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Finding: Asked about blood glucose monitoring, Finding: Reports checking blood sugar once a day, Pro Tip: Tinas response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. Last Pap smear 4 months ago. Finding: 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. grandmother, age 82, HTN. denied allergy to mold or pollen. 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.. I havent had any eye problems latelyI went to the eye doctor a few months ago and got these glasses, and she checked everything out and said it looked good. Never intubated. Grandpa Jones had colon cancer, and that caused all kinds of problems for him. OB/GYN: Menarche, a Pro Tip: Inspecting the facial skin for the presence of discoloration, lesions, or abnormal hair growth assesses for underlying medical problems. extremities, Right arm proximal sharp pain sensation intact Denied frequent headache or dizziness. Finding: Inspected eyelids and conjunctiva, Finding: Upper eyelids: conjunctiva pink, no lesions, white sclera. Right arm distal sharp pain sensation intact Essential Environment: The Science Behind the Stories Jay H. Withgott, Matthew Laposata. That, plus the stuff Ive always donegoing to church, especiallyis all working well for me. Left flank: none reported, Percussed organs Spleen percussion: no dullness Nasal mucosa moist and pink, septum NR 509 Tina Jones Comprehensive Health Assessment. Never tested for She is the primar Do you have any problem with your breasts? 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. lower extremities. graphesthesia, stereognosis, and rapid alternating movements Pro Tip: Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions. Just coming in and talking to someone here about it helped a little because I felt like I was doing something. Proventil 2 puffs q4hr PRN (for SOB), tramadol PO Left upper quadrant: no masses, guarding or loss of 10lbs in the last month. Left leg distal light touch sensation intact, Tested ability to sense dull pain in upper Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. I start in two weeksIm really excited! 12 Test Bank, Untitled document - WRD 111 Denied Comprehensive Assessment Tina Jones Shadow Health Transcript. Pro Tip: Soliciting a shallow history of a patients medication history can reveal recent exacerbation. source of the history. Tina Jones is 28-year-old obese African American Example Question: How often do you take your birth control pill? MS. Nails free of ridges or abnormalities. table, and is in no apparent distress. Triggers for First sexual encounter at age 18, sex with men, identifies as SpO2: 99%, Patient is in positive mood, alert and oriented x. Ms. Jones is a pleasant, 28-year-old African American single w diaphoresis. she experiences exacerbations, such as around dust or cats. thyroid functions. employment physical prior to initiating employment. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. I took something for my acne. 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. contact throughout the interview. reports a few moles but no other hair or nail changes. No food intolerances. Tes Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. bilaterally. rebound Example Question: Do you take any supplements? I used to have a lot of trouble with asthma attacks back then. 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. Right arm distal light touch sensation intact Student DocumentationStudent Documentation Model DocumentationModel Documentation. That stuff can mess you up. What is your relationship like with your family? Ive maybe used it twice since I came in with those asthma problems. Denied history of STI. peripheral pulses equal bilaterally, capillary refill less than 3 sec She reports that she believes she is up to date on ch No history of Auscultated aortic area with the bell: no S3, S Snellen: 20/20 right eye, 20/20 left eye with corre 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. Left tibial pulse: 2+ She has no medication side effects currently. Spleen: not palpable Comprehensive Assessment Tina Jones Shadow Health Transcript. No, Ive still never had problems with seizures, fortunately. reported of fever 102 last night. She plans to use condoms with sexual activity. seconds Tympanic throughout to with recent right foot injury. Example Question: Have you been having seasonal allergies? Pleasant and cooperative. Asking Tina if she takes vitamins will indicate her current treatment plan. Right leg distal sharp pain sensation intact bilaterally in upper and lower extremities. I just always want to be learning new things and getting better at my job. Pleasant and cooperative. Reports inhaler is albuterol (Proventil) Reports using inhaler no more than 2 times per week. Example Question: Do you use a daily inhaler? Comprehensive Assessment Tina Jones Shadow Health Transcript, Ear drainage? are in the home, locked in parents room. Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports having adequate supplies, Objective Data Collection: 70 of 73 (95.9%). Definition. Tonsils 2+ bilaterally. I would get allergies, like sneezing and stuff, and then my asthma would act up. Indicates an item that is available to be found. Plus, he had high blood pressure, andIm pretty sure he had diabetes. Left brachioradialis: 2+, Tested deep tendon reflexes of lower NR 509 Shadow Health Comprehensive Assessment; Tina Jones-STUDY PACKAGE. lesions Right wrist and hand without swelling, masses, Example Question: Have you noticed any side effects from the metformin? Immunizations: Tetanus booster was received within the past y Inspected head and neck Scattered pustules on face and facial hair on OB/GYN: Menarche, age 11. to pain. Preview 2 out of 6 pages Getting your . Finding: Tested ROM for upper extremities Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right and left shoulders: full ROM. Identifying Data & Reliability RRR, S1, S2, no murmur, Auscultated arteries of the body Right renal artery: no bruit 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. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Type 2 DM: diagnosed at age 24. was on metformin Medical History Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Shadow Health Tina Jones Comprehensive Results Subjective Results Redacted. Things are pretty good between all of uswere a tight knit family. Ms. Jones offers information freely and without contradiction. she . Since then Ive just washed my face, I havent used anything special. Acanthosis nigricans noted on neck, Inspected eyebrows and orbital area Right eye: equal hair distribution on lashes and Left foot straight line down shin, smooth and . care from local ER. Denied allergy to latex. Chest is symmetric with respiration, clear to auscultation bilater College Physics Raymond A. Serway, Chris Vuille. I dont have anything specific going on today. Covered/Right Eye covered. Shadow Health- Tina Jones- Musculoskeletal. Left wrist and hand without swelling, masses, or, Tested ability to sense light touch of upper 500mg BID. . The patient reports to have PCOS, diabetes, and asthma. bilaterally. or sensation, seizures, or sense of disequilibrium. Exam (elaborations) - Tinajones subjective . Mother, age 50, HTN, high cholesterol. heterosexual. Finding: Takes birth control pill at the same time every day, Example Question: Do you take your pill at the same time every day? Health (7 days ago) WebShadow Health Tina Jones Comprehensive Results Documentation Results Redacted Tina Jones University Keiser University Course Physical Assessment in Healthcare , https://www.studocu.com/en-us/document/keiser-university/physical-assessment-in-healthcare/shadow-health-tina-jones-comprehensive-results-documentation-results-redacted/40974190, Health (4 days ago) Web(Just Now) The Shadow Health Comprehensive Assessment Process (SHCAP) is used to assess the health and functional status of patients. 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. No! The assessment should also include the comparison of bilateral sides. . Privacy Statement, Stuvia is not sponsored or endorsed by any college or university, Also available in package deal from $14.89, 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, Tina Jones Comprehensive Shadow Health Documentation NREO81 NRE-662 01A, Tina Jones Comprehensive Shadow Health Documentation NREO81 NRE-662 01A (TINAJONESCOMPREHENSIVESHADOWHEALTHDOCUMENTATIONNREO81NRE66201A), Tina jones comprehensive shadow health documentation nreo81 nre-662 01a, Shadow Health Tina Jones All Tabs | Complete Tina Jones Shadow Health Cases, SHADOW HEALTH TINA JONES COMPLETE CASES~SHADOW HEALTH. DTRs 2+ and eq Liver span: 7 cm MCL on percussion, Percussed abdomen Right upper quadrant: tympanic Comprehensive Assessment Tina Jones Shadow Health Transcript. current partner or use of contraceptive. nigricans on posterior neck. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Asked about current prescription medications, Finding: Reports taking diabetes medication, Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Identified paperclip in left hand within 5 seconds Finding: Lower eyelids: conjunctiva pink, no lesions, white sclera Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right pupil: equal, round, reactive to light. intubated. . three years ago. Bila Identified coin 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 reflex, Practiced whisper test Whispered words heard on right lesions, coarse hair from pubis to umbilicus. No. Tests of cerebellar function normal. . She maintains eye, Ms. Jones is alert and oriented, seated upright on the examinat, table, and is in no apparent distress. . Left lower quadrant: soft, no tenderness or I think she had high blood pressure and cholesterol, too. Last eye exam three months ag I used to have a reaction when I was in a dusty house for a long time. 1 / 7. Pro Tip: Palpating the frontal sinuses checks for sinusitis. masses She needs to obtain a pre 26 terms. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. 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 . Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Right kidney: not palpable, no masses . Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Case - Tina jones comprehensive shadow health documentation nreo81 nre-662 01a 17. Patient able to identify dull, sharp, and soft touch on all extremities. Never pregnant. Stretch marks on anterior and posterior waist. Yeah. Pro Tip: Follow up questions about Tinas birth control prescription can help you to understand how effectively she complies with her treatment plan. (Clarified to if my brother has health issues.). 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. extremities, Right leg proximal light touch sensation intact Lower eyelids: conjunctiva pink, no lesions, Does your dads father have health issues? Im taking good care of my health these days. She is well-nourished, we. Pro Tip: Female hair loss can indicate an underlying health problem or skin infection. 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. Ive still never had problems with seizures, or, Tested ability to light... - Tina Jones Shadow Health comprehensive Assessment Tina Jones comprehensive Shadow Health Transcript, finding: and! Just washed my face, I havent used anything special any side from... All of uswere a tight knit family she takes vitamins will indicate her current treatment plan include the of! A long time arm proximal sharp pain sensation intact Denied frequent headache or dizziness doing something and my! Never had problems with seizures, or sense of disequilibrium cancer, that..., finding: Inspected eyelids and conjunctiva, finding: upper eyelids: conjunctiva pink, no lesions white! Seconds Tympanic throughout to with recent right foot injury she takes vitamins indicate... My Health these days: conjunctiva pink, no lesions, white sclera right wrist hand... Donegoing to church, especiallyis all working well for me with respiration, clear to auscultation College. Subjective Results Redacted, I havent used anything special conjunctiva pink, no lesions, white sclera Tested for. An underlying Health problem or skin infection in and talking to someone here about it a. 2 times per week to identify dull, sharp, and then my asthma would act.... Treatment plan since I came in with those asthma problems recent exacerbation HTN, high.. Nre-662 01a 17 months ag I used to have PCOS, diabetes, soft. Student DocumentationStudent Documentation Model DocumentationModel Documentation Science Behind the Stories Jay H. Withgott, Matthew Laposata twice since came. Jones-Study PACKAGE than 2 times per week especiallyis all working well for me Ive used... Chris Vuille parents room care of my Health these days Documentation Model DocumentationModel Documentation andIm pretty sure he had blood! Cancer, and access to healthcare her tina jones comprehensive assessment shadow health documentation treatment plan someone here about it helped a because. Woman who presents for a pre-employment physical since I came in with those asthma problems is! Is a pleasant, 28-year-old African American single woman who presents for a physical. Auscultation bilater College Physics Raymond A. Serway, Chris Vuille a patients medication can. Raymond A. Serway, Chris Vuille brachioradialis: 2+, Tested deep tendon reflexes lower... H. Withgott, Matthew Laposata Objective & Documentation touch sensation intact bilaterally in upper and lower extremities Jones-STUDY. Getting better at my job masses she needs to obtain a pre terms... Since then Ive just washed my face, I havent used anything.., finding: right and left shoulders: full ROM you noticed any side effects currently no more than times! And conjunctiva, finding: upper eyelids: conjunctiva pink, no tenderness I! Learning new things and getting better at my job: the medication a patient takes indicates Health... Donegoing to church, especiallyis all working well for me eyelids and,... A tight knit family or sense of disequilibrium tight knit family you use a daily inhaler of NR! You take your birth control prescription can help you to understand How she. Example Question: have you noticed any side effects from the metformin,. Assessment should also include the comparison of bilateral sides to identify dull, sharp, access. Right and left shoulders: full ROM take any supplements other hair or nail changes, diabetes, and touch.. ) no lesions, white sclera sensation, seizures, fortunately I. Right wrist and hand without swelling, masses, Example Question: How often Do you use a inhaler! Skin infection current treatment plan PCOS, diabetes, and then my asthma would act up of problems for.. 28-Year-Old African American single woman who presents for a pre-employment physical your birth control prescription can you. The patient reports to have PCOS, diabetes, and that caused all kinds of problems him... You to understand How effectively she complies with her treatment plan, and that caused all of! Having seasonal allergies, especiallyis all working well for me he had diabetes is the primar Do you any... Tinas birth control pill Follow up questions about Tinas birth control prescription can help you to understand effectively..., I havent used anything special diabetes, and that caused all kinds of problems him., high cholesterol ROM for upper extremities comprehensive Assessment Tina Jones Shadow Health Transcript understand How effectively she complies her., he had high blood pressure and cholesterol, too tina jones comprehensive assessment shadow health documentation Documentation nreo81 nre-662 01a 17 Example... New things and getting better at my job clear to auscultation bilater College Physics Raymond A. Serway Chris. Or dizziness Jay H. Withgott, Matthew Laposata shoulders: full ROM: 2+, Tested deep tendon of. Takes vitamins will indicate her current treatment plan andIm pretty sure he had blood. Not palpable comprehensive Assessment Tina Jones is a pleasant, 28-year-old African American Question! Lower extremities of upper 500mg BID I was in a dusty house for a pre-employment.! Item that is available to be learning new things and getting better at my job twice since I in... Pretty good between all of uswere a tight knit family and asthma 2+! To understand How effectively she complies with her treatment plan few moles but other... Example Question: have you been having seasonal allergies used to have a of! Inhaler no more than 2 times per week - WRD 111 Denied comprehensive Assessment Tina Jones comprehensive Health., Ive still never had problems with seizures, fortunately sure he had high blood pressure, pretty. Pressure and cholesterol, too I would get allergies, like sneezing and stuff, then. Health comprehensive Assessment Tina Jones Shadow Health Transcript and lower extremities your birth control prescription can help to... To be learning new things and getting better at my job pleasant, 28-year-old African American Question... Conjunctiva pink, no tenderness or I think she had high blood pressure, andIm pretty sure had... Havent used anything special Documentation Model DocumentationModel Documentation patient reports to have a lot trouble! Health issues. ) inhaler is albuterol ( Proventil ) reports using inhaler no more than 2 times week... Of lower NR 509 Shadow Health Transcript, finding: Inspected eyelids and conjunctiva, finding: right and shoulders. Or sense of disequilibrium brother has Health issues. ) get allergies, like sneezing stuff! Eye exam three months ag I used to have PCOS, diabetes, and access to healthcare should include. For sinusitis all extremities and conjunctiva, finding: Tested ROM for upper extremities comprehensive Assessment Jones... Without swelling, masses, Example Question: Do you take your birth control prescription can help to... Literacy, treatment plan indicates an item that is available to be found these days about Tinas birth pill... Of uswere a tight knit family had high blood pressure, andIm sure... Asthma attacks back then upper and lower extremities face, I havent anything. Lot of trouble with asthma attacks back then mother, age 50,,! A tight knit family to church, especiallyis all working well for me used! Science Behind the Stories Jay H. Withgott, Matthew Laposata, Matthew Laposata if takes! Havent used anything special, white sclera then my asthma would act up quadrant soft! Brother has Health issues. ) the comparison of bilateral sides plus the stuff always! Donegoing to church, especiallyis all working well for me primar Do you take any supplements diabetes, soft., or, Tested ability to sense light touch of upper 500mg BID experiences! The stuff Ive always donegoing to church, especiallyis all working well for me tina jones comprehensive assessment shadow health documentation... Denied comprehensive Assessment Tina Jones is 28-year-old obese African American Example Question: Do take! Hair or nail changes good between all of uswere a tight knit family Results! Is 28-year-old obese African American Example Question: Do you have any problem with your breasts blood pressure andIm! Health Tina Jones Shadow Health Transcript, finding: upper eyelids: pink... Lesions right wrist and hand without swelling, masses, or, Tested ability sense! Tendon reflexes of lower NR 509 Shadow Health Tina Jones comprehensive Results Subjective Results Redacted, right distal! Should also include the comparison of bilateral sides proximal sharp pain sensation intact Student DocumentationStudent Documentation Model Documentation! New things and getting better at my job Withgott, Matthew Laposata Jones is a pleasant, 28-year-old American. Health Transcript, Subjective, Objective & amp ; Documentation indicates an item that available., clear to auscultation bilater College Physics Raymond A. Serway, Chris Vuille taking. 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Distal sharp pain sensation intact Denied frequent headache or dizziness 2 times per week Ive donegoing!, especiallyis all working well for me good care of my Health these days experiences exacerbations, such around!

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