Documentation – Tina Jones Neurological Shadow Health assessment

Documentation – Tina Jones Neurological Shadow Health assessment

History of Present Illness (HPI):
Ms. Jones visited the clinic with complaints of a headache and neck stiffness. These symptoms started two days after she was in a minor car accident. About a week ago, she was a passenger in a parking lot accident, estimating the speed to be around 5-10 mph. Neither she nor the driver sought immediate medical care, and they felt fine after the accident. However, two days later, Ms. Jones developed a bilateral temporal dull ache with neck discomfort. She mentioned feeling like her neck might be slightly swollen.

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She did not lose consciousness during the accident and hasn’t experienced any changes in her level of consciousness since then. She reports having a daily headache lasting approximately 1-2 hours, which she occasionally treats with over-the-counter Tylenol (650 mg) for relief. She denies any other associated symptoms.

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Review of Systems:
– General: No changes in weight, fatigue, weakness, fever, chills, or night sweats.
– Head: No history of trauma before this incident, and no current headache.
– Eyes: Ms. Jones doesn’t wear corrective lenses but has noticed worsening vision over the past few years, particularly after reading for extended periods. No increased tearing or itching.
– Ears: No hearing loss, tinnitus, vertigo, discharge, or earache.
– Nose/Sinuses: No runny nose, stuffiness, sneezing, itching, previous allergies, epistaxis, or sinus pressure.
– Musculoskeletal: No muscle weakness, pain, difficulties with range of motion, joint instability, or swelling.
– Neurologic: No 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 Assessment:

– General: Ms. Jones, a 28-year-old obese African American woman, appears uncomfortable but is in no acute distress. She is alert and oriented, maintaining eye contact during the interview and physical examination.
– Head: Her head is of normal shape and free from any traumatic injury.
– Eyes: Both eyes show equal hair distribution.
– Neurologic: The sense of smell is intact and symmetric. Her left eye has 20/20 vision, while her right eye has 20/40 vision. Fundoscopic exams indicate no hemorrhages in the left eye and mild retinopathic changes in the right eye. Pupils are equal, round, and react to light in both eyes. Extraocular movements are normal, and convergence is normal. Facial sensation is intact, and facial features are symmetrical. Rinne and Weber tests are normal. The gag reflex is intact. Shoulder shrugging is symmetric with a strength score of 5 against resistance. The neck has full range of motion with a strength score of 5 against resistance. The tongue appears symmetrical with no abnormalities. Bilateral upper and lower extremity deep tendon reflexes are equal and 2+ bilaterally. Point-to-point movements are smooth and accurate for finger-to-nose and heel-to-shin. Rapid alternating movements of the upper extremities are normal bilaterally. Gait is steady with continuous symmetric steps. Sensation is intact in both upper and lower extremities, and the sense of extremity position is also intact. Stereognosis and graphesthesia are intact bilaterally.


– Ms. Jones is experiencing an acute post-traumatic headache following a low-speed motor vehicle accident where she was a restrained passenger.


– Encourage Ms. Jones to continue monitoring her symptoms and to report any worsening in the frequency or severity of her headaches.
– Initiate treatment with ibuprofen 800 mg by mouth every 8 hours with food for the next five days.
– Recommend adjunct therapy of topical heat or ice as needed for comfort three to four times a day.
– Educate Ms. Jones about the signs that should prompt her to seek immediate medical care, including experiencing the worst headache of her life, acute changes in vision, hearing, or consciousness, episodes of nausea or vomiting associated with headaches, or new-onset numbness, tingling, or paralysis.
– Instruct her to call the office in two days to discuss her symptoms. If there’s no improvement, a computerized tomography scan (CT scan) or magnetic resonance imaging (MRI) can be considered for further evaluation.

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