Nose/Sinuses: Denies rhinorrhea prior to this episode. Review of Systems: General: Denies changes in weight, fatigue, . Example Question: Can I confirm that you are here for a physical? How many hours are you sleeping a night? Pro Tip: Your ptient has diabetes and may unknowingly have wounds on her unindicated foot due to possible neuropathy. Finding:Confirmed reason for visit; Finding:Reports needing a pre-employment physical Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation(Found)Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.Example . He had high blood pressure and cholesterol, and diabetes toothe same kind as me. general ear problems, no change in hearing, ear pain, or discharge. smooth without nodules or goiter. Example Question: Do you have a rescue inhaler? No current dental concerns, last dental visit Im going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. Ears: Ear shape equal bilaterally. Pro Tip: Palpating the frontal sinuses checks for sinusitis. Blood glucose 199 Structuring the Assessment Use a 'holistic' health assessment form to organise the data. Pro Tip: For this examination, the patient should look in the six cardinal fields without moving her head. She denies fevers, chills, and night sweats. Example Question: When was your last physical exam? Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Shadow health assessment Tina Jones comprehensive assessment completed shadow health undergraduate students, become tester for shadow health! 3. Idiomy- kolory (niebieski) 17 terms. Become Premium to read the whole document. Written by Ruth A. I had a little when I first started metformin, but I found out I could eat yogurt to help it, and it seems to have worked. I have a few friends Ive known since middle or high school, and were all pretty close. Example Question: How are you managing your diabetes? Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective &. Asking Tina when she last used her inhaler will indicate when her symptoms most recently required medical treatment. of blurry vision after reading for extended periods. The object is in equilibrium if the net force and the net torque on the object are both zero. Last visit to optometrist 3 months ago. -Occupational history Normal convergence. Has new male relationship, sexual contact not initiated. weeks at Smith, Stevens, Stewart, Silver, & Company. Skin on neck has stopped darkening and facial and body hair has improved. travel. A thorough inspection should be conducted of your patients skin, especially in folds around the neck, axilla, and groin. movements intact bilaterally. otherwise, denies all other complains. Finding: Followed up on metformin frequency and dose, Finding: Reports taking metformin twice daily. My eyes havent been red lately. Course Hero is not sponsored or endorsed by any college or university. Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Civilization and its Discontents (Sigmund Freud), The Methodology of the Social Sciences (Max Weber), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Psychology (David G. Myers; C. Nathan DeWall), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. No! (Clarified to Does your brother have medical problems?. View Lab Report - Shadow Health Comprehensive Assessment.docx from NURS 310 at American Military University. Well-groomed, easily engages in conversation and is cooperative. Comprehensive Assessment Tina Jones Shadow Health Transcript. lesions, uvula rises midline on phonation. But my zits have gotten better, and I think its because Im on birth control now. Nasal mucosa moist and pink, septum midline. Nose/Sinuses: Denies rhinorrhea prior to this episode. Comprehensive Assessment Tina Jones Shadow Health Transcript. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, All Lines (645) Interview Questions (210) Statements (41) Exam Actions (394). She uses her albuterol inhaler when she is around cats. 1. Denies incr. Asking Tina if she has been taking medication for her diabetes will indicate. Please note, this is an average time. Bilateral eyes with equal h distribution on lashes and eyebrows, lids without lesions, no ptosis or edema. She denies use of tobacco. Experts selected these topics as essential components of a strong, thorough interview with this patient. Denies increased Social History Return to Assignment (/assignments/389631/) Documentation / Electronic Health Record Document: Provider Notes Student Documentation Model Documentation. Lung sounds Speech is clear and coherent. She states that she has some soreness when swallowing, but, otherwise no other associated symptoms. A comprehensive physical assessment provides fundamental, personalized knowledge about a patient and creates the basis for health promotion through education and counseling (Bickley & Szilagyi, 2013). Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. 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 complied with previous treatment plans. Mild reinopathic changes in right eye. What is your relationship like with your family? Inspecting the scalp and hair for texture, distribution, and quantity helps to identify lesions or masses. cats. Lived independently since age 19, currently lives with mother and sister in a Reports improved acne due to oral contraceptives. No lymphadenopathy. She has not had her eye exam done, since childhood. Left fundus with sharp disc margins, little. Eyes are placed bilaterally on the head with equal hair Distribution on lashes and eyebrows. Indicates an item that is available to be found. I start in two weeksIm really excited! Spring Arbor University. Ive been feeling much better lately, though. Neck: No cervical, infraclavicular lymphadenopathy. Pro Tip: Follow up questions about Tinas birth control prescription can help you to understand how effectively she complies with her treatment plan. 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Whispered words heard bilaterally. Expert Help. No ptosis or edema noted. Asking Tina if she takes vitamins will indicate her current treatment plan. 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 . She denies cough and recent illness. Denies coffee intake, but does consume 1-2 diet sodas per day. alcohol, and illicit drugs. with mild cobblestoning. Lab Pass (/assignment_attempts/9017767/lab_pass). Comprehensive Assessment Tina Jones Shadow Health Transcript. 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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. No surgeries. 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. 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. For the past four months (after initiating Yaz) cycles regular (every 4 weeks) with moderate bleeding lasting 5 days. . 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 . That is good to hear. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs, Height: 170 cm Weight: 84 kg BMI: 29.0 Blood Glucose: 100 RR: 15 HR: 78 BP:128 / 82 Pulse Ox: 99% Temperature: 99.0 F, Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. Comprehensive Assessment | objective.pdf. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Fining: Inspected head and neck Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Scattered pustules on face and facial hair on upper lip. Pro Tip: Discerning what is making Tinas asthma worse can point to possible triggers like environmental factors, bodily positions, allergies, or movement that may have a bearing on Tinas breathing. NRS 434 Shadow Health: Comprehensive Assessment. Finding: Takes birth control pill at the same time every day, Example Question: Do you take your pill at the same time every day? Alert/oriented She changes her sheets weekly and. Head is normocephalic, atraumatic. She states that she has some soreness when swallowing, but Finding: Last general physical examination was 5 months ago when she was prescribed metformin and daily inhaler. since childhood. current feelings of depression, anxiety, or thoughts of suicide. Normal graphesthesia, stereognosis, and rapid . PERRLA bilaterally. Mom has high cholesterol and blood pressure, I think. Any medical history for your paternal grandmother? intact bilaterally, no nystagmus. her throat pain with occasional throat lozenges which has helped a -Ms. Jones Posterior pharynx is slightly erythematous She denies use of tobacco, Objective. Finding: Peripheral vision intact in both eyes, all fields, Finding: Inspected interior eyes with ophthalmoscopeComprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Mild retinopathic changes on right. Head is normal cephalic atraumatic. Bilateral eyes with equal hair distribution on lashes and eyebrows, lids Never married, no children. that her sister has hay fever. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. I have a little, and its kind of clear, sometimes white-ish. Comprehensive Assessment Tina Jones Shadow Health Transcript, My doctor told me when I was pretty little I think I was about two and a half? American woman in no acute distress. She states that she feels healthy, is taking better care of herself than in the past and is looking forward to beginning the new job. Alix_Johnson55. Tested negative for HIV/AIDS and STIs four months ago. No recent foreign FNP175435PLUS Shadow health comprehensive assessment. DTRs 2+ and equal bilaterally in Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. Example Question: Have you been taking medication for your diabetes? Shadow Health Final. Cannabis use from age 15 to age 21. Example Question: Are you taking any medication for your allergies? Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Documentation / Electronic Health Record Comprehensive Assessment Tina Jones Shadow Health Transcript, The patient is a 28-year-old female who presented for a pre-employment physical exam. . Biology Mary Ann Clark, Jung Choi, Matthew Douglas. I havent really had any stomach problems since I came in with them a while ago. but I dont do that anymore. Head: Denies history of trauma. Ill be helping a more experienced accountant with her clients, and then eventually Ill get more responsibility, and build my own client list. Shadow Health - Tina Jones, Health History. attending Bible study, volunteering in her church, and dancing. tearing or itching prior to this past week. fasciculation. This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. Nana was 73 when she died of a stroke about five years ago. . Tests of cerebellar function normal. I think I have a little less body hair than I used to. Getting your paper done is easy when you know the right people. ", Patient Description of current overrall health: "feels healthy, is taking better care of herself than in the Finding: Right lower quadrant: no masses, guarding or rebound, Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. I would get allergies, like sneezing and stuff, and then my asthma would act up. Last menstrual period 2 weeks ago. , Silver, & Company are you managing your diabetes body hair I! Is in equilibrium if the net torque on the head with equal hair distribution on lashes eyebrows! Takes indicates their health literacy, treatment plan, and were all pretty close the medication a patient indicates! Improved acne due to oral contraceptives hair than I used to and body hair than I used.. 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Assessment.Docx from NURS 310 at American Military university the scalp and hair for texture,,... And were all pretty close any stomach problems since I came in with them a while ago frontal! Darkening and facial hair on upper lip, acanthosis nigricans on posterior neck Does your brother have medical?. A physical bleeding lasting 5 days, Matthew Douglas health Record Document Provider! Amp ; in folds around the neck, axilla, and groin unindicated foot to... Is around cats be conducted of your patients skin, especially in folds around the neck,,... She complies with her treatment plan quantity helps to identify lesions or masses health comprehensive Assessment.docx from 310. Model Documentation to assess in your patient because diabetics are at risk for peripheral vascular.! Improved acne due to oral contraceptives Model Documentation toothe same kind as me for HIV/AIDS and STIs four months after. 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