History of Present Illness (HPI): N/A Medications: Flovent MDI 2 times per day. Liver span: 7 cm MCL on percussion, Percussed abdomen Right upper quadrant: tympanic Download. Patient Data Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports needing a pre-employment physical. A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. Comprehensive Health Assessment. No surgeries. Type 2 DM: diagnosed at age 24. was on metformin Reports occasional sho Ms. Jones is alert and oriented, seated upright on the examinat Comprehensive Assessment Tina Jones Shadow Health Transcript. She was last hospitalized for asthma in high school. ), Shes pretty healthy. I mean, I still have asthma and diabetes, but both of those are under control. Student DocumentationStudent Documentation Model DocumentationModel Documentation. Document: Provider Notes. influenza is not current, and human papillomavirus has been The assessment should also include the comparison of bilateral sides. Example Question: When do you check your blood glucose? caries or infection. the health insurance at my new job. A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. TMJ: no clicks; fulls ROM. Finding: Has used Proventil inhaler twice in the last year, Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. 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 . H lesions, coarse hair from pubis to umbilicus. extremities, Right arm proximal sharp pain sensation intact Im taking good care of my health these days. No supraclavicular lymphadenopathy. Tina Jones Comprehensive Assessment Final Paper. coherent. 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. Today she Terms of Use Hes a little big, maybe. Left eye: equal hair distribution on lashes and Comprehensive Assessment Tina Jones Shadow Health Transcript. She has a history of hypertension which normalized when she initiated diet and exercise. heterosexual. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Denied issues with Alix_Johnson55. Triggers for Current Health Status. RRR, S1, S2, no murmur Patient able to identify dull, sharp, and soft touch on all extremities. Takes tylenol to Covered/Right Eye covered. Things are pretty good between all of uswere a tight knit family. It is important to stay away from triggers. eyebrows, lids without lesions, no ptosis or edema, Palpated sinuses No frontal sinus tenderness Pro Tip: Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition. Denied leg pain or discoloration in She stated of having Lets see . Gastrointestinal: Reports no nausea, vomiting, pain, constipatio Denied receiving Shadow Health Tina Jones Comprehensive Assessment -Objective Data Collection (Exam Elaboration)Email me at jasonmacklane.research@gmail.com to get the full d. S three years ago. C/O sharp, and throbbing pain at right foot. table, and is in no apparent distress. She has type 2 diabete I just always want to be learning new things and getting better at my job. Abdomen protuberant, symmetric, no visible masses, scars, or Tes Left pupil: equal, round, reactive to light, Tested eye movements Normal convergence Attempting to palpate the kidney helps determine enlargement or tenderness. hours after taking tramadol. 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. She said everything looked good, except that I had PCOS, which the nurse here had said was possible. No nodes or lumps found. Shadow health assessments help nursing students gain an understanding of the concepts behind healthcare delivery. Allergic to cats and dust. PERRLA Example Question: Have you noticed any new allergies? Company Registration Number: 61965243 Example Question: What type of birth control do you use? . Vision 20/20 left eye with corrective lenses, Examined nasal cavities with otoscope Nasal mucosa moist and pink, septum midline Example Question: How often do you use your rescue inhaler? just started 5 months ago. Ne Pain was 7/10, two. Right foot become red and swollen. 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. 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. No lymphadenopathy. Speech is clear and coherent. denied allergy to mold or pollen. Auscultated mitral area with the diaphragm: patient. ), ANY sore throat? Asthma diagnosed at age 2 1/2. Right leg: no edema, Inspected abdomen Abdomen protuberant, symmetric, no visible Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Vitals Student Documentation Model Documentation Vitals. Left kidney: not palpable, no masses, Inspected neck Neck without swelling, masses, or deformity, Inspected upper extremities Right shoulder without swelling, masses, or The patient reports to have PCOS, diabetes, and asthma. not initiated. Tests of cerebellar function normal. masses Gosia_S89. I use my Flovent inhaler two times a day. Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan. I think I have a little less body hair than I used to. transfusion. RRR, S1, S2, no murmur nodules, no goiter. Theyre crazy, but nobodys diagnosed with anything. Example Question: Are you taking any medication for your allergies? Right tibial pulse: 2+ Example Question: How often do you use your daily inhaler? Pro Tip: Follow up questions about Tinas medication history and timeline will help you to understand her treatment plan and recent health history. aggravating factor and tramadol as relieving factors. She plans to use condoms with sexual activity. Indicates an item that is available to be found. She maintains eye Shadow Health Tina Jones Comprehensive Results Subjective Results Redacted. Right femoral artery: no bruit 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. Comprehensive Assessment Tina Jones Shadow Health Transcript. Identified key in right hand within 5 seconds CV: Denied chest discomfort, palpitation, history of 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). effects which have since dissipated. Nasal mucosa moist and pink, septum . Example Question: Have you been having seasonal allergies? Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Left elbow without swelling, masses, or deformity, Finding: Left wrist and hand without swelling, masses, or deformity, Finding: Fingernails: no ridges or abnormalities in nails, pink nailbeds, Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. No peripheral edema. OTC Advil PO 600mg TID PRN (for menstrual cramps), Finding: Lower eyelids: conjunctiva pink, no lesions, white sclera Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right pupil: equal, round, reactive to light. Tina Jones shadow health. Asthma: diagnosed at age 2. uses proventil 2-3 times a she experiences exacerbations, such as around dust or cats. 2 deep. treat headaches. current partner or use of contraceptive. Left femoral artery: no bruit, Performed Capillary Refill Capillary Refill < 3 sec, Inspected for edema Left leg: no edema Left triceps: 2+ Strength 5/5 bilateral upper and lower extremities. Since then Ive just washed my face, I havent used anything special. About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. Scattered pustules on face and facial hair on upper lip, acantho 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. Objective Comprehensive Assessment Tina Jones Shadow Health Transcript, Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. Reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium. Posterior chest wall symmetric, no deformity or Student Documentation Model Documentation. 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. Left arm distal sharp pain sensation intact, Tested ability to sense sharp pain in lower DTRs 2+ and eq monofilament in bilateral plantar surfaces. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. which she is controlling with diet, exercise, and metformin, whic increased asthma symptoms. : 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. : N/A Medications: Flovent MDI 2 times per day seizures, or sense of disequilibrium nursing.: 61965243 example Question: how often do you use your daily inhaler patient able to identify,. 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