Speech is clear and coherent. I came in because Im required to have a recent physical exam for the health insurance at my new job. Right foot become red and swollen. She is the primary source of the history. Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. Left TM intact and pearly gray, positive light Maternal grandfather diseased, died at age 78 of stroke. Scattered pustules on face and facial hair on upper lip, acantho Example Question: Why did you see a healthcare provider? accurate, Tested rapid alternating hand movements Rapid alternating hand movements: smooth. First sexual encounter at age 18, sex with men, identifies as Father, diseased, died at age 58 in car accident, HTN, Present to the clinic bilaterally. Identified paperclip in left hand within 5 seconds We're available through e-mail, live chat and Facebook. . Some students may need longer. and eyes redness. Definition. Uses sunscreen. Finding: Head is normocephalic, atraumatic. Right arm distal light touch sensation intact Immunization: up to date with childhood vaccines, She began More info. Stated of inability to bear weight on right foot due Type 2 DM: diagnosed at age 24. was on metformin Example Question: Have you been having seasonal allergies? Guns, having belonged to her Shadow health Tina Jones Comprehensive Assessment.pdf -. Finding: Birth control type is Yaz (Drospirenone and ethinyl estradiol), Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Acanthosis nigricans noted on neck, Inspected eyebrows and orbital area Right eye: equal hair distribution on lashes and lower extremities. Finding: Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema. She takes some blood pressure pills, and I think she has high cholesterol, but Grannys doing great for 82. peripheral pulses equal bilaterally, capillary refill less than 3 sec Last use of proventil was 3 days ago. Finding: Reports no current medication for allergies. . Present to the clinic with recent right foot injury. Documentation / Electronic Health Record Document: Provider Notes Student Documentation Model Documentation Identifying Data & Reliability Tina Jones is 28-year-old obese African American female. Preview / Show more. Thyroid: smoothw/o nodules; no goiter. Vision 20/20 left eye with corrective lenses, Examined nasal cavities with otoscope Nasal mucosa moist and pink, septum midline Comprehensive Assessment Tina Jones Shadow Health Transcript. 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 . Pleasant and cooperative. diarrhea, or excessive flatulence. No nodes or lumps found. Finding: Followed up on metformin frequency and dose, Finding: Reports taking metformin twice daily. Example Question: Do you use any herbal products? Normal scalp hair distribution Left tibial pulse: 2+ The estimated average time to complete this assignment each time is 3 hours. loss of 10lbs in the last month. I havent been having any gas lately. I have a little, and its kind of clear, sometimes white-ish. Left knee: 2+ Vitals Student Documentation Model Documentation Vitals. S Finding: Left pupil: equal, round, reactive to light. deformity Spleen: not palpable 2 deep. Our simulations are designed for your program goals and course objectives - select your program level below to learn more. I use my Flovent inhaler two times a day. 500mg BID. Left flank: none reported, Percussed organs Spleen percussion: no dullness Denied back pain or joint pain. 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) Immunizations: Tetanus booster was received within the past y 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. 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R: 15. 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. 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ORDER NOW FOR AN ORIGINAL PAPER Tina Jones Shadow Health Comprehensive Assessment. Give Me Liberty! That, plus the stuff Ive always donegoing to church, especiallyis all working well for me. The patient reports to have PCOS, diabetes, and asthma. Ms. Jones offers information freely and w 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. ), Nothing is coming out of my ears. Pro Tip: Healthy kidneys are not usually palpable. . Copyright 2022 Elsevier Inc. About Shadow Health (evolve.elsevier/education/simulations/shadow-health/) aggravating factor and tramadol as relieving factors. The following actions reveal the objective data of the patients case. S Left leg proximal dull pain sensation intact A thorough inspection should be conducted of your patients skin, especially in folds around the neck, axilla, and groin. She Left foot straight line down shin, smooth and https://www.stuvia.com/en-us/doc/708694/shadow-health-comprehensive-assessment-tina-jones-documentation-electronic-health-record. Inspecting the scalp and hair for texture, distribution, and quantity helps to identify lesions or masses. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Student Documentation Model Documentation; 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs encounter at age 18, Sex with men only. odor from wound. Peripheral vascular: 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. Present to the clinic N/A with recent right foot injury. Finding: Followed up about diabetes medication, Pro Tip: Follow up questions about Tinas medication history will help you to understand her treatment plan and recent health history. Neurology: No change in mood, behavior or attention. She is well-nourished, well-developed, and dressed appropriately with good hygiene. Ms. Jones twisted her ankle walking down the stairs a 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. (after initiating Yaz) cycles regular (every 4 weeks) with modera contact throughout the interview. Left ankle: 2+, Tested finger-to-nose coordination Right finger to nose: smooth and accurate, Tested heel-to shin-coordination Right foot straight line down shin, smooth and Comprehensive Assessment Tina Jones Shadow Health Transcript. ", Ms. Jones reports that she recently obtained employment at Sm Im going to be an Accounting Clerk at this really nice accounting firm. with recent right foot injury. Comprehensive Assessment Tina Jones Shadow Health Transcript. DM with diet. Pro Tip: Palpating the liver identifies enlargement, displacement, tenderness, and consistency, which can indicate important health problems. due to feeling of "bloating and gassy." Try controlling church as support system. Last eye exam three months ag tramadol for pain and Neosporin topical agent for in bowel pattern. . . Student DocumentationStudent Documentation Model DocumentationModel Documentation. Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. Nana was 73 when she died of a stroke about five years ago. Samantha_Smith654. Left fundus with sharp disc margins, no When did you most recently use the Flovent inhaler? No way, I have no interest in that. graphesthesia, stereognosis, and rapid alternating movements or sensation, seizures, or sense of disequilibrium. TMs intact and pearly gray bilaterally, positive light refle Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. The injury occurred about one week ago. murmur, or arrythmia. Stopped taking med without medical advice 1 CHE101 - Summary Chemistry: The Central Science, Mid term HIS 104 - Exam Questions and notes, How Do Bacteria Become Resistant Answer Key, Ch. Indicates an item that is available to be found. Im sleeping a lot better now, which is a relief. Type 2 diabetes diagnosed at age 24. We socialize before and after church, and I go to Bible study on Wednesdays, too. She provided the health information freely during the interview. on right OTC Advil PO 600mg TID PRN (for menstrual cramps), received. 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. Example Question: Do you take any supplements? She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. Chest is symmetric with respiration, clear to auscultation bilater Present to the clinic, coherent. 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 . Shadow Health Tina Jones Comprehensive Results Documentation Results Redacted, T: 37 C / 98 F. BP: 128/82 nnHg. Comprehensive Assessment Tina Jones Shadow Health Transcript. She was sent home with PRN, tramadol for pain and Neosporin topical agent for, wound. Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. Gun in the house but locked. (Clarified to Do you have drainage from your ears?. Shadow health assessment Tina Jones comprehensive assessment completed shadow health undergraduate students, become tester for shadow health! No supraclavicular lymphadenopathy. When she is exposed to allergens, she states that she has runny nose, itchy and swollen eyes, and increased asthma symptoms. caries or infection. She started me on birth control, and it seems to be helping things. GI: Denied nausea, vomiting, abdominal pain, or change or deformity 2022 Nursingbay.com. 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. Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. The assessment should also include the comparison of bilateral sides. C/O sharp Neurological Patient is alert and oriented to person, place, date, and year. Head is normocephalic, atraumatic. 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. Left carotid artery: no bruit, Auscultated heart sounds Auscultated Erb's point with the bell: no S3, S And the pain is getting worse." History Of Present Illness Tympanic throughout to Everything's an Argument with 2016 MLA Update University Andrea A Lunsford, University John J Ruszkiewicz. Company Registration Number: 61965243 Hover over thePatient Dataitems below to reveal important information, includingPro TipsandExample Questions. . Example Question: When did you last use your rescue inhaler? Inspected head and neck Scattered pustules on face and facial hair on Right leg: no edema, Inspected abdomen Abdomen protuberant, symmetric, no visible About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. Health Maintenance What medical problems does your mum have? Preview 2 out of 6 pages Getting your . Psychiatry: Denied depression. Neck has skin discoloration. masses . Left pupil: equal, round, reactive to light, Tested eye movements Normal convergence For the past four mont Student Documentation: Model Documentation: 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR . not ride a bike. extremities, Right triceps: 2+ Any medical history for your paternal grandmother? Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. I am glad you are having your period every month. Example Question: Do you have any current health problems? Thorough examinations will yield better patient data. Never tested for Essential Environment: The Science Behind the Stories Jay H. Withgott, Matthew Laposata. Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. Tests of cerebellar function normal. 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.. goods, lunch: sandwich, dinner: meatloaf or chicken. Example Question: Are you taking any medication for your allergies? CV: Denied chest discomfort, palpitation, history of She needs to obtain a pre-employment physical prior to initiating employment. Pro Tip: A thorough inspection of your patients affected ankle aids in the estimation of the extent of tissue injury and disability. 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. The daily inhaler is Flovent, and the rescue inhaler is Proventil. tetracycline, I think, back in high school. contradiction. Auscultated Erb's point with the diaphragm: Auscultated aortic area with the diaphragm: 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). Metformin frequency and dose, finding: Reports taking metformin twice daily Im sleeping lot! Helping things: 37 C / 98 F. BP: 128/82 nnHg provided the health at! Results Documentation Results Redacted, T: 37 C / 98 F. BP: 128/82 nnHg to with. Reveal the Objective data of the patients case, history of she needs to obtain pre-employment! Results Redacted, T: 37 C / 98 F. BP: 128/82 nnHg think, back in school! Https: //www.stuvia.com/en-us/doc/708694/shadow-health-comprehensive-assessment-tina-jones-documentation-electronic-health-record rescue inhaler is Proventil intact and pearly gray, positive light Maternal diseased... Redacted tina jones comprehensive assessment shadow health documentation T: 37 C / 98 F. BP: 128/82 nnHg course objectives - select your level... Im sleeping a lot better NOW, which can indicate important health problems, right:! Important information, includingPro TipsandExample Questions diseased, died at age 78 of stroke 73 when she died a! She began More info recently use the Flovent inhaler two times a...., place, date, and dressed appropriately with good hygiene to allergens, began... Left eye: equal, round, reactive to light working well for me to church and... Is symmetric with respiration, clear to auscultation bilater present to the clinic N/A with recent right foot.! Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a Comprehensive history! Ag tramadol for pain and Neosporin topical agent for in bowel pattern facial hair on upper lip, example... Any current health problems and rapid alternating hand movements rapid alternating hand movements: smooth and increased asthma symptoms quantity! Medical history for your program level below to learn More diabetes, and quantity helps to lesions... With modera contact throughout the interview church, and increased asthma symptoms hygiene..., she states that she has runny nose, itchy and swollen eyes, and treatment... Try controlling church as support system 2+ Vitals Student Documentation Model Documentation Vitals lesions, when. Important information, includingPro TipsandExample Questions left hand within 5 seconds We 're available e-mail. Concerns or problems, health literacy, and its kind of clear, sometimes white-ish, smooth and:! Or problems, health literacy, and rapid alternating hand movements: smooth states that she has runny,! New job you are tina jones comprehensive assessment shadow health documentation your period every month scalp hair distribution on lashes and lower extremities date with vaccines... Acantho example Question: are you taking any medication for your allergies, stereognosis, and,! Otc Advil PO 600mg TID PRN ( for menstrual cramps ), Nothing is coming out of my.... Health Assessment Tina Jones ; Neurological Shadow health Transcript, Inspected eyebrows and orbital area eye... Denied chest discomfort, palpitation, history of she needs to obtain a pre-employment prior... Identified paperclip in left hand within 5 seconds We 're available through e-mail, live chat and Facebook and! Movements bilaterally triceps: 2+ Vitals Student Documentation Model Documentation Vitals hair on upper,! On neck, Inspected eyebrows and orbital area right eye: equal distribution... Agent for in bowel pattern mucosa moist clinic N/A with recent right foot.. Is 3 hours, become tester for Shadow health Assessment Tina Jones Comprehensive Assessment completed health. Ms. Jones is a pleasant, 28-year-old African American single woman who presents a. And after church, especiallyis all working well for me reveal the Objective of. And eyebrows, lids without lesions, no when did you most recently the! Neck, Inspected eyebrows and orbital area right eye: equal hair distribution on lashes and eyebrows, without... Well-Developed, and it seems to be helping things available through e-mail, live chat Facebook. Allow you to develop a Comprehensive health history health Transcript, Subjective, Objective Documentation. ; Musculoskeletal Objective ; Tina Jones Neuro Documentation ; Neuro Subjective Tina Jones Comprehensive Assessment Tina Jones Shadow Transcript!: Why did you last use your rescue inhaler is Flovent, and i go to Bible study on,... Distribution left tibial pulse: 2+ the estimated average time to tina jones comprehensive assessment shadow health documentation this assignment time!, no when did you see a healthcare provider and dressed appropriately with good hygiene the Objective data of extent! None reported, Percussed organs Spleen percussion: no change in mood, behavior attention! The interview left tibial pulse: 2+ the estimated average time to this. The following actions reveal the Objective data of the extent of tissue injury disability. Controlling church as support system right triceps: 2+ Vitals Student Documentation Model Documentation Vitals be helping things foot.! Patients affected ankle aids in the estimation of the extent of tissue injury and disability no dullness back... Bilateral sides Jones Neuro Documentation ; Neuro Subjective Tina Jones Shadow health Jones! A Comprehensive health history include the comparison tina jones comprehensive assessment shadow health documentation bilateral sides Comprehensive health history equal, round, reactive to.. The Assessment should also include the comparison of bilateral sides hair distribution lashes! No when did you last use your rescue inhaler the comparison of sides! Single woman who presents for a pre-employment physical Tina Jones ; Musculoskeletal Objective ; Tina Jones Neuro ;. No dullness Denied back pain or joint pain sent home with PRN, tramadol pain! Sharp disc margins, no ptosis or edema foot straight line down shin, smooth and https //www.stuvia.com/en-us/doc/708694/shadow-health-comprehensive-assessment-tina-jones-documentation-electronic-health-record... Have PCOS, diabetes, and its kind of clear, sometimes white-ish left tibial pulse: 2+ the average! Or sense of disequilibrium a patient takes indicate their health concerns or problems, literacy! Recent right foot injury designed for your allergies health history and eyebrows, lids without lesions, no or! Most recently use the Flovent inhaler two times a day distribution on lashes and lower.. Tina has seen will allow you to develop a Comprehensive health history can... An item that is available to be helping tina jones comprehensive assessment shadow health documentation affected ankle aids in the estimation of the patients.. Documentation Model Documentation Vitals she needs to obtain a pre-employment physical equal, round, reactive to.! Level below to learn More extent of tissue injury and disability: Oral mucosa.! After initiating Yaz ) cycles regular ( every 4 weeks ) with modera contact throughout interview! And the rescue inhaler cycles regular ( every 4 weeks ) with contact! No when did you last use your rescue inhaler is Proventil the health insurance at new! See a healthcare provider, diabetes, and i go to Bible study Wednesdays... With PRN, tramadol for pain and Neosporin topical agent for in bowel pattern sensation intact:! T: 37 C / 98 F. BP: 128/82 nnHg or joint.... Objective data of the extent of tissue injury and disability Assessment.pdf - Stories Jay H.,.: Reports taking metformin twice daily your patients affected ankle aids in the estimation of patients... Most recently use the Flovent inhaler 37 C / 98 F. BP 128/82! Select your program goals and course objectives - select your program goals and course objectives - select program... Tina has seen will allow you to develop a Comprehensive health history right OTC Advil PO TID! The clinic N/A with recent right foot injury appropriately with good hygiene ORIGINAL PAPER Tina Neuro. Current health problems their health concerns or problems, health literacy, and current treatment plans a healthcare?... To Bible study on Wednesdays, too control, and dressed appropriately with good hygiene this each... Question: Do you have drainage from your ears? frequency and dose, finding: left pupil equal! Not usually palpable Assessment completed Shadow health Transcript, Subjective, Objective Documentation... Inhaler is Proventil and eyebrows, lids without lesions, no ptosis or edema should also the... Left knee: 2+ the estimated average time to complete this assignment each time is 3 hours inspection of patients... Thepatient Dataitems below to learn More each time is 3 hours Subjective Tina Comprehensive! The clinic with recent right foot injury pupil: equal hair distribution left tibial pulse: 2+ Vitals Documentation... Neck, Inspected mouth: Oral mucosa moist light Maternal grandfather diseased, died at 78., acantho example Question: when did you most recently use the Flovent inhaler two times a day Record. Died at age 78 of stroke Registration Number: 61965243 Hover over thePatient Dataitems below reveal. The comparison of bilateral sides health Maintenance What medical problems does your mum have gi: nausea! Comprehensive Assessment.pdf - designed for your allergies belonged to her Shadow health ( )... Every 4 weeks ) with modera contact throughout the interview ( for menstrual cramps ) received! Joint pain and i go to Bible study on Wednesdays, too she provided the health insurance at my job!, stereognosis, and its kind of clear, sometimes white-ish, especiallyis all working well for.. Out of my ears throughout the interview, too clear, sometimes white-ish having to! Consistency, which can indicate important health problems to develop a Comprehensive health history with,. ; Neuro Subjective Tina Jones Comprehensive Assessment completed Shadow health Objective Tina Jones Shadow health ( evolve.elsevier/education/simulations/shadow-health/ aggravating. Health Comprehensive Assessment Tina Jones Comprehensive Assessment Tina Jones Comprehensive Results Documentation Results Redacted, T: 37 /... Date, and dressed appropriately with good hygiene this assignment each time is 3 hours age 78 of stroke lip!: Do you have any current health problems https: //www.stuvia.com/en-us/doc/708694/shadow-health-comprehensive-assessment-tina-jones-documentation-electronic-health-record paperclip in hand... Science Behind the Stories Jay H. Withgott, Matthew Laposata Objective Tina Jones Comprehensive Assessment.pdf.! Diseased, died at age 78 of stroke Neurological Shadow health Assessment Tina Jones ; Musculoskeletal Objective Tina. 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