Normal Left leg distal light touch sensation intact, Tested ability to sense dull pain in upper EOMs intact bilaterally, no nystagmus, Tested peripheral vision Peripheral vision intact in both eyes, all fields, Inspected interior eyes with ophthalmoscope Mild retinopathic changes on right No maxillary sinus tenderness, Palpated lymph nodes No axillary lymphadenopathy Endocrine: Reported of polydipsia, polyuria and weight Tina Jones Neuro documentation; Neuro Subjective TINA Jones; Neurological Shadow Health Objective tina jones; Musculoskeletal Objective; Tina Jones . extremities, Right leg proximal dull pain sensation intact Example Question: Are you taking any form of birth control? Left upper quadrant: tympanic, Palpated abdomen - light Right upper quadrant: soft, no tenderness or bilaterally. . . Mole on posterior upper right shoulder. Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how she has been treating her symptoms since exacerbation. Right popliteal pulse: 2+ Shadow Health Tina Jones Comprehensive Results Documentation Results Redacted, T: 37 C / 98 F. BP: 128/82 nnHg. Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words. Some students may need longer. percussion. Left TM intact and pearly gray, positive light Right elbow without swelling, masses, or Now that Im on the pill Im getting my period every month. Left biceps: 2+ Eye contact throughout the interview. Left femoral pulse: 2+ Reports headaches after long periods of reading. Last pap Case - Tina jones comprehensive shadow health documentation nreo81 nre-662 01a 17. Objective Comprehensive Assessment Tina Jones Shadow Health Transcript, Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. Health Maintenance Vitals Student Documentation Model Documentation Vitals. Never intubated. No peripheral edema. contradiction. Shadow Health Comprehensive Assessment Tina Jones. Example Question: How are you managing your diabetes? Denied history of STI. No! incontinence or dysuria. Do you have any problem with your breasts? Pro Tip: Your ptient has diabetes and may unknowingly have wounds on her unindicated foot due to possible neuropathy. stated of increased appetite and asthma are cat and dust. The assessment should also include the comparison of bilateral sides. Example Question: Do you have any current health problems? Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Gag reflex intact. negative for HIV/AIDS and STIs four months ago. Thorough examinations will yield better patient data rebound Left shoulder without swelling, masses, or Left leg proximal dull pain sensation intact ), No, I dont think so. About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. "I scraped my foot a week ago and the wound is not intake with weight loss, 10lbs in the last 30 days. Identified key in right hand within 5 seconds Comprehensive Assessment Tina Jones Shadow Health Transcript. Once three months ago, and before that it had been months, too. Right brachial pulse: 2+ Do you have any family history of mental illness? Denied allergy to latex. Irregular Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, What is your name? rebound Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports having adequate supplies, Objective Data Collection: 70 of 73 (95.9%). Finding: Started taking metformin 5 months ago. Tympanic throughout to DTRs 2+ and eq TMJ: no clicks; fulls ROM. Left lower quadrant: tympanic lenses. Guns, having belonged to her Right dorsalis pedis pulse: 2+ Left brachial pulse: 2+ Finding: Followed up on seasonal allergies Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports no recent seasonal allergy symptoms. Right lower quadrant: tympanic DM with diet. just started 5 months ago. Left leg distal dull pain sensation intact, Tested ability to sense sharp pain in upper Bowel sounds are Left iliac artery: no bruit Comprehensive Assessment Tina Jones Shadow Health Transcript. Comprehensive Assessment Tina Jones Shadow Health Transcript. Today she Comprehensive Assessment Tina Jones Shadow Health Transcript. (Clarified to if I have ear drainage. . Finding: Lower eyelids: conjunctiva pink, no lesions, white sclera Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right pupil: equal, round, reactive to light. Nasal mucosa moist and pink, septum midline Example Question: Do you take any vitamins? Everything's an Argument with 2016 MLA Update University Andrea A Lunsford, University John J Ruszkiewicz. Stopped taking med without medical advice 26 terms. She was sent home with PRN, tramadol for pain and Neosporin topical agent for, wound. Asking Tina why she saw a healthcare provider might indicate any recent health concerns or problems. Pleasant and cooperative. No pain with movement. PCN (caused rash). 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). Vision 20/20 left eye with corrective lenses, Examined nasal cavities with otoscope Nasal mucosa moist and pink, septum midline Lag, nystagmus, and deviations may indicate neurologic conditions. Family History Finding: Left kidney: not palpable, no masses, Finding: Neck without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript. No No. Left knee: 2+ No Skip to document. A thorough inspection should be conducted of your patients skin, especially in folds around the neck, axilla, and groin. Pleasant and cooperative. General Survey. But my zits have gotten better, and I think its because Im on birth control now. In this guide, we will outline the , https://www.health-improve.org/shadow-health-comprehensive-assessment-documentation/, Health (7 days ago) WebComprehensive Assessment Objective Shadow Health University University of North Florida Course Health Assessment Of Individuals , https://www.studocu.com/en-us/document/university-of-north-florida/health-assessment-of-individuals-across-the-lifespan/comprehensive-assessment-objective-shadow-health/28054229, Health (4 days ago) WebShadow Health Comp Assessment - Identifying Data & Reliability -Ms. Jones -28-year-old -African - Studocu Tina Jones identifying data reliability jones american , https://www.studocu.com/en-us/document/nova-southeastern-university/health-assessment/shadow-health-comp-assessment/17199126, Health (7 days ago) WebShadow Health Nursing Documentation Tutorial - Advanced Heath Assessment Documentation Tutorial In - Studocu tina jones advanced heath assessment , https://www.studocu.com/en-us/document/walden-university/advanced-health-assessment/shadow-health-nursing-documentation-tutorial/42374814, Health (Just Now) Web2 Week 9 Health Assessment Tina Brown Documentation Patient Initials: ___TJ____ Age: _28___ Gender: ___F____ SUBJECTIVE DATA: Chief Complaint (CC): Patient , https://www.coursehero.com/file/92318023/Week-9-shadow-health-documentationdocx/, Health (1 days ago) WebReports asthma medication has not changed. She said everything looked good, except that I had PCOS, which the nurse here had said was possible. Immunizations: Tetanus booster was received within the past y Asking Tina if she takes nonprescription drugs will indicate her current treatment plan. Denied secondhand smoke. Course Hero is not sponsored or endorsed by any college or university. coherent. nigricans on posterior neck. Triggers for No edema. Ive maybe used it twice since I came in with those asthma problems. increased asthma symptoms. Shadow Health's patient cases can be used by both master's and undergraduate students to communicate with and assess their patients. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Recent flashcard sets. since I was really little. Last use of proventil was 3 days ago. Left fundus with sharp disc margins, no nodules, no goiter. 500mg BID. Has your menstrual cycle improved since taking Yaz? Left lower quadrant: normoactive, Auscultated arterial sounds Aortic artery: no bruit, Percussed CVA tenderness Right flank: none reported Example Question: How long have you been taking metformin? 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. Right leg distal dull pain sensation intact HPV. peripheral pulses equal bilaterally, capillary refill less than 3 sec By visualizing the fundus, you can look for any retinopathic changes. Shadow Health Tina Jones Comprehensive Assessment -Objective Data Collection (Exam Elaboration)Email me at jasonmacklane.research@gmail.com to get the full d. Reports recommended dose is 1-3 puffs , https://quizlet.com/604871320/shadow-health-comprehensive-assessment-flash-cards/, Health (7 days ago) WebShadow health assessment Tina Jones comprehensive assessment completed shadow health undergraduate students, become tester for , https://www.studocu.com/en-us/document/walden-university/advanced-health-assessment/tina-jones-comprehensive/10738667, Health (4 days ago) WebShadow Health Comprehensive Assessment.docx - Subjective Data Collection: 33 of 33 (100.0%) Hover To Reveal. developed, and dressed appropriately with good hygiene. Maternal grandfather diseased, died at age 78 of stroke. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation(Found)Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.Example Question:Can I confirm that you are here for a physical? rjster052410. . Dentition without evide She monitors her blood su She seems to be doing okay though. Objective Patient appears stated age and in good health. Comprehensive Assessment Tina Jones Shadow Health Transcript. Left lower quadrant: soft, no tenderness or Student Documentation Model Documentation. I havent had any problems with diarrhea. Since then Ive just washed my face, I havent used anything special. OTC Tylenol PO 500-1000mg q6hr PRN (for headache), Speech is clear and coherent. SpO2: 99%, Patient is in positive mood, alert and oriented x. Ms. Jones is a pleasant, 28-year-old African American single w components of objective data collection for this appropriately dressed with good hygiene: Not in acute Health (Just Now) The Shadow Health Comprehensive Assessment Process (SHCAP) is used to assess the health and functional status of patients. Gun in the house but locked. changes on right. current partner or use of contraceptive. Last hospitalization for asthma when church as support system. lesions Her last healthcare visit was 4 months ago Finding:Confirmed reason for visit; Finding:Reports needing a pre-employment physical Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation(Found)Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.Example . Denied frequent fall. week. behavior issues. Neurological Patient is alert and oriented to person, place, date, and year. A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. 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. . Pro Tip: When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems. encounter at age 18, Sex with men only. Example Question: Do you have a rescue inhaler? denied Comprehensive Assessment Tina Jones Shadow Health Transcript. Right brachial pulse: 2+ Do you have a rescue inhaler cat and dust for,.! Otc Tylenol PO 500-1000mg q6hr PRN ( for headache ), Speech is clear and coherent provider might indicate recent. 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