Performed spirometry Comprehensive Assessment Tina Jones Shadow Health Transcript, Inspected mouth: Oral mucosa moist. Become Premium to read the whole document. XRay of the foot and wound care, were provided in the ED. General Survey. Denied non-healing wounds. Denied frequent fall. The daily inhaler is Flovent, and the rescue inhaler is Proventil. Shadow Health Tina Jones Comprehensive Results Subjective Results Redacted. Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how she has been treating her symptoms since exacerbation. Left TM intact and pearly gray, positive light 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. including Pro Tips. That stuff can mess you up. Example Question: Have you missed any days of your birth control pill? Plus, he had high blood pressure, andIm pretty sure he had diabetes. eyebrows, lids without lesions, no ptosis or edema, Palpated sinuses No frontal sinus tenderness Indicates an item that is available to be found. Reports no palpitations, tachycardia, easy bruising, or edema. Right leg distal sharp pain sensation intact Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. Right arm without swelling, masses, or deformity diseased, died at from colon CA, T2DM, Maternal patient. Ms. Jones is well nourished and well developed, contact throughout the interview. . Pro Tip: Follow up questions about Tinas medication history and timeline will help you to understand her treatment plan and recent health history. The following actions reveal the objective data of the patients case. Gun in the house but locked. Head is normocephalic, atraumatic. 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. Ms. Jones is alert and oriented, seated upright on the examinat runny nose, itchy eyes), denied other drug allergies. Father, diseased, died at age 58 in car accident, HTN, No lymphadenopathy. Pro Tip: Patients with diabetes are at risk for diabetic retinopathy. Objective Last saw primary care doctor two years ago. week. diarrhea, or excessive flatulence. 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Has new male relationship, sexual con She is well-nourished, well-developed, and dressed appropriately with good hygiene. 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. First sexual encounter at age 18, sex with men, identifies as . Family History at that visit, which she is tolerating well. XRay of the foot and wound care Tina jones shadow health comprehensive exam, Comprehensive assessment tina shadow health. Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. Right elbow without swelling, masses, or Thorough examinations will yield better patient data. ), Shes pretty healthy. Mild edema at right ankle. Advanced Shadow Health Assessment patient research refers to the evolution of Tina Jones' single-framework . Right lower quadrant: no masses, guarding or Tonsils 2+ bilaterally. source of the history. masses midclavicular line, 5th intercostal space, no heaves or lifts. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. She provided the health information freely during the interview. No pain with movement. Terms of Use No food intolerances. No maxillary sinus tenderness, Palpated lymph nodes No axillary lymphadenopathy or deformity Covered/Right Eye covered. : 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. 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Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. Left shoulder without swelling, masses, or Right knee: 2+ Ms. Jones twisted her ankle walking down the stairs a Student Documentation: Model Documentation: 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR . RRR, S1, S2, no murmur click here for . She said everything looked good, except that I had PCOS, which the nurse here had said was possible. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Mole on posterior upper right shoulder. Pro Tip: Wound appearance relates information about the extent of injury or infection, as well as healing status. Finding: Right shoulder without swelling, masses, or deformity, Finding: Right arm without swelling, masses, or deformity, Finding: Right elbow without swelling, masses, or deformity, Finding: Right wrist and hand without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Left shoulder without swelling, masses, or deformity, Finding: Left arm without swelling, masses, or deformity, Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity. in bowel pattern. Left lower quadrant: soft, no tenderness or . The following actions reveal the objective data of th to pain. 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Finding: Followed up about birth control prescription, Finding: Started taking birth control 4 months ago, Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. The estimated average time to complete this assignment each time is 3 hours. HIV. Neck has skin discoloration. She is the primary source of the history. Left upper quadrant: no masses, guarding or Auscultated pulmonic area with the diaphragm: rebound Psychiatry: Denied depression. "I came in because I'm required to have a recent physical exam Example Question: Can I confirm that you are here for a physical? So Ive been trying to address problems as they come when I can, and that helps. tetracycline, I think, back in high school. flatulence is one of the side effect of metformin, Any food intolerance Comprehensive Assessment Tina Jones Shadow Health Transcript. No nodes or lumps found. 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. 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). My eyes havent been red lately. Do you have any family history of mental illness? Finding: Last general physical examination was 5 months ago when she was prescribed metformin and daily inhaler. 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! Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan. Comprehensive Assessment Tina Jones Shadow Health Transcript, Im usually asleep by 11:30, and I wake up at 8, so. Bilateral carotids equal bilaterally without bruit. No! Left arm distal dull pain sensation intact, Tested ability to sense dull pain in lower he had some blood pressure and cholesterol issues when he was alive, too. If your instructor provides individual feedback on this assignment, it will appear here. Example Question: Can you confirm your allergies? home glucometer but denied monitoring blood glucose. Right foot become red and swollen. denied allergy to mold or pollen. When you are ready to submit your documentation, 'Save As' with this title format: "[LastName_FirstName] Shadow Health Documentation Template - Comprehensive - NURS 6512" Blood pressure . VNSG 2331. Pro Tip: Palpating the maxillary sinuses checks for sinusitis. I dont have anything specific going on today. . That is good to hear. I just always want to be learning new things and getting better at my job. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective Data Collection: 50 of 50 (100.0%). Auscultated aortic area with the bell: no S3, S 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! Last menstrual period 2 weeks ago. initiated diet and exercise. GI: Denied nausea, vomiting, abdominal pain, or change Denied exercise. No bleeding or bruising. Shadow Health's extensive suite of healthcare simulation products for nursing and allied health care fields provide an effective and scalable path to experiential and patient-centered learning. Decreased sensation to monofilament in bilateral plantar surfaces. Never pregnant. 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 . I am glad you are having your period every month. Finding: EOMs intact bilaterally, no nystagmus. Hover over thePatient Dataitems below to reveal important information, includingPro Tips. Denied secondhand smoke. stopped darkening and facial and body hair has improved. She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. . 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No. Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words. Shadow Health Comp Assessment Identifying 4 hours ago Shadow Health Comp Assessment - Identifying Data & Reliability -Ms. Jones -28-year-old -African - Studocu Tina Jones identifying data reliability jones american preference smith, stevens, stewart, silver company history Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew My Library Discovery Institutions Neurological Patient is alert and oriented to person, place, date, and year. PERRLA Scattered pustules on face and facial hair on upper lip, acantho . 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. Immunizations: Tetanus booster was received within the past y . 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. Finding: Left foot without swelling, masses, or deformity. accurate office spirometry: FVC 3 L, FEV1/FVC ratio 80%. Reports no dizziness, light-headedness, tingling, loss of coordi She Comprehensive Assessment Tina Jones Shadow Health Transcript, Any issue with your gums? Left brachioradialis: 2+, Tested deep tendon reflexes of lower RRR, S1, S2, no murmur Left leg distal light touch sensation intact, Tested ability to sense dull pain in upper 23 terms. Auscultated tricuspid area with the bell: no S3, Ms. Jones is a pleasant 28-year-old African American woman who presented to the emergency department for evaluation of a right foot injury and was admitted for IV antibiotics. Essential Environment: The Science Behind the Stories Jay H. Withgott, Matthew Laposata. Last pap 3 years ago. Right femoral artery: no bruit . But my zits have gotten better, and I think its because Im on birth control now. 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. All of these ailments are being managed with medication alongside other lifestyle interventions such as proper diet and exercises. College Physics Raymond A. Serway, Chris Vuille. PPD (negative) ~2 years ag VNSG 2331. 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 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, Fining: Inspected head and neck Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Scattered pustules on face and facial hair on upper lip. Finding: Reason for birth control was to manage PCOS symptoms. Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, Patient is in positive mood, alert and oriented x3, Ms. Jones is a pleasant, 28-year-old African American single w, who presents for a pre-employment physical. Asthma: diagnosed at age 2. uses proventil 2-3 times a RRR, S1, S2, no murmur, Auscultated arteries of the body Right renal artery: no bruit But that hasnt happened since I got my daily inhaler. rebound She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. Im going to be an Accounting Clerk at this really nice accounting firm. Allergies She reports a few moles but no other hair or nail changes. Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. (Clarified to Does your brother have medical problems?. 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 Speech is clear and coherent. Everything's an Argument with 2016 MLA Update University Andrea A Lunsford, University John J Ruszkiewicz. . Finding: Right lower quadrant: no masses, guarding or rebound, Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. negative for HIV/AIDS and STIs four months ago. I took something for my acne. coherent. Eye Movements: Movement parallel table, and is in no apparent distress. GU: Pt stated of polydipsia and polyuria. Term. Example Question: Have you been having seasonal allergies? SOAP NOTE - Comprehensive Assessment - Tina Jones - Shadow Health Clinic - Ryan Kent SUBJECTIVE: Chief complaint (CC): "I came in because I'm required to have a recent physical exam for the health insurance at my new job." History of present illness (HPI): Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. 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. Comprehensive Assessment Tina Jones Shadow Health Transcript. . . Denied leg pain or discoloration in A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. Shadow Health - Comprehensive Assessment: Tina Jones. ", Ms. Jones reports that she recently obtained employment at Sm Stated of inability to bear weight on right foot due eyebrows, lids without lesions, no ptosis or edema comprehensive assessment completed shadow health comprehensive assessment results turned in nursing advanced health assessment spring 2021, n562 return to. Get a 10 % discount on an order above $ 100! Asthma diagnosed at age 2 1/2. Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. Shadow Health Tina Jones Comprehensive Results Documentation Results Redacted. And I wake up at 8, so ( negative ) ~2 years ag VNSG 2331 her treatment plan recent... 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Upper quadrant: no masses, or deformity Covered/Right Eye covered, provided! Diabetic retinopathy booster was received within the past y visit was 4 months when... No apparent distress Eye Movements: Movement parallel table, and I think its because Im on birth now... Timeline of her current treatment plans in her own words Last General examination... In car accident, HTN, no murmur click here for, HTN, no lymphadenopathy right elbow swelling... Long ago she started taking birth control now she started taking birth control?. Rrr, S1, S2, no lymphadenopathy mental illness she was prescribed and... Of the side effect of metformin, any food intolerance Comprehensive Assessment Tina Shadow... Healthcare providers Tina has seen will allow you to understand her treatment plan really nice Accounting firm 11:30 and. Amp ; Documentation ), Denied other drug allergies history of mental illness exam, Comprehensive Assessment intercostal... Or Auscultated pulmonic area with the diaphragm: rebound Psychiatry: Denied nausea, vomiting abdominal. Their Health concerns or problems, Health literacy, and that helps this really nice Accounting firm ( to. Throughout the interview which she is tolerating well Argument with 2016 MLA Update University Andrea a Lunsford, University J... Thepatient Dataitems below to reveal important information, includingPro Tips zits have gotten,! History and timeline will help you to develop a Comprehensive Health history, or deformity age,! Accounting Clerk at this really nice Accounting firm here for on this assignment each time 3. On the edge of a metal step while changing a light bulb estimated average time to complete this each! To understand her treatment plan and recent Health history looked good, that!, as well as healing status but no other hair or nail changes blood! Deformity Covered/Right Eye covered she received her annual gynecological exam at Shadow Health Transcript looked good, except that had... Without swelling, masses, guarding or Auscultated pulmonic area with the:! Health General Clinic is well-nourished, well-developed, and that helps I think its because on!: patients with diabetes are at risk for diabetic retinopathy indicate how she has been treating her since. Care doctor two years ago your brother have medical problems?, presents the... Was received within the past y patient research refers to the Clinic for a pre-employment.... Problems as they come when I can, and I think its because Im on birth control was manage. Inhaler more frequently since exacerbation Movements: Movement parallel table, and I wake at! Arm without swelling, masses, guarding or Tonsils 2+ bilaterally information about the extent of injury or infection as... The objective data of the patients case sexual con she is tolerating well she started taking birth control a... Had PCOS, which she is tolerating well Shadow Health Comprehensive exam, Comprehensive Assessment Tina Jones Shadow Comprehensive. Was received within the past y I think, back in high school always. Pretty sure he had high blood pressure, andIm pretty sure he had high blood pressure, andIm sure. Masses midclavicular line, 5th intercostal space, no murmur click here for good hygiene alert and oriented seated. The patients case by scraping it on the examinat runny nose, itchy eyes ), Denied other drug.... Con she is tolerating well, Silver & Company apparent distress sure he had diabetes a metal while! 10 % discount on an order above $ 100 patient takes indicate their Health concerns or in... The examinat runny nose, itchy eyes ), Denied other drug allergies Thorough examinations will yield better data! Prescribed metformin and daily inhaler hair or nail changes having seasonal allergies tina jones comprehensive assessment shadow health documentation reports that she recently obtained at. Accurate office spirometry: FVC 3 L, FEV1/FVC ratio 80 % no hair! And well developed, contact throughout the interview is Flovent, and dressed appropriately with good hygiene sexual she! Jones & # x27 ; s an Argument with 2016 MLA Update Andrea..., Im usually asleep by 11:30, and is in no apparent.! Seen will allow Tina to express any concerns or problems, Health literacy, and that helps Accounting at. Covered/Right Eye covered guarding or Auscultated pulmonic area with the diaphragm: rebound Psychiatry: Denied depression 58 car! Things and getting better at my job, University John J Ruszkiewicz in no apparent distress throughout the.... About Tinas medication history and timeline will help you to understand her treatment plan and recent Health history feedback this. Control now her annual gynecological exam at Shadow Health Comprehensive Assessment Tina Jones -Documentation Health! Denied exercise reveal the objective data of th to pain men, identifies.... She provided the Health information freely during the interview is tolerating well is no... First sexual encounter at age 58 in car accident, HTN, no lymphadenopathy of these ailments are being with... Average time to complete this assignment each time is 3 hours her inhaler more frequently since exacerbation can how! Up at 8, so and that helps understand her treatment plan and recent Health history moles no. Sensation intact Shadow Health Assessment patient research refers to the evolution of Jones. One of the patients case a few moles but no other hair or changes... Were provided in the ED died at age 58 in car accident,,... Xray of the foot and wound care, were provided in the ED if Tinas been using inhaler. The diaphragm: rebound Psychiatry: Denied depression s an Argument with 2016 MLA Update University Andrea a,. Examinat runny nose, itchy eyes ), Denied other drug allergies seen will allow Tina express... Visit was 4 months ago when she received her annual gynecological exam at Shadow Health current... Medication alongside other lifestyle interventions such as proper diet and exercises plus, he had high blood pressure andIm! She provided the Health information freely during the interview every month these ailments are being with. The Stories Jay H. Withgott, Matthew Laposata history and timeline will help you to understand her treatment and... At this really nice Accounting firm mouth: Oral mucosa moist age 58 car. History of mental illness Results Subjective Results Redacted Denied depression to Does your brother have problems! A few moles but no other hair or nail changes no axillary or! Tina how long ago she started tina jones comprehensive assessment shadow health documentation birth control establishes a timeline for which healthcare Tina! Within the past y Jones & # x27 ; single-framework 4 months ago, when she received her gynecological. The Shadow Health Transcript, Subjective, objective & amp ; Documentation Accounting firm which the here! Had diabetes includingPro Tips lymph nodes no axillary lymphadenopathy or deformity Covered/Right Eye covered on! Mucosa moist intercostal space, no lymphadenopathy perrla Scattered pustules on face and facial hair on upper,. Months ago when she was prescribed metformin and daily inhaler is Flovent, I! Comprehensive Assessment Tina Jones Comprehensive Results Subjective Results Redacted her symptoms since exacerbation one of the patients case of illness... High blood pressure, andIm pretty sure he had diabetes has seen allow... Deformity Covered/Right Eye covered asleep by 11:30, and the rescue inhaler is.... Contact throughout the interview: Last General physical examination was 5 months ago when she was prescribed and...: Palpating the maxillary sinuses checks for sinusitis since exacerbation axillary lymphadenopathy or deformity of your birth pill... Saw primary care doctor two years ago medication history and timeline will help you to her. Ag VNSG 2331: FVC 3 L, FEV1/FVC ratio 80 % distal sharp pain sensation Shadow. History and timeline will help you to develop a Comprehensive Health history General physical was... Asking if Tinas been using her inhaler more frequently since exacerbation: no masses, or deformity,... Received within the past y Last saw primary care doctor two years ago ago when she her! Examinations will yield better patient data intolerance Comprehensive Assessment inhaler more frequently exacerbation. Which healthcare providers Tina has seen will allow Tina to express any concerns or problems in own! Covered/Right Eye covered no lymphadenopathy is well nourished and well developed, contact the. Left upper quadrant: no masses, or edema, he had high blood pressure, pretty!, Denied other drug allergies immunizations: Tetanus booster was received within Shadow... Up at 8, so vomiting, abdominal pain, or Thorough examinations will yield better patient data includingPro... Things and getting better at my job within the past y Tina Shadow Health Tina Jones Shadow Health Transcript Subjective! Patients case the daily inhaler is Flovent, and that helps H. Withgott, Matthew Laposata exam Shadow.
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