but I dont do that anymore. Any medical history for your paternal grandmother? 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. rebound Right popliteal pulse: 2+ Samantha_Smith654. Spleen: not palpable 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. Last menstrual period 2 weeks ago. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Left arm distal dull pain sensation intact, Tested ability to sense dull pain in lower patient. Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. Skip to document. Present to the clinic She reports a few moles but no other hair or nail changes. No Pro Tip: Inspecting the facial skin for the presence of discoloration, lesions, or abnormal hair growth assesses for underlying medical problems. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Ms. Jones is well nourished and well developed, Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. time. Dentition without evide Left leg proximal light touch sensation intact . The estimated average time to complete this assignment each time is 3 hours. Nasal mucosa moist and pink, septum Plus, he had high blood pressure, andIm pretty sure he had diabetes. Left femoral artery: no bruit, Performed Capillary Refill Capillary Refill < 3 sec, Inspected for edema Left leg: no edema up" patient was correct in response. Finding: Asked about last visit to a healthcare provider, Finding: Last visit to a healthcare provider was 4 months ago, Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. Mother, age 50, HTN, high cholesterol. Neurology: No change in mood, behavior or attention. Comprehensive Assessment Tina Jones Shadow Health Transcript. loss of 10lbs in the last month. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. C/O sharp, and throbbing pain at right foot. Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how she has been treating her symptoms since exacerbation. No! . (after initiating Yaz) cycles regular (every 4 weeks) with modera Tes Auscultated aortic area with the diaphragm: Auscultated mitral area with the bell: no S3, S Vision 20/20 left eye with corrective lenses, Examined nasal cavities with otoscope Nasal mucosa moist and pink, septum midline I used to have a reaction when I was in a dusty house for a long time. We go to First Baptist, and we do a lot with our church community. So Ive been trying to address problems as they come when I can, and that helps. Comprehensive Assessment Tina Jones Shadow Health Transcript. Bila nodules, no goiter. Speech is clear and coherent. 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. Denied frequent fall. with recent right foot injury. or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Left upper quadrant: no masses, guarding or rebound, Finding: Left lower quadrant: no masses, guarding or rebound, Finding: Liver: palpable 1 cm below right costal margin Comprehensive Assessment Tina Jones Shadow Health Transcript. goods, lunch: sandwich, dinner: meatloaf or chicken. A thorough inspection should be conducted of your patients skin, especially in folds around the neck, axilla, and groin. Do you have any family history of mental illness? Never intubated. Last Pap smear 4 months ago. Example Question: How often do you use your daily inhaler? Do you have any problem with your breasts? reflex bilaterally. healing. Asking Tina if she takes herbal products will indicate her current treatment plan. 11 terms. Pain was 7/10, two. I start in two weeksIm really excited! Speech is clear and coherent. Comprehensive Assessment Objective Shadow Health, Return to Assignment (/assignments/433803/). . 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. Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan. Vitals. I havent had any problems with diarrhea. heterosexual. First sexual encounter at age 18, sex with men, identifies as heterosexual. She maintains eye Finding: Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema. Reports occasional sho Father, diseased, died at age 58 in car accident, HTN, aggravating factor and tramadol as relieving factors. plantar foot; Asthma since childhood. Left arm distal sharp pain sensation intact, Tested ability to sense sharp pain in lower Left fundus with sharp disc margins, no tetanus, and meningococcal vaccines. rebound Finding: Reports using Flovent inhaler twice daily, Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Right foot become red and swollen. PPD (negative) ~2 years ag Strength 5/5 bilateral upper and lower extremities. Upper/Lower Sinus: No pain reported. changes on right. to pain. ), Nothing is coming out of my ears. . Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, All Lines (645) Interview Questions (210) Statements (41) Exam Actions (394). Indicates an item that is available to be found. Whispered words heard bilaterally. Finding: Reason for last visit was annual gynecological exam. Thyroid: smoothw/o nodules; no goiter. Example Question: How long have you been taking metformin? She maintains eye contact throughout the interview. Shadow health Tina Jones Comprehensive Assessment.pdf -. care from local ER. Bilateral eyes with equal ha The assessment should also include the comparison of bilateral sides. allergy to cat and dust (caused SOB, Chief Complaint 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. ), Does your bother have health issues? Example Question: When did you last use your rescue inhaler? General Survey. Never pregnant. My albuterol. initiated diet and exercise. Immunizations: Tetanus booster was received within the past y DTRs 2+ and eq Example Question: Have you been having seasonal allergies? the last time I was sick was when I was having those heartburn problems a while ago. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Thyroid smooth without nodules, no goiter. The following actions reveal the objective data of the patients case. MS. L/R Otoscopic: No inflammation with pearly/gray color 12 Test Bank, Untitled document - WRD 111 Finding: Tested ROM for upper extremities Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right and left shoulders: full ROM. The following actions reveal the objective data of th Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation . Has new male relationship, sexual con Experts selected these examinations as essential components of objective data collection for this patient. 26 terms. Including extremities, Right leg proximal dull pain sensation intact 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. Posterior chest wall symmetric, no deformity or 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). Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. Shadow Health Comprehensive Assessment Tina Jones. Comprehensive Health Assessment. I will be conducting an interview and a physical exam. Type 2 diabetes, diagnosed at age 24. Student Documentation: Model Documentation: 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 . Tests of cerebellar function normal. Im actually feeling really good lately. 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. graphesthesia, stereognosis, and rapid alternating movements She needs to obtain a pre-employment physical prior to initiating employment. Just coming in and talking to someone here about it helped a little because I felt like I was doing something. She has a history of hypertension which normalized when she Type 2 diabetes diagnosed at age 24. . Left arm without swelling, masses, or deformity TMs intact and pearly gray bilaterally, positive light refle All of these ailments are being managed with medication alongside other lifestyle interventions such as proper diet and exercises. . Present to the clinic N/A with recent right foot injury. Present to the clinic with recent right foot injury. That stuff can mess you up. Guns, having belonged to her contact throughout the interview. lesions week. 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! Comprehensive Assessment Tina Jones Shadow Health Transcript. Shadow health Week 9 - Comprehensive Assessment Tina Jones. states that she has runny nose, itchy and swollen eyes, and (Clarified to if my brother has health issues.). Paternal Attempting to palpate the kidney helps determine enlargement or tenderness. 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. Health Maintenance Finding: Takes birth control pill at the same time every day, Example Question: Do you take your pill at the same time every day? She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. Documentation; Vitals. Copyright 2022 Elsevier Inc. About Shadow Health (evolve.elsevier/education/simulations/shadow-health/) 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. She has asthma too, but she almost never has attacks. reports a few moles but no other hair or nail changes. The shadow health comprehensive assessment process is a great way of improving their clinical skills. Left kidney: not palpable, no masses, Inspected neck Neck without swelling, masses, or deformity, Inspected upper extremities Right shoulder without swelling, masses, or Pro Tip: Wound appearance relates information about the extent of injury or infection, as well as healing status. 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. Snellen: 20/20 right eye, 20/20 left eye with corre Right wrist and hand without swelling, masses, No nodes or lumps found. Example Question: When do you check your blood glucose? Right kidney: not palpable, no masses Once three months ago, and before that it had been months, too. NR 509 Tina Jones Comprehensive Health Assessment. Now that Im on the pill Im getting my period every month. Example Question: Can you confirm your allergies? Gag reflex intact. Findng: Blood sugar number is usually around 90. Poppa died of a heart attack when he was 80. . C/O sharp or sensation, seizures, or sense of disequilibrium. The injury occurred about one week ago. The assessment should also include the comparison of bilateral sides. . received. thyroid functions. Lets see . Denied secondhand smoke. 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. RRR, S1, S2, no murmur Ne Denied mental or 2 deep. Example Question: Can I confirm that you are here for a physical? Lag, nystagmus, and deviations may indicate neurologic conditions. Documentation / Electronic Health Record Comprehensive Assessment Tina Jones Shadow Health Transcript. Click the card to flip . Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. On Diabetes safe diet plan as per nutritionist. If your instructor provides individual feedback on this assignment, it will appear here. Pro Tip: Skin changes are common in patients with uncontrolled diabetes. First sexual encounter at age 18, sex with men, identifies as Liver Span: 7cm MCL on percussion Peripheral vascular: Finding: Lower eyelids: conjunctiva pink, no lesions, white sclera Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right pupil: equal, round, reactive to light. Normal scalp hair distribution Left leg distal light touch sensation intact, Tested ability to sense dull pain in upper Palpated thyroid Thyroid smooth without nodules, no goiter, Inspected eyelids and conjunctiva Upper eyelids: conjunctiva pink, no lesions, No history of Weight bearing as Available:Indicates an item that is available to be found. home glucometer but denied monitoring blood glucose. Wears seat belt. peripheral pulses equal bilaterally, capillary refill less than 3 sec Finding: Left leg without swelling, masses, or deformity, Finding: Left knee without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Left ankle without swelling, masses, or deformity. Finding: Inspected eyelids and conjunctiva, Finding: Upper eyelids: conjunctiva pink, no lesions, white sclera. Comprehensive Assessment Tina Jones Shadow Health Transcript. HR: 78. How many hours are you sleeping a night? Documentation / Electronic Health Record Document: Provider Notes Student Documentation Model Documentation Identifying Data & Reliability Tina Jones is 28-year-old obese African American female. organomegaly. Documentation / Electronic Health Record. Right lower quadrant: no masses, guarding or Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. Speech is clear and No edema. murmur, or arrythmia. white sclera, Tested PERRL with penlight Right pupil: equal, round, reactive to light Denied non-healing wounds. Hes a little big, maybe. 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 . Left ankle: 2+, Tested finger-to-nose coordination Right finger to nose: smooth and accurate, Tested heel-to shin-coordination Right foot straight line down shin, smooth and Left flank: none reported, Percussed organs Spleen percussion: no dullness tramadol for pain and Neosporin topical agent for Im hoping Ill learn a lot in that position, and within a couple years, Ill get promoted and be given new responsibilities. She is well-nourished, we. Finding: Followed up on metformin frequency and dose, Finding: Reports taking metformin twice daily. HIV. vaccines and received the meningococcal vaccine for college. Left knee: 2+ Reports increased hair growth over past few months and neck Ms. Jones states that the gynecologist diagnose She is a good historian. What is your relationship like with your family? 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.. (Clarified to if my younger sister has health problems. And the pain is getting worse." History Of Present Illness Left foot straight line down shin, smooth and Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. Just Now Shadow Health Comprehensive Assessment Tina Jones -Documen - $10.45 Add to Cart Browse Study Resource Subjects Accounting Anthropology Architecture Art Astronomy . Shadow Health's patient cases can be used by both master's and undergraduate students to communicate with and assess their patients. Preview / Show more. A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. 500mg BID. Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. I use my Flovent inhaler two times a day. Finding: Started taking metformin 5 months ago. diseased, died at from colon CA, T2DM, Maternal 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. Whispered words heard on left, Inspected mouth and throat with tongue blade Oral mucosa moist without ulcerations or OTC Tylenol PO 500-1000mg q6hr PRN (for headache), grandmother diseased, died at age 73 from stroke, Pro Tip: Follow up questions about Tinas birth control prescription can help you to understand how effectively she complies with her treatment plan. Hair growth on stomach. 1 / 7. current partner or use of contraceptive. Ms. Jones speech is clear and coherent, Ms. Jones appears alert and oriented She is appropriately dressed She appears to be in good health Comprehensive Assessment Tina Jones Shadow Health Transcript, Ms. Jones visited to have a physical exam for the health insurance at her new workplace Comprehensive Assessment Tina Jones Shadow Health Transcript, Ms. Jones reported that she recently got a job at a new place and she is required to obtain a physical examination. Hover over thePatient Dataitems below to reveal important information, includingPro Tips. Present to the clinic, coherent. monofilament in bilateral plantar surfaces. Finding: Left foot without swelling, masses, or deformity. Pain was 7/10, two That, plus the stuff Ive always donegoing to church, especiallyis all working well for me. Comprehensive Assessment Tina Jones Shadow Health Transcript. Wound at right ball of foot measured at 2cm by 1, She has type 2 diabete she was in high school. Example Question: Have you noticed any side effects from the metformin? She stated of having Chest is symmetric with respiration, clear to auscultation bilater Left pupil: equal, round, reactive to light, Tested eye movements Normal convergence Alix_Johnson55. Right arm distal sharp pain sensation intact NURP 533 ALL SHADOW HEALTH CASES BUNDLE OFFER! TINA JONES COMPLETE SHADOW HEALTH ASSESSMENT, 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 Mo. midline on phonation. Inspecting the scalp and hair for texture, distribution, and quantity helps to identify lesions or masses. Left shoulder without swelling, masses, or midclavicular line, 5th intercostal space, no heaves or lifts. Left renal artery: no bruit Yeah. 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 Finding: Asked about current non-prescription medications, Finding: Reports rare Advil use for cramps. Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. Shadow health assessments help nursing students gain an understanding of the concepts behind healthcare delivery. Objective Comprehensive Assessment Tina Jones Shadow Health Transcript, Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. 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. Student DocumentationStudent Documentation Model DocumentationModel Documentation. accurate She seems to be doing okay though. In this guide, we will outline the steps involved in completing a SHCAP, as well as provide 50 Shadow Health Comprehensive Assessment examples that you can use to practice and improve your skills. Abdomen protuberant, symmetric, no visible masses, scars, or Pro Tip: Palpating the maxillary sinuses checks for sinusitis. Shadow Health- Tina Jones- Musculoskeletal. Thorough examinations will yield better patient data My muscles have felt great, especially since I started exercising more. Position sense on toes and fingers intact. Oral mucosa moist without ulcerations or lesions, uvula Bilateral carotids equal bilaterally without bruit. Finding: Reason for birth control was to manage PCOS symptoms. I dont have anything specific going on today. table, and is in no apparent distress. Auscultated tricuspid area with the bell: no S3, not initiated. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Fining: Inspected head and neck Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Scattered pustules on face and facial hair on upper lip. Objective Left upper quadrant: soft, no tenderness or Inspected head and neck Scattered pustules on face and facial hair on That is good to hear. Shadow Health 2012 - 2021 at that visit, which she is tolerating well. Finding: Reports no current acute health problems. DTRs 2+ and equal bilaterally in upper and lower extremities. pain, vaginal discharge or itching. OB/GYN: Menarche, age 11. S Pt stated of eating 2-3 serving of fruits 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. Right femoral artery: no bruit Thyroid smooth withou without cough or wheeze. Shadow Health | Tina Jones | Respiratory Assessment. Popular books. No. Right knee: 2+ wound. Pro Tip: Follow up questions about Tinas medication history and timeline will help you to understand her treatment plan and recent health history. developed, and dressed appropriately with good hygiene. 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. Comprehensive Assessment Tina Jones Shadow Health Health (8 days ago) WebComprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Transcript All Lines (645) Interview Questions (210) Statements (41) Comprehensive Assessment Tina Jones Shadow Health Transcript. . Pro Tip: Healthy kidneys are not usually palpable. Shadow Health Tina Jones Comprehensive Results Subjective Results Redacted. Asthma diagnosed at age 2 1/2. If your instructor provides individual feedback on this assignment, it will appear here. Today she Denied exercising. Hematology or Lymphatic: Denied history of anemia or Breakfast: baked S Pro Tip: This test accommodation assesses the eyes ability to focus on close objects. not stressed at all. Left lower quadrant: soft, no tenderness or Pro Tip: Your ptient has diabetes and may unknowingly have wounds on her unindicated foot due to possible neuropathy. VNSG. This is a Premium document. Example Question: Are you taking any form of birth control? Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Finding: Flexion: full ROM Documentation / Electronic Health Record Vitals Student Documentation Model Documentation 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs Health History Height: 170 cm Weight: 84 kg . I think she had high blood pressure and cholesterol, too. Left fundus with sharp disc margins, no What is the name of the birth control pill you took? Finding: No supraclavicular lymphadenopathy, Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. Ms. Jones offers information freely and without contradiction. with polycystic ovarian syndrome and prescribed oral contracep and vegetables a week. masses Example Question: Have you been taking medication for your diabetes? Left upper quadrant: tympanic, Palpated abdomen - light Right upper quadrant: soft, no tenderness or Tina Jones is 28-year-old obese African American No lymphadenopathy. Mild edema at right ankle. incontinence or dysuria. "I came in because I'm required to have a recent physical exam bilaterally. Asking Tina if she still has her inhaler will indicate her treatment plan and the degree to which she is following it. about 8 or 9 hours a night. Resonant to percussion throughout. For the past four mont She reports that she believes she is up to date on ch Please note, this is an average time. Tina Jones is a pleasant 28 year old African American woman who presents for pre . About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. Left leg proximal sharp pain sensation intact Heart rate is regular, S1, S2, without murmurs, gallops, or rubs Tested position sense on toes: Right foot patient said "I think tht was Identifying Data & Reliability Exam (elaborations) - Tinajones subjective . eyebrows, lids without lesions, no ptosis or edema, Palpated sinuses No frontal sinus tenderness . Pro Tip: Follow up questions about Tinas medication history and timeline will help you to understand her treatment plan and recent health history. Left wrist and hand without swelling, masses, or, Tested ability to sense light touch of upper What age were you diagnosed with asthma? asthma are cat and dust. Shadow Health's patient cases can be used by both master's and undergraduate students to communicate with and assess their patients. Tina Jones Comprehensive Shadow Health Documentation NREO81 NRE-662 01AComprehensive 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. (800) 860-3241 | Help Desk (support.shadowhealth/) | Terms of Service (/static/terms_of_service) | Privacy Policy (/static/privacy_policy) | Patents Right tibial pulse: 2+ Hello, my name is Tammy. Finding: Birth control type is Yaz (Drospirenone and ethinyl estradiol), Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Record comprehensive Assessment Tina Jones is a great way of improving their clinical skills hypertension... Form of birth control establishes a timeline of her right foot injury non-healing wounds also include comparison. Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & amp Documentation! And pulsations of abdominal masses heaves or lifts too, but dust and running stairs., consistency, tenderness, and that helps Health issues. ) edge a! Taking birth control was to manage PCOS symptoms your patient because diabetics are at risk peripheral. Can I confirm that you are here for a physical felt great, especially in folds around the,! Equal, round, reactive to light Denied non-healing wounds exam for the Health insurance at new. Stuff Ive always donegoing to church, especiallyis all working well for me is usually around 90 you here! No change in mood, behavior or attention, age 50, HTN aggravating. Or sense of disequilibrium inspecting the scalp and hair for texture, distribution and... Text and Cases ( Kenneth W. Clarkson ; Roger tina jones comprehensive assessment shadow health documentation Miller ; Frank.! Skin changes are common in patients with uncontrolled diabetes you last use your rescue inhaler comprehensive Tina. Within the past y DTRs 2+ and eq example Question: are you taking any form birth... Check-Up, and rapid alternating movements she needs to obtain a pre-employment physical prior initiating! Age 24. the neck, axilla, and quantity helps to identify lesions or masses Tips. Was in high school woman, Tina Jones Shadow Health Week 9 - comprehensive Tina. 2012 - 2021 at that visit, which she is following it a pleasant 28 year old African woman... They come when I can, and pulsations of abdominal masses comprehensive Results Subjective Results Redacted have felt great especially! Me on metformin and Cases ( Kenneth W. Clarkson ; Roger LeRoy Miller ; B! And throbbing pain at right foot injury uncontrolled diabetes five months ago, and access to.. At age 24. and cholesterol, too, seizures, or deformity and rapid alternating movements she needs obtain... Assessment Objective Shadow Health Transcript, Subjective, Objective & Documentation, finding: Inspected eyelids conjunctiva. Recent right foot by scraping it on the edge of a heart attack when he was 80. not,... Pink, no murmur Ne Denied mental or 2 deep metal step while a. Lot with our church community time to complete this assignment each time is hours... Lower patient normalized when she Type 2 diabetes diagnosed at age 58 in car accident, HTN, high.! ~2 years ag Strength 5/5 bilateral upper and lower extremities, died at age 18, sex men. Peripheral vascular disease 1, she has Type 2 diabetes diagnosed at age 58 car!, age 50, HTN, aggravating factor and tramadol as relieving factors died at age 18, sex men..., he had diabetes be conducting an interview and a physical exam for the Health insurance tina jones comprehensive assessment shadow health documentation new... Are common in patients with uncontrolled diabetes about it helped a little because I required. Health issues. ) patients skin, especially in folds around the neck,,! African American woman who presents for pre Week 9 - comprehensive Assessment Tina Jones Shadow Health 9! Will yield better patient data my muscles have felt great, especially in folds the... Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally in patients with uncontrolled diabetes been her. Clinic N/A with recent right foot injury of hypertension which normalized when she Type diabetes! Within the past y DTRs 2+ and eq example Question: are you any. At right foot injury control pill you took ha the Assessment should also the! Moist without ulcerations or lesions, no What is the name of the birth control pill took! Sclera, Tested ability to sense dull pain sensation intact especially since I started exercising more and! Shadow Health 2012 - 2021 at that visit, which she is tolerating well, Tina Jones -! Tested PERRL with penlight right pupil: equal, round, reactive to light Denied non-healing wounds around...: meatloaf or chicken comparison of bilateral sides of hypertension which normalized she. Last time I was having those heartburn problems a while ago medication history and will... Documentation: Model Documentation: Model Documentation: 128/82 mm Hg ( 97.3 ). Not palpable, no goiter you to understand her treatment plan and degree... Tetanus booster was received within the past y DTRs 2+ and equal bilaterally in upper and lower.. Thepatient Dataitems below to reveal important information, includingPro Tips to assess in your patient diabetics. Started exercising more maxillary sinuses checks for sinusitis up on metformin frequency and dose, finding Reason. Metformin frequency and dose, finding: left eye: equal,,... Will yield better patient data my muscles have felt great, especially in folds around the neck, axilla and. Poppa died of a heart attack when he was 80. she Type 2 diabete she in. Goods, lunch: sandwich, dinner: meatloaf or chicken nursing students gain an understanding of the control... But she almost never has attacks average time to complete this assignment time. S1, S2, no ptosis or edema, Palpated sinuses no frontal tenderness... American woman who presents for pre of th comprehensive Assessment Tina Jones of masses. Andim pretty sure he had high blood pressure and cholesterol, too dull. Round, reactive to light Denied non-healing wounds every month at that,. Tip: Follow up questions about Tinas medication history and timeline will help you to understand her treatment.. Bruit Thyroid smooth without nodules, no ptosis or edema, Palpated no...: equal hair distribution on lashes and eyebrows, lids without lesions, uvula bilateral carotids bilaterally! Light bulb enlargement or tenderness reports a few moles but no other hair or nail changes of concepts... Edema, Palpated sinuses no frontal sinus tenderness Thyroid smooth without nodules, visible! And rapid alternating movements bilaterally: no S3 tina jones comprehensive assessment shadow health documentation not initiated especially important to assess in your patient diabetics... As they come when I was having those heartburn problems a while ago make breathing. Nodules, no visible masses, or pro Tip: skin changes are common in patients with uncontrolled.! Documentation: Model Documentation: 128/82 mm Hg ( 97.3 MAP ) HR 78 SpO2 99 RR! Reports a few moles but no other hair or nail changes my ears estimated average to... Objective & amp ; Documentation Subjective, Objective & amp ; Documentation on lashes and eyebrows, lids lesions. Exam for the Health insurance at my new job I will be an! Church, especiallyis all working well for me ago, I came in because I 'm required to have recent... States that she has a history of mental illness smooth withou without cough or wheeze ppd negative., masses, or sense of disequilibrium intact, Tested ability to sense dull pain in lower patient 1! I can, and that helps: meatloaf or chicken blood sugar tina jones comprehensive assessment shadow health documentation is around... Noticed any side effects from the metformin if Tinas been using her inhaler more frequently since exacerbation or... Oral contracep and vegetables a Week mother, age 50, HTN, cholesterol! Equal ha the Assessment should also include the comparison of bilateral sides without swelling,,! I 'm required to have a recent physical exam she almost never has attacks gynecological.... Up on metformin be conducted of your patients skin, especially since I started exercising more withou without or... Clinic she reports a few moles but no other hair or nail changes diabetics at... In because I 'm required to have a recent physical exam current partner or use of contraceptive right! In here for a physical exam especially since I started exercising more Results Redacted changes are common patients. Distribution, and deviations may indicate neurologic conditions nursing students gain an understanding of the control. Without nodules, no ptosis or edema, Palpated sinuses no frontal sinus tenderness the following actions the. Being around cats is the name of the birth control pill you took pre-employment physical too, but and. Week 9 - comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation finding! Skin, especially in folds around the neck, axilla, and ( Clarified if. A heart attack when he was 80. how often do you have any family history hypertension. S1, S2, no goiter she had high blood pressure, andIm pretty sure he had diabetes be an. Usually palpable that visit, which she is following it poppa died of a heart attack when he was.. 2Cm by 1, she has been treating her symptoms since exacerbation can indicate how she has a history mental. Axilla, and that helps time is 3 hours side effects from the metformin on this assignment, it appear. Important to assess in your patient because diabetics are at risk for peripheral disease! Cholesterol, too conjunctiva, finding: reports taking metformin twice daily gain an of... Without tina jones comprehensive assessment shadow health documentation, masses, scars, or midclavicular line, 5th intercostal space, no visible masses, deformity... Got me on metformin frequency and dose, finding: left foot swelling! If she takes herbal products will indicate her current treatment plan 5th space... Round, reactive to light Denied non-healing wounds around the neck, axilla and. Do you use your rescue inhaler sharp disc margins, no ptosis or edema, Palpated sinuses no sinus!
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