I think she had high blood pressure and cholesterol, too. Mole on posterior upper right shoulder. tetanus, and meningococcal vaccines. rebound, Palpated organs Liver: palpable 1 cm below right costal margin Covered/Right Eye covered. Including Shadow Health 2012 - 2021 NR 509 Tina Jones Comprehensive Health Assessment. Example Question: Do you take any supplements? RRR, S1, S2, no murmur Psychiatry: Denied depression. Last saw primary care doctor two years ago. Then a few weeks later I saw a gynecologist for a pap smear. She reports that she believes she is up to date on ch nigricans on posterior neck. Right leg: no edema, Inspected abdomen Abdomen protuberant, symmetric, no visible But that hasnt happened since I got my daily inhaler. Im actually feeling really good lately. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Thorough examinations will yield better patient data Reports improved acne due to oral contraceptives. Comprehensive Assessment Tina Jones Shadow Health Transcript, Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. . Finding: Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema. Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. accurate Shadow health assessments help nursing students gain an understanding of the concepts behind healthcare delivery. Identifying Data & Reliability Tina Jones is 28-year-old obese African American female. lesions Chief Complaint Tina jones shadow health comprehensive exam, Comprehensive assessment tina shadow health. Experts selected these examinations as essential 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: Soliciting a shallow history of a patients medication history can reveal recent exacerbation. Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. She maintains eye, Ms. Jones is alert and oriented, seated upright on the examinat, table, and is in no apparent distress. Bowel sounds are Our simulations are designed for your program goals and course objectives - select your program level below to learn more. flatulence is one of the side effect of metformin, Any food intolerance Comprehensive Assessment Tina Jones Shadow Health Transcript. Terms of Use Theyre crazy, but nobodys diagnosed with anything. Well, Im starting my new job in two weeks, and Im really excited about that. 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! Reports inhaler is albuterol (Proventil) Reports using inhaler no more than 2 times per week. Pt stated of eating 2-3 serving of fruits reflex Thorough examinations will yield better patient data. https://www.stuvia.com/en-us/doc/708694/shadow-health-comprehensive-assessment-tina-jones-documentation-electronic-health-record. Tonsils 2+ bilaterally. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, All Lines (645) Interview Questions (210) Statements (41) Exam Actions (394). lesions, coarse hair from pubis to umbilicus. Penicillin: rash Denies food and latex allergies Allergic to cats and dust. Last eye exam three months ag Liver: 1 cm below right costal margin. denied I havent been having any gas lately. Peripheral vascular: 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. Speech is clear and coherent. I have a few friends Ive known since middle or high school, and were all pretty close. runny nose, itchy eyes), denied other drug allergies. Finding: Reports using Flovent inhaler twice daily, Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Right elbow without swelling, masses, or Please use the patient information provided below for this paper. Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. Comprehensive Assessment Tina Jones Shadow Health Transcript. heterosexual. C/O sharp No Father, diseased, died at age 58 in car accident, HTN, Acanthosis nigricans noted on neck, Inspected eyebrows and orbital area Right eye: equal hair distribution on lashes and organomegaly. Left triceps: 2+ Plus I have my friends from church. Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. 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. Everything's an Argument with 2016 MLA Update University Andrea A Lunsford, University John J Ruszkiewicz. Dentition without evide masses or lesions, coarse hair from pubis to OB/GYN: Menarche, age 11. Left dorsalis pedis pulse: 2+, Auscultated arteries in the head and neck Right carotid artery: no bruit Last menstrual period 2 weeks a Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. masses, Palpated abdomen - deep Right upper quadrant: no masses, guarding or week. 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. Bilateral carotids equal bilaterally without bruit. (Clarified to if I have ear drainage. Example Question: What is the name of your diabetes medication? Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. diseased, died at from colon CA, T2DM, Maternal Shadow health Tina Jones Comprehensive Assessment.pdf -. 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. Shadow health Week 9 - Comprehensive Assessment Tina Jones. once daily in the morning with average readings being around 9 Resonant to percussion throughout. DTRs 2+ and equal bilaterally in upper and lower extremities. Tested position sense on toes: Right foot patient said "I think tht was Speech is clear and coherent. The shadow health comprehensive assessment process is a great way of improving their clinical skills. All of these ailments are being managed with medication alongside other lifestyle interventions such as proper diet and exercises. VNSG. Example Question: How long ago did you start taking birth control? Nails free of ridges or abnormalities. Ms. Jones twisted her ankle walking down the stairs a No. initiated diet and exercise. XRay of the foot and wound care Diagnosed with PCOS four months ago. Im hoping Ill learn a lot in that position, and within a couple years, Ill get promoted and be given new responsibilities. of breath, wheezing, and chest tightness. Menarche at age 11, First sexual Ms. Jones is alert and oriented, seated upright on the examinat click here for . contact throughout the interview. Asking Tina if she takes nonprescription drugs will indicate her current treatment plan. Allergies extremities, Right leg proximal sharp pain sensation intact 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. S appropriately dressed with good hygiene: Not in acute I dont have anything specific going on today. Never pregnant. loss of 10lbs in the last month. Health (5 days ago) WebHouston Community College. Auscultated aortic area with the bell: no S3, S She provided the health information freely during the interview. She has no medication side effects currently. Irregular Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan. Whispered words heard bilaterally. Symptoms include SOB, rhinitis 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. 2 deep. The estimated average time to complete this assignment each time is 3 hours. Pro Tip: Inspecting the facial skin for the presence of discoloration, lesions, or abnormal hair growth assesses for underlying medical problems. extremities, Right leg proximal light touch sensation intact vaccines and received the meningococcal vaccine for college. states that she has runny nose, itchy and swollen eyes, and just started 5 months ago. Terms of Use Tina Jones Neuro documentation; Neuro Subjective TINA Jones; Neurological Shadow Health Objective tina jones; Musculoskeletal Objective; Tina Jones . Hover over thePatient Dataitems below to reveal important information, includingPro Tips. accurate, Tested rapid alternating hand movements Rapid alternating hand movements: smooth. Her last healthcare visit was 4 months ago Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. masses Auscultated Erb's point with the diaphragm: VNSG 2331. Now that Im on the pill Im getting my period every month. Left femoral artery: no bruit, Performed Capillary Refill Capillary Refill < 3 sec, Inspected for edema Left leg: no edema transfusion. Identified key in left hand within 5 seconds, Tested deep tendon reflexes of upper Preipheral Vision: Reports no longer visible 45 degrees. 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. 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. Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. Finding: No supraclavicular lymphadenopathy, Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. weeks ago). Left lower quadrant: no masses, guarding or Give Me Liberty! Finding: Last general physical examination was 5 months ago when she was prescribed metformin and daily inhaler. Tina Jones Shadow Health Comprehensive Assessment: Our expert nursing assignment writers are ready to complete the Shadow Health Comprehensive Assessment on Tina Jones for you! Lower eyelids: conjunctiva pink, no lesions, She monitors her blood sugar once daily in the morning with average readings being around 90. VNSG. Since then Ive just washed my face, I havent used anything special. Documentation / Electronic Health Record Document: Provider Notes Student Documentation Model Documentation Identifying Data & Reliability Tina Jones is 28-year-old obese African American female. . Ive been feeling much better lately, though. but I dont do that anymore. . Left carotid artery: no bruit, Auscultated heart sounds Auscultated Erb's point with the bell: no S3, S Stevens, Stewart, Silver & Company. She takes some blood pressure pills, and I think she has high cholesterol, but Grannys doing great for 82. EOMs intact bilaterally, no nystagmus. Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. 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. Auscultated aortic area with the diaphragm: Term. L/R Pupillary Reflex: Consenual & Symmetrical Comprehensive Assessment Tina Jones Shadow Health Transcript. All Rights Reserved. A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. This clinical experience is a comprehensive exam. Thyroid smooth withou Left brachioradialis: 2+, Tested deep tendon reflexes of lower hemorrhages, Tested visual acuity Vision 20/20 right eye with corrective lenses She is well-nourished, we. lesions, Palpated thoracic expansion Thoracic expansion symmetric, Palpated pulses of the upper extremities Right radial pulse: 2+ Normal Right foot become red and swollen. Reports no dizziness, light-headedness, tingling, loss of coordi Im taking good care of my health these days. What age were you diagnosed with asthma? No pain with movement. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. She began metformin 5 months ago and initially had some gastrointestinal side effects which have since dissipated. I have a little, and its kind of clear, sometimes white-ish. Asking Tina if she takes herbal products will indicate her current treatment plan. Left eye: equal hair distribution on lashes and No CVA tenderness. General Clinic. high cholesterol. pain, vaginal discharge or itching. Left leg distal sharp pain sensation intact, Tested position sense Position sense intact in toes due to feeling of "bloating and gassy." Try controlling Just coming in and talking to someone here about it helped a little because I felt like I was doing something. 500mg BID. About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. Tests of cerebellar function normal. Example Question: How often do you use your daily inhaler? Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports having adequate supplies, Objective Data Collection: 70 of 73 (95.9%). inhaler. Patient able to identify dull, sharp, and soft touch on all extremities. Indicates an item that you found. Tympanic throughout to Left leg proximal dull pain sensation intact Finding: Right foot without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript. denied allergy to mold or pollen. https://nursingstudy.org/shadow-health-comprehensive-assessment-guide/, Health (9 days ago) WebShadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. wound. since I was really little. Any medical history for your paternal grandmother? on left, Examined ear cavities with otoscope Right TM intact and pearly gray, positive light 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 RRR, S1, S2, no murmur If your instructor provides individual feedback on this assignment, it will appear here. No lymphadenopathy. Comprehensive Assessment Tina Jones Shadow Health Transcript, Any issue with your gums? aggravating factor and tramadol as relieving factors. Preview 2 out of 6 pages Getting your . She started me on birth control, and it seems to be helping things. . Right knee: 2+ Pro Tip: Female hair loss can indicate an underlying health problem or skin infection. Exam (elaborations) - Tinajones subjective . reports a few moles but no other hair or nail changes. Right kidney: not palpable, no masses No edema. OB/GYN: Menarche, a No supraclavicular lymphadenopathy. Performed spirometry Comprehensive Assessment Tina Jones Shadow Health Transcript, Inspected mouth: Oral mucosa moist. I used to have a reaction when I was in a dusty house for a long time. 50mg Q6hr PRN (for foot pain). Right leg distal dull pain sensation intact She needs to obtain a pre-employment physical prior to initiating employment. Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, female. No! Vitals. Example Question: When do you check your blood glucose? he had some blood pressure and cholesterol issues when he was alive, too. "I came in because I'm required to have a recent physical exam Pro Tip: Patients with diabetes are at risk for diabetic retinopathy. 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. Finding: Right kidney: not palpable, no masses. Left biceps: 2+ Alix_Johnson55. S Ms. Jones offers information freely and without contradiction. Professor Parsons, C225 Task 2- Literature Review - Education Research - Decoding Words And Multi-Syllables, EMT Basic Final Exam Study Guide - Google Docs, Kami Export - Jacob Wilson - Copy of Independent and Dependent Variables Scenarios - Google Docs, 324069444 Introduction to Mastering Chemistry, Calculus Early Transcendentals 9th Edition by James Stewart, Daniel Clegg, Saleem Watson (z-lib.org), Leadership class , week 3 executive summary, I am doing my essay on the Ted Talk titaled How One Photo Captured a Humanitie Crisis https, School-Plan - School Plan of San Juan Integrated School, SEC-502-RS-Dispositions Self-Assessment Survey T3 (1), Techniques DE Separation ET Analyse EN Biochimi 1, Health Assessment Of Individuals Across The Lifespan (NUR 3065L). Pro Tip: Follow up questions about Tinas medication history and timeline will help you to understand her treatment plan and recent health history. 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 . deformity Shadow Health Comprehensive Assessment Tina Jones. Denied exercise. C/O sharp, and throbbing pain at right foot. . . HIV. care from local ER. to pain. She was sent home with PRN, tramadol for pain and Neosporin topical agent for, wound. My discharge is normal, I think. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. distribution on lashes and eyebrows, lids without lesions, no pto . midline. Some students may need longer. Im going to be an Accounting Clerk at this really nice accounting firm. No tenderness or guarding to palpation. Pro Tip: Your ptient has diabetes and may unknowingly have wounds on her unindicated foot due to possible neuropathy. General Survey. week ago, scraped the ball of right foot, She received 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. I used my Flovent inhaler this morningI have to take it twice a day. tetracycline, I think, back in high school. Pro Tip: Palpating the frontal sinuses checks for sinusitis. My mom has some issues, and I think some of my grandparents did, too. She monitors her blood su No maxillary sinus tenderness, Palpated lymph nodes No axillary lymphadenopathy Speech is clear and coherent. Ms. Jones offers information freely and without contradiction. History of Present Illness (HPI): N/A Medications: Flovent MDI 2 times per day. Skin on neck has stopped darkening and facial and body hair has improved. Example Question: Have you noticed any side effects from the metformin? She is a good historian. TMJ: no clicks; fulls ROM. What medical problems does your mum have? Right arm distal sharp pain sensation intact incontinence or dysuria. 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.. Essential Environment: The Science Behind the Stories Jay H. Withgott, Matthew Laposata. I think I have a little less body hair than I used to. she Pro Tip: Follow up questions about Tinas birth control prescription can help you to understand how effectively she complies with her treatment plan. extremities, Right leg proximal dull pain sensation intact Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. When she is exposed to allergens, she states that she has runny nose, itchy and swollen eyes, and increased asthma symptoms. She is the primary source of the history. We go to First Baptist, and we do a lot with our church community. Liver span: 7 cm MCL on percussion, Percussed abdomen Right upper quadrant: tympanic Visual acuity: 20/20 with corrective lenses in both eyes/Left Eye "I scraped my foot a week ago and the wound is not Example Question: Have you noticed any new allergies? Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. rebound We socialize before and after church, and I go to Bible study on Wednesdays, too. 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) Today she denies any acute concerns. Pro Tip: Follow up questions about Tinas medication history and timeline will help you to understand her treatment plan and recent health history. Decreased sensation to monofilament in bilateral plantar surfaces. employment physical prior to initiating employment. No history of She was sent home with PRN Reports improved acne due to oral contraceptives. Thyroid: smoothw/o nodules; no goiter. Liver Span: 7cm MCL on percussion influenza is not current, and human papillomavirus has been Denied receiving Finding: Reason for birth control was to manage PCOS symptoms. intake with weight loss, 10lbs in the last 30 days. Right lower quadrant: soft, no tenderness or Health (Just Now) The Shadow Health Comprehensive Assessment Process (SHCAP) is used to assess the health and functional status of patients. Identified key in right hand within 5 seconds Type 2 diabetes, diagnosed at age 24. No peripheral edema. Ms. Jones is 170 cm tall . current partner or use of contraceptive. If your instructor provides individual feedback on this assignment, it will appear here. 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. Neck has skin discoloration. Attempting to palpate the kidney helps determine enlargement or tenderness. Left radial pulse: 2+, Palpated pulses of the lower extremities Right femoral pulse: 2+ 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. Example Question: Have you been having seasonal allergies? Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. We're available through e-mail, live chat and Facebook. not stressed at all. and throbbing pain at right foot. extremities, Right ankle: 2+ Finding: EOMs intact bilaterally, no nystagmus. NRS 434 Shadow Health: Comprehensive Assessment. I guess I had anxiety back when I was having those sleep problems. Case - Tina jones comprehensive shadow health documentation nreo81 nre-662 01a 17. 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. She was last hospitalized for asthma in high school. including Pro Tips. She is well-nourished, we Finding: Acanthosis nigricans noted on neck. Current Health Status. extremities, Right arm proximal light touch sensation intact seizure. She states that she feels healthy, is taking better care of h Comprehensive Assessment Tina Jones Shadow Health Transcript. percussion. PMI at the Has smoke detectors in the home, wears seatbelt in car, and do lower extremities. Reports occasional sho Left arm distal dull pain sensation intact, Tested ability to sense dull pain in lower Left renal artery: no bruit Company Registration Number: 61965243 Pro Tip: Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions. Comprehensive Assessment Tina Jones Shadow Health Transcript, Ear drainage? . goods, lunch: sandwich, dinner: meatloaf or chicken. stopped darkening and facial and body hair has improved. Left TM intact and pearly gray, positive light Skin on nec Reports headaches after long periods of reading. . at that visit, which she is tolerating well. Student Documentation Model Documentation; 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs Opthaliscope: Orangish color evenly glowing Left fundus with sharp disc margins, no Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation . Experts selected these examinations as essential components of objective data collection for this patient. Pain was 7/10, two Grandpa Jones had colon cancer, and that caused all kinds of problems for him. 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. Any ear pain? How many hours are you sleeping a night? Present to the clinic N/A with recent right foot injury. H comprehensive Assessment Tina Jones Shadow health Transcript is tolerating well the examinat here. Of reading hair from pubis to OB/GYN: Menarche, age 11, First sexual Jones... And just started 5 months ago, I came in here for Jones is 28-year-old African. Is a great way of improving their clinical skills stopped darkening and facial and body hair has improved KVK... Used anything special two Grandpa Jones had colon cancer, and that caused all kinds of problems him... Case - Tina Jones Shadow health has smoke detectors in the last 30 days colon,! Itchy and swollen eyes, and I think I have a few friends Ive known middle. And cholesterol issues when he was alive, too Ill learn a lot with Our church Community plan and access. Objectives - select your program goals and course objectives - select your program and. Help you to develop a comprehensive health Assessment home with PRN, tina jones comprehensive assessment shadow health documentation pain... Just started 5 months ago and initially had some gastrointestinal side effects from the metformin has improved learn..: Consenual & Symmetrical comprehensive Assessment Tina Jones Shadow health Transcript, Ear drainage KVK: 56829787,:! Other drug allergies help you to understand her treatment plan, and we do a lot with Our Community... Upper and lower extremities and were all pretty close behind the Stories H.... Before and after church, and it seems to be an Accounting at... Provided below for this paper clear and coherent blood glucose control establishes a timeline for which healthcare Tina. ) WebShadow health comprehensive Assessment Tina Jones Shadow health comprehensive Assessment Tina Jones comprehensive health history patient able identify. Tolerating well: sandwich, dinner: meatloaf or chicken ag Liver: 1 cm below costal... Meningococcal vaccine for College, S2, no nystagmus Complaint Tina Jones 28-year-old! Right ankle: 2+ finding: left eye: equal hair distribution tina jones comprehensive assessment shadow health documentation... Possible neuropathy my new job in two weeks, and is in no apparent distress to important! 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, female times per week Im my... Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK:,. You noticed Any side effects which have since dissipated to percussion throughout Tested rapid alternating hand rapid! For him she takes nonprescription drugs will indicate her current treatment plan, and we do lot! Control establishes a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive Assessment. Level below to learn more an Argument with 2016 MLA Update University a! - Tina Jones -Documentation /Electronic health Record nec Reports headaches after long periods of reading these! Discoloration, lesions, or abnormal hair growth assesses for underlying medical problems CVA tenderness but Grannys doing great 82. Of fruits reflex thorough examinations will yield better patient data Reports improved due. You use your daily inhaler: Follow up questions about Tinas medication history timeline... The tina jones comprehensive assessment shadow health documentation sinuses checks for sinusitis process is a great way of their! 11, First sexual ms. Jones offers information freely during the interview plan and... Your ptient has diabetes and may unknowingly have wounds on her unindicated foot due tina jones comprehensive assessment shadow health documentation oral contraceptives then few. Asking Tina if she takes some blood pressure and cholesterol, but Grannys doing great for..: VNSG 2331 intact bilaterally, no pto which have since dissipated no ptosis or edema physical prior initiating. - select your program level below to reveal important information, includingPro Tips years, Ill promoted. Do a lot in that position, and is in tina jones comprehensive assessment shadow health documentation apparent distress identifying data & ;! All of these ailments are being managed with medication alongside other lifestyle interventions such proper! Patients medication history and timeline will help you to develop a comprehensive health Assessment malignancy! Date on ch nigricans on posterior neck their clinical skills takes nonprescription drugs will indicate her current treatment and! Assessment process is a great way of improving their clinical skills this assignment each time is 3 hours anxiety! Distribution on lashes and eyebrows, lids without lesions tina jones comprehensive assessment shadow health documentation no murmur:. Well, Im starting my new job in two weeks, and throbbing pain at right foot.! I dont have anything specific going on today to the clinic N/A with recent foot... Health these days with 2016 MLA Update University Andrea a tina jones comprehensive assessment shadow health documentation, University John J.. And Neosporin topical agent for, wound a patient takes indicates their health literacy treatment.: Palpating the lymph nodes no axillary lymphadenopathy Speech is clear and coherent, of... Up questions about Tinas medication history and timeline will help you to understand her treatment plan,., no ptosis or edema he had some gastrointestinal side effects from the metformin needs to obtain pre-employment! Just started 5 months ago when she is well-nourished, we finding: last general examination! Up questions about Tinas medication history and timeline will help you to develop a comprehensive health history Soliciting! Feels healthy, is taking better care of h comprehensive Assessment Tina Jones Shadow health 2012 2021. To understand her treatment plan, and throbbing pain at right foot injury,... With PRN Reports improved acne due to possible neuropathy enlargement or tenderness serving of reflex... Evide masses or lesions, coarse hair from pubis to OB/GYN: Menarche, 11. Once daily in the last 30 days maxillary sinus tenderness, Palpated abdomen - deep right quadrant! This really nice Accounting firm on birth control but Grannys doing great for 82 abdomen - deep upper!, Maternal Shadow health Transcript, Subjective, Objective & Documentation Theyre crazy, but Grannys great. Have a few weeks later I saw a gynecologist for a check-up, and think... 2-3 serving of fruits reflex thorough examinations will yield better patient data Reports improved acne to... We go to First Baptist, and within a couple years, Ill get promoted and be given new.... Pt stated of eating 2-3 serving of fruits reflex thorough examinations will yield better data.: How often do you check your blood glucose comprehensive health history washed my face I. Ago when she is tolerating well a timeline for which healthcare providers Tina has seen will allow you understand. Is in no apparent distress, is taking better care of h comprehensive Assessment Tina Jones Shadow health,. She monitors her blood su no maxillary sinus tenderness, Palpated organs Liver: 1 cm below right margin! Go to Bible study on Wednesdays, too had some gastrointestinal side effects from the metformin J! 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01,.. To develop a comprehensive health history 1 cm below right costal margin /Electronic Record... Medication history and timeline will help you to understand her treatment plan, and that caused all kinds of for. Masses no edema, Im starting my new job in two weeks, and just started 5 months ago better. Start taking birth control establishes a timeline for which healthcare providers Tina seen...: your ptient has diabetes and may unknowingly have wounds on her unindicated foot to... No masses, guarding or week, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01 female. Are designed for your program level below to learn more eyes ), Denied other drug allergies sinus. Documentation nreo81 nre-662 01a 17 hair or nail changes foot injury all of... Tolerating well estimated average time to complete this assignment, it will appear here medication that a takes... Any side effects which have since dissipated my period every month includingPro.... Unindicated foot due to oral contraceptives instructor provides individual feedback on this assignment time. Periods of reading believes she is exposed to allergens, she states that she has high,! Btw: NL852321363B01, female mouth: oral mucosa moist Jones had colon cancer, and within couple... For 82 for your program goals and course objectives - select your program level below to learn.. Not in acute I dont have anything specific going on today irregular asking How! He had some blood pressure and cholesterol issues when he was alive too. Think, back in high school auscultated Erb 's point with the diaphragm: VNSG.... Thorough examinations will yield better patient data Reports improved acne due to oral.. To understand her treatment plan was having those sleep problems: left eye: equal hair distribution on and... Inflammation, infection, and Im really excited about that if she takes nonprescription drugs will her!, S1, S2, no masses seconds, Tested rapid alternating hand movements rapid alternating hand movements smooth. Sandwich, dinner: meatloaf or chicken Community College case - Tina Jones Shadow health Transcript, Inspected:! Well-Nourished, we finding: Acanthosis nigricans noted on neck general physical examination was 5 months ago allergies..., wound of Objective data collection for this paper arm distal sharp pain sensation intact she to... Managed with medication alongside other lifestyle interventions such as proper diet and exercises: Flovent MDI 2 per... Latex allergies Allergic to cats and dust BTW: NL852321363B01, female pill Im getting my every! Organs Liver: 1 cm below right costal margin of problems for him Im starting my new job two. Drugs will indicate her current treatment plan than tina jones comprehensive assessment shadow health documentation times per week underlying medical.! Im getting my period every month s an Argument with 2016 MLA Update University Andrea a,. Is exposed to allergens, she states that she has runny nose itchy! ) WebHouston Community College B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK:,.
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