical examination. Head: Head is normocephalic and atraumatic Eyes: the eyes are bilateral with equal hair distribution. neurologic: The sense of smell is intact and symmetric Left eye vision: 20/20 Right eye vision:20/40 The results obtainied from the left fundoscopic exam shows sharp disc margin and no hemorrhages while the right fundoscopic exam shows mild retinopathic changes. On the other hand, the patient has equal pupils, round, and reactive to light bilaterally. The extraocular movements atr bilaterally intact with normal convergence. The facial sensatins are intact and the facial features are symmetric. Additionally, the rinne and weber test are bilaterally normal as the gag reflux is intact. The ability to shrug shoulder is symmetric with a scroe of 5 strength againist resistance. The neck has a full range of motion with a 5 strength against resistance. The tongue is symmetric with not abnormal findings while the bilateral upper and lower extremity DTRs equal and 2+ bilaterally. point-to-point movements were smooth ad accurate for finger-to-nose and heal-to-shin. The rapid alternating movements of the upper extremities are intact bilaterally while the gait is steady with continuous symmetric steps. The sensation is intanct to bilateral upper and lower extreamities with a semse of extreamity posistion being intact. Stereognosisand graphethesia intact bilatterally.	General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress, but appears uncomfortable while sitting in exam chair. She is alert and oriented. She maintains eye contact throughout interview and examination. • Head: Head is normocephalic and atraumatic • Eyes: Bilateral eyes with equal hair distribution. • Neurologic: Sense of smell intact and symmetric. Left eye vision: 20/20. Right eye vision: 20/40. Left fundoscopic exam reveals sharp disc margins, no hemorrhages. Right fundoscopic exam reveals mild retinopathic changes. Pupils equal, round, and reactive to light bilaterally. Extraocular movements intact bilaterally. Normal convergence. Facial sensation intact; facial features and symmetric. Rinne and Weber tests normal bilaterally. Gag reflex intact. Ability to shrug shoulders symmetric; 5 strength against resistance. Neck with full range of motion against resistance; 5 strength against resistance. Tongue symmetric with no abnormal findings. Bilateral upper and lower extremity DTRs equal and 2+ bilaterally. Point-to-point movements smooth and accurate for finger-to-nose and heel-to-shin. Rapid alternating movements of the upper extremities intact bilaterally. Gait steady with continuous, symmetric steps. Sensation intact to bilateral upper and lower extremities; sense of extremity position intact. Stereognosis and graphesthesia intact bilaterally.
Assessment -Acute post-traumatic headache following a low-speed MVAwhere Ms. Jones was a restrained passenger.	Acute post-traumatic headache following low-speed MVA where Ms. Jones was a restrained passenger
Plan -Encouraging Ms. Jones to continue monitoring her symptoms and report any increase in frequency or severity of her headache is essential. -It is important to initiate treatment with ibuprofen 800mg by nmouth every 8 hours a reccommended with food for the next five days. -Adjunt therapy of topical heat or ice per comfort TID-QID is another great treatmet option for Ms. Jones. -Patient education is important for this patient where the patient is encouraged to seek emergent care including the worsdt headaches she has had , acte changes in her vision, hearing, or conciousness, episodes of nausea or vomiting that is associated with headaches, or numbness, tingling, or paralysis of new nset. -For follo-up on Ms. Jones, it is advisable for her t call the office after 2 days to discuss symptoms and if there is no decrease in symptoms, a computerized tomographyscan (CT scan)or magnetic reasoning imaging (MRI) can be used.	Encourage Ms. Jones to continue to monitor symptoms and report any increase in frequency or severity of her headaches. • Initiate treatment with ibuprofen 800 mg by mouth every 8 hours as needed with food for the next 5 days. • Ms. Jones can also use adjunct therapy of topical heat or ice per comfort TID-QID. • Educate on mild stretches for upper back and neck. • Educate on when to seek emergent care including the worst headache of her life, acute changes in vision, hearing, or consciousness, episodes of nausea or vomiting associated with headache, or numbness, tingling, or paralysis of new onset. • Ask Ms. Jones to call the office in two days to discuss symptoms. If no decrease in symptoms, order a computerized tomography scan or magnetic resonance imaging.