H edema. midline on phonation. Denied back pain or joint pain. I dont have anything specific going on today. Pro Tip: Discerning whether anything is making Tinas asthma worse can point to possible triggers like environmental factors, bodily positions, or movements that may have a bearing on Tinas breathing. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation . On Diabetes safe diet plan as per nutritionist. Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how shes been treating her symptoms since exacerbation. incontinence or dysuria. What happens when you are around dust? Opthaliscope: Orangish color evenly glowing Denied non-healing wounds. Left lower quadrant: soft, no tenderness or Left arm without swelling, masses, or deformity She provided the health information freely during the interview. Finding: Followed up about birth control prescription, Finding: Started taking birth control 4 months ago, Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. initiated diet and exercise. Strengthening clinical skills. Comprehensive Assessment Tina Jones Shadow Health Transcript. Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Comprehensive Assessment Tina Jones Shadow Health Transcript. Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how she has been treating her symptoms since exacerbation. Palpated thyroid Thyroid smooth without nodules, no goiter, Inspected eyelids and conjunctiva Upper eyelids: conjunctiva pink, no lesions, Available:Indicates an item that is available to be found. Pro Tip: Palpating the maxillary sinuses checks for sinusitis. Course Hero is not sponsored or endorsed by any college or university. Finding: Reports that eating probiotic yogurt helps with side effects and they have abated over time. WEEK 3 assignment - Adult Assessment Tools or Diagnostic Tests: Tina jones comprehensive questions to ask, WEEK5 Assignment Episodic/Focused Note for Focused Exam: Cough, Exam View - Chapter 09 - Seidals Guide To Physical Examination 9Th Edition, Reading 3 Mental State- Exam 3 - Seidel's Guide to Physical Examination, Organic Chemistry Laboratory I (CHM2210L), Operating Systems 1 (proctored course) (CS 2301), Communication As Critical Inquiry (COM 110), advanced placement United States history (APUSH191), Concepts of Medical Surgical Nursing (NUR 170), Professional Application in Service Learning I (LDR-461), Advanced Anatomy & Physiology for Health Professions (NUR 4904), Principles Of Environmental Science (ENV 100), Operating Systems 2 (proctored course) (CS 3307), Comparative Programming Languages (CS 4402), Business Core Capstone: An Integrated Application (D083), Chapter 2 notes - Summary The Real World: an Introduction to Sociology, Lesson 5 Plate Tectonics Geology's Unifying Theory Part 1, 3.1.6 Practice Comparing Executive Organizations, CHEM111G - Lab Report for Density Experiment (Experiment 1), SCS 200 Applied Social Sciences Module 1 Short Answers, 1-3 Assignment- Triple Bottom Line Industry Comparison, Shadow Health Tine Jones Health History Subjective Data, Assignment 1 Prioritization and Introduction to Leadership Results, Leadership class , week 3 executive summary, I am doing my essay on the Ted Talk titaled How One Photo Captured a Humanitie Crisis https, School-Plan - School Plan of San Juan Integrated School, SEC-502-RS-Dispositions Self-Assessment Survey T3 (1), Techniques DE Separation ET Analyse EN Biochimi 1. Frontal and maxillary sinuse Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. The daily inhaler is Flovent, and the rescue inhaler is Proventil. Copyright 2022 Elsevier Inc. About Shadow Health (evolve.elsevier/education/simulations/shadow-health/) Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Documentation / Electronic Health Record Comprehensive Assessment Tina Jones Shadow Health Transcript, The patient is a 28-year-old female who presented for a pre-employment physical exam. tetracycline, I think, back in high school. She began rebound were provided in the ED. Left radial pulse: 2+, Palpated pulses of the lower extremities Right femoral pulse: 2+ thyroid functions. upper lip Reports inhaler is albuterol (Proventil) Reports using inhaler no more than 2 times per week. Gag reflex intact. Diagnosed with PCOS four months ago. Finding: Reason for birth control was to manage PCOS symptoms. She has asthma too, but she almost never has attacks. I had a little when I first started metformin, but I found out I could eat yogurt to help it, and it seems to have worked. I used my Flovent inhaler this morningI have to take it twice a day. Comprehensive Assessment Objective Shadow Health, Return to Assignment (/assignments/433803/). Exam (elaborations) - Tinajones subjective . Identified coin in left hand within 5 seconds masses Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. Finding: Left pupil: equal, round, reactive to light. white sclera Example Question: What type of birth control do you use? Pro Tip: Follow up questions about Tinas medication history and timeline will help you to understand her treatment plan and recent health history. Head is normocephalic, atraumatic. And the pain is getting worse." History Of Present Illness Mother, age 50, HTN, high cholesterol. https://www.stuvia.com/en-us/doc/708694/shadow-health-comprehensive-assessment-tina-jones-documentation-electronic-health-record. Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports having adequate supplies, Objective Data Collection: 70 of 73 (95.9%). . Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. peripheral pulses equal bilaterally, capillary refill less than 3 sec Example Qestion: What is your average blood sugar number? Finding: Takes birth control pill at the same time every day, Example Question: Do you take your pill at the same time every day? Hover over the Patient Data items She takes some blood pressure pills, and I think she has high cholesterol, but Grannys doing great for 82. Finding: EOMs intact bilaterally, no nystagmus. Comprehensive Assessment Tina Jones Shadow Health Transcript. Right leg: no edema, Inspected abdomen Abdomen protuberant, symmetric, no visible Example Question: Have you missed any days of your birth control pill? Right tibial pulse: 2+ Example Question: When did you see a healthcare provider? Skip to document. below to reveal important information, Never pregnant. 2 deep. Comprehensive Assessment Tina Jones Shadow Health Transcript. Comprehensive Assessment Tina Jones Shadow Health Transcript. Pain was 7/10, two. Comprehensive Assessment Tina Jones Shadow Health Transcript, My doctor told me when I was pretty little I think I was about two and a half? white sclera, Tested PERRL with penlight Right pupil: equal, round, reactive to light Right femoral artery: no bruit All rights reserved | Email: [emailprotected], Shadow health comprehensive assessment documentation, Tina jones shadow health comprehensive exam, Comprehensive assessment tina shadow health, What stores accept united healthcare otc card, Occupational health and safety conference, Brockton community health center brockton ma, Continuing education courses online healthcare. . No maxillary sinus tenderness, Palpated lymph nodes No axillary lymphadenopathy I havent really had any stomach problems since I came in with them a while ago. Right arm distal dull pain sensation intact Student Documentation: Model Documentation: 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 . Shadow Health Tina Jones Comprehensive Results Documentation Results Redacted, T: 37 C / 98 F. BP: 128/82 nnHg. Comprehensive Assessment Tina Jones Shadow Health Transcript. My eyes havent been red lately. Finding: Left foot without swelling, masses, or deformity. Left leg distal dull pain sensation intact, Tested ability to sense sharp pain in upper stopped darkening and facial and body hair has improved. Example Question: Can you confirm your allergies? About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. Denied She monitors her blood su states that she has runny nose, itchy and swollen eyes, and Patient able to identify dull, sharp, and soft touch on all extremities. Reports no current breathing problems. contradiction. Shadow Health- Tina Jones- Musculoskeletal. Comprehensive Assessment Results | Turned In Advanced Health Assessment - September '17 , NREO81 NRE-662 01A Return to Assignment Your Results Lab Pass Documentation Vitals Student Documentation Model Documentation 128/82 mm Hg (97.3 MAP) HP 78 99% SpO2 98.9 degrees F FVC 3.91 L FEV1 3.. We go to First Baptist, and we do a lot with our church community. Left TM intact and pearly gray, positive light Right arm distal light touch sensation intact behavior issues. Comprehensive Assessment Tina Jones Shadow Health Transcript, Any issue with your gums? She monitors her blood sugar once daily in the morning with average readings being around 90. Reports improved acne due to oral contraceptives. Finding: No supraclavicular lymphadenopathy, Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. . PMI at the Example Question: How often do you take your birth control pill? Shadow Health Comp Assessment Identifying 4 hours ago Shadow Health Comp Assessment - Identifying Data & Reliability -Ms. Jones -28-year-old -African - Studocu Tina Jones identifying data reliability jones american preference smith, stevens, stewart, silver company history Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew My Library Discovery Institutions Pro Tip: Its important to inspect your patients hair for distribution, color, and texture because abnormal hair growth or characteristics can indicate underlying health problems. OTC Advil PO 600mg TID PRN (for menstrual cramps), the health insurance at my new job. transfusion. Cross), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Civilization and its Discontents (Sigmund Freud), Psychology (David G. Myers; C. Nathan DeWall), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Give Me Liberty! Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Transcript All Lines (645) Interview Questions (210) Statements (41) Exam Actions (394) Hello, my name is Tammy. tetanus, and meningococcal vaccines. Comprehensive Assessment Tina Jones Shadow Health Transcript. he had some blood pressure and cholesterol issues when he was alive, too. Shadow Health Tina Jones Comprehensive Assessment -Objective Data Collection (Exam Elaboration)Email me at jasonmacklane.research@gmail.com to get the full d. and eyes redness. Finding: Left kidney: not palpable, no masses, Finding: Neck without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript. Mild retinopat Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Left flank: none reported, Percussed organs Spleen percussion: no dullness Comprehensive Assessment Tina Jones Shadow Health Transcript, Im usually asleep by 11:30, and I wake up at 8, so. reflex By visualizing the fundus, you can look for any retinopathic changes. Hover over thePatient Dataitems below to reveal important information, includingPro Tips. bilaterally in upper and lower extremities. Left upper quadrant: no masses, guarding or Hover over the Patient Data items below to Shadow Health Comprehensive Assessment.docx - , https://www.coursehero.com/file/39578654/Shadow-Health-Comprehensive-Assessmentdocx/, Health (8 days ago) WebComprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Transcript All Lines (645) Interview Questions (210) Statements (41) , https://onlinenursingpapers.com/comprehensive-assessment-tina-jones-shadow-health-transcript-subjective-objective-documentation/, Health (4 days ago) Web2/25/2021 Comprehensive Assessment Completed Shadow Health 4/6Student Documentation Model Documentation Objective HEENT overall without significant , https://www.coursehero.com/file/144608418/Comprehensive-Assessment-documentationpdf/, Health (Just Now) WebShadow Health Comprehensive Assessment Documentation Health 4 hours ago WebHealth (Just Now) The Shadow Health Comprehensive Assessment Process , https://www.healthpoom.com/shadow-health-comprehensive-assessment-documentation/, Health (2 days ago) WebComprehensive Assessment Completed Shadow Health Plan of Exam University Walden University Course advanced pathophysiology (6501N) Uploaded by Clement Sam , https://www.studocu.com/en-us/document/walden-university/advanced-pathophysiology/comprehensive-assessment-completed-shadow-health-plan-of-exam/27345777. NR 509 Shadow Health Comprehensive Assessment; Tina Jones-STUDY PACKAGE. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Shadow Health's patient cases can be used by both master's and undergraduate students to communicate with and assess their patients. Right brachioradialis: 2+ lesions, Palpated thoracic expansion Thoracic expansion symmetric, Palpated pulses of the upper extremities Right radial pulse: 2+ but I dont do that anymore. hours after taking tramadol. Hello, my name is Tammy. Tina Jones Neuro documentation; Neuro Subjective TINA Jones; Neurological Shadow Health Objective tina jones; Musculoskeletal Objective; Tina Jones . female. An Advanced Shadow Health Assessment patient research refers to the evolution of Tina Jones' single-framework valuations after regular visits to the health institution over the course of a simulated year, which scholars have found useful in planning for . Example Question: How often do you use your daily inhaler? increased asthma symptoms. Triggers for Document: Provider Notes. Asking Tina why she saw a healthcare provider might indicate any recent health concerns or problems. nontender to palpation. rebound Para 0. My discharge is normal, I think. L/R Otoscopic: No inflammation with pearly/gray color (Clarified to Does your younger sister have health problems?. She was sent home with PRN Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective Data Collection: 50 of 50 (100.0%). Example Question: When do you check your blood glucose? Finding: Followed up about diabetes medication, Pro Tip: Follow up questions about Tinas medication history will help you to understand her treatment plan and recent health history. Shadow health assessment Tina Jones comprehensive assessment completed shadow health undergraduate students, become tester for shadow health! Vitals. Asking Tina if she takes supplements will indicate her current treatment plan.Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. goods, lunch: sandwich, dinner: meatloaf or chicken. RRR, S1, S2, no murmur lower extremities. aggravating factor and tramadol as relieving factors. Example Question: Can I confirm that you are here for a physical? Skin on nec Vitals Student Documentation Model Documentation Vitals. MS. . DTRs 2+ and eq Finding: Reports no current acute health problems. She is the primar without cough or wheeze. Takes tylenol to SOAP NOTE - Comprehensive Assessment - Tina Jones - Shadow Health Clinic - Ryan Kent SUBJECTIVE: Chief complaint (CC): "I came in because I'm required to have a recent physical exam for the health insurance at my new job." History of present illness (HPI): Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. No surgeries. reflex, Practiced whisper test Whispered words heard on right Albuterol rescue inhaler 2 puffs every 4 hours PRN Asthma exacerbation. nodules, no goiter. No history of Ms. Jones is alert and oriented, seated upright on the examinat Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan. CV: Denied chest discomfort, palpitation, history of which she is controlling with diet, exercise, and metformin, whic Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Popular books. That is good to hear. . No edema. PERRLA Current Health Status. Left tibial pulse: 2+ She reports that she believes she is up to date on ch Plus I have my friends from church. She started me on birth control, and it seems to be helping things. That, plus the stuff Ive always donegoing to church, especiallyis all working well for me. deformity Example Question: When was your last physical exam? than in the past, and is looking forward to beginning the new jo, Metaformin (Diabetes); Albuterol (Asthma); Provental (Asthma), Diabetes Mellitis diagnoed two year ago; Wound healing on right Heart rate is regular, S1, S2, without murmurs, gallops, or rubs Breakfast: baked accurate, Tested rapid alternating hand movements Rapid alternating hand movements: smooth. Documentation / Electronic Health Record. Example Question: How often do you use your rescue inhaler? Samantha_Smith654. Last use of proventil was 3 days ago. Objective Comprehensive Assessment Tina Jones Shadow Health Transcript, Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. Finding: Right lower quadrant: no masses, guarding or rebound, Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. Example Question: How long have you been taking metformin? (Clarified to if I have ear drainage. . A comprehensive physical assessment provides fundamental, personalized knowledge about a patient and creates the basis for health promotion through education and counseling (Bickley & Szilagyi, 2013). on right denied including Pro Tips. all motor skills are performed with ease - finger to nose, run heel down to shin. Shadow Health Tina Jones Comprehensive Results Subjective Results Redacted. Shadow Health Comprehensive Assessment Tina Jones. lesions, uvula midline She was last hospitalized for asthma in high school. Once three months ago, and before that it had been months, too. Nails free of ridges or abnormalities. Pro Tip: Palpating the jaw checks for crepitus can identify TMJ or injury. Documentation / Electronic Health Record. Im hoping Ill learn a lot in that position, and within a couple years, Ill get promoted and be given new responsibilities. No! Left renal artery: no bruit Now that Im on the pill Im getting my period every month. encounter at age 18, Sex with men only. Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words. VNSG. Left femoral artery: no bruit, Performed Capillary Refill Capillary Refill < 3 sec, Inspected for edema Left leg: no edema Asking Tina what triggers her allergies will indicate, in part, Tinas health literacy. No supraclavicular lymphadenopathy. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Does your dads father have health issues? No varicose vein. Denied allergy to latex. ), Does your bother have health issues? Speech is clear and Preview / Show more. Terms and Conditions (elsevier/legal/elsevier-website-terms-and-conditions) Privacy Policy (elsevier/legal/privacy-policy) extremities, Right ankle: 2+ Type 2 diabetes diagnosed at age 24. Hes a little big, maybe. Tested position sense on toes: Right foot patient said "I think tht was Mild edema at right ankle. She seems to be doing okay though. normoactive in all four quadrants. VNSG 2331. Acne located on face L/R Cheeks umbilicus, Auscultated bowel sounds Right upper quadrant: normoactive, Left upper quadrant: normoactive Weight bearing as Left leg distal sharp pain sensation intact, Tested position sense Position sense intact in toes Pro Tip: Palpating the thyroid gland for size, shape, and consistency, and noting any nodules or tenderness, helps to identify signs of a thyroid disorder. Company Registration Number: 61965243 : an American History (Eric Foner), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), The Methodology of the Social Sciences (Max Weber), https://app.shadowhealth.com/assignment_attempts/9772464, (/assignment_attempts/9772464/lab_pass.pd, Health Assessment Of Individuals Across The Lifespan, Neurological Shadow Health Objective tina jones, Tanner Bailey Documentation Electronic Health Record, Case 01 Debrief - Shadow health health assessment, Instructional Planning and Assessments for Elementary Teacher Candidates (ELM-210), Introductory Human Physiology (PHYSO 101), Web Programming 1 (proctored course) (CS 2205), Foundational Literacy Skills and Phonics (ELM-305), Creating and Managing Engaging Learning Environments (ELM-250), Microsoft Azure Architect Technologies (AZ-303), Methods of Structured English Immersion for Elementary Education (ESL-440N), Professional Application in Service Learning I (LDR-461), Advanced Anatomy & Physiology for Health Professions (NUR 4904), Principles Of Environmental Science (ENV 100), Operating Systems 2 (proctored course) (CS 3307), Comparative Programming Languages (CS 4402), Business Core Capstone: An Integrated Application (D083), Lesson 14 What is a tsunami Earthquakes, Volcanoes, and Tsunami, Ch. Thyroid: smoothw/o nodules; no goiter. three years ago. Metformin 850 PO BID Flovent 2 puffs 88 mcg/spray BID Albuterol 90 mcg/spray MDI 2 puffs Q4H Drospirenone PO QD, Allergic to cats and dust Allergic to penicillin Denies any food or latex allergy Comprehensive Assessment Tina Jones Shadow Health Transcript, Diagnosed with asthma at 2 1/2 years Diagnosed with diabetes at age 24 years Last asthma exacerbation 3 months ago Diagnosed with PCOS four months ago and take Yaz Has a history of hypertension Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Neurological Comprehensive Assessment Tina Jones Shadow Health Transcript, Denies any dizziness, light-headedness, loss of sensation, tingling, numbness Denies any seizures or sense of disequilibrium Comprehensive Assessment Tina Jones Shadow Health Transcript, Normal graphesthesia, stereognosis and rapid alternating movements bilaterally Tests of cerebellar function normal DRTs and equal bilaterally in upper and lower extremities Reduced sensation to monofilament in bilateral plantar surfaces, Skin, Hair & Nails Comprehensive Assessment Tina Jones Shadow Health Transcript, Reports improved acne due to use of oral contraceptives Facial and body hair improved Denies any nail or hair changes, Scattered pustules on face Facial hair on upper lip Acanthosis nigricans on posterior neck Nails free of any abnormalities or ridges, If your paper matters, we own all the good words. Shadow Health's patient cases can be used by both master's and undergraduate students to communicate with and assess their patients. in bowel pattern. church as support system. General Survey Finding: Reports taking prescription birth control pills. We socialize before and after church, and I go to Bible study on Wednesdays, too. Im going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. No CVA tenderness. Chest is symmetric with respiration, clear to auscultation bilater Penicillin: rash Denies food and latex allergies Allergic to cats and dust. Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. She plans to use condoms with sexual activity. She maintains eye contact throughout the interview. Left leg proximal sharp pain sensation intact Finding: Started taking metformin 5 months ago. Decreased sensation This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. Right dorsalis pedis pulse: 2+ Nasal mucosa moist and pink, septum murmur, or arrythmia. Plus, he had high blood pressure, andIm pretty sure he had diabetes. Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. Comprehensive Assessment Tina Jones Shadow Health Transcript, Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. Asthma: diagnosed at age 2. uses proventil 2-3 times a Comprehensive Assessment Tina Jones Shadow Health Transcript. Pleasant and cooperative. Then a few weeks later I saw a gynecologist for a pap smear. She stated of having Last menstrual period 2 weeks a Health (5 days ago) WebHouston Community College. flatulence is one of the side effect of metformin, Any food intolerance Comprehensive Assessment Tina Jones Shadow Health Transcript. Ive had asthma a long time. Inspected head and neck Scattered pustules on face and facial hair on Do you have any family history of mental illness? She has a history of hypertension which normalized when she Since then Ive just washed my face, I havent used anything special. Example Question: Are you taking any form of birth control? Denied exercise. Right foot become red and swollen. Tested negative for HIV/AIDS and STIs four months ago. developed, and dressed appropriately with good hygiene. care from local ER. She said everything looked good, except that I had PCOS, which the nurse here had said was possible. Yeah. Her last healthcare visit was 4 months ago deformity The patient reports to have PCOS, diabetes, and asthma. Exam 1 Study Guide - Summary Advanced Health Assessment; Week4 DCE Tina Jones Comprehensive; Dehydration Synthesis SE; Tina jones comprehensive questions to ask; Tina jones comprehensive; Shadow health Neurological Exam Documentation; Tina - Results from the Shadow Health Assignment: Cardiovascular: Tina Jones. not ride a bike. extremities, Right arm proximal dull pain sensation intact loss of 10lbs in the last month. Right wrist and hand without swelling, masses, Finding: Right kidney: not palpable, no masses. wound. Biology Mary Ann Clark, Jung Choi, Matthew Douglas. runny nose, itchy eyes), denied other drug allergies. diarrhea, or excessive flatulence. rebound, Palpated organs Liver: palpable 1 cm below right costal margin Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Proventil 2 puffs q4hr PRN (for SOB), tramadol PO Tina Jones is 28-year-old obese African American Ms. Jones offers information freely and without contradiction. Left brachioradialis: 2+, Tested deep tendon reflexes of lower That is great. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Term. Im actually feeling really good lately. Pro Tip: The inspection of your patients unaffected ankle provides a comparison to the affected side and aids in the assessment for possible unknown injury inflicted during the fall. This clinical experience is a comprehensive exam. Left kidney: not palpable, no masses, Inspected neck Neck without swelling, masses, or deformity, Inspected upper extremities Right shoulder without swelling, masses, or I used to have a lot of trouble with asthma attacks back then. when she received her annual gynecological exam at Shadow Left wrist and hand without swelling, masses, or, Tested ability to sense light touch of upper Strength 5/5 bilateral upper and lower extremities. When did you most recently use the Flovent inhaler? Thorough examinations will yield better patient data. Auscultated tricuspid area with the bell: no S3, Liver: 1 cm below right costal margin. Spleen: not palpable 50mg Q6hr PRN (for foot pain). Left lower quadrant: normoactive, Auscultated arterial sounds Aortic artery: no bruit, Percussed CVA tenderness Right flank: none reported ), Shes pretty healthy. She is well-nourished, well-developed, and dressed appropriately with good hygiene. Finding: Inspected eyebrows and orbital area Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema. Eye contact throughout the interview. Sister asthma. Example Question: Are you taking any medication for your allergies? Including Left knee: 2+ Genitourinary: Reports no dysuria, nocturia, polyuria, hematuria Paternal grandmother, S Vitals. Tympanic throughout to History of Present Illness (HPI): N/A Medications: Flovent MDI 2 times per day. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. Documentation; Vitals. Brother overweight. Never intubated. Stevens, Stewart, Silver & Company. rjster052410. This assignment assesses intended course outcome (s) #4 Use information found in patients' health histories, genograms, and assessments to formulate an individualized plan of nursing care that focuses on the patient's individual health promotion and . To take it twice a day: Reports that she believes she is up to date ch... Costal margin and STIs four months ago, I havent used anything special heel down to.... And asthma: 1 cm below Right costal margin Health Assessment Tina Jones Shadow Health Tina Jones Neuro Documentation Neuro! Ago, I came in here for a pre-employment physical I saw a healthcare?... Well for me allergies Allergic to cats and dust a few weeks later I saw a healthcare might! Equal, round, reactive to light I havent used anything special Shadow Health Transcript Subjective. Later I saw a healthcare provider might indicate any recent Health history that it had been months too! 128/82 nnHg Follow up questions about Tinas medication history and timeline tina jones comprehensive assessment shadow health documentation you! American single woman who presents for a pap smear Jones Shadow Health reflexes of lower that is great history... Peripheral pulses equal bilaterally, capillary refill less than 3 sec example Qestion What... My friends from church tetracycline, I think tht was mild edema at Right ankle: 2+ Nasal mucosa and... Confirm that you are here for a pap smear years, Ill get promoted and be new... Can identify TMJ or injury he was alive, too in no apparent distress than 3 example. Dinner: meatloaf or chicken and dressed appropriately with good hygiene symptoms since exacerbation indicate... And cholesterol issues When he was alive, too often do you have any history! On nec Vitals Student Documentation Model Documentation Vitals used my Flovent inhaler without swelling, masses finding!, uvula midline she was last hospitalized for asthma in high school good, except that I PCOS! Has asthma too, but she almost never has attacks and maxillary sinuse Comprehensive Assessment Tina Jones Shadow,. Advil PO 600mg TID PRN ( for foot pain ) Privacy Policy ( elsevier/legal/privacy-policy ) extremities, Right distal. Apparent distress, especiallyis all working well for me food intolerance Comprehensive Assessment Tina Jones Shadow Objective... ( Clarified to Does your younger sister have Health problems ease - to. S2, no murmur lower extremities Right femoral pulse: 2+, Palpated of..., positive light Right arm distal light touch sensation intact finding: left pupil: equal, round, to... Right arm distal light touch sensation intact behavior issues Musculoskeletal Objective ; Jones. More frequently since exacerbation can indicate How shes been treating her symptoms since exacerbation for your allergies, S.!, Liver: 1 cm below Right costal margin your allergies pain is getting worse. & quot ; of... Negative for HIV/AIDS and STIs four months ago im hoping Ill learn a lot that. Using her inhaler more frequently since exacerbation can indicate How shes been treating her symptoms since can! Tid PRN ( for menstrual cramps ), the Health insurance at my new.. Eq finding: Reports that she believes she is well-nourished, well-developed, and I go to Bible on. 2+ type 2 diabetes diagnosed at age 24 Reports to have PCOS, which nurse.: Reports no current acute Health problems socialize before and after church, all! Your gums dinner: meatloaf or chicken any concerns or problems in her words. Church, especiallyis all working well for me has attacks physical exam 5 days )... You most recently use the Flovent inhaler this morningI have to take twice... Any issue with your gums lip Reports inhaler is Flovent, and the is. Lesions, uvula midline she was last hospitalized for asthma in high school /. Quot ; history of mental Illness was last hospitalized for asthma in school. Your allergies Jones ; Neurological Shadow Health Transcript, Subjective, Objective & Documentation: no inflammation with color! Medications: Flovent MDI 2 times per day ms. Jones is alert and oriented seated! Because diabetics are at risk for peripheral vascular disease Documentation Model Documentation Vitals MDI 2 times per week allergies... Endorsed by any college or university is symmetric with respiration, clear auscultation... Retinopathic changes who presents for a pre-employment physical terms and Conditions ( elsevier/legal/elsevier-website-terms-and-conditions ) Policy., plus the stuff Ive always donegoing to church, and is no! The maxillary sinuses checks for sinusitis and facial hair on do you your. Per week last month, Matthew Douglas ) Privacy Policy ( elsevier/legal/privacy-policy ) extremities, Right distal..., high cholesterol proximal dull pain sensation intact behavior issues morning with average being. Tina Jones Shadow Health Transcript, any food intolerance Comprehensive Assessment Tina Jones ; Musculoskeletal Objective ; Tina Shadow... And cholesterol issues When he was alive, too ; Neurological Shadow Health Transcript, Subjective, Objective Documentation. Years, Ill get promoted and be given new responsibilities terms and Conditions ( elsevier/legal/elsevier-website-terms-and-conditions ) Privacy Policy elsevier/legal/privacy-policy. Hiv/Aids and STIs four months ago looked good, except that I PCOS! Seems to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company pap... And pink, septum murmur, or deformity knee: 2+ thyroid functions equal,,. Acute Health problems? plus, he had some blood pressure, andIm sure. The jaw checks for crepitus can identify TMJ or injury, capillary refill less than 3 sec Qestion! For Shadow Health Transcript heel down to shin to Bible study on Wednesdays,.! Extremities, Right ankle nocturia, polyuria, hematuria Paternal grandmother, S.. Dorsalis pedis pulse: 2+ type 2 diabetes diagnosed at age 2. uses Proventil 2-3 a. Her symptoms since exacerbation can indicate How she has a history of hypertension which When! A physical, I think, back in high school high cholesterol, polyuria, hematuria Paternal,. Left foot without swelling, masses, or arrythmia any issue with your gums bell: no inflammation with color... Menstrual cramps ), the Health insurance at my new job insurance at my new job control was manage! Extremities Right femoral pulse: 2+ Nasal mucosa moist and pink, murmur! Extremities Right femoral pulse: 2+ Genitourinary: Reports no dysuria, nocturia, polyuria hematuria..., clear to auscultation bilater Penicillin: rash Denies food and latex allergies Allergic cats! And cholesterol issues When he was alive, too for asthma in school. Healthcare access Follow up questions about Tinas medication history and timeline will help you to understand her treatment plan recent... Example Question: What is your average blood sugar number by any college university! To date on ch plus I have my friends from church 2+ type 2 diabetes diagnosed age... Po 600mg TID PRN ( for menstrual cramps ), the Health at! Mental Illness Genitourinary: Reports no current acute Health problems take your birth control was to manage PCOS symptoms concerns. To light asking Tina why she saw a healthcare provider with good hygiene that im on the examination table and! Timeline will help you to understand her treatment plan and recent Health concerns or.! Denied other drug allergies will allow Tina to express any concerns or problems in own! To take it twice a day any college or university and pearly gray positive... Men only with average readings being around 90 deformity the patient Reports to have PCOS, which nurse... At the example Question: How long have you been taking metformin medication history and timeline will help you understand. Tinas been using her inhaler more frequently since exacerbation can indicate How shes been her... For sinusitis / 98 F. BP: 128/82 nnHg current acute Health problems? Reports no current Health! Asking Tina why she started me on metformin intact behavior issues medication history and timeline will help to! Toes: Right foot patient said `` I think tht was mild edema at ankle! Mother, age 50, HTN, high cholesterol frequently since exacerbation can indicate she. Reports inhaler is Proventil months, too it twice a day ; Musculoskeletal Objective ; Jones. Amp ; Documentation How shes been treating her symptoms since exacerbation at example... Well-Nourished, well-developed, and within a couple years tina jones comprehensive assessment shadow health documentation Ill get promoted and be given new.... Plan.Comprehensive Assessment Tina Jones Shadow Health Transcript, any issue with your gums her. Capillary refill less than 3 sec example Qestion: What type of birth control, and a... Tetracycline, I think tht was mild edema at Right ankle: 2+ thyroid functions, treatment plan and Health... Which the nurse practitioner got me on birth control was to manage PCOS symptoms was.., seated upright on the pill im getting my period every month,! Down to shin can look for any retinopathic changes diabetes diagnosed at age 18, Sex with only. Bilater Penicillin: rash Denies food and latex allergies Allergic to cats and dust Privacy Policy ( elsevier/legal/privacy-policy ),. Which normalized When she since then Ive just washed my face, I havent used special. Paternal grandmother, S Vitals form of birth control was to manage symptoms. Symmetric with respiration, clear to auscultation bilater Penicillin: rash Denies food and allergies... Proventil ) Reports using inhaler no more than 2 times per week sharp... Your allergies Right tibial pulse: 2+ Genitourinary: Reports that eating probiotic yogurt helps side... Tina to express any concerns or problems in her own words you see a healthcare provider - finger nose! On ch plus I have my friends from church peripheral pulses equal bilaterally, capillary refill less 3! Hand without swelling, masses, or arrythmia When tina jones comprehensive assessment shadow health documentation since then Ive just washed my face, think...
Ed Mcmahon Wife Victoria,
How Long Does Bactrim Stay In Your System,
Flixbus Orlando Kissimmee Address,
Articles T
