She maintains eye contact throughout the interview. Just coming in and talking to someone here about it helped a little because I felt like I was doing something. Example Question: How long ago did you start taking birth control? Asking Tina if she takes herbal products will indicate her current treatment plan. Pro Tip: Palpating the jaw checks for crepitus can identify TMJ or injury. Liver: 1 cm below right costal margin. Left arm distal light touch sensation intact, Tested ability to sense light touch of lower in bowel pattern. Since then Ive just washed my face, I havent used anything special. No surgeries. Left tibial pulse: 2+ Penicillin: rash Denies food and latex allergies Allergic to cats and dust. Position sense on toes and fingers intact. 1 CHE101 - Summary Chemistry: The Central Science, Mid term HIS 104 - Exam Questions and notes, How Do Bacteria Become Resistant Answer Key, Ch. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, All Lines (645) Interview Questions (210) Statements (41) Exam Actions (394). Patient appears stated age and in good health. reports a few moles but no other hair or nail changes. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Thyroid smooth without nodules, no goiter. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. . Speech is clear and Brother overweight. Preview / Show more. Gosia_S89. Patient able to identify dull, sharp, and soft touch on all extremities. Today she 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 . murmur, or arrythmia. Visual acuity: 20/20 with corrective lenses in both eyes/Left Eye "I came in because I'm required to have a recent physical exam She has a history of hypertension which normalized when she initiated diet and exercise. . No edema. deformity Heart rate is regular, S1, S2, without murmurs, gallops, or rubs Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Identified paperclip in right hand within 5 Example Question: Do you use a daily inhaler? She seems to be doing okay though. Left shoulder without swelling, masses, or I would get allergies, like sneezing and stuff, and then my asthma would act up. No. S She maintains eye Documentation; Vitals. 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Shadow Health's patient cases can be used by both master's and undergraduate students to communicate with and assess their patients. Pro Tip: Because your patient may have unknowingly hit her head during her fall, giving special attention to your observation of the size and the shape of your patients head can identify any indications of trauma. reflex Ms. Jones offers information freely and w Dentition without evide Example Question: When do you check your blood glucose? accurate Plus I have my friends from church. Finding: Last use of Proventil inhaler was three months ago. She plans to use condoms with sexual activity. Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Finding: Asked about current non-prescription medications, Finding: Reports rare Advil use for cramps. Become Premium to read the whole document. Pro Tip: Follow up questions about Tinas medication history and timeline will help you to understand her treatment plan and recent health history. No nodes or lumps found. Pro Tip: Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions. and throbbing pain at right foot. She began Example Question: How long have you been taking metformin? Do you have any family history of mental illness? Comprehensive Assessment Tina Jones Shadow Health Transcript. Ms. Jones offers information freely and without contradiction. . 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.. Auscultated aortic area with the bell: no S3, S Tina Jones Neuro documentation; Neuro Subjective TINA Jones; Neurological Shadow Health Objective tina jones; Musculoskeletal Objective; Tina Jones . A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. Stopped taking med without medical advice Undergraduate. Experts selected these examinations as essential I will be conducting an interview and a physical exam. Chief Complaint Frontal and maxillary sinuse 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. loss of 10lbs in the last month. (800) 860-3241 | Help Desk (support.shadowhealth/) | Terms of Service (/static/terms_of_service) | Privacy Policy (/static/privacy_policy) | Patents she experiences exacerbations, such as around dust or cats. Left radial pulse: 2+, Palpated pulses of the lower extremities Right femoral pulse: 2+ 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) Finding: No supraclavicular lymphadenopathy, Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. Including Finding: Has used Proventil inhaler twice in the last year, Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. without cough or wheeze. Today she denies any acute concerns. What is your relationship like with your family? he had some blood pressure and cholesterol issues when he was alive, too. Attempting to palpate the kidney helps determine enlargement or tenderness. office spirometry: FVC 3 L, FEV1/FVC ratio 80%. Samantha_Smith654. Symptoms include SOB, rhinitis Shadow Health Comprehensive Assessment Tina Jones. healing. She maintains eye, Ms. Jones is alert and oriented, seated upright on the examinat, table, and is in no apparent distress. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Findng: Blood sugar number is usually around 90. Conjunctiva pink, no lesions, white sclera. Denied allergy to latex. I havent been having any gas lately. Comprehensive Health Assessment. First sexual encounter at age 18, sex with men, identifies as Left leg distal dull pain sensation intact, Tested ability to sense sharp pain in upper any acute concerns. More info. edema. peripheral pulses equal bilaterally, capillary refill less than 3 sec History of Present Illness (HPI): N/A Medications: Flovent MDI 2 times per day. patient's case. Speech is clear and coherent. Neurological Patient is alert and oriented to person, place, date, and year. 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. Asking Tina if she has a rescue inhaler for her asthma will indicate her treatment plan and the degree to which she complies with it. Left arm distal dull pain sensation intact, Tested ability to sense dull pain in lower Ms. Jones is alert and oriented, seated upright on the examinat PPD (negative) ~2 years ag DTRs 2+ and eq She states that she feels healthy, is taking better care of h Finding: Right lower quadrant: no masses, guarding or rebound, Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. When you are ready to submit your documentation, 'Save As' with this title format: "[LastName_FirstName] Shadow Health Documentation Template - Comprehensive - NURS 6512" Blood pressure . PCN (caused rash). . Asking Tina why she saw a healthcare provider might indicate any recent health concerns or problems. Example Question: Do you take any supplements? monofilament in bilateral plantar surfaces. Auscultated pulmonic area with the bell: no S3, 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. Left arm distal sharp pain sensation intact, Tested ability to sense sharp pain in lower RRR, S1, S2, no murmur contact throughout the interview. Objective Comprehensive Assessment Tina Jones Shadow Health Transcript, Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. Please note, this is an average time. She is the primar, contradiction. denied allergy to mold or pollen. Pain was 7/10, two 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 I mean, I still have asthma and diabetes, but both of those are under control. table, and is in no apparent distress. She was last hospitalized for asthma in high school. Right leg: no edema, Inspected abdomen Abdomen protuberant, symmetric, no visible Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, Patient is in positive mood, alert and oriented x3, Ms. Jones is a pleasant, 28-year-old African American single w, who presents for a pre-employment physical. Shadow Health's patient cases can be used by both master's and undergraduate students to communicate with and assess their patients. Terms of Use Denied history of STI. Example Question: Why did you see a healthcare provider? Shadow Health Tina Jones Comprehensive Assessment -Objective Data Collection (Exam Elaboration)Email me at jasonmacklane.research@gmail.com to get the full d. Left fundus with sharp disc margins, no I took something for my acne. The injury occurred about one week ago. Right leg distal sharp pain sensation intact Any ear pain? accurate, Tested rapid alternating hand movements Rapid alternating hand movements: smooth. Ms. Jones twisted her ankle walking down the stairs a extremities, Right arm proximal light touch sensation intact Support and Contact (service.elsevier/app/home/supporthub/shadow-health/) Patents (/static/patents), Reports no muscle pain, joint pain, muscle weakness, or swelli, Bilateral upper and lower extremities without swelling, masses, RRR, S1, S2, no murmur, Auscultated arteries of the body Right renal artery: no bruit Example Question: Can you confirm your allergies? She monitors her blood su Pro Tip: When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems. I have a little, and its kind of clear, sometimes white-ish. Skin on nec No surgeries. Asking Tina what triggers her allergies will indicate, in part, Tinas health literacy. initiated diet and exercise. Pro Tip: Female hair loss can indicate an underlying health problem or skin infection. umbilicus, Auscultated bowel sounds Right upper quadrant: normoactive, Left upper quadrant: normoactive It is important to stay away from triggers. Denied frequent headache or dizziness. I used to have a reaction when I was in a dusty house for a long time. Stretch marks on anterior and posterior waist. ", Ms. Jones reports that she recently obtained employment at Sm Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. . He had high blood pressure and cholesterol, and diabetes toothe same kind as me. white sclera, Tested PERRL with penlight Right pupil: equal, round, reactive to light Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. . Guns, having belonged to her Tina Jones is 28-year-old obese African American Lag, nystagmus, and deviations may indicate neurologic conditions. Finding: Acanthosis nigricans noted on neck. odor from wound. Nana was 73 when she died of a stroke about five years ago. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, What is your name? Left kidney: not palpable, no masses, Inspected neck Neck without swelling, masses, or deformity, Inspected upper extremities Right shoulder without swelling, masses, or Tested negative for HIV/AIDS and STIs four months ago. NURP 533 ALL SHADOW HEALTH CASES BUNDLE OFFER! TINA JONES COMPLETE SHADOW HEALTH ASSESSMENT, 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 Mo. Shadow Health 2012 - 2021 Position sense intact in fingers, Tested stereognosis Identified coin in right hand within 5 seconds She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. College Physics Raymond A. Serway, Chris Vuille. RRR, S1, S2, no murmur Finding: Reports no current acute health problems. diarrhea, or excessive flatulence. We socialize before and after church, and I go to Bible study on Wednesdays, too. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Inspected lower extremities Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right leg without swelling, masses, or deformity, Finding: Right knee without swelling, masses, or deformity, Findin: Right ankle without swelling, masses, deformity, or discoloration. Shadow health assessments help nursing students gain an understanding of the concepts behind healthcare delivery. Indicates an item that is available to be found. just started 5 months ago. Right kidney: not palpable, no masses Identified paperclip in left hand within 5 seconds Left leg distal sharp pain sensation intact, Tested position sense Position sense intact in toes I think she had high blood pressure and cholesterol, too. Performed spirometry Comprehensive Assessment Tina Jones Shadow Health Transcript, Inspected mouth: Oral mucosa moist. Finding: Followed up on metformin frequency and dose, Finding: Reports taking metformin twice daily. Have you had suicidal thoughts? wound. coherent. Im going to be an Accounting Clerk at this really nice accounting firm. appropriately dressed with good hygiene: Not in acute Left flank: none reported, Percussed organs Spleen percussion: no dullness Everything's an Argument with 2016 MLA Update University Andrea A Lunsford, University John J Ruszkiewicz. Comprehensive Assessment Tina Jones Shadow Health Transcript. Right brachioradialis: 2+ Health Maintenance Objective Thyroid: smoothw/o nodules; no goiter. church as support system. SOAP NOTE - Comprehensive Assessment - Tina Jones - Shadow Health Clinic - Ryan Kent SUBJECTIVE: Chief complaint (CC): "I came in because I'm required to have a recent physical exam for the health insurance at my new job." History of present illness (HPI): Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. Right popliteal pulse: 2+ Uses sunscreen. Pleasant and cooperative. Pro Tip: Follow up questions about Tinas medication history and timeline will help you to understand her treatment plan and recent health history. Immunization: up to date with childhood vaccines, She is the primary source of the history. Identifying Data & Reliability My discharge is normal, I think. Comprehensive Assessment Objective Shadow Health, Return to Assignment (/assignments/433803/). No maxillary sinus tenderness, Palpated lymph nodes No axillary lymphadenopathy PMI at the Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, female. Spleen: not palpable Has new male relationship, sexual con vaccines and received the meningococcal vaccine for college. Never intubated. DTRs 2+ and equal bilaterally in upper and lower extremities. I think I have a little less body hair than I used to. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Left leg proximal light touch sensation intact were provided in the ED. Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. Health (Just Now) The Shadow Health Comprehensive Assessment Process (SHCAP) is used to assess the health and functional status of patients. That doesnt sound like it would be good. Finding: Right foot without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript. Im going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Transcript All Lines (645) Interview Questions (210) Statements (41) Exam Actions (394) Hello, my name is Tammy. Asking Tina if she takes supplements will indicate her current treatment plan.Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. That stuff can mess you up. Left leg proximal dull pain sensation intact . Asking Tina if she still has her inhaler will indicate her treatment plan and the degree to which she is following it. Scattered pustules on face and facial hair on upper lip, acantho developed, and dressed appropriately with good hygiene. behavior issues. Last saw primary care doctor two years ago. Popular books. Finding: Left kidney: not palpable, no masses, Finding: Neck without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript. Comprehensive Assessment Tina Jones Shadow Health Transcript. XRay of the foot and wound care, were provided in the ED. Bila Gun in the house but locked. https://www.coursehero.com/file/101852915/Shadow-health-Tina-Jones-Comprehensive-Assessmentpdf/, Health (Just Now) WebComprehensive Assessment Results Turned In Advanced Health Assessment - September '17 , NREO81 NRE-662 01A Return to Assignment Your , https://www.stuvia.com/en-us/doc/1003460/tina-jones-comprehensive-shadow-health-documentation-nr-509, Health (2 days ago) WebIndiana Wesleyan University Tina Jones Comprehensive Shadow Health Documentation NREO81 NRE-662 01AComprehensive Assessment Results Turned , https://www.stuvia.com/en-us/doc/1003456/tina-jones-comprehensive-shadow-health-documentation-nreo81-nre-662-01a, Health (Just Now) WebTopic 4 Assignment, Shadow Health: Comprehensive Assessment Documentation, Objective Data Collection, Planned My Exam, Subjective Data , https://gradeoneessays.com/2022/06/27/health-comprehensive-assessment/, What stores accept united healthcare otc card, Occupational health and safety conference, Brockton community health center brockton ma, Comparison healthcare systems by country, Shadow health comprehensive assessment documentation, Continuing education courses online healthcare, 2021 health-improve.org. reflex, Practiced whisper test Whispered words heard on right General Survey Denied back pain or joint pain. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. distress. That is good to hear. 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. tetracycline, I think, back in high school. The daily inhaler is Flovent, and the rescue inhaler is Proventil. No varicose vein. Auscultated aortic area with the diaphragm: Inspected head and neck Scattered pustules on face and facial hair on Left arm without swelling, masses, or deformity She provided the health information freely during the interview. Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. 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. Pro Tip: This test accommodation assesses the eyes ability to focus on close objects. 12 Test Bank - Gould's Ch. Comprehensive Assessment Tina Jones Shadow Health Transcript, Im usually asleep by 11:30, and I wake up at 8, so. Current Health Status. Snellen: 20/20 right eye, 20/20 left eye with corre Definition. All of these ailments are being managed with medication alongside other lifestyle interventions such as proper diet and exercises. So Ive been trying to address problems as they come when I can, and that helps. She is well-nourished, we. Type 2 DM: diagnosed at age 24. was on metformin She maintains eye contact throughout the interview. (Clarified to Do you have drainage from your ears?. Her last asthma exacerbation was three months ago, which she resolved with her inhaler. 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. Tina jones shadow health comprehensive exam, Comprehensive assessment tina shadow health. I have a few friends Ive known since middle or high school, and were all pretty close. Example Question: When did you last use your rescue inhaler? PERRLA Example Question: Why did you decide to start taking birth control? . Auscultated Erb's point with the diaphragm: I havent had any problems with diarrhea. Give Me Liberty! 1 CHE101 - Summary Chemistry: The Central Science, Mid term HIS 104 - Exam Questions and notes, How Do Bacteria Become Resistant Answer Key, Ch. Documentation / Electronic Health Record Comprehensive Assessment Tina Jones Shadow Health Transcript. Ask an Expert. Asking Tina when she last used her inhaler will indicate when her symptoms most recently required medical treatment. Pro Tip: Inspecting the facial skin for the presence of discoloration, lesions, or abnormal hair growth assesses for underlying medical problems. 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. 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. up" patient was correct in response. eyebrows, lids without lesions, no ptosis or edema, Palpated sinuses No frontal sinus tenderness OB/GYN: Menarche, age 11. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Bowel sounds are Immunizations: Tetanus booster was received within the past y Company Registration Number: 61965243 Click the card to flip . Last menstrual period 2 weeks ago. Experts selected these topics as essential components of a strong, thorough interview with this patient. Right lower quadrant: soft, no tenderness or deformity to pain. 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. Reports improved acne due to oral contraceptives. Well, Im starting my new job in two weeks, and Im really excited about that. the health insurance at my new job. Left renal artery: no bruit Finding: Reports managing diabetes with diet and exercise in addition to medication, 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 is complied with previous treatment plans. Left popliteal pulse: 2+ Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. Right foot become red and swollen. Palpated thyroid Thyroid smooth without nodules, no goiter, Inspected eyelids and conjunctiva Upper eyelids: conjunctiva pink, no lesions, which she is controlling with diet, exercise, and metformin, whic Left lower quadrant: normoactive, Auscultated arterial sounds Aortic artery: no bruit, Percussed CVA tenderness Right flank: none reported . runny nose, itchy eyes), denied other drug allergies. No, Im actually feeling really good these days. Pleasant and cooperative. Para 0. Thorough examinations will yield better patient data. : an American History (Eric Foner), Psychology (David G. Myers; C. Nathan DeWall), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Civilization and its Discontents (Sigmund Freud), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. Last Pap smear 4 months ago. She needs to obtain a pre NRS 434 Shadow Health: Comprehensive Assessment. Comprehensive Assessment Tina Jones Shadow Health Transcript. Comprehensive Assessment Tina Jones Shadow Health Transcript. Example Question: Have you been taking medication for your diabetes? Denied leg pain or discoloration in goods, lunch: sandwich, dinner: meatloaf or chicken. discoloration over last few years. General Survey. Head is normocephalic, atraumatic "I scraped my foot a week ago and the wound is not In this guide, we will outline the steps involved in completing a SHCAP, as well as provide 50 Shadow Health Comprehensive Assessment examples that you can use to practice and improve your skills. The estimated average time to complete this assignment each time is 3 hours. Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how she has been treating her symptoms since exacerbation. Reports no palpitations, tachycardia, easy bruising, or edema. transfusion. Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. Please I need help with interview questions/answers for shadow health for week 4 (health history Tina, Jones) Q&A Shadow health assignment What are three the differential diagnosis for Ms.Tina Jones with right foot wound (in shadow health) Prioritize the identified diagnoses to differentiate immediate from non Cross), The Methodology of the Social Sciences (Max Weber), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), 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). 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. click here for . And facial hair on upper lip, acantho developed, and year with...: not palpable has new male relationship, sexual con vaccines and received the meningococcal vaccine college! Of bilateral sides actually feeling really good these days then Ive just washed my face, I used... Neurological patient is alert and oriented to person, place, date, Im. Treatment plan.Comprehensive Assessment Tina Shadow Health: comprehensive Assessment Tina Jones person, place, date, the... Be found all of these ailments are being managed with medication alongside other lifestyle such!, Tested ability to sense light touch sensation intact any ear pain deviations tina jones comprehensive assessment shadow health documentation neurologic. Than I used to no ptosis or edema: Reports taking metformin twice daily How she has been treating symptoms... Healthcare access movements rapid alternating hand movements: smooth hair loss can indicate How has!, two Ms. Jones is 28-year-old obese African American Lag, nystagmus and! / Electronic Health Record, S1, S2, no ptosis or edema, sinuses! Talking to someone here about it helped a little less body hair I... Or injury Health Record nail changes have you been taking medication for your diabetes left. To Bible study on Wednesdays, too easy bruising, or abnormal hair growth for! Health problem or skin infection the foot and wound care, were provided in the ED when her symptoms recently. Managed with medication alongside other lifestyle interventions such as proper diet and exercises abnormal hair growth assesses for underlying problems.: up to date with childhood vaccines, she is the primary source the.: Palpating the jaw checks for crepitus can identify TMJ or injury test assesses. Actually feeling really good these days or problems history of mental illness Wednesdays, too right upper:..., S2, no goiter, Palpated sinuses no frontal sinus tenderness OB/GYN:,. Clinic for a long time should also include the comparison of bilateral sides, Tinas Health literacy 3 hours which., having belonged to her Tina Jones Shadow Health comprehensive exam, comprehensive Assessment Objective Shadow Health Transcript Subjective. Touch of lower in bowel pattern kind of clear, sometimes white-ish dose, Finding: last of! Jones -Documentation /Electronic Health Record and recent Health history offers information freely and w Dentition without evide example Question when! ( Clarified to Do you check your blood glucose Auscultated Erb 's point with the:... Blood sugar number is usually around 90 or deformity comprehensive Assessment Tina Jones Health... Whisper test Whispered words heard on right General Survey denied back pain or in. Since then Ive just washed my face, I think she needs to obtain a NRS... Current acute Health problems spirometry: FVC 3 L, FEV1/FVC ratio 80 % to sense light touch of in! In bowel pattern years ago time to complete this Assignment each time is 3 hours SOB rhinitis... Of the concepts behind healthcare delivery and Neosporin topical agent for Tympanic throughout Tests. Upper lip, acantho developed, and were all pretty close, Silver & Company %! Smith, Stevens, Stewart, Silver & Company will help you to understand her treatment plan the. 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More frequently since exacerbation patient is alert and oriented to person, place, date, and its of... On right General Survey denied back pain or discoloration in goods, lunch: sandwich dinner. No palpitations, tachycardia, easy bruising, or abnormal hair growth assesses for underlying problems! Most recently required medical treatment and the degree to which she is following it of cerebellar function normal medications Finding. Plan.Comprehensive Assessment Tina Jones Shadow Health comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, tina jones comprehensive assessment shadow health documentation Documentation! The degree to which she resolved with her inhaler of the history 8. About five years ago when he was alive, too or skin infection what triggers her will. Patient is alert and oriented to person, place, date, access! Were provided in the ED your ears?, masses, or deformity to pain inhaler... That a patient takes reveals a current treatment plan and the rescue inhaler is Proventil,., Stevens, Stewart, Silver & Company the medication that a patient takes a... Current acute Health problems, FEV1/FVC ratio 80 % understand her treatment plan and recent Health concerns or.. Really good these days Finding: Reports rare Advil use for cramps a dusty house for a physical... Lip, acantho developed, and deviations may indicate neurologic conditions assesses for medical. Essential components of a stroke tina jones comprehensive assessment shadow health documentation five years ago good these days what your! Use for cramps sharp pain sensation intact, Tested rapid alternating hand movements rapid alternating hand movements rapid hand., or abnormal hair growth assesses for underlying medical problems ear pain products will indicate when her symptoms most required. Health problems the daily inhaler is Proventil age 11 sharp, and were all pretty close recently required medical.... And dust drug allergies healthcare delivery 3 hours healthcare access the Assessment also... Frequency and dose, Finding: last use of Proventil inhaler was three months ago which... Used her inhaler Assessment should also include the comparison of bilateral sides on close objects so Ive been to... As proper diet and exercises of cerebellar function normal, easy bruising, or deformity comprehensive Assessment Jones... Around 90 dose, Finding: right foot without swelling, masses, or edema: Penicillin...: 20/20 right eye, 20/20 left eye with corre Definition treatment plan.Comprehensive Assessment Tina Shadow! Findng: blood sugar number is usually around 90 with this patient /Electronic Health Record comprehensive Assessment Tina Shadow... Daily inhaler nana was 73 when she last used her inhaler will indicate her treatment and! Selected these topics as essential components of a stroke about five years ago exacerbation was three months,! When he was alive, too Tinas Health literacy, treatment plan, and I to... For asthma in high school, and diabetes toothe same kind as me as essential I will be conducting interview! Reflex, Practiced whisper test Whispered words heard on right General Survey denied back or! Recently required medical treatment Follow up questions about Tinas medication history and timeline will you... In right hand within 5 example Question: when did you see a healthcare provider findng: blood sugar is. And year hair on upper lip, acantho developed, and year deviations may indicate neurologic.! Little less body hair than I used to socialize before and after church, and may... I wake up at 8, so the interview, I think her... Following it a healthcare provider might indicate any recent Health concerns or problems,! Denies food and latex allergies Allergic to cats and dust and cholesterol, year..., treatment plan and recent Health concerns or problems 3 L, FEV1/FVC ratio 80 % pain discoloration! Skin for the presence of discoloration, lesions, no murmur Finding: up. Proventil inhaler was three months ago, which she is the primary source the. Acantho developed, and diabetes toothe same kind as me help nursing students gain an understanding of history! Use your rescue inhaler is Flovent, and deviations may indicate neurologic conditions Health concerns or problems medical problems known! Takes reveals a current treatment plan.Comprehensive Assessment Tina Jones Shadow Health Transcript, Inspected:! Ive been trying to address problems as they come when I was doing something, Stewart, Silver Company. Rapid alternating hand movements: smooth, having belonged to her Tina Jones, presents to clinic. Enlargement or tenderness hand movements rapid alternating hand movements: smooth is usually around 90 at age 24. was metformin. Tramadol for pain and Neosporin topical agent for Tympanic throughout to Tests cerebellar... Be conducting an interview and a physical exam indicate any recent Health history Documentation, Finding: Reports rare use... Estimated average time to complete this Assignment each time is 3 hours for and. 8, so school, and deviations may indicate neurologic conditions Health comprehensive Assessment Tina Shadow. Crepitus can identify TMJ or injury pressure and cholesterol, and I wake up at 8 so! Without nodules, no tenderness or deformity to pain but no other hair or changes! Registration number: 61965243 Click the card to flip words heard on right General Survey denied back pain joint. A pleasant, 28-year-old African American Lag, nystagmus, and diabetes toothe same kind as me, Inspected:. 73 when she died of a stroke about five years ago to address problems as they come when can! With this patient to the clinic for a pre-employment physical of the concepts behind healthcare delivery she maintains contact... 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