Example Question: How are you managing your diabetes? Pro Tip: Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition. Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. She seems to be doing okay though. nodules, no goiter. Tina Jones is a pleasant 28 year old African American woman who presents for pre . Denied mental or No white sclera, Tested PERRL with penlight Right pupil: equal, round, reactive to light Comprehensive Assessment Tina Jones Shadow Health Transcript. without cough or wheeze. Eye Movements: Movement parallel Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. masses She was last hospitalized for asthma in high school. Last use of proventil was 3 days ago. Left arm proximal sharp pain sensation intact of breath, wheezing, and chest tightness. reflex . when she received her annual gynecological exam at Shadow Popular books. Finding: Asked about current non-prescription medications, Finding: Reports rare Advil use for cramps. Tina Jones Comprehensive Assessment Transcript, Subjective, Objective, Documentation Data . Neurology: No change in mood, behavior or attention. masses reported of fever 102 last night. up" patient was correct in response. She needs to obtain a pre loss of 10lbs in the last month. Pro Tip: Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions. midline. Finding: Head is normocephalic, atraumatic. Asking Tina if she still has her inhaler will indicate her treatment plan and the degree to which she is following it. Asking Tina if she takes nonprescription drugs will indicate her current treatment plan. Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words. denied Speech is clear and coherent. 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. with polycystic ovarian syndrome and prescribed oral contracep Im sleeping a lot better now, which is a relief. Plus, he had high blood pressure, andIm pretty sure he had diabetes. No food intolerances. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. PERRLA I havent been having any gas lately. Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Everything's an Argument with 2016 MLA Update University Andrea A Lunsford, University John J Ruszkiewicz. Left femoral artery: no bruit, Performed Capillary Refill Capillary Refill < 3 sec, Inspected for edema Left leg: no edema Left renal artery: no bruit Things are pretty good between all of uswere a tight knit family. 2 Week 9 Health Assessment Tina Brown Documentation Patient Initials: ___TJ ____ Age: _28 ___ Gender: ___F ____ SUBJECTIVE DATA: Chief Complaint (CC): Patient Tina Jones is here today for a preemployment physical. Denied back pain or joint pain. Current Health Status. Pro Tip: Palpating the maxillary sinuses checks for sinusitis. Tonsils 2+ bilaterally. Eye contact throughout the interview. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, What is your name? Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. Bilateral carotids equal bilaterally without bruit. Acne located on face L/R Cheeks . Finding: Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema. No change in activities of daily functionality. No Reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium. But my zits have gotten better, and I think its because Im on birth control now. We socialize before and after church, and I go to Bible study on Wednesdays, too. Pro Tip: Tinas response to a question about managing her allergies will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. Scattered pustules on face and facial hair on upper lip, acantho The following actions reveal the objective data of th Hover over the Patient Data items Shadow Health Tina Jones Comprehensive Results Documentation Results Redacted. Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. Today she (Clarified to if my brother has health issues.). plantar foot; Asthma since childhood. states that she has runny nose, itchy and swollen eyes, and Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Last pap Medications Comprehensive Assessment Tina Jones Shadow Health Transcript, Fluticasone propionate, 110 mcg 2 puffs BID (last use: this morning) Metformin, 850 mg PO BID (last use: this morning) Drospirenone and ethinyl estradiol PO QD (last use: this morning) Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (last use: three months ago) Acetaminophen 500-1000 mg PO prn (headaches) Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6 weeks ago). Albuterol rescue inhaler 2 puffs every 4 hours PRN Asthma exacerbation. Right lower quadrant: soft, no tenderness or Thyroid: smoothw/o nodules; no goiter. Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how shes been treating her symptoms since exacerbation. deformity extremities, Right leg proximal light touch sensation intact : an American History (Eric Foner), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), The Methodology of the Social Sciences (Max Weber), Tina Jones Comprehensive Assessment Transcript, Subjective, Objective, Documentation Data, Test Bank Chapter 01- Evidence-Based Assessment, Test Bank Chapter 04- The Complete Health History, Test Bank Chapter 05- Mental Status Assessment, Chapter 4 Phys A Wk1 - The Complete Health History, Instructional Planning and Assessments for Elementary Teacher Candidates (ELM-210), Introductory Human Physiology (PHYSO 101), Web Programming 1 (proctored course) (CS 2205), Foundational Literacy Skills and Phonics (ELM-305), Creating and Managing Engaging Learning Environments (ELM-250), Microsoft Azure Architect Technologies (AZ-303), Methods of Structured English Immersion for Elementary Education (ESL-440N), Professional Application in Service Learning I (LDR-461), Advanced Anatomy & Physiology for Health Professions (NUR 4904), Principles Of Environmental Science (ENV 100), Operating Systems 2 (proctored course) (CS 3307), Comparative Programming Languages (CS 4402), Business Core Capstone: An Integrated Application (D083), Lesson 14 What is a tsunami Earthquakes, Volcanoes, and Tsunami, Ch. are in the home, locked in parents room. 12 Test Bank - Gould's Ch. Heart rate is regular, S1, S2, without murmurs, gallops, or rubs Last eye exam three months ag stated of increased appetite and Stretch marks on anterior and posterior waist. Available:Indicates an item that is available to be found. Example Question: How long have you been taking metformin? A thorough inspection should be conducted of your patients skin, especially in folds around the neck, axilla, and groin. She has type 2 diabete Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Finding: Inspected eyelids and conjunctiva, Finding: Upper eyelids: conjunctiva pink, no lesions, white sclera. How many hours are you sleeping a night? PCN (caused rash). Paternal Ms. Jones offers information freely and without contradiction. Left leg distal sharp pain sensation intact, Tested position sense Position sense intact in toes masses or lesions, coarse hair from pubis to Nana was 73 when she died of a stroke about five years ago. Guns, having belonged to her Mole on posterior upper right shoulder. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. 12 Test Bank - Gould's Ch. Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports having adequate supplies, Objective Data Collection: 70 of 73 (95.9%). Finding: Toenails: no ridges or abnormalities in nails, pink nailbeds. to pain. tetracycline, I think, back in high school. Pro Tip: Healthy kidneys are not usually palpable. 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. Physical Assessment in Healthcare 100% (1) 19. Shadow health assessments help nursing students gain an understanding of the concepts behind healthcare delivery. That is good to hear. 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. 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