Hypothyroidism SOAP NOTE

Hypothyroidism SOAP NOTE

Patient Initials: Age:  Gender:

SUBJECTIVE DATA:

Chief Complaint (CC): “ ”.

History of Present Illness (HPI):

Medications:

Allergies:

Past Medical History (PMH):

Current medication:

Past Surgical History (PSH):

Family History:

Personal/Social History:

Immunization: up to date.

Lifestyle:

Review of Systems:

General:

HEENT:

Neck:

Breasts:

Respiratory:

Cardiovascular/Peripheral Vascular:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Psychiatric:

Neurological

Skin:

Hematologic:

Endocrine:

OBJECTIVE DATA:

Physical Exam:

Vital signs: Temperature: ; BP:  mmHg; HR: bpm; RR:  /min; Oxygen Saturation: %; Pain: (0-10 scale), Weight lb; Height; BMI

General:.

HEENT:

Neck:

Chest

Lungs:

Heart:

Peripheral Vascular:

Genital/Rectal:

Musculoskeletal:

Neurological:

Skin:

ASSESSMENT:

Differential Diagnosis

1. Hyperthyroidism.

2.

3.

From both the subjective and objective data, it is clear that the main diagnosis is

PLAN:

Treatment Plan: (please prescription with dose)

Non-pharmacological approaches

For the follow-up, the patient should get back to the hospital after

References: 2 or 3 with APA format

 

Soap Note 2 Chronic Conditions (15 Points)

Pick any Chronic Disease from Weeks 6-10

Follow the MRU Soap Note Rubric as a guide:

Use APA format and must include minimum of 2 Scholarly Citations.

Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)

Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 50%. Copy paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement.

Please use the sample templates for you soap note, keep these templates for when you start clinicals.

The use of templates is ok with regards of Turn it in, but the Patient History, CC, HPI, The Assessment and Plan should be of your own work and individualized to your made up patient

 

Musculoskeletal Results | Turned In Advanced Physical Assessment – March 2020, advanced_physical_assessment__td8__031720__sect1

Return to Assignment (/assignments/313477/)

Documentation / Electronic Health Record

Document: Provider Notes

Student Documentation Model Documentation

Subjective

This is a 28 yo pleasant african american female. She is the primary source of history and offers information freely. she speaks clearly and coherent and maintains contact throughout the exam. She presents to the clinic with c/o back pain for 3 days. Pain is 5/10, takes advil and pain reduces to 2-3/10. Her pain in her lower back and upper buttocks. Gets worse when she is laying down. Is able to perform her normal acitivities. Medication: Proventil, albuterol. advil for pain, PRN Med allergy: PCN: hives and rash Medical history: Diabetes no meds Asthma: on Proventil and albuterol. Controlled asthma with meds No surgical history. No hx of trauma No family history of musculskeletal system disease Family history of HTN and Diabetes

HPI: Ms. Jones presents to the clinic complaining of back pain th began 3 days ago after she “tweaked it” while lifting a heavy box while helping a friend move. She states that lifted several boxes before this event without incident and does not know the weight the box that caused her pain. The pain is in her low back and bilateral buttocks, is a constant aching with stiffness, and does n radiate. The pain is aggravated by sitting (rates a 7/10) and decreased by rest and lying flat on her back (pain of 3-4/10). The pain has not changed over the past three days and she has treat with 2 over the counter ibuprofen tablets every 5-6 hours. Her current pain is a 5/10, but she states that the ibuprofen can decrease her pain to 2-3/10. She denies numbness, tingling, mus weakness, bowel or bladder incontinence. She presents today as pain has continued and is interfering with her activities of daily liv Social History: Ms. Jones’ job is mostly supervisory, although sh does report that she may have to sit or stand for extended period time. She denies lifting at work or school. She states that her pai has limited her activities of daily living. She denies use of tobacc alcohol, and illicit drugs. She does not exercise. Review of Systems: General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats. • Musculoskeletal: Den muscle weakness, pain, joint instability, or swelling. She does sta that she has difficulties with range of motion. She does state tha pain in her lower back has impacted her comfort while sleeping a sitting in class. She denies numbness, tingling, radiation, or bowel/bladder dysfunction. She denies previous musculoskeleta injuries or fractures. • Neurologic: Denies loss of sensation, numbness, tingling, tremors, weakness, paralysis, fainting, blackouts, or seizures.

Your Results Lab Pass (/assignment_attempts/6633867/lab_pass.pd

Overview

Transcript

Subjective Data Collection

Objective Data Collection

Education & Empathy

Documentation

Document: Provider Notes

 

 

Student Documentation Model Documentation

Objective

HENT: WNL No abnormalities found Upper extremiteis: WNL: no abnormality found: ROM: wnl Spine: reduced ROM for extension and flexion and lateral bending Hips: ROM wnl Lower extremity: Root foot with scar: healed well . Strength tests all wnl for upper and lower extremities.

General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented. maintains eye contact throughout interview and examination. Musculoskeletal: Bilateral upper extremities without muscle atrop or joint deformity. Bilateral upper extremities with full range of mo of shoulder, elbow, and wrist. No evidence of swollen joints or sig of infection. Bilateral lower extremities without muscle atrophy or joint deformity, full range of motion of bilateral hips, knees, and ankles. No evidence of swollen joints or signs of infection. Flexio extension, lateral bending, and rotation of the spine with reduced ROM – pain and difficulty. Bilateral upper extremity strength equa and 5/5 in neck, shoulders, elbows, wrists, hands. Bilateral lowe extremity strength equal and 5/5 in hip flexors, knees, and ankles

Assessment

Lower Back Pain Low back muscle strain related to lifting

Plan

Refer to physical therapy Review body mechanics Advil prn as needed, Discuss exercise and weight bearing exercises Return to clinic if symptoms worsen

Provide Ms. Jones with materials detailing stretching techniques the lower back. • Initiate treatment with ibuprofen 600 mg by mo every six to eight hours with food as needed for pain for the next weeks. She may use acetaminophen 500-1000 mg by mouth eve hours for breakthrough pain. • Ms. Jones can also use adjunct therapy of topical heat or ice per comfort TID-QID. • Educate on proper body mechanics and lifting techniques. • Educate on whe seek emergent care including loss of bowel or bladder function, acute changes in sensation of lower extremities, or limitations in movement of lower extremities. • Return to clinic in two weeks fo follow up and evaluation of symptoms.

Comments

If your instructor provides individual feedback on this assignment, it will appear here.

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Neurological Results | Turned In Advanced Physical Assessment – March 2020, advanced_physical_assessment__td8__031720__sect1

Return to Assignment (/assignments/313478/)

Documentation / Electronic Health Record

Document: Provider Notes

Student Documentation Model Documentation

Subjective

Ms Jones who is african american pleasant female who presents to the clinic with c/o headache and neck stiffness She was in a slow moving car accident last week, and her symptoms just started two days ago. She was wearing her seat belt. She has a dull headache at the crown of her head and the back is at the back of her neck. She was no loss of consciousness. She takes tylenol which helps, with the pain 3/10. She feels her neck swollen, but has been resolving recently. Moving her neck hurts. ROS: She denies any fatigue, wt loss, fever or chills. Head: NO trauma, or LOC or dizziness,. Eyes: she wears reading glasses, and gets blurry when she reads to much. Ears: no hearing loss or ringing of her ears, no vertigo or earache. Denies any neck stiffnes. Musculoskeletal: denies problems with her ROM Denies any neurological disease or problems. No family hx of neurological disease or problems. Medical hx: Diabetes: no meds Asthma: Medications: Albuterol, proventil, tylenol and advil Allergy med: PCN: hives, and rash

HPI: Ms. Jones presents to the clinic complaining of a headache 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 spee 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 accompan by neck ache. She states that she feels as though her neck may slightly swollen as well. She did not lose consciousness in the accident and denies changes in level of consciousness since tha time. She states that she gets a headache every day that lasts approximately 1-2 hours. She occasionally takes 650 mg of over counter Tylenol with relief of the pain. She denies known associa symptoms. Review of Systems: General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats. • Head: Denies history trauma before this incident. Denies current headache. • Eyes: Sh does not wear corrective lenses, but notes that her vision has be worsening over the past few years, but no acute changes. She complains of blurry vision after reading for extended periods. De increased tearing or itching. • Ears: Denies hearing loss, tinnitus, vertigo, discharge, or earache. • Nose/Sinuses: Denies rhinorrhea Denies stuffiness, sneezing, itching, previous allergy, epistaxis, o sinus pressure. • Musculoskeletal: Denies muscle weakness, pai difficulties with range of motion, joint instability, or swelling. • Neurologic: Denies loss of sensation, numbness, tingling, tremor weakness, paralysis, fainting, blackouts, or seizures. Denies bow or bladder dysfunction. Denies changes in concentration, sleep, coordination, appetite.

Your Results Lab Pass (/assignment_attempts/6635634/lab_pass.pd

Overview

Transcript

Subjective Data Collection

Objective Data Collection

Education & Empathy

Documentation

Document: Provider Notes

 

 

Student Documentation Model Documentation

Objective

Oriented to person, place and time. Judgement and knowledge intact: Memory intact. no slurred speech Head: symmetrical no lesions, no trauma Weber test intact, rinne test intact, facial sensation intact, gag reflex intact Eyes: Blurry vision with prolong reading: Right eye vision 20/40: retina: with glacoma cupping. Left eye vision 20/20: retina: sharp edges Pupils: PERRL present Point to point intact for finger to nose, heel to shin. Sensation present in extremites except monofilament decreased sensation on foot. Present sensation at heels of both foot. DTR: 2+ for all reflexes Gait: wnl Graphesthesia: able to identify Sterognosis: able to identify

General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress, but appears uncomfortab while sitting in exam chair. She is alert and oriented. She maintai 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 visio 20/20. Right eye vision: 20/40. Left fundoscopic exam reveals sh disc margins, no hemorrhages. Right fundoscopic exam reveals retinopathic changes. Pupils equal, round, and reactive to light bilaterally. Extraocular movements intact bilaterally. Normal convergence. Facial sensation intact; facial features and symmet Rinne and Weber tests normal bilaterally. Gag reflex intact. Ability shrug shoulders symmetric; 5 strength against resistance. Neck full range of motion against resistance; 5 strength against resista 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 intac bilaterally. Gait steady with continuous, symmetric steps. Sensat intact to bilateral upper and lower extremities; sense of extremity position intact. Stereognosis and graphesthesia intact bilaterally.

Assessment

Headache and Neck pain due to s/p slow moving MVA Acute post-traumatic headache following low-speed MVA where Jones was a restrained passenger

Plan

Try Motrin 800mg po every 8 hours prn for headache Offer ice or heat to see if it helps with pain Educate on Warning signs: report any increase headache or worsening headaches, LOC, dizzinees or vomiting Education on exercises for ROM of neck Report to ER if headache is severe, LOC, nausea and vomiting, dizziness. Advise to have someone with her to watch her for the next 2 days if worsening symtoms. Telephone appt in 2 days to follow up with symptoms. Consider neuro consult if symptoms don’t resolve CAT scan if sx worsens or no improvement

Encourage Ms. Jones to continue to monitor symptoms and repo any increase in frequency or severity of her headaches. • Initiate treatment with ibuprofen 800 mg by mouth every 8 hours as nee 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 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 nause vomiting associated with headache, or numbness, tingling, or paralysis of new onset. • Ask Ms. Jones to call the office in two d to discuss symptoms. If no decrease in symptoms, order a computerized tomography scan or magnetic resonance imaging

Comments

If your instructor provides individual feedback on this assignment, it will appear here.

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Neurological Results | Turned In Advanced Physical Assessment – March 2020, advanced_physical_assessment__td8__031720__sect1

Return to Assignment (/assignments/313478/)

Transcript

Started: Apr 15, 2020 | Total Time: 126 min

Question 04/15/20 6:44 PM MD

Question 04/15/20 6:45 PM MD

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Your Results Lab Pass (/assignment_attempts/6635634/lab_pass.pd

Overview

Transcript

Subjective Data Collection

Objective Data Collection

Education & Empathy

Documentation

All Lines (286) Interview Questions (100) Statements (35) Exam Actions (151)

Hey.

What brings you to the clinic today

Well, I got into a little fender bender a week ago and I’ve been getting these headaches ever since. And my neck is sore too.

Thanks for saying that.

Thanks.

How long has this headache been

Well, I was in the car accident a week ago, but the headaches and neck stuff started a few days after that.

Where is the pain at

It’s really just been the headaches, but my neck is sore, too.

How long is the pain lasting

About an hour or two.

Can you describe the pain

The headaches feel like a dull ache, kind of in the crown of my head, and the back of my head.

 

 

Question 04/15/20 6:46 PM MD

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Is there anything that makes it feel better (Clarified to Is there anything that makes you feel better?.)

I’ve been taking Tylenol. And resting helps, too. (Clarified to if anything makes me feel better.)

How does it get worse (No matching questions found.)

is your pain any worse (Clarified to Is your pain getting worse?.)

No, it’s stayed about the same. (Clarified to if the pain is getting worse.)

is the pain radiating anywhere

Maybe? The soreness in my neck feels like it goes up into my head. But its just my neck and head that hurt.

Is there any symptoms that goes with it (Clarified to Are there any aggravating factors?.)

Moving my neck definitely makes it hurt more, but I’m not sure what causes the headaches . . . [AUDIO COMING SOON] (Clarified to if there are aggravating factors.)

What is the Pain Scale from 1 to 10 (Clarified to Can you rate your current pain level on a scale of 0 to 10?.)

It’s just my neck that hurts right now. . . I guess I’d say it’s a 3 out of 10. (Clarified to how I would rate my pain on a scale.)

Are you wearing a seatbelt

Yes, I always do.

Can you tell me how fast you were going (Clarified to How fast were you going?.)

Oh, it was really slow. We were in a parking lot. Maybe not even fifteen miles an hour. (Clarified to how fast I was going.)

Do you have any sweating

I don’t get sweaty, but sometimes I wake up hot and have to kick off my sheets.

Is your neck swollen

Yeah. It’s kind of hard to tell but I had a hard time buttoning one of my shirts last week. I think the swelling has gone down a little bit, though.

Did you lose consciousness

No.

 

 

Question 04/15/20 6:49 PM MD

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Do you feel tired or wheat

No, not really.

Do you have any fevers or chills

No, neither of those. [AUDIO COMING SOON]

Do you have any vision changes

Well, no, my vision hasn’t changed recently — not since the accident. But sometimes my vision gets blurry when I do a lot of reading… that’s been going on for awhile.

Do you have trouble hearing

My hearing is fine.

Do you feel faint

Nope.

Do you hear ringing of your ears

No, I don’t think so.

Talking to you using pain medication

I’ve been taking Tylenol.

What is your dosage of Tylenol (Clarified to What is the dose of Tylenol?.)

I’m not sure the actual dosage, but I generally take 2 regular strength pills. (Clarified to what dose of Tylenol I take.)

How often are you taking Tylenol

I’ve been taking it every day since I started getting these headaches.

Does it help with the pain (Clarified to Does the pain medication alleviate the pain?.)

Yeah, it has been helping some. (Clarified to if the pain medication helps.)

Do you have difficult range of motion (Clarified to Are you having difficulty moving your neck?.)

I can move my neck fine, but it hurts when I do. (Clarified to if I have a hard time moving my neck.)

 

 

Question 04/15/20 6:52 PM MD

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Do you have difficulty breathing (Clarified to Are you having difficulty breathing right now?.)

No, my breathing is fine right now. (Clarified to if I am having difficulty breathing now.)

Are you able to concentrate on task

Yeah, my concentration seems fine

Do you have trouble sleeping

Nope. I’ve been sleeping fine.

Do you have trouble hearing

My hearing is fine.

Do you have trouble walking

Nope.

What is your medical history

I’ve had asthma since I was little, and I have sugar diabetes, too.

Are you taking medication for diabetes

I don’t take anything for my diabetes anymore.

OK, I understand.

Are you taking medications for your asthma (Clarified to Do you use medication for your asthma?.)

I just use my inhaler. (Clarified to if I take anything to control my asthma.)

What medication are you using

Just some Tylenol for my headaches and my neck… and I use my daily inhaler, too.

What is your inhaler medication name

I have a Flovent daily inhaler and a Proventil rescue inhaler.

When was your last asthma attack

 

 

Question 04/15/20 6:55 PM MD

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Oh gosh, I guess probably the last time I had to go to the hospital for it, which was when I was sixteen. I definitely haven’t had one since high school.

Are you allergic to any medication

Yeah, I’m allergic to penicillin.

What happens with Penicillin

I don’t remember that well because the last time I had penicillin I was pretty little. . . I think I got a rash, like, hives. The doctor told me not to take it again after that.

What over the counter medication are you taking

Usually I’ll take Tylenol sometimes for a headache, and I take Advil for cramps. Lately I’ve been taking the Tylenol more than usual.

I appreciate you saying that.

Do you have any allergies

Yeah, I’m allergic to cats.

What happens with cats

Whenever I’m around cats, I start sneezing, my eyes get itchy. . . and my asthma starts to act up.

Do you get nosebleeds

No.

Do you have any muscle weakness

No, I wouldn’t say I feel weak.

Do you have trouble concentrating

No, not really.

Do you have trouble sleeping

Nope. I’ve been sleeping fine.

Do you have trouble eating

No, I really try not to worry too much about what I eat.

 

 

Question 04/15/20 6:58 PM MD

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Question 04/15/20 6:59 PM MD

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Question 04/15/20 7:00 PM MD

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Do you have any seizures

No. I’ve seen somebody have one, though. It’s scary.

Do illicit drugs

No.

Any changes in your bladder (Clarified to Have you had a recent change in your energy level?.)

No, I don’t think so. (Clarified to if my energy level has changed.)

Have you had any family history of neurological problems (Clarified to Have you had neurological problems?.)

Definitely not. (Clarified to if I have had neurological problems.)

Do you have any family history of neurological problems

I don’t think so.

Have you had any surgeries

Nope. No surgeries… I’ve been lucky.

Nausea and vomiting

No, not at all.

Have you placed ice on your neck

I just have this weird dark skin there. It’s not like scars or anything… I don’t know what it’s from.

Have you use heat or ice for your neck pain

I haven’t been doing anything in particular for my neck. . . just resting and trying not to move it too much.

Does your neck pain worse when sitting up

Yeah, my neck hurts when I move it.

I appreciate you telling me that.

Thanks for understanding.

 

 

Musculoskeletal Results | Turned In Advanced Physical Assessment – March 2020, advanced_physical_assessment__td8__031720__sect1

Return to Assignment (/assignments/313477/)

Documentation / Electronic Health Record

Document: Provider Notes

Student Documentation Model Documentation

Subjective

This is a 28 yo pleasant african american female. She is the primary source of history and offers information freely. she speaks clearly and coherent and maintains contact throughout the exam. She presents to the clinic with c/o back pain for 3 days. Pain is 5/10, takes advil and pain reduces to 2-3/10. Her pain in her lower back and upper buttocks. Gets worse when she is laying down. Is able to perform her normal acitivities. Medication: Proventil, albuterol. advil for pain, PRN Med allergy: PCN: hives and rash Medical history: Diabetes no meds Asthma: on Proventil and albuterol. Controlled asthma with meds No surgical history. No hx of trauma No family history of musculskeletal system disease Family history of HTN and Diabetes

HPI: Ms. Jones presents to the clinic complaining of back pain th began 3 days ago after she “tweaked it” while lifting a heavy box while helping a friend move. She states that lifted several boxes before this event without incident and does not know the weight the box that caused her pain. The pain is in her low back and bilateral buttocks, is a constant aching with stiffness, and does n radiate. The pain is aggravated by sitting (rates a 7/10) and decreased by rest and lying flat on her back (pain of 3-4/10). The pain has not changed over the past three days and she has treat with 2 over the counter ibuprofen tablets every 5-6 hours. Her current pain is a 5/10, but she states that the ibuprofen can decrease her pain to 2-3/10. She denies numbness, tingling, mus weakness, bowel or bladder incontinence. She presents today as pain has continued and is interfering with her activities of daily liv Social History: Ms. Jones’ job is mostly supervisory, although sh does report that she may have to sit or stand for extended period time. She denies lifting at work or school. She states that her pai has limited her activities of daily living. She denies use of tobacc alcohol, and illicit drugs. She does not exercise. Review of Systems: General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats. • Musculoskeletal: Den muscle weakness, pain, joint instability, or swelling. She does sta that she has difficulties with range of motion. She does state tha pain in her lower back has impacted her comfort while sleeping a sitting in class. She denies numbness, tingling, radiation, or bowel/bladder dysfunction. She denies previous musculoskeleta injuries or fractures. • Neurologic: Denies loss of sensation, numbness, tingling, tremors, weakness, paralysis, fainting, blackouts, or seizures.

Your Results Lab Pass (/assignment_attempts/6633867/lab_pass.pd

Overview

Transcript

Subjective Data Collection

Objective Data Collection

Education & Empathy

Documentation

Document: Provider Notes

 

 

Student Documentation Model Documentation

Objective

HENT: WNL No abnormalities found Upper extremiteis: WNL: no abnormality found: ROM: wnl Spine: reduced ROM for extension and flexion and lateral bending Hips: ROM wnl Lower extremity: Root foot with scar: healed well . Strength tests all wnl for upper and lower extremities.

General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented. maintains eye contact throughout interview and examination. Musculoskeletal: Bilateral upper extremities without muscle atrop or joint deformity. Bilateral upper extremities with full range of mo of shoulder, elbow, and wrist. No evidence of swollen joints or sig of infection. Bilateral lower extremities without muscle atrophy or joint deformity, full range of motion of bilateral hips, knees, and ankles. No evidence of swollen joints or signs of infection. Flexio extension, lateral bending, and rotation of the spine with reduced ROM – pain and difficulty. Bilateral upper extremity strength equa and 5/5 in neck, shoulders, elbows, wrists, hands. Bilateral lowe extremity strength equal and 5/5 in hip flexors, knees, and ankles

Assessment

Lower Back Pain Low back muscle strain related to lifting

Plan

Refer to physical therapy Review body mechanics Advil prn as needed, Discuss exercise and weight bearing exercises Return to clinic if symptoms worsen

Provide Ms. Jones with materials detailing stretching techniques the lower back. • Initiate treatment with ibuprofen 600 mg by mo every six to eight hours with food as needed for pain for the next weeks. She may use acetaminophen 500-1000 mg by mouth eve hours for breakthrough pain. • Ms. Jones can also use adjunct therapy of topical heat or ice per comfort TID-QID. • Educate on proper body mechanics and lifting techniques. • Educate on whe seek emergent care including loss of bowel or bladder function, acute changes in sensation of lower extremities, or limitations in movement of lower extremities. • Return to clinic in two weeks fo follow up and evaluation of symptoms.

Comments

If your instructor provides individual feedback on this assignment, it will appear here.

© Shadow Health 2012 – 2020 (800) 860-3241 | Help Desk (https://support.shadowhealth.com/) | Terms of Service (/static/terms_of_service) | Privacy Policy (/static/privacy_policy) | Patents

(https://www.shadowhealth.com/patents)

®

 

Neurological Results | Turned In Advanced Physical Assessment – March 2020, advanced_physical_assessment__td8__031720__sect1

Return to Assignment (/assignments/313478/)

Documentation / Electronic Health Record

Document: Provider Notes

Student Documentation Model Documentation

Subjective

Ms Jones who is african american pleasant female who presents to the clinic with c/o headache and neck stiffness She was in a slow moving car accident last week, and her symptoms just started two days ago. She was wearing her seat belt. She has a dull headache at the crown of her head and the back is at the back of her neck. She was no loss of consciousness. She takes tylenol which helps, with the pain 3/10. She feels her neck swollen, but has been resolving recently. Moving her neck hurts. ROS: She denies any fatigue, wt loss, fever or chills. Head: NO trauma, or LOC or dizziness,. Eyes: she wears reading glasses, and gets blurry when she reads to much. Ears: no hearing loss or ringing of her ears, no vertigo or earache. Denies any neck stiffnes. Musculoskeletal: denies problems with her ROM Denies any neurological disease or problems. No family hx of neurological disease or problems. Medical hx: Diabetes: no meds Asthma: Medications: Albuterol, proventil, tylenol and advil Allergy med: PCN: hives, and rash

HPI: Ms. Jones presents to the clinic complaining of a headache 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 spee 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 accompan by neck ache. She states that she feels as though her neck may slightly swollen as well. She did not lose consciousness in the accident and denies changes in level of consciousness since tha time. She states that she gets a headache every day that lasts approximately 1-2 hours. She occasionally takes 650 mg of over counter Tylenol with relief of the pain. She denies known associa symptoms. Review of Systems: General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats. • Head: Denies history trauma before this incident. Denies current headache. • Eyes: Sh does not wear corrective lenses, but notes that her vision has be worsening over the past few years, but no acute changes. She complains of blurry vision after reading for extended periods. De increased tearing or itching. • Ears: Denies hearing loss, tinnitus, vertigo, discharge, or earache. • Nose/Sinuses: Denies rhinorrhea Denies stuffiness, sneezing, itching, previous allergy, epistaxis, o sinus pressure. • Musculoskeletal: Denies muscle weakness, pai difficulties with range of motion, joint instability, or swelling. • Neurologic: Denies loss of sensation, numbness, tingling, tremor weakness, paralysis, fainting, blackouts, or seizures. Denies bow or bladder dysfunction. Denies changes in concentration, sleep, coordination, appetite.

Your Results Lab Pass (/assignment_attempts/6635634/lab_pass.pd

Overview

Transcript

Subjective Data Collection

Objective Data Collection

Education & Empathy

Documentation

Document: Provider Notes

 

 

Student Documentation Model Documentation

Objective

Oriented to person, place and time. Judgement and knowledge intact: Memory intact. no slurred speech Head: symmetrical no lesions, no trauma Weber test intact, rinne test intact, facial sensation intact, gag reflex intact Eyes: Blurry vision with prolong reading: Right eye vision 20/40: retina: with glacoma cupping. Left eye vision 20/20: retina: sharp edges Pupils: PERRL present Point to point intact for finger to nose, heel to shin. Sensation present in extremites except monofilament decreased sensation on foot. Present sensation at heels of both foot. DTR: 2+ for all reflexes Gait: wnl Graphesthesia: able to identify Sterognosis: able to identify

General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress, but appears uncomfortab while sitting in exam chair. She is alert and oriented. She maintai 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 visio 20/20. Right eye vision: 20/40. Left fundoscopic exam reveals sh disc margins, no hemorrhages. Right fundoscopic exam reveals retinopathic changes. Pupils equal, round, and reactive to light bilaterally. Extraocular movements intact bilaterally. Normal convergence. Facial sensation intact; facial features and symmet Rinne and Weber tests normal bilaterally. Gag reflex intact. Ability shrug shoulders symmetric; 5 strength against resistance. Neck full range of motion against resistance; 5 strength against resista 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 intac bilaterally. Gait steady with continuous, symmetric steps. Sensat intact to bilateral upper and lower extremities; sense of extremity position intact. Stereognosis and graphesthesia intact bilaterally.

Assessment

Headache and Neck pain due to s/p slow moving MVA Acute post-traumatic headache following low-speed MVA where Jones was a restrained passenger

Plan

Try Motrin 800mg po every 8 hours prn for headache Offer ice or heat to see if it helps with pain Educate on Warning signs: report any increase headache or worsening headaches, LOC, dizzinees or vomiting Education on exercises for ROM of neck Report to ER if headache is severe, LOC, nausea and vomiting, dizziness. Advise to have someone with her to watch her for the next 2 days if worsening symtoms. Telephone appt in 2 days to follow up with symptoms. Consider neuro consult if symptoms don’t resolve CAT scan if sx worsens or no improvement

Encourage Ms. Jones to continue to monitor symptoms and repo any increase in frequency or severity of her headaches. • Initiate treatment with ibuprofen 800 mg by mouth every 8 hours as nee 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 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 nause vomiting associated with headache, or numbness, tingling, or paralysis of new onset. • Ask Ms. Jones to call the office in two d to discuss symptoms. If no decrease in symptoms, order a computerized tomography scan or magnetic resonance imaging

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Musculoskeletal Results | Turned In Advanced Physical Assessment – March 2020, advanced_physical_assessment__td8__031720__sect1

Return to Assignment (/assignments/313477/)

Transcript

Started: Apr 15, 2020 | Total Time: 79 min

Question 04/15/20 4:42 PM MD

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Your Results Lab Pass (/assignment_attempts/6633867/lab_pass.pd

Overview

Transcript

Subjective Data Collection

Objective Data Collection

Education & Empathy

Documentation

All Lines (235) Interview Questions (76) Statements (55) Exam Actions (104)

Hey.

May I ask what brings you in today (No matching questions found.)

She went to the clinic today (No matching questions found.)

What brings you into the clinic this morning

Well, I have a lot of pain in my lower back. It really hurts, and it doesn’t seem to be going away. It’s making it kind of hard to get things done, so I decided to come in and have it looked at.

Thanks for understanding.

May I ask when did this pain start (Clarified to When did the pain start?.)

It started three days ago, right when I first tweaked my back. (Clarified to when the pain started.)

Do you have any medical history of muscular skeletal system

Other than my back? I have diabetes and asthma.

What are you taking for diabetes

I don’t take medicine for it anymore.

What are you taking for your asthma

 

 

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I have a Flovent daily inhaler and a Proventil rescue inhaler.

How often are you using your proventil

I haven’t used my rescue inhaler in months — not since I started the daily Flovent one.

That makes sense.

Can I ask where is the pain located

It hurts in my lower back and even, like, the top of my butt.

How long does it pain last

It’s pretty constant.

What does it feel like

It’s like. . . an ache.

Is there something that makes it worse

Well, I’ve been taking Advil for it. Otherwise the only thing that really helps is lying flat on my back.

How often are you taking Advil

I’ve been taking them every five or six hours, like it says on the bottle.

How many days have you been taking it (Clarified to For how many days have you been on pain pills?.)

I’ve been taking the Advil about three days, maybe a little less–since the night after I hurt myself. (Clarified to how many days I have been taking pain pills.)

Is there something that makes your back pain worse

It definitely feels worst when I’m sitting up. Moving around can make it hurt more, too.

Is there anything related with the back pain

Taking Advil has been helping a little. . . and it feels better when I lie flat on my back.

Does your back pain radiates anywhere

No, it isn’t spreading.

 

 

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Are you able to walk okay

I can walk, but it does hurt a little.

Do you need to use a walker

I can walk, but it does hurt a little.

From 1 to 10 what is your pain scale (Clarified to Can you rate your current back pain level on a scale of 0 to 10?.)

Without medication, it depends on what position I’m in, but I’d say probably it averages about 5 out of 10. (Clarified to to rate my back pain on a scale.)

When you take the medication what is your pain scale

When the Advil’s just kicking in the pain goes down to a 2 or 3 out of 10, I’d say.

Are you having any joint pain

No, my joints feel fine.

Are you able to stand up

It actually feels a little better when I’m standing than when I’m sitting.

Have you had history of muscle soreness before

Sore muscles aren’t usually a problem for me, but I think it’s this muscle in my back that is causing me so much pain. [AUDIO COMING SOON]

May I ask what do you do at work

Well, since being promoted to supervisor, I’ve been in charge of scheduling other employees, taking inventory, and placing orders for supplies. I’m still on the floor a lot though, dealing with customers and that sort of thing. It’s mostly a lot of standing and walking around.

Have you had any muscle injury

Well, I guess it’s the muscle in my back that’s hurting.

Has this ever happened before (No matching questions found.)

Did you have this problem before

No, nothing like this has ever happened to me. . . my back is usually totally fine.

 

 

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Do you have a family history of back pain

No, I don’t think so.

Do you have any family medical history

My mom has some issues, and I think some of my grandparents did, too.

What is your mother’s medical history

Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though.

What is your medical history of your grandparents

Well. . . I have diabetes. And asthma.

Are you allergic to any medication

Yeah, I’m allergic to penicillin.

What happens if penicillin

I don’t remember that well because the last time I had penicillin I was pretty little. . . I think I got a rash, like, hives. The doctor told me not to take it again after that.

Are you taking any other medication

I’ve been taking Advil for my back, and I also have my inhalers.

Are you taking any illicit drugs

No.

Have you ever had ligament sprain

No.

Have you found any history of muscular skeletal system (No matching questions found.)

do you have family history of skeletal muscular problems

Not that I know of.

Able to do your daily activities (Clarified to Are you able to perform all of your usual daily activities?.)

 

 

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Well, I came in because the pain wasn’t going away, and I can’t really sit or move a lot. But I can do everything I need to, it’s just much harder. (Clarified to if I am able to perform daily activities.)

Do you have muscle weakness

No, I wouldn’t say I feel weak.

Do you have problems with your pelvic area

I’ve always been a little on the heavy side, but I think that’s just how my body is. I don’t struggle with it.

Do you exercise daily

I don’t usually exercise much, and I definitely haven’t since this happened.

do you have Arthritis

No, I don’t, fortunately.

Hip pain radiate anywhere

No, it isn’t spreading.

Have you had any trauma

No, nothing like this has ever happened to me. . . my back is usually totally fine.

Do you have family history of osteoporosis

No.

I appreciate you telling me that.

OK, I understand.

Do you have any muscular skeletal problems

Well, I guess it’s the muscle in my back that’s hurting.

Is that all (No matching questions found.)

Thanks for telling me.

Sure, I think I understand what you mean.

 

 

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Alright, thanks for letting me know.

That makes sense.

Does your hands feel swollen (Clarified to Are your hands numb?.)

I haven’t been numb anywhere. (Clarified to if my hands are numb.)

Does your arms feel cold

No, it’s just my back that hurts.

Hurt to move your arms

No, it’s just my back that hurts.

Do you get carpal tunnel (No matching questions found.)

Do you have carpal tunnel (No matching questions found.)

does your hands swell (Clarified to Do your hands feel cold?.)

No. (Clarified to if my hands are cold.)

do you have \Carpal tunnel (No matching questions found.)

do you have Carpal tunnel (No matching questions found.)

Do you have problems with your hands

Nope.

Thanks for telling me.

Thanks for saying that.

Can you point to the pain

The pain’s just in my back and the top of my butt.

Have you had any surgery

Nope. No surgeries… I’ve been lucky.

 

 

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OK, I understand.

Does your thighs hurt (No matching questions found.)

do you have pain in your thighs (No matching questions found.)

do you have pain on your thigh

Nope.

Sure, I think I understand what you mean.

Alright, thanks for letting me know.

Do they get swollen (No matching questions found.)

Do your ankles get swollen (Clarified to Are your ankles giving you trouble?.)

My ankles are fine. [AUDIO COMING SOON] (Clarified to if I have ankle problems.)

I appreciate you saying that.

Sure, I think I understand what you mean.

That makes sense.

OK, I understand.

Do you feel any pain

Yes! My back feels really bad right now.

Do you have neck pain

No, there’s nothing going on with my neck. . . it’s just my back that’s bothering me.

Thanks for telling me.

Alright, thanks for letting me know.

Sure, I think I understand what you mean.

Do you have any pain

Yes! My back feels really bad right now.

 

 

Question 04/15/20 5:22 PM MD

Question 04/15/20 5:27 PM MD

Thanks for telling me.

Alright, thanks for letting me know.

That makes sense.

OK, I understand.

Alright, thanks for letting me know.

Does your left side hurt

Nope.

Thanks for telling me.

Thanks.

OK, I understand.

That makes sense.

Sure, I think I understand what you mean.

OK, I understand.

I appreciate you telling me that.

Thanks for telling me.

Alright, thanks for letting me know.

Rotate your left foot away from you so you can see the bottom outer edge of the foot (No matching questions found.)

Sure, I think I understand what you mean.

That makes sense.

OK, I understand.

Thanks for telling me.

Sure, I think I understand what you mean.

Alright, thanks for letting me know.

That makes sense.

 

 

Question 04/15/20 5:56 PM MD

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Question 04/15/20 5:59 PM MD

OK, I understand.

Alright, thanks for letting me know.

Sure, I think I understand what you mean.

Thanks for telling me.

That makes sense.

Sure, I think I understand what you mean.

Thanks for understanding.

OK, I understand.

Alright, thanks for letting me know.

That makes sense.

Thanks for telling me.

OK, I understand.

That makes sense.

Thanks for telling me.

What is your diet like

It’s pretty good, I think. I’m not a huge health nut or anything.

Have you had a change of weight

No, I don’t really think so.

Have you gained weight recently (Clarified to Have you gained or lost weight recently?.)

No, I don’t really think so. (Clarified to if I have gained or lost weight recently.)

Are you having trouble eating (Clarified to Do you have problems eating food?.)

No, I really try not to worry too much about what I eat. (Clarified to if I have problems with eating.)

Sciatica pain (No matching questions found.)

 

 

Question 04/15/20 5:59 PM MDdo you have sciatica pain

I don’t have that. Or, no one’s told me I do. [AUDIO COMING SOON]

Comments

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