tina jones comprehensive assessment shadow health documentation

Indicates an item that is available to be found. Gosia_S89. Right brachial pulse: 2+ Heart rate is regular, S1, S2, without murmurs, gallops, or rubs Type 2 DM: diagnosed at age 24. was on metformin Example Question: Do you have any current health problems? source of the history. bilaterally. 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Auscultated tricuspid area with the diaphragm: Example Question: Have you noticed any new allergies? Denied history of STI. A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. Lag, nystagmus, and deviations may indicate neurologic conditions. Pro Tip: Follow up questions about Tinas medication history and timeline will help you to understand her treatment plan and recent health history. Ive been feeling much better lately, though. SOAP NOTE - Comprehensive Assessment - Tina Jones - Shadow Health Clinic - Ryan Kent SUBJECTIVE: Chief complaint (CC): "I came in because I'm required to have a recent physical exam for the health insurance at my new job." History of present illness (HPI): Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. Shadow health Tina Jones Comprehensive Assessment.pdf -. S lesions, coarse hair from pubis to umbilicus. Example Question: Have you been having seasonal allergies? Asthma diagnosed at age 2 1/2. No, Im actually feeling really good these days. 12 Test Bank - Gould's Ch. My mom has some issues, and I think some of my grandparents did, too. 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. 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. Right arm distal light touch sensation intact Finding: Right kidney: not palpable, no masses. Popular books. 2022 Nursingbay.com. Identified paperclip in right hand within 5 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. Including changes on right. loss of 10lbs in the last month. Pro Tip: This test accommodation assesses the eyes ability to focus on close objects. Course Hero is not sponsored or endorsed by any college or university. lower extremities. Tested negative for HIV/AIDS and STIs four months ago. Father, diseased, died at age 58 in car accident, HTN, Speech is clear and coherent. But my zits have gotten better, and I think its because Im on birth control now. 2 deep. organomegaly. Company Registration Number: 61965243 Im going to be an Accounting Clerk at this really nice accounting firm. This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. Stopped taking med without medical advice extremities, Right leg proximal light touch sensation intact Comprehensive Assessment Tina Jones Shadow Health Transcript, My doctor told me when I was pretty little I think I was about two and a half? Plus, he had high blood pressure, andIm pretty sure he had diabetes. She began metformin 5 months ago and initially had some gastrointestinal side effects which have since dissipated. Today she C/O sharp, and throbbing pain at right foot. Finding: No supraclavicular lymphadenopathy, Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. hours after taking tramadol. Strength 5/5 bilateral upper and lower extremities. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. 23 terms. Im taking good care of my health these days. Pleasant and cooperative. Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity. Hair growth on stomach. HR: 78. extremities, Right ankle: 2+ Preview 2 out of 6 pages Getting your . Lower eyelids: conjunctiva pink, no lesions, I have a few friends Ive known since middle or high school, and were all pretty close. 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. Asking Tina why she saw a healthcare provider might indicate any recent health concerns or problems. without cough or wheeze. If your instructor provides individual feedback on this assignment, it will appear here. All Rights Reserved. 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. of breath, wheezing, and chest tightness. We're available through e-mail, live chat and Facebook. Reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium. Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan. She is well-nourished, we Student Documentation: Model Documentation: 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 . 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. What is the name of the birth control pill you took? Right lower quadrant: no masses, guarding or Documentation / Electronic Health Record Document: Provider Notes Student Documentation Model Documentation Identifying Data & Reliability Tina Jones is 28-year-old obese African American female. I came in because Im required to have a recent physical exam for the health insurance at my new job. 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Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. tetracycline, I think, back in high school. DM with diet. Example Question: Do you have a rescue inhaler? She maintains eye contact throughout the interview. Medical History Comprehensive Assessment Tina Jones Shadow Health Transcript. Brother overweight. Reports increased hair growth over past few months and neck 26 terms. were provided in the ED. influenza is not current, and human papillomavirus has been Liver Span: 7cm MCL on percussion Preview / Show more. Denied frequent fall. Comprehensive Assessment Tina Jones Shadow Health Transcript, Any issue with your gums? Irregular effects which have since dissipated. I had a little when I first started metformin, but I found out I could eat yogurt to help it, and it seems to have worked. Left triceps: 2+ Now that Im on the pill Im getting my period every month. https://www.stuvia.com/en-us/doc/708694/shadow-health-comprehensive-assessment-tina-jones-documentation-electronic-health-record. Example Question: Do you use any herbal products? Theyre crazy, but nobodys diagnosed with anything. three years ago. initiated diet and exercise. Pro Tip: Palpating the spleen identifies enlargement or displacement, which can indicate several serious health conditions. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Asked about current prescription medications, Finding: Reports taking diabetes medication, Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Present to the clinic, coherent. Denied temperature intolerance or Yeah. No supraclavicular lymphadenopathy. Right elbow without swelling, masses, or Undergraduate. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Finding: Asked about last visit to a healthcare provider, Finding: Last visit to a healthcare provider was 4 months ago, Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. . transfusion. Reports headaches after long periods of reading. due to feeling of "bloating and gassy." Try controlling What happens when you are around dust? Identified key in right hand within 5 seconds Asking Tina if she takes supplements will indicate her current treatment plan.Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. 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). Left shoulder without swelling, masses, or are in the home, locked in parents room. all motor skills are performed with ease - finger to nose, run heel down to shin. 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: When do you check your blood glucose? Attempting to palpate the kidney helps determine enlargement or tenderness. Asking Tina what triggers her allergies will indicate, in part, Tinas health literacy. Just Now Shadow Health Comprehensive Assessment Tina Jones -Documen - $10.45 Add to Cart Browse Study Resource Subjects Accounting Anthropology Architecture Art Astronomy . She has type 2 diabete Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. employment physical prior to initiating employment. Houston Community College. Finding: Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema. asthma are cat and dust. extremities, Right arm proximal dull pain sensation intact Last dose this morning. Mild edema at right ankle. odor from wound. OTC Tylenol PO 500-1000mg q6hr PRN (for headache), Left knee: 2+ Finding: Reports no current medication for allergies. asthma exacerbation was yesterday, which she resolved with h My albuterol. deformity 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. developed, and dressed appropriately with good hygiene. . No edema. Im going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. Stated of inability to bear weight on right foot due OTC Advil PO 600mg TID PRN (for menstrual cramps), Please I need help with interview questions/answers for shadow health for week 4 (health history Tina, Jones) Q&A Shadow health assignment What are three the differential diagnosis for Ms.Tina Jones with right foot wound (in shadow health) Prioritize the identified diagnoses to differentiate immediate from non Ms. Jones is alert and oriented, seated upright on the examinat I havent smoked pot since I was twenty or twenty-one. Denied non-healing wounds. Example Question: What is the dose of your metformin? I used my Flovent inhaler this morningI have to take it twice a day. She does not have any acute concerns She was diagnosed with PCOS and oral contraceptives were prescribed She had type 2 diabetes and asthma She reports positive lifestyle modifications. Example Question: How many times a day do you take metformin? Term. Left carotid artery: no bruit, Auscultated heart sounds Auscultated Erb's point with the bell: no S3, S That, plus the stuff Ive always donegoing to church, especiallyis all working well for me. 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. Finding: Started taking metformin 5 months ago. appropriately dressed with good hygiene: Not in acute Tes Finding: Left pupil: equal, round, reactive to light. Vitals. 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. Identifying Data & Reliability Tina Jones is 28-year-old obese African American female. 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. 11 terms. Health Maintenance Auscultated aortic area with the diaphragm: Identified coin in left hand within 5 seconds Confirming the name of Tinas birth control pill will solicit information about her health history and current treatment plan. Any medical history for your paternal grandmother? Indicates an item that you found. Wound at right ball of foot measured at 2cm by 1, By visualizing the fundus, you can look for any retinopathic changes. Left iliac artery: no bruit RRR, S1, S2, no murmur Present to the clinic N/A with recent right foot injury. Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. . Skin on nec Normal Cross), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Civilization and its Discontents (Sigmund Freud), Psychology (David G. Myers; C. Nathan DeWall), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), 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), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Give Me Liberty! midclavicular line, 5th intercostal space, no heaves or lifts. patient's case. reflex, Practiced whisper test Whispered words heard on right Ive had asthma a long time. Never pregnant. 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 We go to First Baptist, and we do a lot with our church community. She 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. Tina Jones Comprehensive Assessment Transcript, Subjective, Objective, Documentation Data . 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