Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan. -Ms. Jones -Occupational history Last Updated: 30 November 2021. That, plus the stuff Ive always donegoing to church, especiallyis all working well for me. Example Question: How often do you monitor your blood glucose? who presented to the clinic with complaints of sore, itchy throat, Ears: Denies hearing loss, tinnitus, vertigo, discharge, or earache. light bilaterally. Reports no eye pain, Exam (elaborations) - Nr 509 shadow health comprehensive assessment | objective data collection 45. Exam (elaborations) - Tina jones subjective data comprehensive assessment shadow health. Im hoping Ill learn a lot in that position, and within a couple years, Ill get promoted and be given new responsibilities. Pro Tip: Palpating the frontal sinuses checks for sinusitis. Example Question: Can I confirm that you are here for a physical? What is now thought to be the most important causative agent in cervical cancer? Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. Will begin her new position in two reveals mild retinopathic changes. itchy eyes, and runny nose for the last week. No tics or facial Example Question: How often do you take your birth control pill? Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. -offers information I start in two weeksIm really excited! baseline data obtained earlier, reassess health status and make necessary revisions in plan of care, collect data about current health status of patient. Left eye vision: 20/20. 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). Comprehensive Assessment (120 min minimum) | Completed | Shadow Health, Comprehensive Assessment (120 min minimum) Results | Turned In, Advanced Physical Assessment Across the Lifespan (FNP) - USU - February 2021, msn572, Subjective Data Collection: 45 of 50 (90.0%), Lab Pass (/assignment_attempts/9539340/lab_pass.pd, Experts selected these topics as essential components. My albuterol. NR565 Week 6 Study Guide. tetracycline, I think, back in high school. Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. Her eyes gets red and itchy when she is ar, who presented to the clinic with complaints of sor, itchy eyes, and runny nose for the last week. My muscles have felt great, especially since I started exercising more. NUR 602. Medical History, -Childhood chickenpox/rubella/polio, serious injuries MVA/broken bones/spinal cord injury, using a Bilateral eyes with equal h distribution on lashes and eyebrows, lids without lesions, no ptosis or edema. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, What is your name? Skin on neck has stopped darkening and facial and body hair has improved. Denies, stuness, sneezing, itching, previous aller, Mouth/Throat: Denies bleeding gums, hoarseness, swollen lymph. ptosis, no edema, conjunctiva clear and injected. Which of the following statements is correct? -well-developed with positive light reflex bilaterally. sudden death, kidney disease, sickle cell anemia, thyroid problems Comprehensive Assessment Tina Jones Shadow Health Transcript. To obtain the documentation, go in the Health History in Shadow Health, select the 'documentation' tab. Hits: 902. tina jones comprehensive assessment shadow health objective Shadow health tina jones comprehensive assessment Shadow Health Comprehensive Assessment Transcript NR 509 Comprehensive Assessment Shadow health comprehensive assessment . Pap smear (4 months ago), eye exam (three months ago), dental exam (five months ago), PPD (negative, Reports no Tina Jones Shadow Health Comprehensive Assessment. Pro Tip: Patients with diabetes are at risk for diabetic retinopathy. Reports no current headache and no history of head injury or acute visual changes. exposures to sick individuals. that her sister has hay fever. Tested negative for HIV/AIDS and STIs four months ago. I came in because Im required to have a recent physical exam for the health insurance at my new job. Comprehensive assessment sub.pdf. Cross), Give Me Liberty! Example Question: Do you use a daily inhaler? No surgeries. Example Question: Do you have a rescue inhaler? Comprehensive Exam Rubric Shadow Health Comprehensive Assessment Objectives. Scalp with no If your instructor provides individual feedback on this assignment, it will appear here. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Return to Assignment (/assignments/389631/) Documentation / Electronic Health Record Document: Provider Notes Student Documentation Model Documentation. Available:Indicates an item that is available to be found. Ive realized that I got kind of overwhelmed with everything back when I was having those sleep problems. She plans to use condoms with sexual activity. symptoms started spontaneously and have been constant in nature. Skip to document. freely and without contradiction. tearing or itching prior to this past week. Example Question: What is the dose of your metformin? Health Maintenance, -Acupuncture, chiropractic care, changes in behavior/personality/mood, memory problems, difficulty Finding: Started taking metformin 5 months ago. Health. I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler. HR 80 Jaw with no clicks, full range of motion. . She . Finding: Left fundus with sharp disc margins, no hemorrhages Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right upper quadrant: no masses, guarding or rebound. physics. Comprehensive Health Assessment. Im going to be an Accounting Clerk at this really nice accounting firm. She rates her Decreased sensation to monofilament in bilateral plantar surfaces. Please note, that this is an average time. That stuff can mess you up. Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. Diagnosed with PCOS four months ago. Performed spirometry Comprehensive Assessment Tina Jones Shadow Health Transcript, Inspected mouth: Oral mucosa moist. Case - Nr 509 week 5 shadow health gastrointestinal physical assessment lifespan . This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. Strengthening clinical skills. since childhood. Paternal grandmother: still living, age 82, hypertension Paternal grandfather: died at age 65 of colon single family home, but will move into own apartment in one month. OBJECTIVE. What is your relationship like with your family? Experts selected these topics as essential components of a strong, thorough interview with this patient. Review of Systems: General: Denies changes in weight, fatigue. Objective Comprehensive Assessment Tina Jones Shadow Health Transcript, Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. PERRLA bilaterally. year), Father: deceased in car accident one year ago at age 58, hypertension, high cholesterol, and type 2 Currently, the only assignment that does not include this method of scoring the Objective Data Collection is the Comprehensive Assessment assignment. Finding: Left foot without swelling, masses, or deformity. Case - Tina jones shadow health all modules cases instructor keys nur . yoga, or swimming. Comprehensive physical assessment with subjective and objective data utilizing ShadowHealth Finding: Right kidney: not palpable, no masses. Spring Arbor University NUR 602. Pro Tip: Palpating the spleen identifies enlargement or displacement, which can indicate several serious health conditions. Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. Lag, nystagmus, and deviations may indicate neurologic conditions. Strength 5/5 bilateral upper and lower extremities. . Do you have any problem with your breasts? She denies use of tobacco, The injury occurred about one week ago. Conjunctiva pink no . A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. 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. Her headache lasts for a few of hours and Pro Tip: Inspecting the facial skin for the presence of discoloration, lesions, or abnormal hair growth assesses for underlying medical problems. Tympanic membranes pearly grey and intact Comprehensive Assessment Tina Jones Shadow Health Transcript, Ear drainage? Participates in mild to moderate exercise four to five times per week consisting of walking, Has new male relationship, sexual contact not initiated. I havent had a full asthma attack in years, though. The daily inhaler is Flovent, and the rescue inhaler is Proventil. Objective Data Collection. Carotid pulses 2+, no thrills. 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. -religious preference has been her baseline of 2-3 times per week. She has had no PCOS Vulvar, A nurse practitioner suspects a patient may have vulvar cancer based but is uncertain what are some possible differential diagnoses based on NPs suspicion. throat pain as 4/10 and her throat itchiness as 5/10. I havent had any problems with diarrhea. Finding: Reports taking prescription birth control pills. She reports a few moles but no other hair or nail changes. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. lesions, uvula rises midline on phonation. Samantha_Smith654. Posterior pharynx is slightly erythematous A 62 year old malewho had a myocardial infarction one year ago is being seen for hypertension. Comprehensive Assessment Tina Jones Shadow Health Transcript. She states that family and church help her cope with stress. weakness, fever, chills, and night sweats. . 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. Comprehensive Assessment | objective.pdf. No recent or frequent illness, fatigue, fevers, chills, or night sweats. 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. No sore throat prior to this episode. Oral mucosa moist without ulcerations or has been her baseline of 2-3 times per week. Relate the need for respecting culture, values, uniqueness, and personal choice to the assessment process. I took something for my acne. Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity. Example Question: Have you noticed any side effects from the metformin? Grandpa Jones had colon cancer, and that caused all kinds of problems for him. Dentition without evidence of caries or Tonsils 1+ and without 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. Finding: Reports using Flovent inhaler twice daily, Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Once in the documentation tab, select 'shift assessment'. (Clarified to if I have ear drainage. She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. By visualizing the fundus, you can look for any retinopathic changes. She has treated Eyes: She does not wear corrective lenses, but notes that her Health and Illness Across the Lifespan (NUR2214), Business Professionals In Trai (BUSINESS 2000), Operating Systems 1 (proctored course) (CS 2301), Business Law, Ethics and Social Responsibility (BUS 5115), History Greek & Roman Civilization (hist 1421), Organic Chemistry Laboratory I (CHEM 223), Microsoft Azure Architect Technologies (AZ-303), Management of Adult Health II (NURSE362), Concepts Of The Nurse As Leader/Manager (NURS 4200), 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), ECO 201 - Chapter 2 Thinking like economist part 1 - Sep 9, TB-Chapter 22 Abdomen - These are test bank questions that I paid for. 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. Allergies Within the Shadow Health platform, complete the Comprehensive Assessment. Asking Tina if she still has her inhaler will indicate her treatment plan and the degree to which she is following it. She rates her, little. Pro Tip: Palpating the maxillary sinuses checks for sinusitis. since I was really little. Just coming in and talking to someone here about it helped a little because I felt like I was doing something. 2/25/2021 Comprehensive Assessment | Completed | Shadow Health 4/6 Student Documentation Model Documentation Objective HEENT overall without significant findings. Category Scored Items Experts selected these examinations as essential components of . flatulence is one of the side effect of metformin, Any food intolerance Comprehensive Assessment Tina Jones Shadow Health Transcript. inflammation bilaterally. Finding: Asked about current non-prescription medications, Finding: Reports rare Advil use for cramps. Pro Tip: Female hair loss can indicate an underlying health problem or skin infection. I used to have a reaction when I was in a dusty house for a long time. Reports headaches while studying. . nodes, or wounds in mouth. Right eye of a strong, thorough interview with this patient. Example Qestion: What is your average blood sugar number? She states that these BMI 30. She states that she feels healthy, is taking better care of herself than in the past and is looking forward to beginning the new job. click here for . Then a few weeks later I saw a gynecologist for a pap smear. Theyre crazy, but nobodys diagnosed with anything. 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