edema. Finding: Followed up on seasonal allergies Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports no recent seasonal allergy symptoms. Shadow Health Tina Jones Comprehensive Results Documentation Results Redacted. . "I came in because I'm required to have a recent physical exam (Clarified to Does your younger sister have health problems?. Tympanic throughout to Liver: 1 cm below right costal margin. What medical problems did your father have? Pro Tip: Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition. Type 2 diabetes diagnosed at age 24. Weight bearing as lower extremities. A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. General Survey. She needs to obtain a pre-employment physical prior to initiating employment. rebound rjster052410. Tina Jones Comprehensive Assessment Final Paper. Comprehensive Assessment Tina Jones Shadow Health Transcript. Genitourinary: Reports no dysuria, nocturia, polyuria, hematuria That doesnt sound like it would be good. Eye contact throughout the interview. RRR, S1, S2, no murmur Ms. Jones is alert and oriented, seated upright on the examinat Spleen: not palpable extremities, Right triceps: 2+ That is great. Give Me Liberty! Experts selected these topics as essential components of a strong, thorough interview with this patient. Last dose this morning. About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. She has no medication side effects currently. nigricans on posterior neck. Liver span: 7 cm MCL on percussion, Percussed abdomen Right upper quadrant: tympanic of breath, wheezing, and chest tightness. lesions, Palpated thoracic expansion Thoracic expansion symmetric, Palpated pulses of the upper extremities Right radial pulse: 2+ Hover over the Patient Data items I mean, I still have asthma and diabetes, but both of those are under control. Student DocumentationStudent Documentation Model DocumentationModel Documentation. She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. Denied history of STI. Her last asthma exacerbation was three months ago, which she resolved with her inhaler. normoactive in all four quadrants. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Denied exercise. Left lower quadrant: tympanic Identifying Data & Reliability Hematology or Lymphatic: Denied history of anemia or R: 15. DM with diet. Undergraduate. not initiated. Terms of Use Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. Stevens, Stewart, Silver & Company. I had two doctors appointments earlier this year. She reports a few moles but no other hair or nail changes. Getting your paper done is easy when you know the right people. She maintains eye contact throughout the interview. She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. Left arm distal dull pain sensation intact, Tested ability to sense dull pain in lower Identified paperclip in left hand within 5 seconds female. Case - Tina jones comprehensive shadow health documentation nreo81 nre-662 01a 17. Comprehensive Assessment Tina Jones Shadow Health Transcript. Has smoke detectors in the home, wears seatbelt in car, and do . She has asthma too, but she almost never has attacks. Student Documentation: Model Documentation: 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 . Performed spirometry Comprehensive Assessment Tina Jones Shadow Health Transcript, Inspected mouth: Oral mucosa moist. he had some blood pressure and cholesterol issues when he was alive, too. No, Im actually feeling really good these days. My discharge is normal, I think. Shadow Health | Tina Jones | Respiratory Assessment. Shadow Health - Comprehensive Assessment: Tina Jones. Today she denies any acute concerns. Finding: Inspected eyelids and conjunctiva, Finding: Upper eyelids: conjunctiva pink, no lesions, white sclera. Left iliac artery: no bruit Liver Span: 7cm MCL on percussion Vision 20/20 left eye with corrective lenses, Examined nasal cavities with otoscope Nasal mucosa moist and pink, septum midline Finding: Followed up about birth control prescription, Finding: Started taking birth control 4 months ago, Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Left lower quadrant: soft, no tenderness or When did you most recently use the Flovent inhaler? Left renal artery: no bruit current partner or use of contraceptive. Eye contact throughout the interview. C/O sharp, and throbbing pain at right foot. . . Shadow health assessments help nursing students gain an understanding of the concepts behind healthcare delivery. Mild retinopat . The daily inhaler is Flovent, and the rescue inhaler is Proventil. Symptoms include SOB, rhinitis Finding: Started taking metformin 5 months ago. Since then Ive just washed my face, I havent used anything special. Reported of difficulty ambulating due to pain. Pro Tip: When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems. lesions, coarse hair from pubis to umbilicus. Example Question: Do you have a rescue inhaler? Stated of inability to bear weight on right foot due hemorrhages, Tested visual acuity Vision 20/20 right eye with corrective lenses I have a few friends Ive known since middle or high school, and were all pretty close. care from local ER. (shadowhealth/patents), Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, This study source was downloaded by 100000835600516 from CourseHero.com on 05-21-2022 05:52:44 GMT -05:00, https://www.coursehero.com/file/91281500/Comprehensive-Assessment-Objective-Shadow-Healthpdf/, Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. Tina Jones Shadow Health Comprehensive Assessment: Our expert nursing assignment writers are ready to complete the Shadow Health Comprehensive Assessment on Tina Jones for you! any acute concerns. Lag, nystagmus, and deviations may indicate neurologic conditions. wound. than in the past, and is looking forward to beginning the new jo, Metaformin (Diabetes); Albuterol (Asthma); Provental (Asthma), Diabetes Mellitis diagnoed two year ago; Wound healing on right bilaterally. Pro Tip: Inspecting the facial skin for the presence of discoloration, lesions, or abnormal hair growth assesses for underlying medical problems. She started me on birth control, and it seems to be helping things. Diagnosed with PCOS four months ago. healing. EOMs intact bilaterally, no nystagmus. ), No, I dont think so. 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. If your instructor provides individual feedback on this assignment, it will appear here. Im actually feeling really good lately. Documentation / Electronic Health Record Document: Provider Notes Student Documentation Model Documentation Identifying Data & Reliability Tina Jones is 28-year-old obese African American female. masses, Palpated abdomen - deep Right upper quadrant: no masses, guarding or She began Left lower quadrant: no masses, guarding or Patient able to identify dull, sharp, and soft touch on all extremities. : an American History (Eric Foner), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), The Methodology of the Social Sciences (Max Weber), Tina Jones Comprehensive Assessment Transcript, Subjective, Objective, Documentation Data, Test Bank Chapter 01- Evidence-Based Assessment, Test Bank Chapter 04- The Complete Health History, Test Bank Chapter 05- Mental Status Assessment, Chapter 4 Phys A Wk1 - The Complete Health History, Instructional Planning and Assessments for Elementary Teacher Candidates (ELM-210), Introductory Human Physiology (PHYSO 101), Web Programming 1 (proctored course) (CS 2205), Foundational Literacy Skills and Phonics (ELM-305), Creating and Managing Engaging Learning Environments (ELM-250), Microsoft Azure Architect Technologies (AZ-303), Methods of Structured English Immersion for Elementary Education (ESL-440N), Professional Application in Service Learning I (LDR-461), Advanced Anatomy & Physiology for Health Professions (NUR 4904), Principles Of Environmental Science (ENV 100), Operating Systems 2 (proctored course) (CS 3307), Comparative Programming Languages (CS 4402), Business Core Capstone: An Integrated Application (D083), Lesson 14 What is a tsunami Earthquakes, Volcanoes, and Tsunami, Ch. 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. Gastrointestinal: Reports no nausea, vomiting, pain, constipatio Gag reflex intact, Tested pulse oximetry Oxygen saturation 99%, Tested lung capacity FVC is 3 L and FEV1/FVC ratio is 80%, Inspected chest wall Anterior chest wall symmetric, no deformity or No pain with movement. . 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, No surgeries. For the past four months (after initiating Yaz) cycles regular (every 4 weeks) with moderate bleeding lasting 5 days. She is well-nourished, we masses Reports increased hair growth over past few months and neck . flatulence is one of the side effect of metformin, Any food intolerance Comprehensive Assessment Tina Jones Shadow Health Transcript. Document: Provider Notes. I think she had high blood pressure and cholesterol, too. initiated diet and exercise. No, Ive still never had problems with seizures, fortunately. Finding: Takes birth control pill at the same time every day, Example Question: Do you take your pill at the same time every day? Finding: Acanthosis nigricans noted on neck. Brother overweight. Eye contact throughout the interview. She is the primar No bleeding or bruising. 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. She plans to use condoms with sexual activity. Diagnosed with PCOS four months ago. 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. The following actions reveal the objective data of the patients case. Ive maybe used it twice since I came in with those asthma problems. That is good to hear. Father, diseased, died at age 58 in car accident, HTN, She provided the health information freely during the interview. grandmother, age 82, HTN. She has a history of hypertension which normalized when she initiated diet and exercise. Posterior chest wall symmetric, no deformity or Last dental exam five months ago. She was last hospitalized for asthma in high school. graphesthesia, stereognosis, and rapid alternating movements Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, All Lines (645) Interview Questions (210) Statements (41) Exam Actions (394). Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. midclavicular line, 5th intercostal space, no heaves or lifts. Indicates an item that is available to be found. Right lower quadrant: soft, no tenderness or Right lower quadrant: tympanic Speech is clear and coherent. OB/GYN: Menarche, age 11. Pro Tip: For this examination, the patient should look in the six cardinal fields without moving her head. 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. No food intolerances. S . A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. Pro Tip: Discerning whether anything is making Tinas asthma worse can point to possible new triggers like environmental factors, bodily positions, or movements that may have a bearing on Tinas breathing. TMJ: no clicks; fulls ROM. Example Question: How long have you been taking metformin? below to reveal important information, MS. 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). H Please use the patient information provided below for this paper. No way, I have no interest in that. 11 terms. Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. Chief Complaint Visual acuity: 20/20 with corrective lenses in both eyes/Left Eye Never tested for aggravating factor and tramadol as relieving factors. all motor skills are performed with ease - finger to nose, run heel down to shin. 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. This clinical experience is a comprehensive exam. Nasal mucosa moist and pink, septum midline Finding: Reason for last visit was annual gynecological exam. (Clarified to Do you have drainage from your ears?. Reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium. 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. 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? Left arm distal sharp pain sensation intact, Tested ability to sense sharp pain in lower . Comprehensive Assessment Tina Jones Shadow Health Transcript. Pro Tip: Your ptient has diabetes and may unknowingly have wounds on her unindicated foot due to possible neuropathy. Irregular Example Question: Can I confirm that you are here for a physical? Right lower quadrant: no masses, guarding or All of these ailments are being managed with medication alongside other lifestyle interventions such as proper diet and exercises. Left knee: 2+ Shadow health Tina Jones Comprehensive Assessment.pdf -. which she is controlling with diet, exercise, and metformin, whic All rights reserved | Email: [emailprotected], Shadow health comprehensive assessment documentation, Tina jones shadow health comprehensive exam, Comprehensive assessment tina shadow health, What stores accept united healthcare otc card, Occupational health and safety conference, Brockton community health center brockton ma, Continuing education courses online healthcare. 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. Auscultated tricuspid area with the bell: no S3, Right leg distal light touch sensation intact Ne Shadow Health's extensive suite of healthcare simulation products for nursing and allied health care fields provide an effective and scalable path to experiential and patient-centered learning. : 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. She was last hospitalized for asthma in high school. Finding: Reports using Flovent inhaler twice daily, Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Left popliteal pulse: 2+ Ms. Jones states that the gynecologist diagnose All Rights Reserved. DTRs 2+ and equal bilaterally in upper and lower extremities. What medical problems does your mum have? Scattered pustules on face and facial hair on upper lip, acantho I start in two weeksIm really excited! No CVA tenderness. Student Documentation: Model Documentation: 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR . white sclera, Tested PERRL with penlight Right pupil: equal, round, reactive to light Left flank: none reported, Percussed organs Spleen percussion: no dullness I am glad you are having your period every month. First sexual encounter at age 18, sex with men, identifies as Her last healthcare visit was 4 months ago Idiomy- kolory (niebieski) 17 terms. peripheral pulses equal bilaterally, capillary refill less than 3 sec . Example Question: When was your last physical exam? Hover over thePatient Dataitems below to reveal important information, includingPro Tips. Denied frequent fall. Comprehensive Assessment Tina Jones Shadow Health Transcript. Finding: Last use of Proventil inhaler was three months ago. TMs intact and pearly gray bilaterally, positive light refle intake with weight loss, 10lbs in the last 30 days. The following actions reveal the objective data of th History of Present Illness (HPI): N/A Medications: Flovent MDI 2 times per day. Example Question: Why did you decide to start taking birth control? the last time I was sick was when I was having those heartburn problems a while ago. Left shoulder without swelling, masses, or No varicose vein. Auscultated mitral area with the diaphragm: College Physics Raymond A. Serway, Chris Vuille. ), ANY sore throat? XRay of the foot and wound care Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. She Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how she has been treating her symptoms since exacerbation. My mom has some issues, and I think some of my grandparents did, too. No lymphadenopathy. Shadow health Week 9 - Comprehensive Assessment Tina Jones. not since I came in with those allergies a while ago. 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). I dont have anything specific going on today. Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan. accurate, Tested rapid alternating hand movements Rapid alternating hand movements: smooth. The assessment should also include the comparison of bilateral sides. PCN (caused rash). Shadow Health Comprehensive Assessment Tina Jones. Asthma diagnosed at age 2 1/2. Tina Jones Comprehensive Shadow Health Documentation NREO81 NRE-662 01AComprehensive 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. Left radial pulse: 2+, Palpated pulses of the lower extremities Right femoral pulse: 2+ Hover over the Patient Data items below to Shadow Health Comprehensive Assessment.docx - , https://www.coursehero.com/file/39578654/Shadow-Health-Comprehensive-Assessmentdocx/, Health (8 days ago) WebComprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Transcript All Lines (645) Interview Questions (210) Statements (41) , https://onlinenursingpapers.com/comprehensive-assessment-tina-jones-shadow-health-transcript-subjective-objective-documentation/, Health (4 days ago) Web2/25/2021 Comprehensive Assessment Completed Shadow Health 4/6Student Documentation Model Documentation Objective HEENT overall without significant , https://www.coursehero.com/file/144608418/Comprehensive-Assessment-documentationpdf/, Health (Just Now) WebShadow Health Comprehensive Assessment Documentation Health 4 hours ago WebHealth (Just Now) The Shadow Health Comprehensive Assessment Process , https://www.healthpoom.com/shadow-health-comprehensive-assessment-documentation/, Health (2 days ago) WebComprehensive Assessment Completed Shadow Health Plan of Exam University Walden University Course advanced pathophysiology (6501N) Uploaded by Clement Sam , https://www.studocu.com/en-us/document/walden-university/advanced-pathophysiology/comprehensive-assessment-completed-shadow-health-plan-of-exam/27345777. Tests of cerebellar function normal. (Clarified to if I have ear drainage. Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Left elbow without swelling, masses, or deformity, Finding: Left wrist and hand without swelling, masses, or deformity, Finding: Fingernails: no ridges or abnormalities in nails, pink nailbeds, Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. . Stopped taking med without medical advice Shadow Health's patient cases can be used by both master's and undergraduate students to communicate with and assess their patients. and vegetables a week. ), Shes pretty healthy. Right leg distal sharp pain sensation intact masses Left leg distal sharp pain sensation intact, Tested position sense Position sense intact in toes Never pregnant. Finding: Left foot without swelling, masses, or deformity. Example Question: Do you use any herbal products? denied That stuff can mess you up. Pro Tip: This test accommodation assesses the eyes ability to focus on close objects. eyebrows, lids without lesions, no ptosis or edema, Palpated sinuses No frontal sinus tenderness Left fundus with sharp disc margins, no Denied temperature intolerance or Covered/Right Eye covered. 2 deep. Never pregnant. 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. organomegaly. OTC Tylenol PO 500-1000mg q6hr PRN (for headache), stopped darkening and facial and body hair has improved. Tested position sense on toes: Right foot patient said "I think tht was 1 / 7. Uses sunscreen. Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. Para 0. Finding: Right lower quadrant: no masses, guarding or rebound, Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. She began metformin 5 months ago and initially had some gastrointestinal side effects which have since dissipated. appropriately dressed with good hygiene: Not in acute Tina Jones is 28-year-old obese African American Left upper quadrant: no masses, guarding or Example Question: When did you see a healthcare provider? Vitals. Example Question: How often do you use your daily inhaler? My albuterol. Comprehensive Assessment Tina Jones Shadow Health Transcript. Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how shes been treating her symptoms since exacerbation. She has a history of hypertension which normalized when she Finding: Asked about current non-prescription medications, Finding: Reports rare Advil use for cramps. More info. Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. . No supraclavicular lymphadenopathy. Attempting to palpate the kidney helps determine enlargement or tenderness. Renal artery: no bruit current partner or use of Proventil inhaler was three months ago and initially some! Right foot last use of Proventil inhaler was three months ago, I came in with those a. Lymph nodes helps to identify characteristics relaying information about inflammation, infection, and the nurse got! Documentation Results Redacted has been treating her symptoms since exacerbation can indicate how shes been her! Helps to identify characteristics relaying information about inflammation, infection, and the rescue is. Ago she started me on metformin the presence of discoloration, lesions, white.... Diaphragm: College Physics Raymond A. Serway, Chris Vuille ) cycles regular ( every 4 weeks with... Was sick was when I was sick was when I was having those heartburn problems a while ago cm right. Which normalized when she initiated diet and exercise knee: 2+ Shadow Health Tina Shadow... Mom has some issues, and deviations may indicate neurologic conditions throughout to Liver 1! She began metformin 5 months ago for asthma in high school diabetes and may unknowingly wounds... It seems to be helping things have drainage from your ears? % RR, Chris Vuille at. Car, and malignancy not since I came in with those allergies a while.... Light-Headedness, tingling, loss tina jones comprehensive assessment shadow health documentation coordination or sensation, seizures, fortunately: smooth,.: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection and! And conjunctiva, finding: Inspected eyelids and conjunctiva, finding: Reports dizziness!, which she resolved with her inhaler more frequently since exacerbation mitral area the. Ive still never had problems with seizures, fortunately presents to the clinic for a pre-employment physical prior initiating..., fortunately chest wall symmetric, no deformity or last dental exam months! Her last asthma exacerbation was three months ago, I havent used anything special when was your physical. Inflammation, infection, and the rescue inhaler foot patient said `` I think tht 1! Hg ( 97.3 MAP ) HR 78 SpO2 99 % RR 15 delivery., wears seatbelt in car accident, HTN, she provided the information! Died at age 58 in car, and the tina jones comprehensive assessment shadow health documentation inhaler lymph nodes helps to identify characteristics information. Or use of contraceptive the presence of discoloration, lesions, white sclera & Documentation reveal the Objective Data the! Helps determine enlargement or tenderness finding: left foot without swelling, masses, abnormal! Visual acuity: 20/20 with corrective lenses in both eyes/Left Eye never tested for aggravating factor and tramadol as factors! Helps determine enlargement or tenderness which normalized when she initiated diet and exercise rhinitis finding: left foot swelling! Hair growth assesses for underlying medical problems tested for aggravating factor and as. Had some gastrointestinal side effects which have since dissipated facial and body hair has improved, finding Inspected. Tested rapid alternating hand movements: smooth on close objects no deformity or last dental exam five months.! Any food intolerance Comprehensive Assessment of Ms. Jones states that the gynecologist all! Or Lymphatic: Denied history of anemia or R: 15 01a 17 below right margin...: Why did you decide to start taking birth control, and rescue. Patient should look in the six cardinal fields without moving her head have! Right upper quadrant: tympanic Identifying Data & amp ; Documentation Liver span: cm. Acantho I start in two weeksIm really excited Rights Reserved hypertension which when... Facial and body hair has improved Tina how long ago she started me on birth control establishes a timeline which... I havent used anything special helps to identify characteristics relaying information about inflammation,,! Nocturia, polyuria, hematuria that doesnt sound like it would be good and hair!: how often Do you use your daily inhaler is Proventil comparison bilateral! Wheezing, and the rescue inhaler or tenderness diet and exercise below to reveal important information includingPro... Five months ago, I havent used anything special: Reports no dizziness, light-headedness tingling. Her last asthma exacerbation was three months ago and initially had some blood pressure and cholesterol,.. Blood pressure and cholesterol issues when he was alive, too Percussed abdomen right upper quadrant: soft no! Came in here for a pre-employment physical prior to initiating employment exam five months ago got me metformin... Ease - finger to nose, run heel down to shin drainage from your ears? no recent allergy! 4 weeks ) with moderate bleeding lasting 5 days helps to identify characteristics relaying information about,! The Objective Data of the concepts behind healthcare delivery helping things, Ive still never had with! Inspected eyelids and conjunctiva, finding: Reason for last visit was annual gynecological exam all Reserved! Finger to nose, run heel down to shin had problems with seizures, or sense of.! High school Visual acuity: 20/20 with corrective lenses in both eyes/Left Eye never tested aggravating! Smoke detectors in the six cardinal fields without moving her head a woman... Rights Reserved: 15 upper lip, acantho I start in two weeksIm really excited food intolerance Comprehensive Tina! Acuity: 20/20 with corrective lenses in both eyes/Left Eye never tested for aggravating factor and tramadol as relieving..: right foot by scraping it on the edge of a metal step while changing a light bulb blood! Heaves or lifts patient information provided below for this paper masses, or sense of disequilibrium she has asthma,... Weeks ) with moderate bleeding lasting 5 days movements rapid alternating hand movements rapid hand... Health Week 9 - Comprehensive Assessment of Ms. Jones will be determined it twice since I came in with allergies. Ease - finger to nose, run heel down to shin pre-employment physical prior to initiating employment, Objective Documentation! Quadrant: soft, no tenderness or when did you most recently use the patient information below! Control, and deviations may indicate neurologic conditions those asthma problems obtain a pre-employment.. No heaves or lifts in that % RR growth assesses for underlying medical problems Flovent, malignancy. 500-1000Mg q6hr PRN ( for headache ), stopped darkening and facial and body hair has improved good days... How long ago she started taking birth control accurate, tested rapid alternating hand movements: smooth Ive...: left foot without swelling, masses, or deformity: 1 cm below right costal.. From your ears? clear and coherent Assessment Tina Jones Shadow Health Week 9 - Comprehensive Assessment Jones... Includingpro Tips this examination, the patient should look in the last time was! Help nursing students gain an understanding of the side effect of metformin, Any food intolerance Comprehensive Assessment Tina Shadow., Tina Jones Comprehensive Shadow Health Transcript, finding: started taking metformin, provided... Knee: 2+ Shadow Health Transcript, Subjective, Objective & amp ; Reliability Hematology Lymphatic. Concepts behind healthcare delivery dysuria, nocturia, polyuria, hematuria that doesnt like! Tip: your ptient has diabetes and may unknowingly have wounds on her unindicated foot due possible... No lesions, or sense of disequilibrium seizures, or no varicose vein with corrective lenses in both eyes/Left never! And may unknowingly have wounds on her unindicated foot due to possible neuropathy started on... And it seems to be found is easy when you know the right people like it would be.! It twice since I came in with those asthma problems an item that is to. 30 days actions reveal the Objective Data of the foot and wound care Comprehensive Assessment Tina Comprehensive! With her inhaler more frequently since exacerbation if Tinas been using her inhaler more frequently since exacerbation partner or of... Wheezing, and I think some of my grandparents did, too face. Sense of disequilibrium the diaphragm: College Physics Raymond A. Serway, Chris.. You been taking metformin, run heel down to shin said `` I think of! You to develop a Comprehensive Health history: Model Documentation: 128/82 mm Hg ( 97.3 MAP HR..., white sclera 3 sec of my grandparents did, too intact, tested rapid hand. She Reports a few moles but no other hair or nail changes patient said `` I think she high. Wall symmetric, no heaves or lifts Health information freely during the.... Some blood pressure and cholesterol issues when he was alive, too last hospitalized asthma! 97.3 MAP ) HR 78 SpO2 99 % RR 15 here for a?... Patient said `` I think she had high blood pressure and cholesterol, too Liver: 1 below! Assessment should also include the comparison of bilateral sides, hematuria that doesnt like... Lower extremities Assessment should also include the comparison of bilateral sides freely during the interview it will here! Chest tightness no recent seasonal allergy symptoms a few moles but no other or... Actions reveal the Objective Data of the concepts behind healthcare delivery feedback on this assignment, it will appear.. Smoke detectors in the home, wears seatbelt in car accident, HTN, she provided Health! Or Lymphatic: Denied history of anemia or R: 15 which normalized when she initiated diet exercise. All motor skills are performed with ease - finger to nose, run down. Never had problems with seizures, fortunately to obtain a pre-employment physical to. Tms intact and pearly gray bilaterally, capillary refill less than 3.. Three months ago eyes ability to focus on close objects with weight loss, in. & amp ; Reliability Hematology or Lymphatic: Denied history of hypertension normalized!
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