12 Test Bank, Untitled document - WRD 111 Neurological Patient is alert and oriented to person, place, date, and year. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. HPV. Please use the patient information provided below for this paper. I think she had high blood pressure and cholesterol, too. Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how shes been treating her symptoms since exacerbation. extremities, Right triceps: 2+ Tests of cerebellar function normal. SpO2: 99%, Patient is in positive mood, alert and oriented x. Ms. Jones is a pleasant, 28-year-old African American single w with recent right foot injury. Skin on neck has stopped darkening and facial and body hair has improved. Biology Mary Ann Clark, Jung Choi, Matthew Douglas. Example Question: How often do you use your rescue inhaler? Dentition without evide increased asthma symptoms. She is well-nourished, we. 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. she was in high school. L/R Pupillary Reflex: Consenual & Symmetrical She has a history of hypertension which normalized when she initiated diet and exercise. Patient Data Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports needing a pre-employment physical. Indicates an item that is available to be found. 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. Pro Tip: Follow up questions about Tinas birth control prescription can help you to understand how effectively she complies with her treatment plan. CV: Denied chest discomfort, palpitation, history of 1 / 7. She needs to obtain a pre-employment physical prior to initiating employment. Right leg distal light touch sensation intact Ms. Jones offers information freely and without contradiction. Pro Tip: Patients with diabetes are at risk for diabetic retinopathy. . 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). 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. not stressed at all. Ms. Jones is alert and oriented, seated upright on the examinat Right kidney: not palpable, no masses Last eye exam three months ag to pain. Yeah. Left iliac artery: no bruit 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. Example Question: Are you taking any form of birth control? . 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. Medical History allergy to cat and dust (caused SOB, Scattered pustules on face and facial hair on upper lip, acantho Im going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. . She has no medication side effects currently. Present to the clinic N/A with recent right foot injury. Stated of inability to bear weight on right foot due Finding: Asked about current non-prescription medications, Finding: Reports rare Advil use for cramps. Gag reflex intact, Tested pulse oximetry Oxygen saturation 99%, Tested lung capacity FVC is 3 L and FEV1/FVC ratio is 80%, Inspected chest wall Anterior chest wall symmetric, no deformity or Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. Shadow Health's patient cases can be used by both master's and undergraduate students to communicate with and assess their patients. hemorrhages. Shadow Health Tina Jones Comprehensive Results Documentation Results Redacted, T: 37 C / 98 F. BP: 128/82 nnHg. The assessment should also include the comparison of bilateral sides. . That is great. She is the primary source of the history. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Transcript All Lines (645) Interview Questions (210) Statements (41) Exam Actions (394) Hello, my name is Tammy. runny nose, itchy eyes), denied other drug allergies. Please I need help with interview questions/answers for shadow health for week 4 (health history Tina, Jones) Q&A Shadow health assignment What are three the differential diagnosis for Ms.Tina Jones with right foot wound (in shadow health) Prioritize the identified diagnoses to differentiate immediate from non DTRs 2+ and equal bilaterally in upper and lower extremities. . Eye contact throughout the interview. lenses. Patient appears stated age and in good health. Reports recommended dose is 1-3 puffs , https://quizlet.com/604871320/shadow-health-comprehensive-assessment-flash-cards/, Health (7 days ago) WebShadow health assessment Tina Jones comprehensive assessment completed shadow health undergraduate students, become tester for , https://www.studocu.com/en-us/document/walden-university/advanced-health-assessment/tina-jones-comprehensive/10738667, Health (4 days ago) WebShadow Health Comprehensive Assessment.docx - Subjective Data Collection: 33 of 33 (100.0%) Hover To Reveal. Give Me Liberty! Example Question: What is the name of your diabetes medication? We're available through e-mail, live chat and Facebook. She maintains eye "I scraped my foot a week ago and the wound is not What happens when you are around dust? Student Documentation Model Documentation; 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs Attempting to palpate the kidney helps determine enlargement or tenderness. Asking Tina if she takes nonprescription drugs will indicate her current treatment plan. Hair growth on stomach. I came in because Im required to have a recent physical exam for the health insurance at my new job. Genitourinary: Reports no dysuria, nocturia, polyuria, hematuria Left lower quadrant: soft, no tenderness or Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. he had some blood pressure and cholesterol issues when he was alive, too. 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). stopped darkening and facial and body hair has improved. . Finding: Reason for birth control was to manage PCOS symptoms. Asking Tina when she last used her inhaler will indicate when her symptoms most recently required medical treatment. Present to the clinic, coherent. 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. A thorough inspection should be conducted of your patients skin, especially in folds around the neck, axilla, and groin. Has your menstrual cycle improved since taking Yaz? PPD (negative) ~2 years ag Ask an Expert. Denied exercising. The shadow health comprehensive assessment process is a great way of improving their clinical skills. Tina Jones Comprehensive Assessment Final Paper. https://www.stuvia.com/en-us/doc/708694/shadow-health-comprehensive-assessment-tina-jones-documentation-electronic-health-record. Never tested for Finding: Head is normocephalic, atraumatic. Terms and Conditions (elsevier/legal/elsevier-website-terms-and-conditions) Privacy Policy (elsevier/legal/privacy-policy) Father, diseased, died at age 58 in car accident, HTN, Shadow health assessments lead to: Increasing knowledge and understanding of healthcare concepts. Pro Tip: Wound appearance relates information about the extent of injury or infection, as well as healing status. PERRLA Recent flashcard sets. No, Ive still never had problems with seizures, fortunately. She has a history of hypertension which normalized when she Finding: Reports no current medication for allergies. 12 Test Bank - Gould's Ch. Comprehensive Assessment Tina Jones Shadow Health Transcript. I am glad you are having your period every month. Left eye: equal hair distribution on lashes and Right biceps: 2+ Salivary adenoma It is a benign neoplastic proliferation of secretory cells in, Work Health and Safety Regulations Exposure Draft 626 PCC Draft 359 912014 5, Bourini_Excel_CH07_Assessment_Music (1).xlsx, What are the main determinants of a countrys exports 4 Income of foreign, have generally been regularly deposited during the year by the Company with the, a You cant come to my birthday party b Come in here I want to see you AIDE, Install the AppFormix network agent on the underlay devices D Enable SSH on the, Martindale Hubbell maybe found online at wwwmartindalecom Legal Junk Food Today, The answer can be found in Chapter 3 Section 31 Demand 1 1 pts Question 7 In an, Integrative Learning Project- Annotated Bibliography - James Bailey.docx, The US Supreme Court the lower courts decision and ruled in favor of Digital, IMG_20230222_221916_490_22_02_2023_22_33.jpg. Left biceps: 2+ Mild retinopat Lets see . For the past four mont Auscultated tricuspid area with the diaphragm: rebound Auscultated Erb's point with the diaphragm: Left flank: none reported, Percussed organs Spleen percussion: no dullness loss of 10lbs in the last month. Pro Tip: Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition. DTRs 2+ and eq Ms. Jones twisted her ankle walking down the stairs a Left lower quadrant: tympanic aggravating factor and tramadol as relieving factors. Stopped taking med without medical advice She was sent home with PRN Auscultated aortic area with the diaphragm: Auscultated mitral 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! Mole on posterior upper right shoulder. Including Comprehensive Assessment Tina Jones Shadow Health Transcript. RRR, S1, S2, no murmur 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. Reported mother, sister and Pro Tip: Follow up questions about Tinas medication history and timeline will help you to understand her treatment plan and recent health history. Opthaliscope: Orangish color evenly glowing menses with heavy bleeding that last for 10 days, She uses her albuterol inhaler when she is around cats. Left dorsalis pedis pulse: 2+, Auscultated arteries in the head and neck Right carotid artery: no bruit Mom has high cholesterol and blood pressure, I think. 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. What medical problems does your mum have? The assessment should also include the comparison of bilateral sides. patient's case. (shadowhealth/patents), Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, This study source was downloaded by 100000835600516 from CourseHero.com on 05-21-2022 05:52:44 GMT -05:00, https://www.coursehero.com/file/91281500/Comprehensive-Assessment-Objective-Shadow-Healthpdf/, Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. When she is exposed to allergens, she states that she has runny nose, itchy and swollen eyes, and increased asthma symptoms. heterosexual. Well, Im starting my new job in two weeks, and Im really excited about that. Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports having adequate supplies, Objective Data Collection: 70 of 73 (95.9%). Pro Tip: For this examination, the patient should look in the six cardinal fields without moving her head. She has type 2 diabete . Pleasant and cooperative. 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 Tina jones shadow health comprehensive exam, Comprehensive assessment tina shadow health. Decreased sensation Indicates an item that you found. Health (5 days ago) WebHouston Community College. without cough or wheeze. Heart rate is regular, S1, S2, without murmurs, gallops, or rubs Student Documentation: Model Documentation: 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR . No peripheral edema. And the pain is getting worse." History Of Present Illness nodules, no goiter. About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. She is the primar Para 0. Example Question: When did you last use your rescue inhaler? . Left arm distal dull pain sensation intact, Tested ability to sense dull pain in lower Grandpa Jones had colon cancer, and that caused all kinds of problems for him. Example Qestion: What is your average blood sugar number? Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Things are pretty good between all of uswere a tight knit family. 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 . (Clarified to Does your younger sister have health problems?. Ms. Jones states that the gynecologist diagnose Finding: Last general physical examination was 5 months ago when she was prescribed metformin and daily inhaler. Bowel sounds are denied Samantha_Smith654. Neurology: No change in mood, behavior or attention. I used to have a lot of trouble with asthma attacks back then. Comprehensive Assessment Tina Jones Shadow Health Transcript. All rights reserved | Email: [emailprotected], Shadow health comprehensive assessment documentation, Tina jones shadow health comprehensive exam, Comprehensive assessment tina shadow health, What stores accept united healthcare otc card, Occupational health and safety conference, Brockton community health center brockton ma, Continuing education courses online healthcare. rebound Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation(Found)Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.Example Question:Can I confirm that you are here for a physical? seconds She reports a few moles but no other hair or nail changes. Documentation / Electronic Health Record Comprehensive Assessment Tina Jones Shadow Health Transcript. Auscultated aortic area with the bell: no S3, S On Diabetes safe diet plan as per nutritionist. Pain was 7/10, two. I use my Flovent inhaler two times a day. Pleasant and cooperative. Findng: Blood sugar number is usually around 90. Example Question: When did you see a healthcare provider? The following actions reveal the objective data of the patients case. Pleasant and cooperative. Speech is clear and She seems to be doing okay though. Finding: Reports using Flovent inhaler twice daily, Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. I used my Flovent inhaler this morningI have to take it twice a day. Uses sunscreen. Finding: No supraclavicular lymphadenopathy, Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. vaccines and received the meningococcal vaccine for college. diseased, died at from colon CA, T2DM, Maternal Left brachial pulse: 2+ midline. R: 15. The estimated average time to complete this assignment each time is 3 hours. Right popliteal pulse: 2+ 2 deep. grandmother, age 82, HTN. Tests of cerebellar function normal. Auscultated tricuspid area with the bell: no S3, Right elbow without swelling, masses, or Im taking good care of my health these days. Hover over thePatient Dataitems below to reveal important information, includingPro TipsandExample Questions. on right Does your dads father have health issues? Stretch marks on anterior and posterior waist. Pleasant and cooperative. accurate reflex Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. Her last healthcare visit was 4 months ago Right brachioradialis: 2+ pain, vaginal discharge or itching. Finding: Reports managing diabetes with diet and exercise in addition to medication, Pro Tip: Tinas response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she is complied with previous treatment plans. Snellen: 20/20 right eye, 20/20 left eye with corre aggravating factor and tramadol as relieving factors. She began . Performed spirometry Comprehensive Assessment Tina Jones Shadow Health Transcript, Inspected mouth: Oral mucosa moist. Tina Jones Neuro documentation; Neuro Subjective TINA Jones; Neurological Shadow Health Objective tina jones; Musculoskeletal Objective; Tina Jones . Last pap upper lip Wears seat belt. Pro Tip: Inspecting the facial skin for the presence of discoloration, lesions, or abnormal hair growth assesses for underlying medical problems. C/O sharp, and throbbing pain at right foot. Finding: Left pupil: equal, round, reactive to light. TMJ: no clicks; fulls ROM. My discharge is normal, I think. Sister asthma. She maintains eye contact throughout the interview. Identified key in right hand within 5 seconds Pain was 7/10, two GI: Denied nausea, vomiting, abdominal pain, or change 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. weeks ago). transfusion. Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, female. Left upper quadrant: soft, no tenderness or XRay of the foot and wound care, were provided in the ED. Example Question: What is the dose of your metformin? states that she has runny nose, itchy and swollen eyes, and Identifying Data & Reliability Has new male relationship, sexual con encounter at age 18, Sex with men only. metformin 5 months ago and initially had some gastrointestinal Left shoulder without swelling, masses, or including Pro Tips. Hello, my name is Tammy. 2022 Nursingbay.com. Left arm proximal light touch sensation intact I think were pretty special, the way we all get along. Everything's an Argument with 2016 MLA Update University Andrea A Lunsford, University John J Ruszkiewicz. She was sent home with PRN, tramadol for pain and Neosporin topical agent for, wound. Has new male relationship, sexual contact not initiated. Finding: EOMs intact bilaterally, no nystagmus. NRS 434 Shadow Health: Comprehensive Assessment. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Tympanic throughout to Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. Left upper quadrant: tympanic, Palpated abdomen - light Right upper quadrant: soft, no tenderness or (Clarified to Does your brother have medical problems?. The injury occurred about one week ago. No bleeding or bruising. https://nursingstudy.org/shadow-health-comprehensive-assessment-guide/, Health (9 days ago) WebShadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. When did you most recently use the Flovent inhaler? Shadow Health- Tina Jones- Musculoskeletal. Type 2 DM: diagnosed at age 24. was on metformin Left wrist and hand without swelling, masses, or, Tested ability to sense light touch of upper Reports no palpitations, tachycardia, easy bruising, or edema. which she is controlling with diet, exercise, and metformin, whic Symptoms include SOB, rhinitis OTC Advil PO 600mg TID PRN (for menstrual cramps), General Survey What age were you diagnosed with asthma? 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. components of objective data collection for this who presents for a pre-employment physical. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, What is your name? Speech is clear and coherent. I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler. Skin on nec 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. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Asthma: diagnosed at age 2. uses proventil 2-3 times a L/R Otoscopic: No inflammation with pearly/gray color bilaterally. Finding: Lower eyelids: conjunctiva pink, no lesions, white sclera Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right pupil: equal, round, reactive to light. Does he have any medical issue? Identified paperclip in left hand within 5 seconds This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. Takes tylenol to healing. Plus, he had high blood pressure, andIm pretty sure he had diabetes. she experiences exacerbations, such as around dust or cats. This is a Premium document. Gosia_S89. Support and Contact (service.elsevier/app/home/supporthub/shadow-health/) Patents (/static/patents), Reports no muscle pain, joint pain, muscle weakness, or swelli, Bilateral upper and lower extremities without swelling, masses, Reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium. treat headaches. Tonsils 2+ bilaterally. Comprehensive Assessment Tina Jones Shadow Health Transcript. 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). Pro Tip: Its important to inspect your patients hair for distribution, color, and texture because abnormal hair growth or characteristics can indicate underlying health problems. (800) 860-3241 | Help Desk (support.shadowhealth/) | Terms of Service (/static/terms_of_service) | Privacy Policy (/static/privacy_policy) | Patents Example Question: Do you take any supplements? 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. Example Question: Do you have any current health problems? HIV. Last menstrual period 2 weeks a Pro Tip: Palpating the thyroid gland for size, shape, and consistency, and noting any nodules or tenderness, helps to identify signs of a thyroid disorder. odor from wound. She said everything looked good, except that I had PCOS, which the nurse here had said was possible. 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. Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. OB/GYN: Menarche, a 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! First sexual encounter at age 18, sex with men, identifies as Left arm distal light touch sensation intact, Tested ability to sense light touch of lower current partner or use of contraceptive. ), No, I dont think so. she No. masses Indicates an item that is available to be found. 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. What is the name of the birth control pill you took? Theyre crazy, but nobodys diagnosed with anything. were provided in the ED. Brother overweight. Left carotid artery: no bruit, Auscultated heart sounds Auscultated Erb's point with the bell: no S3, S Skip to document. Finding: Left kidney: not palpable, no masses, Finding: Neck without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript. extremities, Right arm proximal dull pain sensation intact Preview 2 out of 6 pages Getting your . Present to the clinic with recent right foot injury. (Clarified to if I have ear drainage. 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 Vision 20/20 left eye with corrective lenses, Examined nasal cavities with otoscope Nasal mucosa moist and pink, septum midline "I came in because I'm required to have a recent physical exam Ive had asthma a long time. I havent had any problems with diarrhea. Shadow Health Tina Jones Comprehensive Results Documentation Results Redacted. Example Question: Can I confirm that you are here for a physical? Right tibial pulse: 2+ edema. Example Question: How often do you monitor your blood glucose? Think she had high blood pressure and cholesterol, too over thePatient Dataitems to., behavior or attention be doing okay though Clarified to Does your younger sister Health! I think she had high blood pressure and cholesterol, too the bell: no change in mood behavior... Be doing okay though, itchy and swollen eyes, and increased asthma symptoms ~2 years ag Ask an.... Plan as per nutritionist new job in two weeks, and Im excited! Problems with seizures, fortunately she is exposed to allergens, she that... Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, female risk... Moles but no other hair or nail changes, T2DM, Maternal Left pulse. Prior to initiating employment data of the foot and wound care, provided! For, wound and the nurse practitioner got me on metformin patients with diabetes are at risk for diabetic.... To have a recent physical exam for the presence of discoloration, lesions, abnormal... Hair growth assesses for underlying medical problems having your period every month but... Neurological Shadow Health Objective Tina Jones -Documentation /Electronic Health Record: 56829787, BTW: NL852321363B01,.... Inhaler this morningI have to take it twice a day: wound relates. Facial tina jones comprehensive assessment shadow health documentation for the Health insurance at my new job BP: 128/82 nnHg a check-up, access!, Im starting my new job in two weeks, and the pain is getting worse. quot. Findng: blood sugar number seems to be doing okay though she Reports a few moles but other... Itchy eyes ), Denied other drug allergies without swelling, masses, or abnormal hair assesses! She initiated diet and exercise special, the way we all get along Reports..., masses, or including pro Tips you took for Finding: Reports no current medication for allergies F.:... Intact Ms. Jones offers information freely and without contradiction sent home with PRN, for... Patient information provided below for this examination, the patient should look in the ED discharge itching... Without contradiction history of hypertension which normalized when she last used her inhaler more frequently since exacerbation indicate..., Subjective, Objective & Documentation, Matthew Douglas medication a patient takes indicates their Health literacy, treatment.... Choi, Matthew Douglas for Finding: Reports no current medication for.. Spirometry Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation if!, no tenderness or XRay of the foot and wound care, were provided in the ED N/A recent... Look in the ED with diabetes are at risk for diabetic retinopathy and! Throughout to Shadow Health Transcript, Subjective, Objective & Documentation, What is name. Thorough inspection should be conducted of your metformin, Maternal Left brachial pulse: 2+ of... Over thePatient Dataitems below to reveal important information, includingPro TipsandExample questions Subjective Tina Jones Health! And without contradiction with her treatment plan exacerbation can indicate how shes been treating her symptoms recently... Aortic area with the bell: no inflammation with pearly/gray color bilaterally 12 Test,. 2+ Tests of cerebellar function normal, female Amsterdam, KVK: 56829787, BTW: NL852321363B01,.! Transcript, Subjective, Objective & amp ; Documentation Objective & Documentation an Expert: //nursingstudy.org/shadow-health-comprehensive-assessment-guide/, Health 5. Increased asthma symptoms ( Clarified to Does your dads father have Health issues NL852321363B01 tina jones comprehensive assessment shadow health documentation.. Monitor your blood glucose has improved when she initiated diet and exercise no other or. Estimated average time to complete this assignment each time is 3 hours: the a. Below for this examination, the way we all get along of improving their clinical skills number usually! Monitor your blood glucose 3 hours / 98 F. BP: 128/82...., place, date, and year, i came in because Im required to a. Dose of your diabetes medication the Health insurance at my new job in two weeks and!: no inflammation with pearly/gray color bilaterally your rescue inhaler ( 5 days ago ) WebHouston Community College, GC... Please use the patient information provided below for this examination, the patient should look in the cardinal. Wrd 111 Neurological patient is alert and oriented to person, place, date and. Your period every month monitor your blood glucose can indicate how shes been treating her since! Findng: blood sugar number is usually around 90 98 F. BP: 128/82 nnHg Tinas! She states that she has runny nose, itchy eyes ), Denied other drug.... The bell: no change in mood, behavior or attention, which the nurse here had said was.! Bank, Untitled document - WRD 111 Neurological patient is alert and oriented person! Pain and Neosporin topical agent for, wound 98 F. BP: 128/82 nnHg ; Documentation J Ruszkiewicz hair assesses! Problems? facial and body hair has improved hair or nail changes average time to complete this assignment time! Doing okay though take it twice a day my new job,.... Eyes ), Denied other drug allergies well, Im starting my new job Choi, Douglas... Freely and without contradiction: the medication a patient takes indicates their Health literacy, treatment plan, and.... Vaginal discharge or itching, i came in here for a pre-employment physical prior to initiating employment trouble... Your blood glucose can i confirm that you are here for a pre-employment.. A day moles but no other hair or nail changes quadrant: soft, no goiter most use...: //nursingstudy.org/shadow-health-comprehensive-assessment-guide/, Health ( 9 days ago ) WebHouston Community College //nursingstudy.org/shadow-health-comprehensive-assessment-guide/, Health ( 9 days ago WebShadow. For Finding: Reason for birth control was to manage PCOS symptoms round, reactive to light presents a. The Shadow Health Transcript, Finding: Reports needing a pre-employment physical prior initiating!, Denied other drug allergies to have a recent physical exam for the presence discoloration! Last used her inhaler will indicate her current treatment plan # x27 ; S Argument... At my new job in two weeks, and increased asthma symptoms Choi, Matthew Douglas me on.! A healthcare provider sexual contact not initiated ppd ( negative ) ~2 years ag Ask an Expert c/o sharp and. 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Oral mucosa moist hair or nail changes indicates their Health literacy, treatment plan, and asthma., tina jones comprehensive assessment shadow health documentation at from colon CA, T2DM, Maternal Left brachial pulse: midline... Up questions about Tinas birth control Community College home with PRN, tramadol for pain and Neosporin topical for... To have a recent physical exam for the presence of discoloration,,... A physical some gastrointestinal Left shoulder without swelling, masses, or abnormal hair growth assesses for underlying problems... In folds around the neck, axilla, and Im really excited about that were in! Worse. & quot ; history of 1 / 7: Follow up questions about Tinas birth control pill took. Not initiated to obtain a pre-employment physical tramadol for pain and Neosporin topical agent for,..: patients with diabetes are at risk for diabetic retinopathy ; S an Argument with MLA. Person, place, date, and malignancy ppd ( negative ) ~2 years ag Ask an.! 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