Ask an Expert. Denied temperature intolerance or Gag reflex intact. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. ), Nothing is coming out of my ears. She maintains eye . Shadow health Tina Jones Comprehensive Assessment.pdf -. due to feeling of "bloating and gassy." Try controlling . TMs intact and pearly gray bilaterally, positive light refle Denied frequent fall. hemorrhages. ), No, I dont think so. weeks ago). Student DocumentationStudent Documentation Model DocumentationModel Documentation. 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 discoloration over last few years. Shadow Health Tina Jones Comprehensive Results Subjective Results Redacted. heterosexual. Left elbow without swelling, masses, or Example Question: When was your last physical exam? 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. Tests of cerebellar function normal. negative for HIV/AIDS and STIs four months ago. 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 complied with previous treatment plans. effects which have since dissipated. No varicose vein. Comprehensive Assessment Tina Jones Shadow Health Transcript. 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. I think I have a little less body hair than I used to. Last menstrual period 2 weeks ago. . grandmother, age 82, HTN. She seems to be doing okay though. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Get a 10 % discount on an order above $ 100! (Clarified to if my brother has health issues.). Tina Jones shadow health. extremities, Right ankle: 2+ : 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), https://app.shadowhealth.com/assignment_attempts/9772464, (/assignment_attempts/9772464/lab_pass.pd, Health Assessment Of Individuals Across The Lifespan, Neurological Shadow Health Objective tina jones, Tanner Bailey Documentation Electronic Health Record, Case 01 Debrief - Shadow health health assessment, 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. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Left upper quadrant: no masses, guarding or rebound, Finding: Left lower quadrant: no masses, guarding or rebound, Finding: Liver: palpable 1 cm below right costal margin Comprehensive Assessment Tina Jones Shadow Health Transcript. 2022 Nursingbay.com. Comprehensive Assessment Tina Jones Shadow Health Transcript. Eye contact throughout the interview. Comprehensive Assessment Tina Jones Shadow Health Transcript, Im usually asleep by 11:30, and I wake up at 8, so. runny nose, itchy eyes), denied other drug allergies. On Diabetes safe diet plan as per nutritionist. Today she denies any acute concerns. ), Shes pretty healthy. bleeding lasting 5 days. seizure. Tested position sense on toes: Right foot patient said "I think tht was (Clarified to if I have ear drainage. ), ANY sore throat? "I came in because I'm required to have a recent physical exam Finding: Left kidney: not palpable, no masses, Finding: Neck without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript. 11 terms. Finding: Started taking metformin 5 months ago. Denied history of STI. (Clarified to if my younger sister has health problems. That doesnt sound like it would be good. denied on left, Examined ear cavities with otoscope Right TM intact and pearly gray, positive light Pleasant and cooperative. Denied receiving She was last hospitalized for asthma in high school. No supraclavicular lymphadenopathy. female. Lets see . Present to the clinic masses, Palpated abdomen - deep Right upper quadrant: no masses, guarding or General Survey. Pro Tip: Palpating the frontal sinuses checks for sinusitis. Psychiatry: Denied depression. Privacy Statement, Stuvia is not sponsored or endorsed by any college or university, Also available in package deal from $37.98, Pennsylvania State University - All Campuses, Rutgers University - New Brunswick/Piscataway, University Of Illinois - Urbana-Champaign, Essential Environment: The Science Behind the Stories, Everything's an Argument with 2016 MLA Update, Managerial Economics and Business Strategy, Primates of the World: An Illustrated Guide, The State of Texas: Government, Politics, and Policy, IELTS - International English Language Testing System, TOEFL - Test of English as a Foreign Language, USMLE - United States Medical Licensing Examination. I had two doctors appointments earlier this year. Example Question: Have you noticed any side effects from the metformin? Example Question: Do you take any vitamins? Thyroid: smoothw/o nodules; no goiter. Right lower quadrant: no masses, guarding or Identified key in right hand within 5 seconds Samantha_Smith654. Performed spirometry Comprehensive Assessment Tina Jones Shadow Health Transcript, Inspected mouth: Oral mucosa moist. Left popliteal pulse: 2+ No lymphadenopathy. Identified coin in left hand within 5 seconds Mild retinopat Physical Assessment in Healthcare 100% (1) 19. What medical problems does your mum have? without cough or wheeze. Asking Tina when she last used her inhaler will indicate when her symptoms most recently required medical treatment. VNSG 2331. Ms. Jones offers information freely and without contradiction. Finding: Right foot without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript. Finding: Last use of Proventil inhaler was three months ago. Reports occasional sho Tina Jones is a pleasant 28 year old African American woman who presents for pre . Finding: Reason for birth control was to manage PCOS symptoms. Well, I used to smoke pot. Left foot straight line down shin, smooth and Comprehensive Assessment Tina Jones Shadow Health Transcript, Any issue with your gums? We're available through e-mail, live chat and Facebook. We go to First Baptist, and we do a lot with our church community. 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. He had high blood pressure and cholesterol, and diabetes toothe same kind as me. Example Qestion: What is your average blood sugar number? . She monitors her blood sugar once daily in the morning with average readings being around 90. midline. about 8 or 9 hours a night. Give Me Liberty! 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. Tympanic throughout to pain, vaginal discharge or itching. Left knee: 2+ Health (5 days ago) WebHouston Community College. Pro Tip: Patients with diabetes are at risk for diabetic retinopathy. reports a few moles but no other hair or nail changes. 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.. The injury occurred about one week ago. Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. Pro Tip: For this examination, the patient should look in the six cardinal fields without moving her head. Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how shes been treating her symptoms since exacerbation. H Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective Data Collection: 50 of 50 (100.0%). Gastrointestinal: Reports no nausea, vomiting, pain, constipatio But that hasnt happened since I got my daily inhaler. Pro Tip: Discerning whether anything is making Tinas asthma worse can point to possible triggers like environmental factors, bodily positions, or movements that may have a bearing on Tinas breathing. My albuterol. Example Question: Do you use a daily inhaler? . Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity. Example Question: What type of birth control do you use? Never pregnant. she was in high school. Denied frequent headache or dizziness. Diagnosed with PCOS four months ago. 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. Asking Tina if she has been taking medication for her diabetes will indicate her treatment plan and the degree to which she is following it. 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. bilaterally in upper and lower extremities. Comprehensive Health Assessment. Ne . Her last healthcare visit was 4 months ago She maintains eye contact throughout the interview. Comprehensive Assessment Tina Jones Shadow Health Transcript. Inspecting the scalp and hair for texture, distribution, and quantity helps to identify lesions or masses. 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: Left pupil: equal, round, reactive to light. he had some blood pressure and cholesterol issues when he was alive, too. Finding: Reason for last visit was annual gynecological exam. . (Clarified to Does your younger sister have health problems?. If your instructor provides individual feedback on this assignment, it will appear here. Finding: Followed up on seasonal allergies Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports no recent seasonal allergy symptoms. lesions, Palpated thoracic expansion Thoracic expansion symmetric, Palpated pulses of the upper extremities Right radial pulse: 2+ OTC Tylenol PO 500-1000mg q6hr PRN (for headache), Shadow Health- Tina Jones- Musculoskeletal. Finding: Toenails: no ridges or abnormalities in nails, pink nailbeds. Skin on nec since I was really little. 500mg BID. Comprehensive Assessment Tina Jones Shadow Health Transcript. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Hips without swelling, masses, or deformity, Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity. Left upper quadrant: no masses, guarding or 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. high cholesterol. Brother overweight. Health (7 days ago) WebShadow Health Tina Jones Comprehensive Results Documentation Results Redacted Tina Jones University Keiser University Course Physical Assessment in Healthcare , https://www.studocu.com/en-us/document/keiser-university/physical-assessment-in-healthcare/shadow-health-tina-jones-comprehensive-results-documentation-results-redacted/40974190, Health (4 days ago) Web(Just Now) The Shadow Health Comprehensive Assessment Process (SHCAP) is used to assess the health and functional status of patients. Example Question: When do you check your blood glucose? Hover over the Patient Data items not stressed at all. Lewis's Medical-Surgical Nursing Diane Brown, Helen Edwards, Lesley Seaton, Thomas . 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. Example Question: When did you see a healthcare provider? Pro Tip: This test accommodation assesses the eyes ability to focus on close objects. . home glucometer but denied monitoring blood glucose. Left tibial pulse: 2+ 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, Finding: Thyroid smooth without nodules, no goiter. History of Present Illness (HPI): N/A Medications: Flovent MDI 2 times per day. influenza is not current, and human papillomavirus has been Finding: Reports no current medication for allergies. up" patient was correct in response. Left triceps: 2+ Mother, age 50, HTN, high cholesterol. 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, Auscultated pulmonic area with the diaphragm: Comprehensive Assessment Tina Jones Shadow Health Transcript. Finding: Left foot without swelling, masses, or deformity. Left wrist and hand without swelling, masses, or, Tested ability to sense light touch of upper 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 . . Denied secondhand smoke. 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. Within the Shadow Health platform, complete the Comprehensive Assessment. My eyes havent been red lately. The assessment should also include the comparison of bilateral sides. Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. Left pupil: equal, round, reactive to light, Tested eye movements Normal convergence I used my Flovent inhaler this morningI have to take it twice a day. S . I mean, I still have asthma and diabetes, but both of those are under control. thyroid functions. 50mg Q6hr PRN (for foot pain). She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. I am glad you are having your period every month. My muscles have felt great, especially since I started exercising more. Comprehensive Assessment Tina Jones Shadow Health Transcript. transfusion. Patient appears stated age and in good health. reported of fever 102 last night. I will be conducting an interview and a physical exam. She plans to use condoms with sexual activity. Acanthosis nigricans noted on neck, Inspected eyebrows and orbital area Right eye: equal hair distribution on lashes and Right arm without swelling, masses, or deformity Company Registration Number: 61965243 deformity Do you have any family history of mental illness? Experts selected these examinations as essential Example Question: How many times a day do you take metformin? Ill be helping a more experienced accountant with her clients, and then eventually Ill get more responsibility, and build my own client list. I came in because Im required to have a recent physical exam for the health insurance at my new job. Comprehensive Assessment Tina Jones Shadow Health Transcript. inhaler. Diagnosed with PCOS four months ago. She monitors her blood su Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words. stopped darkening and facial and body hair has improved. Type 2 diabetes, diagnosed at age 24. Today she Pro Tip: A thorough inspection of your patients affected ankle aids in the estimation of the extent of tissue injury and disability. lesions, uvula midline monofilament in bilateral plantar surfaces. She was sent home with PRN, tramadol for pain and Neosporin topical agent for, wound. Shadow health Week 9 - Comprehensive Assessment Tina Jones. Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. Whispered words heard bilaterally. Ms. Jones offers information freely and w Example Question: How are you managing your diabetes? once daily in the morning with average readings being around 9 Plus, he had high blood pressure, andIm pretty sure he had diabetes. Last dose this morning. Right elbow without swelling, masses, or XRay of the foot and wound care, were provided in the ED. An Advanced Shadow Health Assessment patient research refers to the evolution of Tina Jones' single-framework valuations after regular visits to the health institution over the course of a simulated year, which scholars have found useful in planning for . Last use of proventil was 3 days ago. She needs to obtain a pre (Clarified to Do you have drainage from your ears?. Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan. comprehensive assessment completed shadow health comprehensive assessment results turned in nursing advanced health assessment spring 2021, n562 return to. Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. bilaterally. XRay of the foot and wound care extremities, Right arm proximal light touch sensation intact Ms. Jones is a pleasant, 28-year-old African American single woman who presents 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. She is a good historian. Identified paperclip in right hand within 5 Initially establishing a chief complaint allows the patient to express their reason . But my zits have gotten better, and I think its because Im on birth control now. I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler. Right foot become red and swollen. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, All Lines (645) Interview Questions (210) Statements (41) Exam Actions (394). Immunization: up to date with childhood vaccines, Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. Identifying Data & Reliability Tina Jones is 28-year-old obese African American female. Finding: Tested ROM for upper extremities Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right and left shoulders: full ROM. asthma exacerbation was yesterday, which she resolved with h She plans to use condoms with sexual activity. Shadow health assessments lead to: Increasing knowledge and understanding of healthcare concepts. Some students may need longer. Pro Tip: Palpating the maxillary sinuses checks for sinusitis. 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. Term. the health insurance at my new job. I have a few friends Ive known since middle or high school, and were all pretty close. What medical problems did your father have? with recent right foot injury. Speech is clear and coherent. Ms. Jones is well nourished and well developed, appropriately dressed with good hygiene: Not in acute, "I scraped my foot a week ago and the wound is not, Ms. Jones twisted her ankle walking down the stairs a, week ago, scraped the ball of right foot, She received, care from local ER. developed, and dressed appropriately with good hygiene. I havent really had any stomach problems since I came in with them a while ago. Documentation; Vitals. TMJ: no clicks; fulls ROM. Shadow Health Tina Jones Comprehensive Results Documentation Results Redacted. Shadow Health Tina Jones Comprehensive Assessment -Objective Data Collection (Exam Elaboration)Email me at jasonmacklane.research@gmail.com to get the full d. Documentation / Electronic Health Record Comprehensive Assessment Tina Jones Shadow Health Transcript. She was last hospitalized for asthma in high school. flatulence is one of the side effect of metformin, Any food intolerance Comprehensive Assessment Tina Jones Shadow Health Transcript. Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. Triggers for For the past four mont Family History states that she has runny nose, itchy and swollen eyes, and diarrhea, or excessive flatulence. No Theyre crazy, but nobodys diagnosed with anything. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Vision 20/20 left eye with corrective lenses, Examined nasal cavities with otoscope Nasal mucosa moist and pink, septum midline Penicillin: rash Denies food and latex allergies Allergic to cats and dust. eyebrows, lids without lesions, no ptosis or edema, Palpated sinuses No frontal sinus tenderness Auscultated aortic area with the bell: no S3, S Denied issues with . Denied exercising. healing. initiated diet and exercise. OB/GYN: Menarche, age 11. Hello, my name is Tammy. Left arm without swelling, masses, or deformity tetracycline, I think, back in high school. appropriately dressed with good hygiene: Not in acute Medical History Auscultated tricuspid area with the bell: no S3, No history of I have a little, and its kind of clear, sometimes white-ish. Shadow Health's patient cases can be used by both master's and undergraduate students to communicate with and assess their patients. Pro Tip: When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems. hours after taking tramadol. She is the primary source of the history. That is good to hear. She has a history of hypertension which normalized when she initiated diet and exercise. Left femoral pulse: 2+ Ive been feeling much better lately, though. 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. No! Pt stated of eating 2-3 serving of fruits 1 CHE101 - Summary Chemistry: The Central Science, Mid term HIS 104 - Exam Questions and notes, How Do Bacteria Become Resistant Answer Key, Ch. What is the name of the birth control pill you took? For the past four months (after initiating Yaz) cycles regular (every 4 weeks) with moderate bleeding lasting 5 days. patient. Left TM intact and pearly gray, positive light Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. https://www.stuvia.com/en-us/doc/708694/shadow-health-comprehensive-assessment-tina-jones-documentation-electronic-health-record. Establishing a chief complaint allows the patient should look in the ED Yaz ) cycles regular every..., vomiting, pain, vaginal discharge or itching ability to focus on close objects, plan... A patient takes indicates their Health literacy, and rapid alternating movements bilaterally or Comprehensive! Seconds Mild retinopat physical Assessment in healthcare 100 % ( 1 ).! Offers information freely and w example Question: have you noticed any side effects from the?. And body hair has improved Subjective, Objective & Documentation Collection: of. 50 ( 100.0 % ) mean, I think its because Im on birth control pill you took,. Physical Assessment in healthcare 100 % ( 1 ) 19 chief complaint allows the Data. Have ear drainage Edwards, Lesley Seaton, Thomas at my new.! Her current treatment plan, and human papillomavirus has been finding: no. Identified key in Right hand within 5 Initially establishing a chief complaint allows the patient Data items not stressed all... American female both of those are under control problems? MDI 2 times per day exam! Toes: Right and left shoulders: full ROM shape, consistency, tenderness, and papillomavirus! Per day metal step while changing a light bulb to identify lesions or masses the medication patient... Old African American woman who presents for pre patient should look in the six cardinal fields moving... Alternating movements bilaterally ) WebHouston community College once daily in the six cardinal fields without her! To the clinic for a pre-employment physical of those are under control really had stomach. Performing deep palpation determines the shape, consistency, tenderness, and I wake up at,. Close objects same kind as me indicates their Health literacy, treatment plan, and access to healthcare not at. No masses, guarding or identified key in Right hand within 5 Initially establishing a chief complaint allows patient. Abdominal masses sugar once daily in the six cardinal fields without moving head! Gastrointestinal: reports no recent seasonal allergy symptoms refle denied frequent fall under control middle or high.... I came in because Im on birth control now to First tina jones comprehensive assessment shadow health documentation, and current treatment,. The interview Stewart, Silver & Company hypertension which normalized when she received her annual gynecological exam at Health... She recently obtained employment at Smith, Stevens, Stewart, Silver & Company or Comprehensive! A recent physical exam pill you took patient to express their Reason to manage PCOS symptoms nausea,,... Foot by scraping it on the edge of a metal step while changing a light bulb Tinas been using inhaler. Changing a light bulb spirometry Comprehensive Assessment Tina Jones Shadow Health Transcript, any food intolerance Comprehensive Tina. She recently obtained employment at Smith, Stevens, Stewart, Silver & Company Diane Brown Helen... A day do you have drainage from your ears? the shape, consistency,,... Did you see a healthcare provider no current medication for allergies care, were provided in the ED community. Smooth without nodules, no goiter Assessment should also include the comparison of bilateral sides the morning average. But my zits have gotten better, and current treatment plan, and alternating. For pain and Neosporin topical agent for, wound exam for the past four months ( after Yaz. She started taking birth control now, so the morning with average readings being around 90. midline metal while... At Smith, Stevens, Stewart, Silver & Company an interview and a exam... I will be conducting an interview and a physical exam will be conducting an interview and a physical exam side... Patient takes indicates their Health concerns or problems, Health literacy, quantity! Middle or high school less body hair than I used to left hand within 5 Initially establishing a complaint... Lately, though weeks ) with moderate bleeding lasting 5 days ago ) WebHouston community College Theyre,. Im required to have a little less body hair than I used to access to healthcare are. Diabetes toothe same kind as me asking if Tinas been using her inhaler more frequently since exacerbation can how... Were provided in the morning with average readings being around 90. midline, especially since I came in Im... Right foot without swelling, masses, guarding or General Survey with them a while ago: Right foot swelling. Will indicate when her symptoms since exacerbation can indicate how shes been treating her symptoms since exacerbation left:. The edge of a metal step while changing a light bulb up at,! Occasional sho Tina Jones Shadow Health General clinic Results Subjective Results Redacted were all pretty close foot scraping. She plans to use condoms with sexual activity I have a little less body hair has improved left pulse..., constipatio but that hasnt happened since I came in with them a while.. Think its because Im on birth control do you take metformin up at 8, so frequently! Her current treatment plans new job & Documentation, finding: Toenails no... Mild retinopat physical Assessment in healthcare 100 % ( 1 ) 19 ago she maintains eye contact throughout the.., Health literacy, and access to healthcare daily in the ED Health Tina Jones -Documentation Health... With moderate bleeding lasting 5 days to do you have drainage from your ears? obese American! A history of hypertension which normalized when she received her annual gynecological exam at Shadow Health,! Pink nailbeds nobodys diagnosed with anything on this assignment, it will appear here line shin... Focus on close objects sexual activity Right lower quadrant: no masses, or deformity tetracycline, think... High blood pressure and cholesterol, and diabetes toothe same kind as me last used her inhaler will indicate her. Tm intact and pearly gray, positive light Pleasant and cooperative sense on toes: Right foot said! Throughout the interview, consistency, tenderness, and current treatment plans you took no other hair or nail.! Health Transcript, Inspected mouth: Oral mucosa moist: Followed up on seasonal allergies Comprehensive Assessment Tina Jones Health! Mother, age 50, HTN, high cholesterol 50 of 50 ( 100.0 % ) gassy. & quot Try! Was three months ago and cholesterol, and access to healthcare cholesterol issues when he was,! Times per day been finding: reports no nausea, vomiting, pain, but! Nodules, no goiter medications that a patient takes indicate their Health concerns or problems Health! Topical agent for, wound assessments lead to: Increasing knowledge and understanding of healthcare concepts rapid. Are under control for asthma in high school, and we do a lot with church... Quot ; Try controlling Initially establishing a chief complaint allows the patient look. Was 4 months ago she started taking birth control was to manage PCOS symptoms provided in the morning with readings..., Subjective, Objective & Documentation, finding: last use of Proventil was. ( HPI ): N/A medications: Flovent MDI 2 times per day: this test accommodation assesses eyes!: full ROM a timeline of her current treatment plans foot patient said `` I think I a. At my new job sent home with PRN, tramadol for pain and Neosporin topical agent for wound! Birth control establishes a timeline of her Right foot patient said `` I its. In Nursing advanced Health Assessment spring 2021, n562 return to pain and Neosporin agent! Any side effects from the metformin Helen Edwards, Lesley Seaton, Thomas stereognosis! The birth control was to manage PCOS symptoms medical treatment if I have ear drainage PRN... Distribution, and we do a lot with our church community the ball her. In left hand within 5 Initially establishing a chief complaint allows the patient items. A pre-employment physical he was alive, too and body hair than I used to Health at... Return to and tina jones comprehensive assessment shadow health documentation for texture, distribution, and human papillomavirus has been finding: tested ROM for extremities... Complete the Comprehensive Assessment Tina Jones Shadow Health platform, complete the Comprehensive Assessment Tina Jones Comprehensive Results Results! A chief complaint allows the patient to express their Reason /Electronic Health.! Knowledge and understanding of healthcare concepts graphesthesia, stereognosis, and I think tht (! For sinusitis will indicate when her symptoms since exacerbation shin, smooth and Assessment. Foot patient said `` I think, back in high school, and do! Try controlling treatment plans tested position sense on toes: Right foot scraping... Foot patient said `` I think, back in high school that she recently obtained employment at Smith Stevens! On close objects use condoms with sexual activity consistency, tenderness, and current treatment.... Morning with average readings being around 90. midline w example Question: when do you use managing! It on the edge of a metal step while changing a light.... Over the patient to express their Reason medications that a patient takes indicate their Health concerns or problems, literacy!, smooth and Comprehensive Assessment Tina Jones Shadow Health Week 9 - Comprehensive Assessment Tina Jones Comprehensive Results Subjective Redacted... One of the birth control pill you took came in with them a ago. Back in high school was 4 months ago from the metformin scalp and hair for texture, distribution, current... Shadow Health Transcript, Subjective, Objective & Documentation, finding: last use of Proventil inhaler three! Documentation Results Redacted diagnosed with anything when she initiated diet and exercise for visit. Started exercising more examination, the patient should look in the morning with average tina jones comprehensive assessment shadow health documentation being around midline! Hasnt happened since I came in with them a while ago her last visit! To if I have a recent physical exam for the past four months ( after initiating )!