tina jones comprehensive assessment shadow health documentation

Including GI: Denied nausea, vomiting, abdominal pain, or change Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, female. Never pregnant. She uses her albuterol inhaler when she is around cats. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. I start in two weeksIm really excited! Opthaliscope: Orangish color evenly glowing Denied back pain or joint pain. I havent had any problems with diarrhea. Objective wound. Pro Tip: Palpating the frontal sinuses checks for sinusitis. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Speech is clear and coherent. Documentation / Electronic Health Record. Houston Community College. Tests of cerebellar function normal. 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! Finding: Followed up on metformin frequency and dose, Finding: Reports taking metformin twice daily. Ms. Jones offers information freely and without contradiction. Example Question: Have you been having seasonal allergies? Indicates an item that you found. My mom has some issues, and I think some of my grandparents did, too. VNSG. ), Nothing is coming out of my ears. Immunization: up to date with childhood vaccines, Asking Tina if she takes nonprescription drugs will indicate her current treatment plan. Example Question: How often do you monitor your blood glucose? Student Documentation Model Documentation. Health (5 days ago) WebHouston Community College. not ride a bike. Biology Mary Ann Clark, Jung Choi, Matthew Douglas. The shadow health comprehensive assessment process is a great way of improving their clinical skills. NR 509 Tina Jones Comprehensive Health Assessment. church as support system. Heart rate is regular, S1, S2, without murmurs, gallops, or rubs Pro Tip: When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems. Since then Ive just washed my face, I havent used anything special. Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. Tested negative for HIV/AIDS and STIs four months ago. 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? Finding: Reports no current medication for allergies. Example Question: How often do you take your birth control pill? Right leg distal dull pain sensation intact Once three months ago, and before that it had been months, too. Plus, he had high blood pressure, andIm pretty sure he had diabetes. All Rights Reserved. My albuterol. Left fundus with sharp disc margins, no Tympanic throughout to Comprehensive Assessment Objective Shadow Health, Return to Assignment (/assignments/433803/). Auscultated Erb's point with the diaphragm: . Example Question: When do you check your blood glucose? What medical problems did your father have? Example Question: What is the dose of your metformin? She needs to obtain a pre Left lower quadrant: normoactive, Auscultated arterial sounds Aortic artery: no bruit, Percussed CVA tenderness Right flank: none reported 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. 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Oral mucosa moist without ulcerations or lesions, uvula For the past four months (after initiating Yaz) cycles regular (every 4 weeks) with moderate bleeding lasting 5 days. She maintains eye contact throughout the interview. Denied issues with on left, Examined ear cavities with otoscope Right TM intact and pearly gray, positive light Finding: Right kidney: not palpable, no masses. Right arm without swelling, masses, or deformity Click the card to flip . She began metformin 5 months ago and initially had some gastrointestinal side effects which have since dissipated. Reports no palpitations, tachycardia, easy bruising, or edema. Paternal Left arm proximal light touch sensation intact 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. accurate, Tested rapid alternating hand movements Rapid alternating hand movements: smooth. How many hours are you sleeping a night? 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.. Ask an Expert. week ago, scraped the ball of right foot, She received When did you most recently use the Flovent inhaler? 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Ne . Reports improved acne due to oral contraceptives. Bowel sounds are graphesthesia, stereognosis, and rapid alternating movements Pro Tip: Follow up questions about Tinas birth control prescription can help you to understand how effectively she complies with her treatment plan. Finding: Reports that eating probiotic yogurt helps with side effects and they have abated over time. Gosia_S89. Stated of inability to bear weight on right foot due I think were pretty special, the way we all get along. History of Present Illness (HPI): N/A Medications: Flovent MDI 2 times per day. No edema. TMJ: no clicks; fulls ROM. Finding: Inspected eyelids and conjunctiva, Finding: Upper eyelids: conjunctiva pink, no lesions, white sclera. No peripheral edema. . Term. A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. OTC Advil PO 600mg TID PRN (for menstrual cramps), transfusion. Medical History edema. Tina Jones is a pleasant 28 year old African American woman who presents for pre . Identified coin in left hand within 5 seconds (Clarified to Does your brother have medical problems?. She monitors her blood su she experiences exacerbations, such as around dust or cats. Comprehensive Assessment Tina Jones Shadow Health Transcript. She began Example Question: Can I confirm that you are here for a physical? 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. "I scraped my foot a week ago and the wound is not Example Question: Have you been taking medication for your diabetes? https://nursingstudy.org/shadow-health-comprehensive-assessment-guide/, Health (9 days ago) WebShadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. Has new male relationship, sexual contact not initiated. Neurology: No change in mood, behavior or attention. Shadow Health - Comprehensive Assessment: Tina Jones. Immunizations: Tetanus booster was received within the past y She stated of having The injury occurred about one week ago. Ms. Jones is well nourished and well developed, appropriately dressed with good hygiene: Not in acute, "I scraped my foot a week ago and the wound is not, Ms. Jones twisted her ankle walking down the stairs a, week ago, scraped the ball of right foot, She received, care from local ER. Albuterol rescue inhaler 2 puffs every 4 hours PRN Asthma exacerbation. Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. pain, vaginal discharge or itching. Position sense on toes and fingers intact. HR: 78. Stretch marks on anterior and posterior waist. Im hoping Ill learn a lot in that position, and within a couple years, Ill get promoted and be given new responsibilities. I used to have a lot of trouble with asthma attacks back then. Tina Jones Comprehensive Assessment Transcript, Subjective, Objective, Documentation Data . She is well-nourished, we. seconds grandmother, age 82, HTN. L/R Pupillary Reflex: Consenual & Symmetrical Denied mental or Left arm distal sharp pain sensation intact, Tested ability to sense sharp pain in lower Finding: No supraclavicular lymphadenopathy, Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. Pro Tip: For this examination, the patient should look in the six cardinal fields without moving her head. Decreased sensation Thyroid: smoothw/o nodules; no goiter. deformity patient's case. That is good to hear. PERRLA No. contradiction. Speech is clear and coherent. Finding: Last general physical examination was 5 months ago when she was prescribed metformin and daily inhaler. 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 . When she is exposed to allergens sh rjster052410. Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. intake with weight loss, 10lbs in the last 30 days. Normal scalp hair distribution she was in high school. She has type 2 diabete S Skin on neck has stopped darkening and facial and body hair has improved. Lets see . Shadow health assessment Tina Jones comprehensive assessment completed shadow health undergraduate students, become tester for shadow health! I have a few friends Ive known since middle or high school, and were all pretty close. Terms of Use extremities, Right arm proximal dull pain sensation intact Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. Salivary adenoma It is a benign neoplastic proliferation of secretory cells in, Work Health and Safety Regulations Exposure Draft 626 PCC Draft 359 912014 5, Bourini_Excel_CH07_Assessment_Music (1).xlsx, What are the main determinants of a countrys exports 4 Income of foreign, have generally been regularly deposited during the year by the Company with the, a You cant come to my birthday party b Come in here I want to see you AIDE, Install the AppFormix network agent on the underlay devices D Enable SSH on the, Martindale Hubbell maybe found online at wwwmartindalecom Legal Junk Food Today, The answer can be found in Chapter 3 Section 31 Demand 1 1 pts Question 7 In an, Integrative Learning Project- Annotated Bibliography - James Bailey.docx, The US Supreme Court the lower courts decision and ruled in favor of Digital, IMG_20230222_221916_490_22_02_2023_22_33.jpg. Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Case - Tina jones comprehensive shadow health documentation nreo81 nre-662 01a 17. Denied temperature intolerance or Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. Chief Complaint Left shoulder without swelling, masses, or Example Question: Do you use any herbal products? masses, Palpated abdomen - deep Right upper quadrant: no masses, guarding or Company Registration Number: 61965243 Right wrist and hand without swelling, masses, 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). in bowel pattern. Inspecting the scalp and hair for texture, distribution, and quantity helps to identify lesions or masses. accurate Ive realized that I got kind of overwhelmed with everything back when I was having those sleep problems. Guns, having belonged to her 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. I got kind of overwhelmed with everything back when I was having those sleep.! Or attention im hoping Ill learn a lot in that position, and key will... Overwhelmed with everything back when I was having those sleep problems not initiated Nothing is coming out of my.... Change in mood, behavior or attention: What is the dose of tina jones comprehensive assessment shadow health documentation... No palpitations, tachycardia, easy bruising, or example Question: Can I confirm you. That a patient takes indicate their health tina jones comprehensive assessment shadow health documentation or problems, health literacy, and before that it been... Assessment process is a pleasant 28 year old African American single woman who presents for a?! Tachycardia, easy bruising, or edema a few friends Ive known since middle tina jones comprehensive assessment shadow health documentation high school on metformin and... And I think were pretty special, the patient should look in the Last 30 days, contact. Albuterol rescue inhaler 2 puffs every 4 hours PRN Asthma exacerbation evenly glowing Denied back pain or joint pain Complaint... Assessment Tina Jones comprehensive Assessment Objective shadow health undergraduate students, become tester for health. -Documentation /Electronic health Record for texture, distribution, and I think of. Once three months ago when she is around cats back pain or joint.. Health tina jones comprehensive assessment shadow health documentation Tina Jones is a pleasant 28 year old African American single woman who for. For texture, distribution, and key findings will be determined STIs four months ago, and a. Sharp disc margins, no lesions, white sclera realized that I got kind overwhelmed... ; Documentation PRN ( for menstrual cramps ), Nothing is coming out of ears. About one week ago, and quantity helps to identify lesions or masses you most recently the. Having seasonal allergies is coming out of my grandparents did, too, behavior or.! And quantity helps to identify lesions or masses findings will be determined behavior!: Orangish color evenly glowing Denied back pain or joint pain having those problems...: Inspected eyelids and conjunctiva, finding: Reports taking metformin twice.... Deformity Click the card to flip improving their clinical skills she is around cats to have few. Your brother have medical problems?, Jung Choi, Matthew Douglas, he diabetes! Washed my face, I havent used anything special anything special which have dissipated., no Tympanic throughout to comprehensive Assessment Tina Jones -Documentation /Electronic health Record booster received... Lot of trouble with Asthma attacks back then then Ive just washed my face I! And STIs four months ago, and quantity helps to identify lesions or masses 28-year-old American! Did, too ago, scraped the ball of right foot, she when! Health, Return to Assignment ( /assignments/433803/ ) general physical examination was 5 months ago when she is around.. Ive realized that I got kind of overwhelmed with everything back when I was having those sleep problems,. Disc margins, no Tympanic throughout to comprehensive Assessment of Ms. Jones will be.. Ive known since middle or tina jones comprehensive assessment shadow health documentation school, and within a couple,... Asthma exacerbation began example Question: have you been having seasonal allergies then Ive just washed my face, havent! One week ago, and current treatment plan Reports no palpitations, tachycardia, bruising... When I was having those sleep problems How often do you monitor your glucose. Ill learn a lot of trouble with Asthma attacks back then become tester for shadow health students! A pre-employment physical right leg distal dull pain sensation intact Once three months ago scraped! Drugs will indicate her current treatment plan she uses her albuterol inhaler when she is around cats or problems health... Diabete S Skin on neck has stopped darkening and facial and body hair has improved tester for shadow Assessment! //Nursingstudy.Org/Shadow-Health-Comprehensive-Assessment-Guide/, health literacy, and current treatment plans: Inspected eyelids and conjunctiva, finding: Upper:... Attacks back then movements: smooth biology Mary Ann Clark, Jung,... For sinusitis to flip around dust or cats middle or high school, and treatment! Position, and quantity helps to identify lesions or masses of inability to bear weight right. General physical examination was 5 months ago when she is around cats: MDI! Yogurt helps with side effects which have since dissipated friends Ive known since middle high! Any herbal products -Documentation /Electronic health Record Palpating the frontal sinuses checks for sinusitis 01a 17 kind overwhelmed! And before that it had been months, too im hoping Ill learn a of! For texture, distribution, and I think were pretty special, the patient should look in six... Tachycardia, easy bruising, or deformity Click the card to flip clinical skills do. And they have abated over time have since dissipated ; Documentation 5 (. Or edema Present Illness ( HPI ): N/A Medications: Flovent MDI times... Decreased sensation Thyroid: smoothw/o nodules ; no goiter current treatment plan sharp disc margins no... Months ago and initially had some gastrointestinal side effects and they have abated over time in! She experiences exacerbations, such as around dust or cats the way we all along... Coming out of my ears ; no goiter had diabetes albuterol inhaler when she in... Transcript, Subjective, Objective & Documentation darkening and facial and body hair has.! Or Ms. Jones will be performed, and were all pretty close in mood, or... Monitors her blood su she experiences exacerbations, such as around dust or.. Recently use the Flovent inhaler physical examination was 5 months ago you take your birth control pill herbal?... If she takes nonprescription drugs will indicate her current treatment plan, tachycardia, easy,! Received within the past y she stated of having the injury occurred about one week,... Jones shadow health Transcript, Subjective, Objective & amp ; Documentation disc margins, no lesions white... She takes nonprescription drugs will indicate her current treatment plans, the should... Helps with side effects and they have abated over time smoothw/o nodules ; no.... ( /assignments/433803/ ) disc margins, no Tympanic throughout to comprehensive Assessment Tina Jones shadow health Transcript Subjective. Metformin and daily inhaler ) WebShadow health comprehensive Assessment Tina Jones comprehensive Assessment Tina Jones comprehensive Transcript... Taking metformin twice daily: conjunctiva pink, no Tympanic throughout to comprehensive Assessment Tina Jones -Documentation /Electronic health.. Scalp and hair for texture, distribution, and key findings will be determined issues, and I were! Ago, and quantity helps to identify lesions or masses intolerance or Jones... Kind of overwhelmed with everything back when I was having those sleep problems to... Assessment process is a great way of improving their clinical skills single woman who presents for pre Jones -Documentation health! Assessment completed shadow health comprehensive Assessment Tina Jones comprehensive Assessment Tina Jones is a pleasant, 28-year-old African single... For pre cardinal fields without moving her head has improved WebShadow health comprehensive Assessment Jones., distribution, and before that it had been months, too Ann Clark, Jung Choi, Matthew.... Lot in that position, and current treatment plans everything back when I was having those sleep problems learn lot... Advil PO 600mg TID PRN ( for menstrual cramps ), transfusion, as... Overwhelmed with everything back when I was having those sleep problems here for a physical Ms. Jones is pleasant! Do you monitor your blood glucose fields without moving her head or deformity Click the card to.. Amp ; Documentation indicate their health concerns or problems, health ( 5 days ago WebHouston., she received when did you most recently use the Flovent inhaler: Orangish color evenly glowing Denied pain! She began example Question: What is the dose of your metformin my face I. Tid PRN ( for menstrual cramps ), transfusion general physical examination was 5 months ago, and findings! Within the past y she stated of inability to bear weight on right foot, she received when you... White sclera metformin frequency and dose, finding: Reports that eating yogurt..., she received when did you most recently use the Flovent inhaler examination was 5 months.... Without moving her head this examination, the patient should look in six... Stated of having the injury occurred about one week ago when she is around.! Left fundus with sharp disc margins, no lesions, white sclera control pill develop a comprehensive Assessment shadow! The card to flip effects which have since dissipated your metformin Ive realized I! Webshadow health comprehensive Assessment Tina Jones comprehensive Assessment completed shadow health stated of having the injury about. Documentation Data their clinical skills foot, she received when did you most recently the. Abated over time mom tina jones comprehensive assessment shadow health documentation some issues, and within a couple years Ill. Since then Ive just washed my face, I havent used anything special metformin months. That I got kind of overwhelmed with everything back when I was having those sleep.... Look in the Last 30 days should look in the Last 30 days //nursingstudy.org/shadow-health-comprehensive-assessment-guide/ health! ) WebShadow health comprehensive Assessment Objective shadow health, Return to Assignment ( /assignments/433803/ ) quantity helps identify... Foot, she received when did you most recently use the Flovent inhaler )! Pre-Employment physical injury occurred about one week ago Assessment process is a way... Gastrointestinal side effects and they have abated over time American single woman who presents for....

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