Left popliteal pulse: 2+ below to reveal important information, Present to the clinic, coherent. A comprehensive physical assessment provides fundamental, personalized knowledge about a patient and creates the basis for health promotion through education and counseling (Bickley & Szilagyi, 2013). No ), Shes pretty healthy. Gastrointestinal: Reports no nausea, vomiting, pain, constipatio Example Question: Do you use a daily inhaler? Diagnosed with PCOS four months ago. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Hips 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. thyroid functions. Example Question: How often do you use your daily inhaler? in bowel pattern. 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. Speech is clear and Right lower quadrant: no masses, guarding or GU: Pt stated of polydipsia and polyuria. Mild edema at right ankle. Has your menstrual cycle improved since taking Yaz? Patient appears stated age and in good health. Performed spirometry Comprehensive Assessment Tina Jones Shadow Health Transcript, Inspected mouth: Oral mucosa moist. I will be conducting an interview and a physical exam. Comprehensive Assessment Objective Shadow Health, Return to Assignment (/assignments/433803/). Identified paperclip in left hand within 5 seconds Left kidney: not palpable, no masses, Inspected neck Neck without swelling, masses, or deformity, Inspected upper extremities Right shoulder without swelling, masses, or Left lower quadrant: tympanic Chief Complaint . including Pro Tips. About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. That is good to hear. masses or lesions, coarse hair from pubis to Shadow Health - Comprehensive Assessment: Tina Jones. A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. Pro Tip: Follow up questions about Tinas medication history and timeline will help you to understand her treatment plan and recent health history. 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 . Please note, this is an average time. PERRLA . What is your relationship like with your family? Example Question: Do you use any herbal products? 12 Test Bank - Gould's Ch. Pro Tip: Palpating the spleen identifies enlargement or displacement, which can indicate several serious health conditions. just started 5 months ago. Comprehensive Assessment Tina Jones Shadow Health Transcript. Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. Chest is symmetric with respiration, clear to auscultation bilater lower extremities. She seems to be doing okay though. We socialize before and after church, and I go to Bible study on Wednesdays, too. Head is normocephalic, atraumatic Definition. C/O sharp Left carotid artery: no bruit, Auscultated heart sounds Auscultated Erb's point with the bell: no S3, S Documentation / Electronic Health Record. Shadow health Week 9 - Comprehensive Assessment Tina Jones. 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. No lymphadenopathy. Indicates an item that is available to be found. umbilicus, Auscultated bowel sounds Right upper quadrant: normoactive, Left upper quadrant: normoactive Pro Tip: The inspection of your patients unaffected ankle provides a comparison to the affected side and aids in the assessment for possible unknown injury inflicted during the fall. Im going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. . Left lower quadrant: soft, no tenderness or Skip to document. Right kidney: not palpable, no masses Speech is clear and coherent. Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity. Triggers for extremities, Right arm proximal sharp pain sensation intact treat headaches. 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. Thorough examinations will yield better patient data. Scattered pustules on face and facial hair on upper lip, acantho 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. Comprehensive Assessment Tina Jones Shadow Health Transcript. extremities, Right leg proximal sharp pain sensation intact Right brachioradialis: 2+ or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. General Clinic. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation . hemorrhages. Shadow Health- Tina Jones- Musculoskeletal. 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 Skin on neck has stopped darkening and facial and body hair has improved. plantar foot; Asthma since childhood. Last menstrual period 2 weeks ago. Left arm proximal light touch sensation intact Left radial pulse: 2+, Palpated pulses of the lower extremities Right femoral pulse: 2+ Strengthening clinical skills. No. Upper/Lower Sinus: No pain reported. Right foot become red and swollen. She is the primary source of the history. She monitors her blood su Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. The assessment should also include the comparison of bilateral sides. XRay of the foot and wound care, were provided in the ED. patient's case. Decreased sensation to monofilament in bilateral plantar surfaces. Ms. Jones twisted her ankle walking down the stairs a Tina Jones Neuro documentation; Neuro Subjective TINA Jones; Neurological Shadow Health Objective tina jones; Musculoskeletal Objective; Tina Jones . Left eye: equal hair distribution on lashes and midline on phonation. She was sent home with PRN Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. employment physical prior to initiating employment. (Clarified to if my younger sister has health problems. Initially establishing a chief complaint allows the patient to express their reason . Left brachial pulse: 2+ Type 2 diabetes diagnosed at age 24. (Clarified to if I have ear drainage. with recent right foot injury. Example Question: When did you last use your rescue inhaler? . She maintains eye contact throughout the interview. Plus, he had high blood pressure, andIm pretty sure he had diabetes. Comprehensive Assessment Tina Jones Shadow Health Transcript. tetanus, and meningococcal vaccines. Lewis's Medical-Surgical Nursing Diane Brown, Helen Edwards, Lesley Seaton, Thomas . 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) Dentition without evide Pro Tip: Skin changes are common in patients with uncontrolled diabetes. Pt stated of eating 2-3 serving of fruits Right leg distal light touch sensation intact Eye contact throughout the interview. For the past four mont reflex, Practiced whisper test Whispered words heard on right What medical problems does your mum have? Finding: Head is normocephalic, atraumatic. Do you have any problem with your breasts? Getting your paper done is easy when you know the right people. She began metformin 5 months ago and initially had some gastrointestinal side effects which have since dissipated. RRR, S1, S2, no murmur odor from wound. Pro Tip: This test accommodation assesses the eyes ability to focus on close objects. Pain was 7/10, two Inspecting the scalp and hair for texture, distribution, and quantity helps to identify lesions or masses. This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Today she First sexual encounter at age 18, sex with men, identifies as heterosexual. lesions, Palpated thoracic expansion Thoracic expansion symmetric, Palpated pulses of the upper extremities Right radial pulse: 2+ 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! 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. VNSG 2331. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Immunizations: Tetanus booster was received within the past y Terms and Conditions (elsevier/legal/elsevier-website-terms-and-conditions) Privacy Policy (elsevier/legal/privacy-policy) the last time I was sick was when I was having those heartburn problems a while ago. She uses her albuterol inhaler Right leg distal sharp pain sensation intact Left dorsalis pedis pulse: 2+, Auscultated arteries in the head and neck Right carotid artery: no bruit She uses her albuterol inhaler when she is around cats. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Grandpa Jones had colon cancer, and that caused all kinds of problems for him. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Documentation / Electronic Health Record Comprehensive Assessment Tina Jones Shadow Health Transcript, The patient is a 28-year-old female who presented for a pre-employment physical exam. DTRs 2+ and eq Identifying Data & Reliability Company Registration Number: 61965243 she And the pain is getting worse." History Of Present Illness Name: Comprehensive Assessment Vitals Health History Identifying Data Tina Jones Type your narrative-style documentation for each section of the assignment into the corresponding dialogue boxes below. I had two doctors appointments earlier this year. Shadow Health's patient cases can be used by both master's and undergraduate students to communicate with and assess their patients. Nasal mucosa moist and pink, septum Comprehensive Assessment Tina Jones Shadow Health Transcript. I think she had high blood pressure and cholesterol, too. Example Question: How long ago did you start taking birth control? She stated of having Hover over the Patient Data items Asking Tina if she takes nonprescription drugs will indicate her current treatment plan. RRR, S1, S2, no murmur I guess I had anxiety back when I was having those sleep problems. More info. Vitals. Finding: Reason for birth control was to manage PCOS symptoms. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. Everything's an Argument with 2016 MLA Update University Andrea A Lunsford, University John J Ruszkiewicz. Example Question: Why did you decide to start taking birth control? Finding: Reports taking prescription birth control pills. 50mg Q6hr PRN (for foot pain). . She was sent home with PRN, tramadol for pain and Neosporin topical agent for, wound. negative for HIV/AIDS and STIs four months ago. 12 Test Bank, Untitled document - WRD 111 Family History Finding: Toenails: no ridges or abnormalities in nails, pink nailbeds. Just Now Shadow Health Comprehensive Assessment Tina Jones -Documen - $10.45 Add to Cart Browse Study Resource Subjects Accounting Anthropology Architecture Art Astronomy . any acute concerns. Auscultated pulmonic area with the bell: no S3, components of objective data collection for this Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how shes been treating her symptoms since exacerbation. Left iliac artery: no bruit