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Neurological Subjective Shadow Health
Health Assessment (NSG 525)
Rush University
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Neurological Results | Turned In
Advanced Health Assessment for the APN - Fall 2021, 625
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Subjective Data Collection: 21 of 21 (100%)
Chief Complaint
History of Present Illness
Your Results Lab Pass (/assignment_attempts/10764512/lab_pass.
Overview Transcript Subjective Data Collection
Objective Data Collection Education & Empathy Documentation
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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 yie better patient data. The following details are facts o patient's case.
Established chief complaint Reports recent "fender bender" Reports headaches Reports neck symptoms
Asked about onset of symptoms Reports accident occurred 1 week ago Reports symptoms began 2 days after accident
Followed up on details of car accident Denies loss of consciousness Reports low vehicle speed Reports wearing seatbelt Reports sitting in front passenger seat Reports no alcohol or drug use during accident
Asked about frequency and duration of symptoms
Reports headaches are daily since they began Reports headaches last 1-2 hours Reports last headache was yesterday afternoon
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Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
Support
Medical History
Social History
Social Determinants of Health
Asked location of pain Reports headache pain in crown and back of head Reports pain does not radiate into shoulders, back, or arms Reports slight pain in back of neck muscles Denies scalp tenderness or injury Denies jaw symptoms Denies facial pain
Asked about severity of pain Rates current head and neck pain severity at 3 o of 10 Rates pain severity at its worst is 4 out of 10
Followed up on headache characteristics Reports headache pain as a dull ache Denies sharp pain Reports headaches not cyclic Reports headaches do not occur in clusters Reports headaches not rapid in crescendo
Asked about aggravating factors Reports that car accident seems to be primary cause Reports pain upon head or neck movement Reports headaches don't have a discernible trigger
Asked about relieving factors for neck pain and headaches
Denies home remedies such as heat or cold Symptoms improve with rest
Confirmed use of medications Confirms medications (no new medications reported) Reports increased Tylenol use
Followed up on Tylenol use Unsure of dosage Takes 2 Tylenol at a time Takes Tylenol once a day Reports minor relief from Tylenol
Confirmed allergies Confirms allergies (no new allergies reported)
Asked about relevant neurological history Reports past frequent headaches Denies history of migraine Denies head trauma Denies history of seizures
Asked about sleep Denies changes in sleep Denies increased sleepiness or yawning
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Neurological Subjective Shadow Health
Course: Health Assessment (NSG 525)
University: Rush University
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