Shadow Health neurological assessment Subjective Data
These are the facts about the patient’s condition and health history, gathered through a combination of questions and the patient’s own statements.
Main Concerns
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– The primary issue:
– The patient has reported a recent car accident.
Tip: It’s crucial to understand the context of the accident, the injuries sustained, and any symptoms related to it.
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– Additional symptoms reported by the patient include:
– Headaches and neck discomfort.
Tip: Detailed information about the location, frequency, and intensity of these symptoms is important for assessment and treatment.
History of the Present Illness
– Information about the accident:
– The accident occurred one week ago.
Tip: Knowing when the accident happened provides context for evaluating the patient’s condition.
– Symptom onset:
– The patient experienced symptoms two days after the accident.
Tip: Identifying when the symptoms started is essential for assessing their connection to the accident.
– Details about the accident:
– The patient was wearing a seatbelt and seated in the front passenger seat.
Tip: This information helps understand the circumstances of the accident and the safety measures taken.
– Pain characteristics:
– The patient reports daily headaches that last 1-2 hours, with the last one occurring yesterday afternoon.
Tip: Knowing the frequency and duration of headaches is critical for diagnosis and treatment.
– Location of pain:
– Headache pain is located in the crown and back of the head. There is no radiation into the shoulders, back, or arms.
Tip: Understanding the precise location of pain helps in determining potential causes.
– Other symptoms:
– The patient experiences slight pain in the back of neck muscles.
Tip: Exploring other symptoms can help identify related issues.
– Pain severity:
– The patient rates the current head and neck pain severity at 3 out of 10. The worst pain severity was 4 out of 10.
Tip: Assessing pain severity provides valuable data for treatment planning.
– Characteristics of headache pain:
– The patient describes headache pain as a dull ache and denies sharp pain. The headaches are not cyclic and do not occur in clusters.
Tip: Understanding the nature of headache pain helps in diagnosis and management.
– Aggravating factors:
– The patient believes the car accident is the primary cause of the pain. She experiences pain upon head or neck movement, but there is no discernible trigger for headaches.
Tip: Identifying factors that worsen or alleviate symptoms is essential for a comprehensive assessment.
Medical History
– Medication use:
– The patient confirms the use of medications but is unsure of the dosage. She takes Tylenol, two tablets at a time, once a day.
Tip: Knowing the type and amount of medication used is important for evaluating the patient’s pain management.
– Allergies:
– The patient has no new reported allergies.
Tip: Understanding allergies helps in preventing adverse reactions to medications.
– Neurological history:
– The patient reports past frequent headaches but denies a history of migraines, head trauma, or seizures.
Tip: Identifying pre-existing conditions and history is important for diagnosis and treatment.
Social History
– Sleep habits:
– The patient denies changes in sleep, increased sleepiness, or yawning.
Tip: Changes in sleep patterns can be indicative of health issues.
Social Determinants of Health
– Impact of the accident on finances:
– The patient has car insurance and doesn’t believe the accident will create a financial burden.
Tip: Exploring the impact of accidents on finances is important for understanding overall well-being.
Review of Systems
– General symptoms:
– The patient denies fever, chills, fatigue, nausea, vomiting, and night sweats.
Tip: These symptoms may be related to head injuries, so their absence is notable.
– Neurological symptoms:
– The patient denies hemiparesis, gait disturbance, body weakness, seeing auras or halos, dizziness, loss of coordination, scotoma, numbness or tingling, and facial flushing.
Tip: Assessing neurological symptoms helps in evaluating brain and nerve health.
– Psych and behavioral history:
– The patient denies depression and increased irritability. She acknowledges problems with concentration and memory but denies confusion.
Tip: Identifying psychological and cognitive changes is important for holistic assessment.
– Eyes and vision:
– The patient denies changes in vision since the accident but reports occasional pre-existing blurry vision.
Tip: Monitoring vision changes is crucial after an accident.
– Ears, nose, and throat:
– The patient denies nasal congestion, tinnitus, changes in hearing, and difficulty swallowing.
Tip: These symptoms can relate to whiplash and should be monitored.
Family History
– Relevant family history:
– The patient denies a family history of migraines, epilepsy, Alzheimer’s disease, and Parkinson’s disease.
Tip: Understanding family history can provide insight into potential hereditary conditions.
Shadow Health neurological assessment Subjective Data
Category
Scored Items
Experts selected these topics as essential components of a strong, thorough interview with this patient.
Patient Data
Not Scored
A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.
Chief Complaint
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
(Available)
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
(Available)
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)
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:
Where in the car were you sitting?
Finding:
Reports no alcohol or drug use during accident
(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:
Was anyone in the car under the influence of alcohol?
Finding:
Asked about frequency and duration of symptoms
Finding:
Reports headaches are daily since they began
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina how often she gets headaches specifies the way her individual symptoms and pain manifest.Example Question:
How many days have you had a headache since they started?
Finding:
Reports headaches last 1-2 hours
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina how long the headaches last specifies the way her individual symptoms and pain manifest.Example Question:
How long do the headaches last?
Finding:
Reports last headache was yesterday afternoon
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina when she got her last headaches specifies the way her individual symptoms and pain manifest.Example Question:
When was your last headache?
Finding:
Asked location of pain
Finding:
Reports headache pain in crown and back of head
(Found)
Pro Tip: Because symptoms often vary from patient to patient, asking Tina where her headaches are occurring will allow you to most effectively treat her specific symptoms.Example Question:
Where are the headaches located?
Finding:
Reports pain does not radiate into shoulders, back, or arms
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina to describe what her injury feels like specifies the way her symptoms and pain manifest.Example Question:
Does the pain radiate?
Finding:
Reports slight pain in back of neck muscles
(Found)
Pro Tip: Because symptoms often vary from patient to patient, asking Tina how her neck feels will allow you to see the ways in which her individual pain manifests.Example Question:
How does your neck feel?
Finding:
Denies scalp tenderness or injury
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina if her scalp is tender specifies the way her individual symptoms and pain manifest.Example Question:
Is your scalp tender?
Finding:
Denies jaw symptoms
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina if her jaw is tender specifies the way her individual symptoms and pain manifest.Example Question:
Do you have jaw pain?
Finding:
Denies facial pain
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina if she is experiencing facial pain specifies the way her individual symptoms and pain manifest.Example Question:
Do you have any facial pain?
Finding:
Asked about severity of pain
Finding:
Rates current head and neck pain severity at 3 out of 10
(Found)
Pro Tip: Pain severity might change over time for a variety of reasons. Asking Tina to rate the severity of her current pain on a scale of 1-10 will provide a quantified and relative measurement of her condition.Example Question:
How would you rate your current pain on a scale from 0 to 10?
Finding:
Rates pain severity at its worst is 4 out of 10
(Found)
Pro Tip: Pain severity might change over time for a variety of reasons. Asking Tina to rate the severity of her pain when it started on a scale of 1-10 will provide a quantified and relative measurement of her condition.Example Question:
How would you rate your pain at its worst on a scale from 0 to 10?
- inding:Followed up on headache characteristics
Finding:
Reports headache pain as a dull ache
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina to describe what her headaches feel like specifies the way her individual symptoms and pain manifest.Example Question:
What do your headaches feel like?
Finding:
Denies sharp pain
(Found)
Pro Tip: Because symptoms often vary from patient to patient, asking Tina whether her headaches feel sharp will allow you to most effectively treat her specific symptoms.Example Question:
Is the headache pain sharp?
Finding:
Reports headaches not cyclic
(Found)
Pro Tip: By understanding the nature of Tina’s pain, you can most effectively treat her. Asking Tina whether her headaches are cyclic will give you a sense for the extent of her pain.Example Question:
Are your headaches cyclic?
Finding:
Reports headaches do not occur in clusters
(Available)
Pro Tip: By understanding the nature of Tina’s pain, you can most effectively treat her. Asking Tina whether her headaches come in clusters will give you a sense for the extent of her pain.Example Question:
Do your headaches come in clusters?
Finding:
Reports headaches not rapid in crescendo
(Available)
Pro Tip: By understanding the nature of Tina’s pain, you can most effectively treat her. Asking Tina whether her headaches crescendo will give you a sense for the extent of her pain.Example Question:
Do your headaches crescendo?
Finding:
Asked about aggravating factors
Finding:
Reports that car accident seems to be primary cause
(Found)
Pro Tip: It’s important to ask the patient if they know the primary cause of an injury.Example Question:
What caused your pain?
Finding:
Reports pain upon head or neck movement
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina if it hurts to move her head specifies the way her individual symptoms and pain manifest.Example Question:
Does it hurt to move your head?
Finding:
Reports headaches don’t have a discernible trigger
(Found)
Pro Tip: Pain severity might change for a variety of reasons. Asking Tina what makes her headaches worse might help you to understand sounds, movements, or times that trigger her pain.Example Question:
What makes your headaches worse?
Finding:
Asked about relieving factors for neck pain and headaches
Finding:
Denies home remedies such as heat or cold
(Available)
Pro Tip: Finding out the non-medication modalities that a patient is treating her pain with will help you understand the severity of the pain.Example Question:
Have you tried home remedies?- Finding:Symptoms improve with rest
(Found)
Pro Tip: Understanding all of the relieving factors, including how a symptom changes at motion or at rest, can help you understand all of the contributing pain factors.Example Question:
Does the headache get better with rest?
Medical History
- Finding:Confirmed use of medications
Finding:
Confirms medications (no new medications reported)
(Found)
Pro Tip: Determining what, if any, medications a patient is taking is a crucial element of a thorough health history and will help you avoid unwanted drug interactions.Example Question:
Are you taking any new medications?
Finding:
Reports increased Tylenol use
(Found)
Pro Tip: The amount of pain medication a patient is taking is an important consideration in understanding their level of pain. For a patient who takes pain medication but still experiences pain, it can indicate higher pain severity than she is reporting.Example Question:
Have you been taking Tylenol?
- Finding:Followed up on Tylenol use
- Finding:Unsure of dosage
(Found)
Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina how much tylenol she takes will illustrate how effectively OTC medication works for her injury.Example Question:
What dose of tylenol do you take?
Finding:
Takes 2 Tylenol at a time
(Available)
Pro Tip: Asking how many pills a patient takes at once time can help you make sure a patient is not taking an unsafe dose.Example Question:
How many Tylenol do you take at a time?
Finding:
Takes Tylenol once a day
(Available)
Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina how often she takes tylenol will illustrate how effectively OTC medication works for her injury.Example Question:
How often do you take tylenol?
Finding:
Reports minor relief from Tylenol
(Found)
Pro Tip: Asking Tina if the Tylenol helps will allow you to assess the severity of her headaches and whether her current treatment plan is effective.Example Question:
Does the Tylenol help?
- Finding:Confirmed allergies
- Finding:Confirms allergies (no new allergies reported)
(Found)
Pro Tip: Asking Tina if she has any new allergies will allow you to understand how, beyond the chief complaint, Tina’s health has been.Example Question:
Do you have any new allergies?
- Finding:Asked about relevant neurological history
- Finding:Reports past frequent headaches
(Found)
Pro Tip: Assessing which of Tina’s pain (if any) is “normal” versus caused by the accident will allow you to understand the scope of her injuries.Example Question:
Do you usually get headaches?
Finding:
Denies history of migraine
(Found)
Pro Tip: Assessing which of Tina’s pain (if any) is “normal” versus caused by the accident will allow you to understand the scope of her injuries.Example Question:
Do you ever get migraines?
Finding:
Denies head trauma
(Found)
Pro Tip: After Tina’s car accident, it is important to establish whether head trauma she might be experiencing predates the accident or, rather, is a result of the crash.Example Question:
Have you ever had any head trauma?
Finding:
Denies history of seizures
(Found)
Pro Tip: A car accident can result in a traumatic brain injury (TBI). Asking Tina if she’s had seizures might indicate whether or not she is experiencing symptoms of a traumatic brain injury.Example Question:
Have you had any seizures?
Social History
- Finding:Asked about sleep
- Finding:Denies changes in sleep
(Found)
Pro Tip: A car accident can result in a traumatic brain injury (TBI). Asking Tina if her sleep habits have changed lately might indicate whether she is experiencing symptoms of a traumatic brain injury.Example Question:
Have your sleep habits changed?
Finding:
Denies increased sleepiness or yawning
(Available)
Pro Tip: A car accident can result in a traumatic brain injury (TBI). Asking Tina if she’s felt more sleepy lately might indicate whether she is experiencing symptoms of a traumatic brain injury.Example Question:
Have you felt more sleepy lately?
Social Determinants of Health
- Finding:Asked about impact of accident on finances
- Finding:Reports having car insurance
(Available)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.Example Question:
Do you have car insurance?
Finding:
Denies accident places extra burden on her financially
(Found)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.Example Question:
Is the car accident going to be a financial burden?
Review of Systems
- Finding:Asked about general symptoms
- Finding:Denies fever
(Found)
Pro Tip: Following a head injury, asking Tina whether she’s had a fever might indicate if she’s suffered any additional complications to her neck trauma.Example Question:
Have you had a fever?
Finding:
Denies chills
(Found)
Pro Tip: Chills after a car accident might indicate shock. Asking Tina if she’s had any chills will reveal whether or not she’s had shock following her accident.Example Question:
Have you had any chills?
Finding:
Denies fatigue or changes in energy level
(Found)
Pro Tip: A car accident can result in a traumatic brain injury (TBI). Asking Tina if she’s felt more fatigued lately might indicate whether she is experiencing symptoms of a traumatic brain injury.Example Question:
Have you felt fatigued?
Finding:
Denies nausea or vomiting
(Found)
Pro Tip: One symptom of a concussion is nausea. Asking Tina whether she’s felt nausea might reveal that she sustained a concussion in her car accident.Example Question:
Have you had nausea?
Finding:
Denies night sweats
(Found)
Pro Tip: One symptom of a concussion is nausea. Asking Tina whether she’s been vomiting might reveal that she sustained a concussion in her car accident.Example Question:
Have you had night sweats?
Finding:
Asked about review of systems for neurological
Finding:
Denies hemiparesis
(Found)
Pro Tip: A car accident can result in muscle damage and feeling weak on one side of the body. Asking Tina whether she feels weak on one side of her body can indicate whether she is suffering from muscle damage.Example Question:
Has one side of your body felt weaker than the other?
Finding:
Denies gait disturbance
(Found)
Pro Tip: A car accident can result in muscle damage or nerve damage. Asking Tina whether her gait has changed might indicate a muscle or tissue injury that is impacting the way she walks.Example Question:
Have you had any changes in your gait?
Finding:
Denies body weakness
(Available)
Pro Tip: A car accident can result in muscle damage and feeling weakness. Asking Tina whether she feels weak can indicate whether or not she is suffering from muscle damage.Example Question:
Have you felt weak?
Finding:
Denies seeing auras or halos
(Available)
Pro Tip: After Tina’s car accident, it is important to establish whether neurological problems she might be experiencing predate the accident or, rather, are a result of the crash. Asking Tina if she’s been seeing auras will indicate whether she’s experiencing a neurological disturbance.Example Question:
Have you experienced any auras?
Finding:
Denies dizziness, light-headedness, syncope, or disequilibrium
(Found)
Pro Tip: A car accident can result in a traumatic brain injury (TBI). Asking Tina if she’s felt dizzy might indicate whether she is experiencing symptoms of a traumatic brain injury.Example Question:
Have you felt dizzy?
Finding:
Denies loss of coordination
(Available)
Pro Tip: People with traumatic brain injuries commonly report loss of coordination. Asking Tina whether she’s lost coordination can indicate that she suffered a traumatic brain injury during her accident.Example Question:
Have you had any loss of coordination?
Finding:
Denies scotoma
(Available)
Pro Tip: People with traumatic brain injuries commonly report scotoma. Asking Tina whether she’s noticed any scotoma can indicate that she suffered a traumatic brain injury during her accident.Example Question:
Have you noticed any scotoma?
Finding:
Denies numbness or tingling
(Available)
Pro Tip: Tingling sensations after a car accident can suggest a herniated disc. Asking Tina whether she’s experiencing tingling sensations might indicate additional musculoskeletal damage caused by the accident.Example Question:
Have you had any tingling sensations?
Finding:
Denies facial flushing
(Available)
Pro Tip: A prolonged flush face can indicate cerebral compression. Asking Tina whether her face has been flushed will indicate if she is suffering from head trauma.Example Question:
Has your face been flushed?
Finding:
Asked about review of systems for psych and behavioral history
Finding:
Denies depression
(Available)
Pro Tip: After an accident, it is not uncommon to feel anxious or depressed. Asking Tina whether she’s felt depressed can indicate long-term concerns following her accident.Example Question:
Have you felt depressed?
Finding:
Denies increased irritability
(Available)
Pro Tip: One symptom of a concussion is irritability. Asking Tina whether she’s been irritable might reveal that she sustained a concussion in her car accident.Example Question:
Have you felt more irritable?
Finding:
Denies problems with concentration or memory
(Found)
Pro Tip: One symptom of a concussion is problems concentrating. Asking Tina whether she’s been experiencing problems concentrating might reveal that she sustained a concussion in her car accident.Example Question:
Have you had any problems concentrating?
Finding:
Denies confusion
(Available)
Pro Tip: One symptom of a concussion is confusion. Asking Tina whether she’s felt confusion might reveal that she sustained a concussion in her car accident.Example Question:
Have you felt confused?
- Finding:Asked about review of systems for eyes and vision
- Finding:Denies changes in vision since accident
(Found)
Pro Tip: Eye and vision problems are fairly common after a brain injury. Asking Tina whether her vision changed since her accident might indicate that she sustained a head injury.Example Question:
Has your vision changed since the accident?
Finding:
Reports occasional blurry vision (pre-dating accident)
(Found)
Pro Tip:Example Question:
Have you ever had blurry vision?
Finding:
Denies unilateral vision disturbance
(Available)
Pro Tip: Eye and vision problems are fairly common after a brain injury. Asking Tina whether she’s had vision problems in just one eye since her accident might indicate that she sustained a head injury.Example Question:
Have you had any vision problems in just one eye?
Finding:
Denies sensitivity to light
(Available)
Pro Tip: Eye and vision problems are fairly common after a brain injury. Asking Tina whether she is sensitive to light since her accident might indicate that she sustained a head injury.Example Question:
Are you sensitive to light since the accident?
Finding:
Asked about review of systems for ears, nose, and throat
Finding:
Denies nasal congestion or rhinorrhea
(Available)
Pro Tip: Whiplash from Tina’s car accident might result in congestion and sinus problems. Asking Tina if she’s been congested can indicate that she suffered from whiplash during the accident.Example Question:
Have you had any congestion?
Finding:
Denies tinnitus
(Available)
Pro Tip: Tinnitus, or hearing ringing, can result from the loudness of a car accident. Asking Tina whether she’s hearing ringing can indicate whether she is suffering from Tinnitus.Example Question:
Have you had ringing in your ears?
Finding:
Denies changes in hearing
(Available)
Pro Tip: Sudden Sensorineural Hearing Losses can be associated with head trauma caused by car accidents. Asking Tina if she’s experiencing hearing loss can indicate possible head trauma.Example Question:
Have you had any hearing loss?
Finding:
Denies difficulty swallowing
(Found)
Pro Tip: Whiplash from Tina’s car accident might result in damage to the soft tissue of her neck. Asking Tina if she is having trouble swallowing might suggest an injury that she sustained in the crash.Example Question:
Have you had any difficulty swallowing?
Family History
- Finding:Asked about relevant family history
- Finding:Denies family history of migraine
(Found)
Pro Tip: Some causes of migraines can be inherited, and so it’s important to understand your patient’s risk level.Example Question:
Is there a history of migraines in your family?
Finding:
Denies family history of epilepsy or seizures
(Available)
Pro Tip: Epilepsy or other forms of seizures can be inherited, and so it’s important to understand your patient’s risk level.Example Question:
Do you have a family history of epilepsy?
Finding:
Denies family history of Alzheimer’s disease
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(Available)
Pro Tip: Conditions like Alzheimer’s disease can be inherited, and so it’s important to understand your patient’s risk level.Example Question:
Do you have a family history of Alzheimer’s disease?
Finding:
Denies family history of Parkinson’s disease