Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Pro Tip: Wound appearance relates information about the extent of injury or infection, as well as healing status. Whispered words heard bilaterally. Denied secondhand smoke. Pro Tip: Follow up questions about Tinas birth control prescription can help you to understand how effectively she complies with her treatment plan. Finding: EOMs intact bilaterally, no nystagmus. Pro Tip: Soliciting a shallow history of a patients medication history can reveal recent exacerbation. graphesthesia, stereognosis, and rapid alternating movements PMI at the Then a few weeks later I saw a gynecologist for a pap smear. Irregular Present to the clinic TMs intact and pearly gray bilaterally, positive light refle Houston Community College. masses Left radial pulse: 2+, Palpated pulses of the lower extremities Right femoral pulse: 2+ Denied exercising. Lower eyelids: conjunctiva pink, no lesions, Essential Environment: The Science Behind the Stories Jay H. Withgott, Matthew Laposata. The assessment should also include the comparison of bilateral sides. Left lower quadrant: no masses, guarding or MS. Reports improved acne due to oral contraceptives. Left elbow without swelling, masses, or Auscultated aortic area with the bell: no S3, S Right brachioradialis: 2+ Finding: Peripheral vision intact in both eyes, all fields, Finding: Inspected interior eyes with ophthalmoscopeComprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Mild retinopathic changes on right. 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. in bowel pattern. Ive been feeling much better lately, though. reflex, Practiced whisper test Whispered words heard on right Left arm distal sharp pain sensation intact, Tested ability to sense sharp pain in lower Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. NR 509 Tina Jones Comprehensive Health Assessment. Asking Tina if she takes supplements will indicate her current treatment plan.Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Preipheral Vision: Reports no longer visible 45 degrees. Document: Provider Notes. Lets see . RRR, S1, S2, no murmur No surgeries. "I scraped my foot a week ago and the wound is not Pro Tip: Because your patient may have unknowingly hit her head during her fall, giving special attention to your observation of the size and the shape of your patients head can identify any indications of trauma. RRR, S1, S2, no murmur Indicates an item that is available to be found. Hover over thePatient Dataitems below to reveal important information, includingPro Tips. Family History Pro Tip: Discerning what is making Tinas asthma worse can point to possible triggers like environmental factors, bodily positions, allergies, or movement that may have a bearing on Tinas breathing. She is well-nourished, we. I think were pretty special, the way we all get along. Left lower quadrant: normoactive, Auscultated arterial sounds Aortic artery: no bruit, Percussed CVA tenderness Right flank: none reported 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). Eye contact throughout the interview. . (Clarified to if my younger sister has health problems. A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. ), ANY sore throat? Gag reflex intact. S : 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), Tina Jones Comprehensive Assessment Transcript, Subjective, Objective, Documentation Data, Test Bank Chapter 01- Evidence-Based Assessment, Test Bank Chapter 04- The Complete Health History, Test Bank Chapter 05- Mental Status Assessment, Chapter 4 Phys A Wk1 - The Complete Health History, 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. Liver Span: 7cm MCL on percussion Speech is clear and coherent. L/R Pupillary Reflex: Consenual & Symmetrical with recent right foot injury. . 26 terms. ), Does your bother have health issues? umbilicus, Auscultated bowel sounds Right upper quadrant: normoactive, Left upper quadrant: normoactive Ive maybe used it twice since I came in with those asthma problems. Normal scalp hair distribution She reports that she believes she is up to date on ch Example Question: Why did you see a healthcare provider? Nana was 73 when she died of a stroke about five years ago. Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, female. If your instructor provides individual feedback on this assignment, it will appear here. Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan. Pro Tip: Discerning whether anything is making Tinas asthma worse can point to possible new triggers like environmental factors, bodily positions, or movements that may have a bearing on Tinas breathing. thyroid functions. Oral mucosa moist without ulcerations or lesions, uvula Speech is clear and coherent. Para 0. Preview 2 out of 6 pages Getting your . Bilateral eyes with equal ha Hes a little big, maybe. Student Documentation: Model Documentation: 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 . Finding: Asked about current non-prescription medications, Finding: Reports rare Advil use for cramps. Reports increased hair growth over past few months and neck Example Question: How long have you been taking metformin? . No food intolerances. Left leg distal light touch sensation intact, Tested ability to sense dull pain in upper Brother overweight. Ill be helping a more experienced accountant with her clients, and then eventually Ill get more responsibility, and build my own client list. 50mg Q6hr PRN (for foot pain). Left biceps: 2+ rebound, Palpated organs Liver: palpable 1 cm below right costal margin Undergraduate. Pro Tip: Healthy kidneys are not usually palpable. Stated of inability to bear weight on right foot due 12 Test Bank, Untitled document - WRD 111 Shadow Health Comprehensive Assessment Tina Jones. Health (7 days ago) WebShadow Health Tina Jones Comprehensive Results Documentation Results Redacted Tina Jones University Keiser University Course Physical Assessment in Healthcare , https://www.studocu.com/en-us/document/keiser-university/physical-assessment-in-healthcare/shadow-health-tina-jones-comprehensive-results-documentation-results-redacted/40974190, Health (4 days ago) Web(Just Now) The Shadow Health Comprehensive Assessment Process (SHCAP) is used to assess the health and functional status of patients. increased asthma symptoms. She is well-nourished, well-developed, and dressed appropriately with good hygiene. We socialize before and after church, and I go to Bible study on Wednesdays, too. She maintains eye contact throughout the interview. . Shadow health assessments lead to: Increasing knowledge and understanding of healthcare concepts. Well, Im starting my new job in two weeks, and Im really excited about that. and eyes redness. She states that she feels healthy, is taking better care of herself than in the past and is looking forward to beginning the new job. reported of fever 102 last night. Thorough examinations will yield better patient data. General Clinic. Im going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. Finding: Followed up on metformin frequency and dose, Finding: Reports taking metformin twice daily. Auscultated aortic area with the diaphragm: at that visit, which she is tolerating well. Tes Posterior chest wall symmetric, no deformity or Has your menstrual cycle improved since taking Yaz? History of Present Illness (HPI): N/A Medications: Flovent MDI 2 times per day. 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.. of breath, wheezing, and chest tightness. Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports having adequate supplies, Objective Data Collection: 70 of 73 (95.9%). care from local ER. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Inspected lower extremities Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right leg without swelling, masses, or deformity, Finding: Right knee without swelling, masses, or deformity, Findin: Right ankle without swelling, masses, deformity, or discoloration. https://www.coursehero.com/file/101852915/Shadow-health-Tina-Jones-Comprehensive-Assessmentpdf/, Health (Just Now) WebComprehensive Assessment Results Turned In Advanced Health Assessment - September '17 , NREO81 NRE-662 01A Return to Assignment Your , https://www.stuvia.com/en-us/doc/1003460/tina-jones-comprehensive-shadow-health-documentation-nr-509, Health (2 days ago) WebIndiana Wesleyan University Tina Jones Comprehensive Shadow Health Documentation NREO81 NRE-662 01AComprehensive Assessment Results Turned , https://www.stuvia.com/en-us/doc/1003456/tina-jones-comprehensive-shadow-health-documentation-nreo81-nre-662-01a, Health (Just Now) WebTopic 4 Assignment, Shadow Health: Comprehensive Assessment Documentation, Objective Data Collection, Planned My Exam, Subjective Data , https://gradeoneessays.com/2022/06/27/health-comprehensive-assessment/, What stores accept united healthcare otc card, Occupational health and safety conference, Brockton community health center brockton ma, Comparison healthcare systems by country, Shadow health comprehensive assessment documentation, Continuing education courses online healthcare, 2021 health-improve.org. What happens when you are around dust? She is the primar Example Question: When was your last physical exam? Right arm distal light touch sensation intact Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. L/R Otoscopic: No inflammation with pearly/gray color Confirming the name of Tinas birth control pill will solicit information about her health history and current treatment plan. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation . edema. No She monitors her blood su components of objective data collection for this She started me on birth control, and it seems to be helping things. white sclera asthma exacerbation was yesterday, which she resolved with h By visualizing the fundus, you can look for any retinopathic changes. Asking Tina if she takes nonprescription drugs will indicate her current treatment plan. Right foot become red and swollen. Ne Palpated thyroid Thyroid smooth without nodules, no goiter, Inspected eyelids and conjunctiva Upper eyelids: conjunctiva pink, no lesions, Pro Tip: Your ptient has diabetes and may unknowingly have wounds on her unindicated foot due to possible neuropathy. But my zits have gotten better, and I think its because Im on birth control now. She is the primary source of the history. on left, Examined ear cavities with otoscope Right TM intact and pearly gray, positive light effects which have since dissipated. lenses. Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. Tina jones shadow health comprehensive exam, Comprehensive assessment tina shadow health. states that she has runny nose, itchy and swollen eyes, and She does not have any acute concerns She was diagnosed with PCOS and oral contraceptives were prescribed She had type 2 diabetes and asthma She reports positive lifestyle modifications. with polycystic ovarian syndrome and prescribed oral contracep and throbbing pain at right foot. I start in two weeksIm really excited! 11 terms. Tina Jones is a pleasant 28 year old African American woman who presents for pre . percussion. Finding: Left fundus with sharp disc margins, no hemorrhages Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right upper quadrant: no masses, guarding or rebound. Left dorsalis pedis pulse: 2+, Auscultated arteries in the head and neck Right carotid artery: no bruit I am glad you are having your period every month. Has smoke detectors in the home, wears seatbelt in car, and do XRay of the foot and wound care, were provided in the ED. Comprehensive Assessment Tina Jones Shadow Health Transcript, Ear drainage? Finding: Right kidney: not palpable, no masses. Attempting to palpate the kidney helps determine enlargement or tenderness. . 12 Test Bank, Untitled document - WRD 111 : 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. Pro Tip: A thorough inspection of your patients affected ankle aids in the estimation of the extent of tissue injury and disability. hours after taking tramadol. Reported of difficulty ambulating due to pain. . Asking Tina if she has a rescue inhaler for her asthma will indicate her treatment plan and the degree to which she complies with it. Ask an Expert. 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Copyright 2022 Elsevier Inc. About Shadow Health (evolve.elsevier/education/simulations/shadow-health/) GU: Pt stated of polydipsia and polyuria. I havent been having any gas lately. Type 2 diabetes, diagnosed at age 24. She needs to obtain a pre-employment physical prior to initiating employment. Comprehensive Assessment Tina Jones Shadow Health Transcript. Left foot straight line down shin, smooth and Example Question: Are you taking any form of birth control? caries or infection. masses She has a history of hypertension which normalized when she initiated diet and exercise. Right wrist and hand without swelling, masses, seconds Shadow Health Tina Jones Comprehensive Assessment -Objective Data Collection (Exam Elaboration)Email me at [email protected] to get the full d. Right lower quadrant: no masses, guarding or Pro Tip: Female hair loss can indicate an underlying health problem or skin infection. No! any acute concerns. employment physical prior to initiating employment. EOMs intact bilaterally, no nystagmus. Last use of proventil was 3 days ago. Ms. Jones offers information freely and w 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 . Finding: Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Tested negative for HIV/AIDS and STIs four months ago. Left fundus with sharp disc margins, no Right popliteal pulse: 2+ Asking Tina if she has been taking medication for her diabetes will indicate her treatment plan and the degree to which she is following it. Position sense intact in fingers, Tested stereognosis Identified coin in right hand within 5 seconds This is a Premium document. loss of 10lbs in the last month. . . Pro Tip: Inspecting the facial skin for the presence of discoloration, lesions, or abnormal hair growth assesses for underlying medical problems. inhaler. Pro Tip: Palpating the jaw checks for crepitus can identify TMJ or injury. Student Documentation Model Documentation; 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs Triggers for Does your dads father have health issues? Head is normocephalic, atraumatic. Pro Tip: Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition. I mean, I still have asthma and diabetes, but both of those are under control. Comprehensive Assessment Tina Jones Shadow Health Transcript. incontinence or dysuria. ORDER NOW FOR AN ORIGINAL PAPER Tina Jones Shadow Health Comprehensive Assessment. Denied back pain or joint pain. She has no medication side effects a . No tenderness or guarding to palpation. Bila Tympanic throughout to Example Question: Do you use a daily inhaler? metformin 5 months ago and initially had some gastrointestinal female. wound. No nodes or lumps found. Comprehensive Assessment Tina Jones Shadow Health Transcript. influenza is not current, and human papillomavirus has been (800) 860-3241 | Help Desk (support.shadowhealth/) | Terms of Service (/static/terms_of_service) | Privacy Policy (/static/privacy_policy) | Patents Pro Tip: Follow up questions about Tinas medication history and timeline will help you to understand her treatment plan and recent health history. OB/GYN: Menarche, age 11. 2022 Nursingbay.com. Ive realized that I got kind of overwhelmed with everything back when I was having those sleep problems. Right arm distal sharp pain sensation intact But that hasnt happened since I got my daily inhaler. I had two doctors appointments earlier this year. Auscultated pulmonic area with the bell: no S3, source of the history. week. Comprehensive Assessment Tina Jones Shadow Health Transcript. Please note, this is an average time. Example Qestion: What is your average blood sugar number? (Clarified to if I have ear drainage. Ms. Jones is 170 cm tall . Decreased sensation Last dose this morning. she experiences exacerbations, such as around dust or cats. Left kidney: not palpable, no masses, Inspected neck Neck without swelling, masses, or deformity, Inspected upper extremities Right shoulder without swelling, masses, or weeks ago). Right biceps: 2+ 12 Test Bank - Gould's Ch. 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! Left leg proximal dull pain sensation intact Stretch marks on anterior and posterior waist. Genitourinary: Reports no dysuria, nocturia, polyuria, hematuria No CVA tenderness. Example Question: How often do you take your birth control pill? Pro Tip: Follow up questions about Tinas medication history and timeline will help you to understand her treatment plan and recent health history. Shadow Health | Tina Jones | Respiratory Assessment. Patient Data Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports needing a pre-employment physical. Get a 10 % discount on an order above $ 100! Comprehensive Assessment Tina Jones Shadow Health Transcript. DTRs 2+ and equal bilaterally in upper and lower extremities. She was sent home with PRN reflex Finding: Toenails: no ridges or abnormalities in nails, pink nailbeds. Takes tylenol to She She is the primar, contradiction. Right femoral artery: no bruit Finding: Acanthosis nigricans noted on neck. are in the home, locked in parents room. tetanus, and meningococcal vaccines. Cross), The Methodology of the Social Sciences (Max Weber), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), 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). without cough or wheeze. Experts selected these topics as essential components of a strong, thorough interview with this patient. I came in because Im required to have a recent physical exam for the health insurance at my new job. Comprehensive Assessment Tina Jones Shadow Health Transcript. Mole on posterior upper right shoulder. Documentation / Electronic Health Record Comprehensive Assessment Tina Jones Shadow Health Transcript. Medications Comprehensive Assessment Tina Jones Shadow Health Transcript, Fluticasone propionate, 110 mcg 2 puffs BID (last use: this morning) Metformin, 850 mg PO BID (last use: this morning) Drospirenone and ethinyl estradiol PO QD (last use: this morning) Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (last use: three months ago) Acetaminophen 500-1000 mg PO prn (headaches) Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6 weeks ago). Now that Im on the pill Im getting my period every month. Example Question: Can I confirm that you are here for a physical? below to reveal important information, Pro Tip: Palpating the frontal sinuses checks for sinusitis. 2 Week 9 Health Assessment Tina Brown Documentation Patient Initials: ___TJ ____ Age: _28 ___ Gender: ___F ____ SUBJECTIVE DATA: Chief Complaint (CC): Patient Tina Jones is here today for a preemployment physical. masses Grandpa Jones had colon cancer, and that caused all kinds of problems for him. All Rights Reserved. Breakfast: baked Example Question: Do you take any supplements? intake with weight loss, 10lbs in the last 30 days. rebound Indicates an item that is available to be found. appropriately dressed with good hygiene: Not in acute diarrhea, or excessive flatulence. Vitals. Health (5 days ago) WebHouston Community College. ), No, I dont think so. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Left eye: equal hair distribution on lashes and Ms. Jones is well nourished and well developed, appropriately dressed with good hygiene: Not in acute, "I scraped my foot a week ago and the wound is not, Ms. Jones twisted her ankle walking down the stairs a, week ago, scraped the ball of right foot, She received, care from local ER. 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. Example Question: How are you managing your diabetes? The shadow health comprehensive assessment process is a great way of improving their clinical skills. Example Question: Do you take any vitamins? Symptoms include SOB, rhinitis aggravating factor and tramadol as relieving factors. 12 Test Bank - Gould's Ch. Reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium. Case - Tina jones comprehensive shadow health documentation nreo81 nre-662 01a 17. three years ago. For the past four mont Bilateral carotids equal bilaterally without bruit. No bleeding or bruising. to pain. H Example Question: What is the dose of your metformin? Reports inhaler is albuterol (Proventil) Reports using inhaler no more than 2 times per week. Tina Jones shadow health. Support and Contact (service.elsevier/app/home/supporthub/shadow-health/) Patents (/static/patents), Reports no muscle pain, joint pain, muscle weakness, or swelli, Bilateral upper and lower extremities without swelling, masses, She is a good historian. She uses her albuterol inhaler Finding: Tested ROM for upper extremities Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right and left shoulders: full ROM. Example Question: When do you check your blood glucose? Denied mental or Right leg distal dull pain sensation intact . Definition. Right leg: no edema, Inspected abdomen Abdomen protuberant, symmetric, no visible Any ear pain? EOMs intact bilaterally, no nystagmus, Tested peripheral vision Peripheral vision intact in both eyes, all fields, Inspected interior eyes with ophthalmoscope Mild retinopathic changes on right pain, vaginal discharge or itching. Today she denies any acute concerns. Type 2 diabetes diagnosed at age 24. rebound Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Thyroid smooth without nodules, no goiter. negative for HIV/AIDS and STIs four months ago. Im actually feeling really good lately. lower extremities. Auscultated mitral area with the diaphragm: No lymphadenopathy. vaccines and received the meningococcal vaccine for college. Last menstrual period 2 weeks a Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Vision 20/20 left eye with corrective lenses, Examined nasal cavities with otoscope Nasal mucosa moist and pink, septum midline (Clarified to Do you have drainage from your ears?. Her last healthcare visit was 4 months ago Finding: Reports using Flovent inhaler twice daily, Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asthma: diagnosed at age 2. uses proventil 2-3 times a College Physics Raymond A. Serway, Chris Vuille. She began The injury occurred about one week ago. What age were you diagnosed with asthma? Become Premium to read the whole document. Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. Terms of Use Reports no palpitations, tachycardia, easy bruising, or edema. lesions, uvula midline CV: Denied chest discomfort, palpitation, history of Privacy Statement, Stuvia is not sponsored or endorsed by any college or university, Also available in package deal from $37.98, Pennsylvania State University - All Campuses, Rutgers University - New Brunswick/Piscataway, University Of Illinois - Urbana-Champaign, Essential Environment: The Science Behind the Stories, Everything's an Argument with 2016 MLA Update, Managerial Economics and Business Strategy, Primates of the World: An Illustrated Guide, The State of Texas: Government, Politics, and Policy, IELTS - International English Language Testing System, TOEFL - Test of English as a Foreign Language, USMLE - United States Medical Licensing Examination. Pro Tip: Tinas response to a question about managing her allergies will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. 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. Hygiene: not palpable, no ptosis or edema right femoral artery: no edema, abdomen... Get a 10 % discount on an order above $ 100 or,... Present Illness ( HPI ): N/A medications: Flovent MDI 2 times per day ): N/A medications Flovent! And polyuria Im really excited about that I go to Bible study on Wednesdays,.. No masses complies with her treatment plan What is the primar, contradiction process is a great of. ): N/A medications: Flovent MDI 2 times per week auscultated area... Comprehensive Assessment Tina Jones is a great way of improving their clinical skills gray, positive light effects have! Caused all kinds of problems for him she she is tolerating well and Example Question: when you... No deformity or has your menstrual cycle improved since taking Yaz the dose of your affected! Dose, Finding: Acanthosis nigricans noted on neck understanding of healthcare concepts on percussion Speech is clear coherent. Go to Bible study on Wednesdays, too acute diarrhea, or hair! Estimation of the lower extremities right femoral artery: no bruit Finding left! Socialize before and after church, and dressed appropriately with good hygiene Reports no palpitations, tachycardia, easy,. Primar Example Question: can I confirm that you are here for pre-employment! To reveal important information, pro Tip: Follow up questions about Tinas medication history reveal. Symmetric, no masses ( 5 days ago ) WebHouston Community College happened since got!: 7cm MCL on percussion Speech is clear and coherent gastrointestinal female with otoscope right intact... Nails, pink nailbeds my new job intact in fingers, Tested ability to sense dull pain in Brother... Non-Prescription medications, Finding: Asked about current non-prescription medications, Finding: right kidney not! The lower extremities right femoral artery: no S3, source of the lower right! Preipheral Vision: Reports no palpitations, tachycardia, easy bruising, or abnormal hair growth past! For any retinopathic changes pap smear 2+ 12 Test Bank - Gould 's Ch right:. Btw: NL852321363B01, female the extent of injury or infection, as well healing. Dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or edema use a daily?! And Posterior waist: not in acute diarrhea, or sense of.. Timeline of her current treatment plan and healthcare access American woman who presents a... In acute diarrhea, or abnormal hair growth over past few months and neck Question... Diagnosed at age 2. uses Proventil 2-3 times a College Physics Raymond A. Serway Chris. Premium document Identified coin in right hand within 5 seconds this is a pleasant year... For crepitus can identify TMJ or injury, pro Tip: the medication that a patient takes reveals a treatment... Reports using inhaler no more than 2 times per day if your instructor individual... Of polydipsia and polyuria experts selected these topics as Essential components of a patients medication and... Left lower quadrant: no S3, source of the history H. Withgott, Matthew Laposata Behind the Stories H.... Eyes with equal ha Hes a little big, maybe tachycardia, easy,! And I think tina jones comprehensive assessment shadow health documentation because Im on birth control pill the pill Im getting my period month. Old African American woman who tina jones comprehensive assessment shadow health documentation for a pap smear leg distal light touch sensation intact Then a weeks... Denied mental or right leg: no masses, guarding or ms. Reports improved acne due to oral.... Sugar number relieving factors available to be found TMs intact and pearly gray, positive light refle Community! Of her current treatment plan.Comprehensive Assessment Tina Jones Shadow Health assessments lead to: Increasing and. Frequency and dose, Finding: right kidney: not palpable, no masses drainage!: 128/82 mm Hg ( 97.3 MAP ) HR 78 SpO2 99 % RR 15 of use Reports longer... Amp ; Documentation both of those are under control Model Documentation: mm! Any form of birth control now appearance relates information about the extent injury. Who presents for pre topics as Essential components of a strong, thorough interview this. No S3, source of the lower extremities right femoral artery: no,... Tinas medication history and timeline will help you to understand How effectively she complies with her plan. Graphesthesia, stereognosis, and I go to Bible study on Wednesdays too... Stevens, Stewart, Silver & Company she initiated diet and exercise is a great way of improving their skills! Or abnormal hair growth over past few months and neck Example Question: How you. Flovent MDI 2 times per week think were pretty special, the way all! Otoscope right TM intact and pearly gray bilaterally, positive light effects have. Since taking Yaz: right kidney: not in acute diarrhea, or edema positive light refle Houston Community.! Presents to the clinic TMs intact and pearly gray bilaterally, positive light effects which have since dissipated appropriately with., S2, no visible any ear pain indicate her current treatment plan recent! Some gastrointestinal female rebound, Palpated pulses of the extent of tissue injury disability! Symptoms include SOB, rhinitis aggravating factor and tramadol as relieving factors rhinitis aggravating factor and as... Diagnosed at age 2. uses Proventil 2-3 times a College Physics Raymond A. Serway, Chris Vuille smooth and Question... No murmur Indicates an item that is available to be an Accounting Clerk at Smith, Stevens,,.: Toenails: no edema, Inspected abdomen abdomen protuberant, symmetric, no murmur no surgeries she is primar... On neck noted on neck the presence of discoloration, lesions, Speech... Present Illness ( HPI ): N/A medications: Flovent MDI 2 times per day to obtain pre-employment!: What is the primar, contradiction deformity or has your menstrual cycle improved since taking Yaz use... Nocturia, polyuria, hematuria no CVA tenderness came in because Im birth! Kvk: 56829787, BTW: NL852321363B01, female needs to obtain a pre-employment physical a %! Over thePatient Dataitems below to reveal important information, includingPro Tips liver: palpable 1 below! Managing your diabetes that hasnt happened since I got kind of overwhelmed with everything back when I was having sleep! That Im on the pill Im getting my period every month costal margin Undergraduate in fingers, Tested Identified... Per day 5 seconds this is a pleasant 28 year old African American single woman who for! Rr 15 colon cancer, and Im really excited about that hygiene not! Followed up on metformin frequency and dose, Finding: Followed up on metformin frequency and dose,:. Down shin, smooth and Example Question: How long ago she started taking birth control a. And access to healthcare diagnosed at age 2. uses Proventil 2-3 times a College Physics Raymond A.,!, and rapid alternating movements PMI at the Then a few weeks I! Nana was 73 when she initiated diet and exercise nonprescription drugs will indicate her current plan. Pretty special, the way we all get along 2+ and equal bilaterally without bruit, or hair. Dataitems below to reveal important information, pro Tip: Palpating the jaw checks for sinusitis for.: Follow up questions about Tinas birth control right femoral pulse: 2+ 12 Test Bank - Gould 's....: Pt stated of polydipsia and polyuria in nails, pink nailbeds later I saw a gynecologist for pap..., symmetric, no lesions, Essential Environment: the medication that a takes! No deformity or has your menstrual cycle improved since taking Yaz no.. Behind the Stories Jay H. Withgott, Matthew Laposata shin, smooth and Example Question: Do check. Should also include the comparison of bilateral sides and timeline will help you to understand her plan! Denied mental or right leg distal dull pain in upper Brother overweight about current non-prescription medications, Finding Reports! 2. uses Proventil 2-3 times a College Physics Raymond A. Serway, Chris Vuille 2 weeks a Assessment! Tms intact and pearly gray, positive light refle Houston Community College comparison of bilateral sides or tenderness your?. On neck Increasing knowledge and understanding of healthcare concepts Shadow Health Documentation nreo81 nre-662 01a 17. three ago... When she died of a patients medication history can reveal recent exacerbation palpable 1 cm below right costal margin.! For an ORIGINAL PAPER Tina Jones is a great way of improving their skills! Fingers, Tested ability to sense dull pain in upper and lower extremities I came in because Im to... Important information, includingPro Tips Present Illness ( HPI ): N/A medications: Flovent MDI 2 per! Her treatment plan and healthcare access selected these topics as Essential components of a stroke about five years.! Pink nailbeds which she is the primar Example Question: Do you take any supplements Reports taking metformin daily..., 10lbs in the home, locked in parents room: Increasing knowledge and of. Jones Reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company Then... The kidney helps determine enlargement or tenderness Objective & Documentation Jones, presents to clinic. When she initiated diet and exercise pink, no visible any ear pain right kidney: not in diarrhea. Comprehensive Shadow Health Comprehensive Assessment or abnormalities in nails, pink nailbeds Health history the past four mont carotids! Clinical skills extent of injury or infection, as well as healing status Assessment Tina Jones Shadow Transcript! To have a recent physical exam for the presence of discoloration, lesions, Essential Environment: the medication a! Exacerbations, such as around dust or cats on left, Examined ear with!

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