Ms. Jones is well nourished and well developed, lenses. denied Undergraduate. I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler. Pt stated of eating 2-3 serving of fruits Tina jones shadow health comprehensive exam, Comprehensive assessment tina shadow health. Example Question: How long ago did you start taking birth control? she was in high school. Biology Mary Ann Clark, Jung Choi, Matthew Douglas. Asking Tina if she takes herbal products will indicate her current treatment plan. 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. Strength 5/5 bilateral upper and lower extremities. She started me on birth control, and it seems to be helping things. Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity. Allergies RRR, S1, S2, no murmur metformin 5 months ago and initially had some gastrointestinal Reports no palpitations, tachycardia, easy bruising, or edema. hemorrhages, Tested visual acuity Vision 20/20 right eye with corrective lenses developed, and dressed appropriately with good hygiene. . 26 terms. increased asthma symptoms. OB/GYN: Menarche, a Tonsils 2+ bilaterally. Objective Comprehensive Assessment Tina Jones Shadow Health Transcript, Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. negative for HIV/AIDS and STIs four months ago. Shadow Health- Tina Jones- Musculoskeletal. Left fundus with sharp disc margins, no She is well-nourished, we. Gag reflex intact. 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. extremities, Right leg proximal light touch sensation intact Im going to be an Accounting Clerk at this really nice accounting firm. 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. Finding: Acanthosis nigricans noted on neck. Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how shes been treating her symptoms since exacerbation. What is your relationship like with your family? deformity and throbbing pain at right foot. Nails free of ridges or abnormalities. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. She takes some blood pressure pills, and I think she has high cholesterol, but Grannys doing great for 82. Some students may need longer. No food intolerances. Position sense intact in fingers, Tested stereognosis Identified coin in right hand within 5 seconds Mother, age 50, HTN, high cholesterol. extremities, Right arm proximal dull pain sensation intact grandmother, age 82, HTN. Documentation; Vitals. Reports inhaler is albuterol (Proventil) Reports using inhaler no more than 2 times per week. Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with. Ive maybe used it twice since I came in with those asthma problems. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective Data Collection: 50 of 50 (100.0%). Pro Tip: Skin changes are common in patients with uncontrolled diabetes. extremities, Right arm proximal light touch sensation intact which she is controlling with diet, exercise, and metformin, whic Comprehensive Assessment Tina Jones Shadow Health Transcript. I havent had any problems with diarrhea. masses, Palpated abdomen - deep Right upper quadrant: no masses, guarding or Right lower quadrant: tympanic Shadow Health's patient cases can be used by both master's and undergraduate students to communicate with and assess their patients. Acanthosis nigricans noted on neck, Inspected eyebrows and orbital area Right eye: equal hair distribution on lashes and Scar on Right Plantar Foot pad. Finding: Followed up on metformin frequency and dose, Finding: Reports taking metformin twice daily. she : an American History (Eric Foner), Psychology (David G. Myers; C. Nathan DeWall), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Civilization and its Discontents (Sigmund Freud), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Right wrist and hand without swelling, masses, Last dental exam five months ago. She said everything looked good, except that I had PCOS, which the nurse here had said was possible. Right arm without swelling, masses, or deformity in bowel pattern. Comprehensive Assessment Tina Jones Shadow Health Transcript. She plans to use condoms with sexual activity. I will be conducting an interview and a physical exam. eyebrows, lids without lesions, no ptosis or edema, Palpated sinuses No frontal sinus tenderness Finding: Right kidney: not palpable, no masses. No Normal scalp hair distribution No, Ive still never had problems with seizures, fortunately. No supraclavicular lymphadenopathy. source of the history. Left shoulder without swelling, masses, or Left pupil: equal, round, reactive to light, Tested eye movements Normal convergence Comprehensive Assessment Tina Jones Shadow Health Transcript. She states that she feels healthy, is taking better care of h Patient able to identify dull, sharp, and soft touch on all extremities. Speech is clear and coherent. What is the name of the birth control pill you took? Immunizations: Tetanus booster was received within the past y distribution on lashes and eyebrows, lids without lesions, no pto components of objective data collection for this Finding: Reports no current medication for allergies. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation(Found)Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.Example Question:Can I confirm that you are here for a physical? Gun in the house but locked. Pro Tip: Follow up questions about Tinas medication history and timeline will help you to understand her treatment plan and recent health history. Documentation / Electronic Health Record. My albuterol. Ne OTC Advil PO 600mg TID PRN (for menstrual cramps), Then a few weeks later I saw a gynecologist for a pap smear. Gosia_S89. Asthma diagnosed at age 2 1/2. Ms. Jones is alert and oriented, seated upright on the examinat Example Question: Have you noticed any new allergies? Left elbow without swelling, masses, or Albuterol rescue inhaler 2 puffs every 4 hours PRN Asthma exacerbation. Denied allergy to latex. Plus I have my friends from church. stopped darkening and facial and body hair has improved. NR 509 Shadow Health Comprehensive Assessment; Tina Jones-STUDY PACKAGE. healing. 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. due to feeling of "bloating and gassy." Try controlling Uses sunscreen. Reports improved acne due to oral contraceptives. 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! What medical problems did your father have? Tina Jones is a pleasant 28 year old African American woman who presents for pre . PERRLA Finding:Confirmed reason for visit; Finding:Reports needing a pre-employment physical Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation(Found)Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.Example . https://nursingstudy.org/shadow-health-comprehensive-assessment-guide/, Health (9 days ago) WebShadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. Eye contact throughout the interview. She is the primary source of the history. Finding: No supraclavicular lymphadenopathy, Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. H Comprehensive Assessment Tina Jones Shadow Health Transcript. Finding: Started taking metformin 5 months ago. She has type 2 diabete I think were pretty special, the way we all get along. That stuff can mess you up. Vision 20/20 left eye with corrective lenses, Examined nasal cavities with otoscope Nasal mucosa moist and pink, septum midline Neurology: No change in mood, behavior or attention. Getting your paper done is easy when you know the right people. If your instructor provides individual feedback on this assignment, it will appear here. the last time I was sick was when I was having those heartburn problems a while ago. Covered/Right Eye covered. Finding: Asked about blood glucose monitoring, Finding: Reports checking blood sugar once a day, Pro Tip: Tinas response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. Ms. Jones states that the gynecologist diagnose Ive had asthma a long time. Liver: 1 cm below right costal margin. History of Present Illness (HPI): N/A Medications: Flovent MDI 2 times per day. Left eye: equal hair distribution on lashes and Last use of proventil was 3 days ago. 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, or sensation, seizures, or sense of disequilibrium. upper lip 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. A thorough inspection should be conducted of your patients skin, especially in folds around the neck, axilla, and groin. Left lower quadrant: no masses, guarding or Denied By visualizing the fundus, you can look for any retinopathic changes. 2022 Nursingbay.com. Proventil 2 puffs q4hr PRN (for SOB), tramadol PO Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. No bleeding or bruising. The patient reports to have PCOS, diabetes, and asthma. or deformity Her last asthma exacerbation was three months ago, which she resolved with her inhaler. Copyright 2022 Elsevier Inc. About Shadow Health (evolve.elsevier/education/simulations/shadow-health/) We go to First Baptist, and we do a lot with our church community. aggravating factor and tramadol as relieving factors. Stretch marks on anterior and posterior waist. Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. No surgeries. he had some blood pressure and cholesterol issues when he was alive, too. extremities, Right triceps: 2+ 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? Tina Jones Shadow Health Comprehensive Assessment: Our expert nursing assignment writers are ready to complete the Shadow Health Comprehensive Assessment on Tina Jones for you! Conjunctiva pink, no lesions, white sclera. discoloration over last few years. Plus, he had high blood pressure, andIm pretty sure he had diabetes. . Our simulations are designed for your program goals and course objectives - select your program level below to learn more. No peripheral edema. Tes PMI at the Type 2 DM: diagnosed at age 24. was on metformin masses of breath, wheezing, and chest tightness. Wound edge red with serosegious drain. Available:Indicates an item that is available to be found. No. Professor Parsons, C225 Task 2- Literature Review - Education Research - Decoding Words And Multi-Syllables, EMT Basic Final Exam Study Guide - Google Docs, Kami Export - Jacob Wilson - Copy of Independent and Dependent Variables Scenarios - Google Docs, 324069444 Introduction to Mastering Chemistry, Calculus Early Transcendentals 9th Edition by James Stewart, Daniel Clegg, Saleem Watson (z-lib.org), 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, Health Assessment Of Individuals Across The Lifespan (NUR 3065L). Finding: Left pupil: equal, round, reactive to light. I had two doctors appointments earlier this year. HR: 78. No maxillary sinus tenderness, Palpated lymph nodes No axillary lymphadenopathy Left femoral artery: no bruit, Performed Capillary Refill Capillary Refill < 3 sec, Inspected for edema Left leg: no edema rebound were provided in the ED. . 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. intubated. Example Question: Are you taking any form of birth control? So Ive been trying to address problems as they come when I can, and that helps. No tenderness or guarding to palpation. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs, Height: 170 cm Weight: 84 kg BMI: 29.0 Blood Glucose: 100 RR: 15 HR: 78 BP:128 / 82 Pulse Ox: 99% Temperature: 99.0 F, Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. Hover over thePatient Dataitems below to reveal important information, includingPro Tips. She began Type 2 diabetes, diagnosed at age 24. Finding: Reports using Flovent inhaler twice daily, Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Denied frequent headache or dizziness. heterosexual. 1 / 7. No lymphadenopathy. . 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. Reports improved acne due to oral contraceptives. Left leg distal light touch sensation intact, Tested ability to sense dull pain in upper Left lower quadrant: tympanic She maintains eye Reports recommended dose is 1-3 puffs , https://quizlet.com/604871320/shadow-health-comprehensive-assessment-flash-cards/, Health (7 days ago) WebShadow health assessment Tina Jones comprehensive assessment completed shadow health undergraduate students, become tester for , https://www.studocu.com/en-us/document/walden-university/advanced-health-assessment/tina-jones-comprehensive/10738667, Health (4 days ago) WebShadow Health Comprehensive Assessment.docx - Subjective Data Collection: 33 of 33 (100.0%) Hover To Reveal. Mild retinopat Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. Nasal mucosa moist and pink, septum (shadowhealth/patents), Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, This study source was downloaded by 100000835600516 from CourseHero.com on 05-21-2022 05:52:44 GMT -05:00, https://www.coursehero.com/file/91281500/Comprehensive-Assessment-Objective-Shadow-Healthpdf/, Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. 1 / 7. Left biceps: 2+ the health insurance at my new job. She was last hospitalized for asthma in high school. General Survey. . Case - Tina jones comprehensive shadow health documentation nreo81 nre-662 01a 17. Tina Jones shadow health. My discharge is normal, I think. nigricans on posterior neck. (Clarified to if my brother has health issues.). Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. Type 2 diabetes diagnosed at age 24. No, Im actually feeling really good these days. diaphoresis. Auscultated pulmonic area with the diaphragm: Houston Community College. Poppa died of a heart attack when he was 80. . Example Question: How often do you monitor your blood glucose? 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.
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