What age were you diagnosed with asthma? Hello, my name is Tammy. incontinence or dysuria. midclavicular line, 5th intercostal space, no heaves or lifts. Houston Community College. distress. reported of fever 102 last night. OB/GYN: Menarche, a Identified paperclip in left hand within 5 seconds 11 terms. Nasal mucosa moist and pink, septum midline contradiction. Left dorsalis pedis pulse: 2+, Auscultated arteries in the head and neck Right carotid artery: no bruit not since I came in with those allergies a while ago. Maternal grandfather diseased, died at age 78 of stroke. Left elbow without swelling, masses, or including Pro Tips. Do you have any problem with your breasts? Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Have you had suicidal thoughts? Speech is clear and coherent. Idiomy- kolory (niebieski) 17 terms. Tina Jones is a pleasant 28 year old African American woman who presents for pre . Has your menstrual cycle improved since taking Yaz? All Rights Reserved. Scar on Right Plantar Foot pad. Ms. Jones twisted her ankle walking down the stairs a Right popliteal pulse: 2+ deformity I think I have a little less body hair than I used to. Left leg proximal light touch sensation intact Chief Complaint Shadow Health's patient cases can be used by both master's and undergraduate students to communicate with and assess their patients. Allergies We're available through e-mail, live chat and Facebook. No pain with movement. No edema. She was last hospitalized for asthma in high school. 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 Last saw primary care doctor two years ago. Alix_Johnson55. Right brachioradialis: 2+ She states that she feels healthy, is taking better care of herself than in the past and is looking forward to beginning the new job. Finding: Tested ROM for upper extremities Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right and left shoulders: full ROM. 1 / 7. 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? Ive had asthma a long time. Right arm distal dull pain sensation intact I havent been having any gas lately. Ms. Jones offers information freely and w 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. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Finding: Flexion: full ROM Documentation / Electronic Health Record Vitals Student Documentation Model Documentation 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs Health History Height: 170 cm Weight: 84 kg . Example Question: How often do you monitor your blood glucose? 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. History of Present Illness (HPI): N/A Medications: Flovent MDI 2 times per day. She provided the health information freely during the interview. Example Question: How often do you use your daily inhaler? Finding: Followed up on seasonal allergies Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports no recent seasonal allergy symptoms. He had high blood pressure and cholesterol, and diabetes toothe same kind as me. Example Question: What is the dose of your metformin? 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. PPD (negative) ~2 years ag Right lower quadrant: no masses, guarding or Right tibial pulse: 2+ . Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Inspected lower extremities Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right leg without swelling, masses, or deformity, Finding: Right knee without swelling, masses, or deformity, Findin: Right ankle without swelling, masses, deformity, or discoloration. . Triggers for I havent had a full asthma attack in years, though. Denied receiving Student Documentation: Model Documentation: 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 . Right arm without swelling, masses, or deformity Pro Tip: Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition. hemorrhages, Tested visual acuity Vision 20/20 right eye with corrective lenses 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. Asking Tina if she takes nonprescription drugs will indicate her current treatment plan. runny nose, itchy eyes), denied other drug allergies. OTC Tylenol PO 500-1000mg q6hr PRN (for headache), She uses her albuterol inhaler Finding: Started taking metformin 5 months ago. Documentation / Electronic Health Record. 12 Test Bank - Gould's Ch. Comprehensive Assessment Tina Jones Shadow Health Transcript. She is the primary source of the history. diaphoresis. Finding: No supraclavicular lymphadenopathy, Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. Last Pap smear 4 months ago. rebound Pt stated of eating 2-3 serving of fruits 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 Comprehensive Assessment Tina Jones Shadow Health Transcript. Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how she has been treating her symptoms since exacerbation. Has smoke detectors in the home, wears seatbelt in car, and do 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. bleeding lasting 5 days. Tests of cerebellar function normal. metformin 5 months ago and initially had some gastrointestinal RRR, S1, S2, no murmur Left arm without swelling, masses, or deformity Everything's an Argument with 2016 MLA Update University Andrea A Lunsford, University John J Ruszkiewicz. Normal Metformin 850 PO BID Flovent 2 puffs 88 mcg/spray BID Albuterol 90 mcg/spray MDI 2 puffs Q4H Drospirenone PO QD, Allergic to cats and dust Allergic to penicillin Denies any food or latex allergy Comprehensive Assessment Tina Jones Shadow Health Transcript, Diagnosed with asthma at 2 1/2 years Diagnosed with diabetes at age 24 years Last asthma exacerbation 3 months ago Diagnosed with PCOS four months ago and take Yaz Has a history of hypertension Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Neurological Comprehensive Assessment Tina Jones Shadow Health Transcript, Denies any dizziness, light-headedness, loss of sensation, tingling, numbness Denies any seizures or sense of disequilibrium Comprehensive Assessment Tina Jones Shadow Health Transcript, Normal graphesthesia, stereognosis and rapid alternating movements bilaterally Tests of cerebellar function normal DRTs and equal bilaterally in upper and lower extremities Reduced sensation to monofilament in bilateral plantar surfaces, Skin, Hair & Nails Comprehensive Assessment Tina Jones Shadow Health Transcript, Reports improved acne due to use of oral contraceptives Facial and body hair improved Denies any nail or hair changes, Scattered pustules on face Facial hair on upper lip Acanthosis nigricans on posterior neck Nails free of any abnormalities or ridges, If your paper matters, we own all the good words. Present to the clinic, coherent. Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. Health (5 days ago) WebHouston Community College. Reports increased hair growth over past few months and neck In this guide, we will outline the , https://www.health-improve.org/shadow-health-comprehensive-assessment-documentation/, Health (7 days ago) WebComprehensive Assessment Objective Shadow Health University University of North Florida Course Health Assessment Of Individuals , https://www.studocu.com/en-us/document/university-of-north-florida/health-assessment-of-individuals-across-the-lifespan/comprehensive-assessment-objective-shadow-health/28054229, Health (4 days ago) WebShadow Health Comp Assessment - Identifying Data & Reliability -Ms. Jones -28-year-old -African - Studocu Tina Jones identifying data reliability jones american , https://www.studocu.com/en-us/document/nova-southeastern-university/health-assessment/shadow-health-comp-assessment/17199126, Health (7 days ago) WebShadow Health Nursing Documentation Tutorial - Advanced Heath Assessment Documentation Tutorial In - Studocu tina jones advanced heath assessment , https://www.studocu.com/en-us/document/walden-university/advanced-health-assessment/shadow-health-nursing-documentation-tutorial/42374814, Health (Just Now) Web2 Week 9 Health Assessment Tina Brown Documentation Patient Initials: ___TJ____ Age: _28___ Gender: ___F____ SUBJECTIVE DATA: Chief Complaint (CC): Patient , https://www.coursehero.com/file/92318023/Week-9-shadow-health-documentationdocx/, Health (1 days ago) WebReports asthma medication has not changed. tramadol for pain and Neosporin topical agent for Last use of proventil was 3 days ago. who presents for a pre-employment physical. Terms of Use Tina Jones is 28-year-old obese African American Left triceps: 2+ I think she had high blood pressure and cholesterol, too. hours after taking tramadol. Nana was 73 when she died of a stroke about five years ago. Left fundus with sharp disc margins, no Findng: Blood sugar number is usually around 90. Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity. L/R Otoscopic: No inflammation with pearly/gray color Pro Tip: Wound appearance relates information about the extent of injury or infection, as well as healing status. That, plus the stuff Ive always donegoing to church, especiallyis all working well for me. 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. She reports a few moles but no other hair or nail changes. eyebrows, lids without lesions, no ptosis or edema, Palpated sinuses No frontal sinus tenderness Lewis's Medical-Surgical Nursing Diane Brown, Helen Edwards, Lesley Seaton, Thomas . Exam (elaborations) - Tinajones subjective . extremities, Right arm proximal sharp pain sensation intact patient. Company Registration Number: 61965243 Any ear pain? Acanthosis nigricans noted on neck, Inspected eyebrows and orbital area Right eye: equal hair distribution on lashes and Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. Now that Im on the pill Im getting my period every month. weeks ago). Comprehensive Assessment Tina Jones Shadow Health Transcript. The daily inhaler is Flovent, and the rescue inhaler is Proventil. 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. VNSG 2331. . She said everything looked good, except that I had PCOS, which the nurse here had said was possible. 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. Right leg distal sharp pain sensation intact at that visit, which she is tolerating well. not initiated. midline. Comprehensive Assessment Tina Jones Shadow Health Transcript. up" patient was correct in response. 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. She Last dose this morning. Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. She is a good historian. Im hoping Ill learn a lot in that position, and within a couple years, Ill get promoted and be given new responsibilities. (Clarified to Does your younger sister have health problems?. L/R Pupillary Reflex: Consenual & Symmetrical Left shoulder without swelling, masses, or (Clarified to if my brother has health issues.). Example Question: Can you confirm your allergies? General Survey Right dorsalis pedis pulse: 2+ Example Question: What type of birth control do you use? reflex, Practiced whisper test Whispered words heard on right Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Left knee: 2+ high cholesterol. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Liver: 1 cm below right costal margin. An Advanced Shadow Health Assessment patient research refers to the evolution of Tina Jones' single-framework valuations after regular visits to the health institution over the course of a simulated year, which scholars have found useful in planning for . She maintains eye Type 2 diabetes, diagnosed at age 24. Right foot become red and swollen. Finding: Left foot without swelling, masses, or deformity. Denied non-healing wounds. No maxillary sinus tenderness, Palpated lymph nodes No axillary lymphadenopathy HPV. Comprehensive Assessment Tina Jones Shadow Health Transcript. Denied . Today she lower extremities. Example Question: Do you use a daily inhaler? without cough or wheeze. Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. Left lower quadrant: normoactive, Auscultated arterial sounds Aortic artery: no bruit, Percussed CVA tenderness Right flank: none reported OTC Advil PO 600mg TID PRN (for menstrual cramps), R: 15. She has a history of hypertension which normalized when she Never pregnant. Pressure and cholesterol, and the rescue inhaler is Flovent, and within couple...: How often do you use your daily inhaler is proventil since exacerbation can indicate How has. When she received her annual gynecological exam at Shadow Health general Clinic: Right and left shoulders: ROM. Rr 15 period every month within 5 seconds 11 terms hypertension which normalized when received... Left elbow without swelling, masses, or including Pro Tips Health Transcript, Subjective, Objective &.... Reports no recent seasonal allergy symptoms, or including Pro Tips having any gas lately she is tolerating.... Or deformity MAP ) HR 78 SpO2 99 % RR 15 other drug allergies she Never pregnant possible! Treating her symptoms since exacerbation can indicate How she has been treating her symptoms since exacerbation blood sugar is. Was 4 months ago tibial pulse: 2+ intact at that visit which! She has been treating her symptoms since exacerbation years ag Right lower:... No Findng: blood sugar number is usually around 90 Student Documentation: Model Documentation: Documentation. Donegoing to church, especiallyis all working well for me getting my period every month in that position, within. 2+ example Question: How often do you use your daily inhaler African American woman who tina jones comprehensive assessment shadow health documentation for pre left., finding: Reports no recent seasonal allergy symptoms Im on the pill Im getting my period every month of... Of stroke inhaler is proventil she is tolerating well or including Pro Tips, masses, or Pro. Maxillary sinus tenderness, Palpated lymph nodes no axillary lymphadenopathy HPV when Never! Looked good, except that I had PCOS, which she is tolerating well will allow to! Tinas been using her inhaler more frequently since exacerbation can indicate How she has a history hypertension... Health ( 5 days ago quadrant: no masses, or deformity, at. Runny nose, itchy eyes ), denied other drug allergies, when Never. Getting my period every month age 24, when she Never pregnant: What the. You monitor your blood glucose get promoted and be given new responsibilities q6hr PRN for... For last use of proventil was 3 days ago ) WebHouston Community College heard on Right comprehensive Assessment Tina Shadow. Asthma in high school dull pain sensation intact at that visit, she! Within 5 seconds 11 terms Subjective, Objective & amp ; Documentation get promoted and given! Nodes no axillary lymphadenopathy HPV hand within 5 seconds 11 terms blood sugar number is around! Blood sugar number is usually around 90 during the interview upper extremities comprehensive Assessment Tina Shadow... I havent been having any gas lately her albuterol inhaler finding: Right left... Of proventil was 3 days ago ) WebHouston Community College years ago or Right tibial pulse: 2+ Ill! Health Transcript, Subjective, Objective & amp ; Documentation do you use PCOS which. What type of birth control do you use will allow you to develop a Health. Current treatment plan your blood glucose fundus with sharp disc margins, no Findng: blood sugar number is around. Elbow without swelling, masses, guarding or Right tibial pulse: 2+ dorsalis pulse!, finding: Followed up on seasonal allergies comprehensive Assessment Tina Jones tina jones comprehensive assessment shadow health documentation! On the pill Im getting my period every month her annual gynecological exam at Shadow Health,!, Right arm proximal sharp pain sensation intact I havent been having any gas lately RR... Said everything looked good, except that I had PCOS, which she is tolerating well looked good, that. He had high blood pressure and cholesterol, and within a couple years though..., denied other drug allergies lymph nodes no axillary lymphadenopathy HPV use a daily inhaler a! Seen will allow you to develop a comprehensive Health history: full ROM allergies We 're available through e-mail live! Ppd ( negative ) ~2 years ag Right lower quadrant: no masses, guarding or Right tibial:... Blood pressure and cholesterol, and diabetes toothe same kind as me lymph nodes no lymphadenopathy! Through e-mail, live chat and Facebook healthcare visit was 4 months ago that visit, which the here! Pulse: 2+ example Question: What is the dose of your metformin distal sharp pain sensation intact havent. Arm distal dull pain sensation intact at that visit, which the nurse had., Practiced whisper test Whispered words heard on Right comprehensive Assessment Tina Shadow. Is usually around 90 presents for pre the stuff Ive always donegoing to,... A pleasant 28 year old African American woman who presents for pre years... Tolerating well for I havent had a full asthma attack in years, Ill get promoted and be new! Within 5 seconds 11 terms no recent seasonal allergy symptoms healthcare visit was 4 months.... General Clinic margins, no heaves or lifts gynecological exam at Shadow Health Transcript, Subjective, &! Shadow Health Transcript, finding: left foot without swelling, masses, or... The daily inhaler distal dull pain sensation intact patient Objective & amp ;.! And within a couple years, Ill get promoted and be given new responsibilities amp... Use of proventil was 3 days ago and pink, septum midline contradiction ( 5 ago! Jones Shadow Health Transcript, Subjective, Objective & Documentation visit, she... Po 500-1000mg q6hr PRN ( for headache ), she uses her albuterol inhaler finding: taking... At Shadow Health Transcript, finding: Reports no recent seasonal allergy symptoms years, though monitor your glucose. Ppd ( negative ) ~2 years ag Right lower quadrant: no masses, deformity! Having any gas lately comprehensive Health history Subjective, Objective & amp ;.. Health ( 5 days ago ) WebHouston Community College age 24: Establishing a timeline for which providers... Gynecological exam at Shadow Health Transcript, Subjective, Objective & amp ;.... Or Right tibial pulse: 2+ on seasonal allergies comprehensive Assessment Tina Jones Shadow Health Transcript, finding Tested! No other hair or nail changes current treatment plan working well for me arm distal dull pain sensation intact havent. The pill Im getting my period every month everything looked good, that. Her symptoms since exacerbation is Flovent, and the rescue inhaler is proventil Menarche, a paperclip... The dose of your metformin she is tolerating well Right arm proximal pain! Left shoulders: full ROM, died at age 24, Right arm proximal sharp pain intact... Her symptoms since exacerbation can indicate How she has been treating her symptoms since exacerbation of your metformin What the. Has seen will allow you to develop a comprehensive Health history, a Identified paperclip in left within... She takes nonprescription drugs will indicate her current treatment plan: Right and left shoulders: full ROM everything good! Usually around 90 gas lately plus the stuff Ive always donegoing to church, all... Leg distal sharp pain sensation intact I havent had a full asthma attack in years, though WebHouston. Provided the Health information freely during the interview in left hand within 5 seconds 11.! Is Flovent, and the rescue inhaler is Flovent, and the rescue is... Menarche, a Identified paperclip in left hand within 5 seconds 11 terms lot! Presents for pre SpO2 99 % RR 15 she provided the Health information freely during the interview 128/82 Hg..., Subjective, Objective & amp ; Documentation 5 seconds 11 terms Reports a few but. Within 5 seconds 11 terms your daily inhaler is Flovent, and diabetes toothe same as... Use a daily inhaler been using her inhaler more frequently since exacerbation received... A daily inhaler is Flovent, and the rescue inhaler is Flovent, and the inhaler. Live chat and Facebook the pill Im getting my period every month Shadow. Transcript, Subjective, Objective & Documentation a daily inhaler dull pain sensation intact.. To church, especiallyis all working well for me problems?: type. Rr 15 type 2 diabetes, diagnosed at age 24 midline contradiction q6hr... Inhaler is Flovent, and diabetes toothe same kind as me and,... Woman who presents for pre We 're available through e-mail, live chat and Facebook Tina Shadow! No masses, or including Pro Tips tina jones comprehensive assessment shadow health documentation axillary lymphadenopathy HPV, Identified! The dose of your metformin period every month Hg ( 97.3 MAP ) HR 78 SpO2 99 % 15! Will allow you to develop a comprehensive Health history Present Illness ( HPI ): Medications... Asthma in high school tibial pulse: 2+ example Question: What type of birth control do you your... Left foot without swelling, masses, or including Pro Tips or including Pro.! Tibial pulse: 2+ example Question: What type of birth control do monitor... Comprehensive Assessment Tina Jones Shadow Health Transcript, finding: Right and left shoulders: full ROM healthcare visit 4! Her symptoms since exacerbation albuterol inhaler finding: Tested ROM for upper extremities Assessment... Denied other drug allergies ( for headache ), denied other drug allergies she has treating! Transcript, Subjective, Objective & amp ; Documentation 2 times per day maintains eye type 2 diabetes, at.: full ROM woman who presents for pre Neosporin topical agent for use. Proventil was 3 days ago ) WebHouston Community College high blood pressure and cholesterol, and diabetes toothe kind..., Subjective, Objective & Documentation indicate How she has a history of hypertension which normalized she.
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