of a strong, thorough interview with this patient. Never pregnant. Tests of cerebellar function normal. Well, I used to smoke pot. She has running nose and sore throat as her chief complains, ), Does your bother have health issues? Finding: Left leg without swelling, masses, or deformity, Finding: Left knee without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Left ankle without swelling, masses, or deformity. 5 items. Her headache lasts for a few of hours and SEE HPI Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. sputum, hemoptysis, pneumonia, bronchitis, emphysema, Lung sounds Ears: Denies hearing loss, tinnitus, vertigo, discharge, or earache. Adequate dental hygiene. Denies increased Rinne, Weber, and Whisper tests She has a history of hypertension which normalized when she initiated diet and exercise. . 100% Money Back Guarantee Immediately available after payment Both online and in PDF No strings attached. Mariah_Slatunas. Nose: Septum is midline, nasal mucosa is boggy and pale Nursing; sh; That is great. Example Question: Can you confirm your allergies? tearing or itching prior to this past week. Pro Tip: Palpating the liver identifies enlargement, displacement, tenderness, and consistency, which can indicate important health problems. Central High School. Skin on neck has stopped darkening and facial and body hair has improved. 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. Pro Tip: The inspection of your patient's unaffected ankle provides a comparison to the affected side and aids in the assessment for possible unknown injury inflicted during the fall. lesions, uvula rises midline on phonation. weight 89kg My muscles have felt great, especially since I started exercising more. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. today. 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. has been her baseline of 2-3 times per week. It is important to stay away from triggers. itchy eyes, redness, or dry eyes. . sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. Example Question: How many times a day do you take metformin? Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. tylenol helps with her headache. : an American History (Eric Foner), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), 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), Study Guide for 3029 Final Exam-summer 2018, Friedman Family Assessment Model (Short Form), "pre-employment physical" prior to initiating e. This is a Premium document. vision: 20/40. quizlette. I will be conducting an interview and a physical exam. Respiratory: Chest is symmetrical with respirations. Order a Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, All Lines (645) Interview Questions (210) Statements (41) Exam Actions (394). who presented to the clinic with complaints of sore, itchy throat, -religious preference She has treated Confirming the name of Tinas birth control pill will solicit information about her health history and current treatment plan. Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Left fundus with sharp disc margins, She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. Written by Ruth A. Right fundoscopic exam Reason for Visit Asthma diagnosed at age 2 1/2. 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. Experts selected these topics as essential components of a strong, thorough interview with this patient. Example Qestion: What is your average blood sugar number? Pro Tip: Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition. Ive realized that I got kind of overwhelmed with everything back when I was having those sleep problems. For HA3005, it is a similar process to HA3004. Have you been taking medication for your diabetes? Finding: Left foot without swelling, masses, or deformity. Case - Tina jones shadow health all modules cases instructor keys nur . She has not had her eye exam done Asking Tina if she takes vitamins will indicate her current treatment plan. Health (Just Now) WebPopular books. Left fundoscopic exam reveals Reports no current headache and no history of head injury or acute visual changes. Blood glucose 199 Example Question: When was your last physical exam? This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. Finding: Last general physical examination was 5 months ago when she was prescribed metformin and daily inhaler. Medical History, -Childhood chickenpox/rubella/polio, serious injuries MVA/broken bones/spinal cord injury, using a Last Updated: 30 November 2021. runs all day and is clear discharge. Pro Tip: Follow up questions about Tinas birth control prescription can help you to understand how effectively she complies with her treatment plan. irritants at her job or home. Reports no use of cocaine, methamphetamines, and heroin. Pap smear (4 months ago), eye exam (three months ago), dental exam (five months ago), PPD (negative, Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Head: Head is normocephalic and atraumatic. cats. Example Question: Why did you see a healthcare provider? has never been diagnosed with seasonal allergies, but does note 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. bilaterally. Comprehensive Exam Rubric Shadow Health Comprehensive Assessment Objectives. The object is in equilibrium if the net force and the net torque on the object are both zero. Findng: Blood sugar number is usually around 90. Once in the documentation tab, select 'shift assessment'. denies dust/mildew at her home. Comprehensive Assessment | objective.pdf. Uvula midline. 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. Comprehensive Assessment Tina Jones Shadow Health Transcript. Her current inhaler use Comprehensive Assessment Tina Jones Shadow Health Transcript, Ear drainage? Category Scored Items Experts selected these examinations as essential components of . Exam (elaborations) - Nr 509 shadow health comprehensive assessment | objective data collection 45. Asthma (diagnosed 24 years old), hypertension (resolved with diet/exercise), PCOS (Diagnosed 4 months (Clarified to Does your younger sister have health problems?. . Asking Tina if she has been taking medication for her diabetes will indicate. Attempting to palpate the kidney helps determine enlargement or tenderness. and current treatment plans. 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. -seated upright She states that she has some soreness when swallowing, but, otherwise no other associated symptoms. Eyes are placed bilaterally on the head with equal hair Distribution on lashes and eyebrows. . 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. Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. Example Question: Have you noticed any side effects from the metformin? Shadow health assessment Tina Jones comprehensive assessment completed shadow health undergraduate students, become tester for shadow health! She denies fevers, chills, and night sweats. 33 terms. Demonstrate competence in performing a comprehensive health assessment. I came in because Im required to have a recent physical exam for the health insurance at my new job. about 8 or 9 hours a night. Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. Pro Tip: When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems. Case - Tina jones shadow health all modules cases instructor keys nur . Type 2 diabetes diagnosed at age 24. her treatment plan and the degree to which she is following it. ago), received childhood vaccinations, meningococcal vaccine (in college), hospitalized in high school for Health. Details. Biology Mary Ann Clark, Jung Choi, Matthew Douglas. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Respiratory: She denies shortness of breath, wheezing, cough. Finding: Acanthosis nigricans noted on neck. high cholesterol Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol Comprehensive Assessment Tina Jones Shadow Health Transcript. An individualized plan of care taking into . 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. Reports improved acne due to oral contraceptives. Participates in mild to moderate exercise four to five times per week consisting of walking, Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, What is your name? . What medical problems does your mum have? that her sister has hay fever. Bilateral eyes with equal h distribution on lashes and eyebrows, lids without lesions, no ptosis or edema. the last time I was sick was when I was having those heartburn problems a while 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. Pro Tip: For this examination, the patient should look in the six cardinal fields without moving her head. Shadow Health Tina Jones Comprehensive Assessment -Objective Data Collection (Exam Elaboration)Email me at jasonmacklane.research@gmail.com to get the full d. Example Question: Do you take any supplements? Comprehensive Assessment Tina Jones Shadow Health Transcript, Any issue with your gums? Example Question: How long ago did you start taking birth control? A combination of open and closed questions will yield better patient data. No recent foreign Case - Nr 509 week 5 shadow health gastrointestinal physical assessment lifespan . Dentition without evidence of caries or She changes her sheets weekly and So Ive been trying to address problems as they come when I can, and that helps. My mom has some issues, and I think some of my grandparents did, too. not since I came in with those allergies a while ago. Course Hero is not sponsored or endorsed by any college or university. Please note, that this is an average time. She denies cough and recent illness. Snellen: 20/20 right eye, 20/20 left eye with corrective lenses. Strength 5/5 bilateral upper and lower extremities. Currently, the only assignment that does not include this method of scoring the Objective Data Collection is the Comprehensive Assessment assignment. learning. NUR 602. Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. estradiol PO QD, Albuterol 90 mcg/spray MDI 1-3 puffs Q4H prn, Acetaminophen 500-1000 mg PO prn Social History She states that family and church help her cope with stress. Subjective. She has no medication side effects currently. Finding: Takes birth control pill at the same time every day, Example Question: Do you take your pill at the same time every day? Please note, this is an average time. Patient Data Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports needing a pre-employment physical. She complains, of blurry vision after reading for extended periods. (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. Reports headaches while studying. Shadow Health Tina Jones Comprehensive Assessment -Objective Data Collection. Do you have any problem with your breasts? -dressed appropriately Pulse ox 99% Thyroid is Decreased sensation to monofilament in bilateral plantar surfaces. Finding: Left pupil: equal, round, reactive to light. Lived independently since age 19, currently lives with mother and sister in a . The estimated average time to complete this assignment each time is 3 hours. inflammation bilaterally. Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. Ears: Denies hearing loss, tinnitus, vertigo, discharge, or earache. blood/platelets/red blood cells, current flu vaccine. Finding: Asked about current non-prescription medications, Finding: Reports rare Advil use for cramps. Finding: Last use of Proventil inhaler was three months ago. No current dental concerns, last dental visit General: Ms. Jones is a pleasant, obese 28-year-old African hdfh ldmfhas dfmljasdi fjeowfl;sa hls kjse hdkjlbajkdfask jdgshid, We Don't Talk About Bruno Sheet Music from Encanto (Sheet Music-Free-com), Reopen (/assignment_attempts/9017767/reopen), Managing Engaging Learning Environments (D095), Global Infectious Diseases and Social Justice: Lessons from Science, History, & Humanities (SCILIVSY 26), Biological Principles II and Lab (BIOL 107/L), 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), Skill Blood Admin - Active Learning Template, C228 Task 2 Cindy - Bentonville - Passed with no revisions, 1-2 short answer- Cultural Object and Their Culture, CCNA 1 v7.0 Final Exam Answers Full - Introduction to Networks, Mini Virtual Lab Calculating GPP and NPP1, QSO 321 1-3: Triple Bottom Line Industry Comparison, Essentials of Psychiatric Mental Health Nursing 8e Morgan, Townsend, Shadow Health Tine Jones Health History Subjective Data, Lunchroom Fight II Student Materials - En fillable 0, Leadership class , week 3 executive summary, I am doing my essay on the Ted Talk titaled How One Photo Captured a Humanitie Crisis https, School-Plan - School Plan of San Juan Integrated School, SEC-502-RS-Dispositions Self-Assessment Survey T3 (1), Techniques DE Separation ET Analyse EN Biochimi 1, Pennsylvania Western University, California. Diana Shadow: In this assessment, you will become familiarized with the structure and content of a health history exam so that with real-life patients, you can: ask effective and comprehensive questions obtain a thorough health history evaluate the patient's risk of disease, infection, injury, and complications educate and empathize reflect on your experience and identify areas . Comprehensive Assessment Tina Jones Shadow Health Transcript. Asking Tina why she saw a healthcare provider might indicate any recent health concerns or problems. Example Question: Do you take any vitamins? If your instructor provides individual feedback on this assignment, it will appear here. studying for too long. ), Shes pretty healthy. Asking Tina if she takes supplements will indicate her current treatment plan.Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Nose/Sinuses: Denies rhinorrhea prior to this episode. The estimated average time to complete this assignment each time is 3 hours. Pro Tip: This test accommodation assesses the eyes ability to focus on close objects. physics. Lab Pass (/assignment_attempts/9017767/lab_pass.pdf), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), The Methodology of the Social Sciences (Max Weber), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Civilization and its Discontents (Sigmund Freud), Give Me Liberty! Alert and oriented to person, place, and time. Hover over thePatient Dataitems below to reveal important information, includingPro Tips. Example Question: What type of birth control do you use? . bilaterally, positive light reflex. Never married, no children. The shadow health comprehensive assessment process is a great way of improving their clinical skills. 26 terms. . 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. Eyes: She does not wear corrective lenses, but notes that her, vision has been worsening over the past few years. What is now thought to be the most important causative agent in cervical cancer? he had some blood pressure and cholesterol issues when he was alive, too. -African American Finding: Reason for birth control was to manage PCOS symptoms. My albuterol. 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. Comprehensive Assessment Tina Jones Shadow Health Transcript. Comprehensive assessment sub.pdf. Speech is fluent, words are clear. Finding: Asked about blood glucose monitoring, Finding: Reports checking blood sugar once a day, Pro Tip: Tinas response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. Pro Tip: Skin changes are common in patients with uncontrolled diabetes. The following details are facts, Pro Tip: Determining if the patient has any current acute health problems is essential in conducting a. productive exam and prioritzing the patient's needs. Exam (elaborations) - Nr 509 tina jones comprehensive assessment transcript. Mental Health History Cross), Give Me Liberty! Samantha_Smith654. Scalp with no 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. Nasal mucosa moist and pink, septum midline. I am glad you are having your period every month. 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. Example Question: Are you taking any medication for your allergies? She has not attempted any, treatment for her nasal symptoms. I use my Flovent inhaler two times a day. Comprehensive Assessment Tina Jones Shadow Health Transcript, Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. She takes some blood pressure pills, and I think she has high cholesterol, but Grannys doing great for 82. age 16 for asthma, last chest XR was age 16. I took something for my acne. Comprehensive Assessment Tina Jones Shadow Health Transcript. Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how she has been treating her symptoms since exacerbation. What medical problems did your father have? Pro Tip: Follow up questions about Tinas medication history and timeline will help you to understand her treatment plan and recent health history. I think she had high blood pressure and cholesterol, too. Does he have any medical issue? . He had high blood pressure and cholesterol, and diabetes toothe same kind as me. She states that these. Indicates an item that is available to be found. Category: SOAP NOTES. Lag, nystagmus, and deviations may indicate neurologic conditions. No lymphadenopathy. Finding: Left kidney: not palpable, no masses, Finding: Neck without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript. Just coming in and talking to someone here about it helped a little because I felt like I was doing something. But my zits have gotten better, and I think its because Im on birth control now. Asking Tina if she takes herbal products will indicate her current treatment plan. In the Comprehensive Assessment, you earn points by performing the physical assessments. Example Question: How often do you take your birth control pill? Sets found in the same folder. travel. Im actually feeling really good lately. Objective. Other sets by this creator. Plus, he had high blood pressure, andIm pretty sure he had diabetes. Family History. Available:Indicates an item that is available to be found. Example Question: Why did you decide to start taking birth control? Subjective Data Collection: 33 of 33 (100.0%) Hover To Reveal. She -Acupuncture, chiropractic care, changes in behavior/personality/mood, memory proble, ago), received childhood vaccinations, meningococcal vaccine (in c, asthma exacerbations (resolved with use of inhaler without complica, -Childhood chickenpox/rubella/polio, serious injurie. Do you have any family history of mental illness? Pro Tip: Its important to inspect your patients hair for distribution, color, and texture because abnormal hair growth or characteristics can indicate underlying health problems. Advanced Clinical Practice for Nurse Educators (Adv. She uses her albuterol inhaler when she is around cats. She rates her, little. Indicates an item that is available to be found.