NSG 323-811 Shadow Health_Subjective Data Collection_NEUROLOGICAL {2020} | NSG323-811 Shadow Health_Subjective Data Collection: 20 of 21 (95.2%)

Available: Indicates an item that is available to be found. 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 (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: 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 (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: Did you lose consciousness during the car accident? Finding: Reports low vehicle speed (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 – – – – – – – – – – – – — – – – – – – – – – – – – – – – – – — -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 (Available) 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 (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? Denies family history of Alzheimer’s disease (Available) Subjective Action 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 (Available) Pro Tip: Conditions like Parkinson’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 Parkinson’s disease? Comments If your instructor provides individual feedback on this assignment, it will appear here. [Show less]

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