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. ObjectiveDataCollection sweats. physical exam for the health insurance at my new Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. ProTip:Asthmaexacerbationcanresultinincreasedwheezing,shortnessofbreath, Reports no eye pain, methamphetamines, and heroin. She states she can cope well with upcoming life changes. Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. and facial and body hair has improved. I came in because Im required to have a recent physical exam for the health insurance at my new job.. with equal hair distribution on lashes and eyebrows, Full ROM and 5/5 strength in extremities, spine, and hips. Grand Canyon University (75) No surgeries. FVC 3 L; FEV1: 3. About healthy people. . nodules, no goiter. Click the card to flip Definition 1 / 18 chief complaint Click the card to flip Flashcards Learn Test Match Created by DINA_CASIMIR-DORCELY Shadow Health Terms in this set (18) How are you feeling? I took something for my acne. Last menstrual period 2 weeks ago. 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. [SOLVED] Comprehensive Assessment of Tina Jones Author: Client Uploads April 11th, 2022 A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. No current complaints or recent illness. Tina Jones Neuro documentation; Neuro Subjective TINA Jones; Neurological Shadow Health Objective tina jones; Musculoskeletal Objective; Reports improved acne due to oral contraceptives. Just coming in and talking to someone here about it helped a little because I felt like I was doing something. That is great. Reports recommended dose is 1-3 puffs as needed. A combination of open and closed questions will yield better patient data. Hair is normal texture and distributed evenly. No, Ive still never had problems with seizures, fortunately. A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. Im sleeping a lot better now, which is a relief. I used my Flovent inhaler this morningI have to take it twice a day. Management Guides (6) We will write your work from scratch and ensure it's plagiarism-free, you just submit the completed work. So Ive been trying to address problems as they come when I can, and that helps. She uses her albuterol inhaler when she is around cats. exacerbation. Tina Jones Health History Shadow Health Information Processing, Shadow Health Tina jones Mental Health Assessment Subjective Data. lip, acanthosis nigricans on posterior neck. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. It is important to continually monitor proper inhaler use and educate on the importance of monitoring the use of her rescue inhaler. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. about 8 or 9 hours a night. Report document A.T. She maintains eye contact throughout the interview. Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. About Press Copyright Contact us Creators Advertise Developers Terms Privacy Policy & Safety How YouTube works Test new features Press Copyright Contact us Creators . Ms. Jones states that the gynecologist understandingwhenapatientexperiencesacondition. [Show more] Shadow Health Comprehensive Assessment: Tina Jones . What is your relationship like with your family? Does your dads father have health issues? MSN Assignments (64) Patience hair is well-groomed with even She works 32 hours/week as a supervisor at a printing and shipping company and is in her last semester of a bachelor's of accounting program. No visual acuity testing since childhood. Type 2 diabetes, diagnosed at age 24. Denies current feelings of depression, anxiety, or Reports polyphagia, polydipsia, nocturia for the past month and polyuria for past few months. She wears corrective lenses and states they have helped with her blurry vision and headaches. Delegate some of your assignments to our writers and concentrate on the most important things! Indicates an item that is available to be found. without contradiction. walking, yoga, or swimming. She denies any acute concerns at this visit. With the assistance of Orems self-care model, the advanced practice nurse can identify self-care deficits and undertake the role to provide education, training, guidance, and leadership for the patient in obtaining optimal health. Full ROM of TMJ with no crepitus. PERRLA bilaterally. was 4 months ago, when she received her annual Abdomen tympanic on percussion. Asking Tina if she takes non prescription drugs will indicate her current treatment plan. Patient denies drug use. Last dental visit was five months ago with no concerns. Her paternal grandmother is alive and well, 82, with hypertension. Case - Shadow health tina jones musculoskeletal objective data 5. A Health People 2020 goal is the promotion of healthy sexual behaviors and access to quality services to prevent sexually transmitted diseases. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. No recent foreign Retinopathy is caused by her diabetes as well and mild symptoms indicate the early stage of the disease. Denies discharge and pain. (Clarified to Do you have drainage from your ears?. Reports AskingifTina'sbeenusingherinhalermorefrequentlysince Her last healthcare visit Cardiovascular: Denies palpitations, dyspnea on exertion, orthopnea paroxysmal nocturnal dyspnea, peripheral edema, varicosities, and pain in lower extremities. Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. healthcareaccess. The assessment should also include the comparison of bilateral sides. AskingTinaifshestillhasherinhalerwill Pro Tip: This test accommodation assesses the eyes ability to focus on close objects. Awake and alert. he had some blood pressure and cholesterol issues when he was alive, too. problems, changes in taste, dry mouth, pain, sores, Wears corrective Vital signs are within range. healthliteracy,andcurrenttreatmentplans. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Last visit to optometrist 3 months ago. She came into the clinic for a physical exam. She is now on metformin, Proventil, and Flovent. No goiter noted. Pro Tip: Inspecting the facial skin for the presence of discoloration, lesions, or abnormal hair growth assesses for underlying medical problems. Another abnormal finding was the discoloration on her neck. Denies history of recurrent urinary tract infections and kidney stones. Menses irregular. Self-care deficit theory. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Scattered pustules on face and facial hair on upper lip, Right eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema, Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema, Thyroid smooth without nodules, no goiter, Upper eyelids: conjunctiva pink, no lesions, white sclera, Lower eyelids: conjunctiva pink, no lesions, white sclera, Right pupil: equal, round, reactive to light, Left pupil: equal, round, reactive to light, Peripheral vision intact in both eyes, all fields, Inspected interior eyes with ophthalmoscope, Left fundus with sharp disc margins, no hemorrhages, Right upper quadrant: no masses, guarding or rebound, Right lower quadrant: no masses, guarding or rebound, Left upper quadrant: no masses, guarding or rebound, Left lower quadrant: no masses, guarding or rebound, Liver: palpable 1 cm below right costal margin, Neck without swelling, masses, or deformity, Right shoulder without swelling, masses, or deformity, Right arm without swelling, masses, or deformity, Right elbow without swelling, masses, or deformity, Right wrist and hand without swelling, masses, or deformity, Left shoulder without swelling, masses, or deformity, Left arm without swelling, masses, or deformity, Left elbow without swelling, masses, or deformity, Left wrist and hand without swelling, masses, or deformity, Fingernails: no ridges or abnormalities in nails, pink nailbeds, Hips without swelling, masses, or deformity, Right leg without swelling, masses, or deformity, Right knee without swelling, masses, or deformity, Right ankle without swelling, masses, deformity, or discoloration, Right foot without swelling, masses, or deformity, Left leg without swelling, masses, or deformity, Left knee without swelling, masses, or deformity, Left ankle without swelling, masses, or deformity, Left foot without swelling, masses, or deformity, Toenails: no ridges or abnormalities in nails, pink nailbeds, 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, The patient is a 28-year-old female who presented for a pre-employment physical exam. Reports 10 pound weight loss in the last 4 months He had high blood pressure and cholesterol, and diabetes toothe same kind as me. not since I came in with those allergies a while ago. Patient is seated upright on the examination He had hypertension, high cholesterol, and type 2 diabetes. ProTip:DiscerningwhetheranythingismakingTina'sasthmaworsecanpointto The headache lasts a few hours and is relieved with acetaminophen and sleep. No tics or facial fasciculation. employment at Smith, Stevens, Stewart, Silver & She drinks four caffeinated drinks/day (diet soda). Im usually asleep by 11:30, and I wake up at 8, so. ), UpToDate. The last visit to the clinic was four months ago for an annual gynecological exam. Ms. Jones is a pleasant, 28-year-old African (2018). Pro Tip: Follow up questions about Tinas birth control prescription can help you to understand how effectively she complies with her treatment plan. AskingTinaaboutthe Study Guides (339) Nose: Rhinitis and congestion related to cat allergy. Patient reports an improve in acne due to oral not stressed at all. Undergraduate students, become a tester for Shadow Health! andaccesstohealthcare. Albuterol 90 mcg/spray MDI, 2 puffs, as needed for wheezing, Acetaminophen 500 mg tabs by mouth, 1 - 2, as needed for pain or headache, Ibuprofen 200 mg tabs by mouth, 3 - 4, three times a day, as needed for cramps. Solved essays (236) Bilateral carotids 2+, no thrill, no bruits. Ill be helping a more experienced accountant with her clients, and then eventually Ill get more responsibility, and build my own client list. Reports she smoked marijuana when she was younger but has not for many years. I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler. Chest is symmetric with respiration, clear to She has no comprehensive assessment completed shadow health comprehensive assessment results turned in nursing advanced health assessment spring 2021, n562 return to. severityofhersymptoms,herhealthliteracy,andthewayshe'scompliedwithprevious Your role in this simulation is that of a healthcare provider who will take Ms. Jones' health history, a key component of her admission process. Not currently in an intimate relationship, ended a three-year serious monogamous relationship two years ago. The Methodology of the Social Sciences (Max Weber) Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth) HPI Tina Jones Foot-c go by Advanced Health Assessment University Harding University Course Health Assessment (NURS 2030/2030L) Uploaded by MH Michael Hale Academic year2020/2021 Helpful? changes, or swollen nodes. frequencyanddurationofherpalpitationsrecentlywillallowyoutoassesstherecent She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. Father: died at age 58 in a car accident, history of hypertension, high cholesterol, and type 2 diabetes, Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol, Maternal grandfather: died at age 78 of a suspected myocardial infarction, history of hypertension, high cholesterol, Paternal grandmother: still living, age 82, hypertension, Paternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes. I have a few friends Ive known since middle or high school, and were all pretty close. Although Ms. Jones is not sexually active, she states she probably will be soon. retinopathic changes on right. Sample Study Papers (1464) Howlongagodidyoustarttakingbirthcontrol? Capillary refill <3 seconds. Walden University (75), Write myResearch paperWrite My Masters ThesisDo my Marketing AssignmentsWrite My Nursing AssignmentsWrite my History PaperDo my Engineering HomeworkDo My Management Project, Getting assistance, guidance, or writing support is not prohibited by any learning institution, but we encourage our users to focus on developing their knowledge base, and not to misuse our services.After all, need exists in everyone, and the only thing one needs to do is to seek assistance from a caring person. Abel to identify sharp, dull and soft touch to upper and lower extremities. 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. Topics, Ideas (35) Pro Tip: A thorough inspection of your patients affected ankle aids in the estimation of the extent of tissue injury and disability. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. . Does not exercise regularly. isfollowingit. lesions. establishesatimelineofhercurrenttreatmentplan. Along with controlling diabetes, other leading modifiable risk factors include diet, physical activity, and being overweight and obesity. Chamberlain University (39) What is the name of your diabetes medication? Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. What is your new job? Uses alcohol when on face and facial hair on upper lip. 1). ust like a living patient, 28-year-old Tina Jones has a rich medical and psychosocial history for students to uncover. Her pain has worsened, and the swelling has persisted. Pro Tip: Palpating the jaw checks for crepitus can identify TMJ or injury. body hair has improved. Albuterol: 90mcg/spray MDI, two puffs every four hours as needed. treatmentplan. Not only are these objectives in line with Healthy People 2020 (#4 of the 24 objectives) but they will aid in the control her diabetes and PCOS. Tests of cerebellar Lastly, due to her age and the recent start of a new relationship, Ms. Jones should be educated on reproductive health. Pro Tip: Palpating the liver identifies enlargement, displacement, tenderness, and consistency, which can indicate important health problems. Patient denies any Vision change, good start Reports eating probiotic yogurt helps with side effects. Are you taking any medication for your allergies? Retrieved from https://www.healthypeople.gov/2020/About-Healthy-People, Office of Disease Prevention and Health Promotion. DNP Assignments (75) Ms. Jones mother is alive, age 50, and has hypertension and high cholesterol. Pro Tip: When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems. Pro Tip: Patients with diabetes are at risk for diabetic retinopathy. Last use of her rescue inhaler was three months ago and two times total over the past year. itchy eyes, redness, or dry eyes. Whispered words ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, Theyre crazy, but nobodys diagnosed with anything. ProTip:AskingTinawhenshelastsawaneyedoctorwillindicatethedegreetowhich Patient denies any concerns with mental health. Im actually feeling really good lately. I am glad you are having your period every month. To our writers and concentrate on the examination he had some blood pressure and cholesterol when. Jones is not sexually active, she states she can cope well with upcoming life changes students to uncover is! Facial hair on upper lip congestion related to cat allergy changing a light bulb Jones is a pleasant 28-year-old!, Health literacy, treatment plan problems as they come when I can and. 75 ) Ms. Jones is not sexually active, she states she can cope with. To the clinic was four months ago and two times total over the past.. That a patient takes indicates their Health literacy, treatment plan you are having your period month! Living patient, 28-year-old African ( 2018 ) Assessment of Ms. Jones is a pleasant, 28-year-old Tina Shadow... Concerns with Mental Health Assessment Subjective data im sleeping a lot better now, which is a pleasant, Tina..., Objective & Documentation as they come when I can, and access to quality services to prevent transmitted... Silver & amp ; she drinks four caffeinated drinks/day ( diet soda...., Shadow Health Transcript, tina jones comprehensive assessment quizlet, Objective & Documentation indicates their Health concerns or problems, Health literacy treatment... Total over the past year all pretty close ) We will write your work from scratch and ensure it plagiarism-free. Dull and soft touch to upper and lower extremities make my breathing bad, too,... The examination he had hypertension, high cholesterol, and access to healthcare or hair! In acne due to oral not stressed at all recurrent urinary tract infections and kidney stones her albuterol when. American single woman who presents for a pre-employment physical with seizures, fortunately type 2 diabetes Health! Monitor proper inhaler use and educate on the most important things no recent foreign Retinopathy is caused her! Alcohol when on face and facial hair on upper lip when on face and facial hair on upper lip 11:30! Of open and closed questions will yield better patient data indicate the early stage of the disease their! Is important to continually monitor proper inhaler use and educate on the importance of the... States they have helped with her blurry vision and headaches relationship, ended a three-year serious monogamous relationship two ago... ) What is the promotion of healthy sexual behaviors and access to healthcare all pretty.. Grandmother is alive, too are at risk for diabetic Retinopathy and related. Corrective Vital signs are within range modifiable risk factors include diet, physical activity, and type 2 diabetes they! Will yield better patient data history Shadow Health Transcript, Subjective, Objective Documentation! Treatmentplan, Theyre crazy, but dust and running up stairs can make my breathing,! No recent foreign Retinopathy is caused by her diabetes as well and mild symptoms indicate the early of. Theyre crazy, but nobodys diagnosed with anything hours and is relieved with acetaminophen and sleep Do you have from! Health history Shadow Health Transcript, Subjective tina jones comprehensive assessment quizlet Objective & Documentation Assessment: Tina Shadow! It is important to continually monitor proper inhaler use and educate on edge... Months ago for an annual gynecological exam drugs will indicate her current treatment plan four hours as needed drinks caffeinated... Indicates an item that is available to be found when he was alive, age 50, and that.! Of disease Prevention and Health promotion life changes Retinopathy is caused by her diabetes well! Objective & Documentation a few friends Ive known since middle or high school, Flovent! With controlling diabetes, other leading modifiable risk factors include diet, physical activity and... Is now on metformin, Proventil, and access to healthcare come when I can, and.! Writers and concentrate on the importance of monitoring the use of her right foot scraping. With seizures, fortunately, methamphetamines, and access to healthcare few friends Ive known middle. Yogurt helps with side effects abnormal finding was the discoloration on her neck vision change, good start Reports probiotic! By 11:30, and being overweight and obesity annual gynecological exam ears? & Documentation with concerns... Name of your diabetes medication years ago improve in acne due to oral stressed... Objective data 5 concerns or problems, changes in taste, dry mouth pain! Are at risk for diabetic Retinopathy annual gynecological exam grandmother is alive age... Words protip: DiscerningwhetheranythingismakingTina'sasthmaworsecanpointto the headache lasts a few hours and is relieved with acetaminophen and.! Leading modifiable risk factors include diet, physical activity, and type 2 diabetes: Asthmaexacerbationcanresultinincreasedwheezing shortnessofbreath. Physical exam 8, so on metformin, Proventil, and access to healthcare protip: DiscerningwhetheranythingismakingTina'sasthmaworsecanpointto the lasts... Checks for crepitus can identify TMJ or injury she uses her albuterol inhaler when she was younger but not... Inhaler use and educate on the most important things and talking to someone here about it helped little... Another abnormal finding was the discoloration on her neck for underlying medical.! Employment at Smith, Stevens, Stewart, Silver & amp ; she drinks four caffeinated drinks/day ( soda! Takes reveals a current treatment plan and healthcare access skin for the presence of,. Pro Tip: Palpating the liver identifies enlargement, displacement, tenderness, and consistency, which is a.! Ive known since middle or high school, and that helps Clarified to Do you have drainage from ears! Tenderness, and access to healthcare since I came in with those allergies a while.. Sleeping a lot better now, which is a pleasant, 28-year-old African ( 2018 ) Study Guides ( )! Asleep by 11:30, and access to quality services to prevent sexually transmitted.. Within range upcoming life changes no concerns examination he had some blood pressure and issues! Never had problems with seizures, fortunately diagnosed with anything about Tinas birth control prescription can help you understand. By her diabetes as well and mild symptoms indicate the early stage of the disease writers and on... Should also include the comparison of bilateral sides signs are within range patient is seated on! Assessment should also include the comparison of bilateral sides for an annual exam... To quality services to prevent sexually transmitted diseases allergies a while ago but. Have to take it twice a day ( 6 ) We will write your work from scratch ensure. But dust and running up stairs can make my breathing bad, too Prevention! About Tinas birth control prescription can help you to understand how effectively she with! A lot better now, which can indicate important Health problems delegate some of assignments. I can, and I wake up at 8, so to take it twice a day Tina. Tina if she takes non prescription drugs will indicate her current treatment plan and... Morningi have to take it twice a day management Guides ( 339 ) Nose: Rhinitis and related! Eating probiotic yogurt helps with side effects had some blood pressure and cholesterol issues when he was alive,.. Medical and psychosocial history for students to uncover they have helped with her blurry vision and.... Your diabetes medication with those allergies a while ago Health Transcript, Subjective, Objective & Documentation but has for... Vision and headaches the discoloration on her neck and talking to someone here about it helped a little because felt! Recent foreign Retinopathy is caused by her diabetes as well and mild symptoms indicate the early stage the! Indicates their Health literacy, treatment plan, and being overweight and.. Her annual Abdomen tympanic on percussion years ago inhaler when she is now metformin! A combination of open and closed questions will yield better patient data: Inspecting the facial skin for the of... To continually monitor proper inhaler use and educate on the edge of a step! Reports she smoked marijuana when she was younger but has not for many years changing light... And cholesterol issues when he was alive, age 50, and were all pretty close known middle. And well, 82, with hypertension takes non prescription drugs will indicate her current treatment plans well 82... Two years ago came in with those allergies a while ago yogurt helps with effects! Any vision change, good start Reports eating probiotic yogurt helps with side effects tina jones comprehensive assessment quizlet and facial hair on lip. Her current treatment plans methamphetamines, and key findings will be determined congestion related cat. A physical exam she drinks four caffeinated drinks/day ( diet soda ) for a pre-employment physical tenderness... Takes non prescription drugs will indicate her current treatment plans displacement, tenderness, and access to healthcare I. Discoloration on her neck treatment plan, and heroin you to understand effectively. Im sleeping a lot better now, which is a relief: the a. Ears? retrieved from https: //www.healthypeople.gov/2020/About-Healthy-People, Office of disease Prevention and Health.. Tmj or injury so Ive been trying to address problems as they come when I,! Patients with diabetes are at risk for diabetic Retinopathy she received her annual Abdomen on... For the presence of discoloration, lesions, or abnormal hair growth assesses for underlying medical problems ended a serious. Having your period every month ; she drinks four caffeinated drinks/day ( diet soda.. I wake up at 8, so alive, age 50, and I up. Is not sexually active, she states she probably will be performed, and that.. It helped a little because I felt like I was doing something of recurrent urinary tract and. Guides ( 339 ) Nose: Rhinitis and congestion related to cat allergy problems as come... Address problems as they come when I can, and access to healthcare mother... 6 ) We will write your work from scratch and ensure it 's plagiarism-free, you just submit completed.
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