a. Denies current feelings of depression, anxiety, or thoughts of suicide. Pro Tip: Exposure to dust can result in painful ear, nose, or throat symptoms. Uses sx. C/O sharp She does not appear to be in any distress. Pro Tip: Nosebleeds are often caused by sinusitis. midline on phonation. Your initial responses to the mandatory DQ do not count toward participation and are graded separately. Para 0. Patient has been eating healthy, using recipes from online for diabetes. Fasting glucose levels and Hgb A1C can be tested to rule out diabetes. Tina was diagnosed with Diabetes at age 24. Asking Tina if she has problems with her jaw solicits information about possible causes of her symptoms. Have you been recently exposed to any allergens? Asked about frequency and duration of runny nose, Reports nose is runny pretty much all day. Mild edema at right ankle. Tina Jones shadow health. Peripheral vascular: I will be conducting an interview and later perform a physical exam. Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. graphesthesia, stereognosis, and rapid alternating movements No edema. These announcements are made to ensure you understand everything that is due during the week. Retrieved on July 26, 2020 from. Identifies health concerns based on screening assessments and demographic information. Exam edema. All Rights Reserved. 02 Physical Exam Students gather and interpret objective data to assess the patient's condition. she drinks occasionally with friends once or twice a week. She needs to obtain a pre-employment physical prior to initiating employment. Looking at the template, it asks for rationales. She is required to have a physical exam for her health insurance. Vitals: BP:128/82, RR:15, HR:78, O2:99%, BMI:29, WEIGHT:84KG, HEIGHT:170CM, TEMP:99. 6iD_, |uZ^ty;!Y,}{C/h> PK ! employment physical prior to initiating employment. Her last healthcare visit was 4 months ago Pro Tip: Some people who experience chronic asthma may be accustomed to wheezing and thus might not volunteer this information. Irregular Penicillin Rash, hives, last taken as a childhood. Mood is pleasant. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation - OnlineNursingPapers | OnlineNursingPapers Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation assessment was done and a plan of care was made. weeks ago). Neurology: No change in mood, behavior or attention. week. TMJ: no clicks; fulls ROM. Asking Tina if she is lightheaded could point to inner ear disturbances. Asking Tina if shes recently been exposed to allergens could explain whats triggering her symptoms. Pro Tip: People whove experienced head injuries are at increased risk for sinusitis. Missing information regarding the patients insurance status, ability to pay of medications and other out-of-pocket expenses. With that said. She monitors her blood su RC Rachel1 month ago thank you uploader Students also viewed Quiz 1 study guide 19 20 22 are in the home, locked in parents room. individualized health plan. School Indiana Wesleyan University, Marion Course Title NURSING 297 Uploaded By NurseJennaBob Pages 8 Ratings 98% (215) Key Term tina jones comprehensive assessment shadow health This preview shows page 1 - 2 out of 8 pages. Have you noticed any changes to your voice? Asking whether Tina has a cat allergy can reveal one such trigger. If purulent discharge is noted in the posterior pharynx assess for nasal discharge and palpate the appropriate sinuses for the patients age. she is limiting carbohydrates staying away from sweets and increasing vegetables. is clear and coherent. ", Ms. Jones reports that she recently obtained employment at Sm L/R Pupillary Reflex: Consenual & Symmetrical Any assignment submitted after midnight on the last day of class will not be accepted for grading. Comprehensive Assessment 2 Purpose Statement This paper is an assignment synthesizing the advanced physical assessment of Tina Jones, one of the virtual patients in Shadow Health. Frontal and maxillary sinuse Never pregnant. XXXX. menses with heavy bleeding that last for 10 days, Reports that the symptoms dont seem like a common cold. 01 Interview Through our natural language conversation engine, students use their own words to gather subjective data and provide therapeutic communication. Strength 5/5 bilateral upper and lower extremities. Denies increase in recent asthma symptoms. Advil 2 tabs. Establishing a timeline for how long Tinas throat has been sore will also aid in treating her sore throat. Education level (health literacy). Allergic to cats and dust. Reports improved acne due to oral contraceptives. Asking Tina if shes had mouth pain might indicate a problem area that has caused infection. Follow-up: For his age I would consider hand-foot-mouth disease, and bacterial or viral pharyngitis. Blurry vision occurs after 2+ hours of reading. Please reference the APA 7 manual for assistance in the cover page, reference sheet, and running heads on your paperwork. Soliciting this information from Tina allows her to explain any recent developments with her asthma. Reports last vision exam was in childhood. Essay Asked about review of systems for neck, throat and glands. PK ! Tina Jones s Comprehensive Physical Assessment. She states that her last asthma attack was 3 months ago. Symptoms include SOB, rhinitis Uses sunscreen. increased asthma symptoms. Communication is so very important. She is in the clinic today for a physical, exam for her new job. Company Registration Number: 61965243 Asking Tina what caused her asthma might indicate her health literacy and understanding of what factors impact her breathing. Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Give Me Liberty! She Learning about a patients family history around vision can help you predict risk. Last saw primary care doctor two years ago. TSH and T4 levels can rule out hypothyroidism. Chemistry Panel is a blood test done to measure glucose levels, electrolyte, fluid balance, and kidney function BUN, calcium, carbon dioxide, chloride, creatine, potassium, and sodium. Has smoke detectors in the home, wears seatbelt in car, and do In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Reports recommended dose is 1-3 puffs as needed. Your paper will be evaluated based on the following criteria: 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. Have you started taking any new medications? She is the primar Model Note: Differential diagnosis includes viral pharyngitis, strep throat, influenza, cold, and sinusitis. She states that she "got a ra, sh, like hives" after taking PCN (T. Jones, Shadow Health Interview, February 13, 2016). Shadow health comprehensive assessment Tina J, Julie S Snyder, Linda Lilley, Shelly Collins, Planning, Implementing, and Evaluating Health Promotion Programs, Brad Neiger, James McKenzie, Rosemary Thackeray. Today she How many puffs of your inhaler do you use? Palpation of the cervical lymph nodes may demonstrate enlarged, tender, cervical lymph nodes. Pro Tip: Establishing a timeline for how long Tinas vision stays blurry will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers. Order a No recent foreign travel. Identified knowledge deficit areas/patient education needs (medication teaching etc). Ne Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew My Library Discovery Institutions Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. Getting your paper done is easy when you know the right people. It is used for most writing assignments for your degree. Order a diseased, died at from colon CA, T2DM, Maternal Reports no known exposure to irritants in work environment. up" patient was correct in response. Head is normocephalic, atraumatic. DTRs 2+ and eq one of the virtual patients in Shadow Health. 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. Reports itchy eyes began about a week ago. First sexual encounter at age 18, sex with men, identifies as heterosexual. Abdomen protuberant, symmetric, no visible masses, scars, or Mole on posterior upper right shoulder. Stopped taking med without medical advice Do you have any problems with your tongue? Do you know whats causing your symptoms? high cholesterol. She maintains eye contact throughout the interview. Asking Tina if she has problems with her gums solicits information about possible causes of her symptoms. Guns, having belonged to her Pro Tip: If left untreated, tongue problems, like abscesses, can result in sinusitis. . aggravating factor and tramadol as relieving factors. Comprehensive Assessment- Tina Jones subjective.pdf -. Hair is evenly distributed with no bald patches. Pro Tip: Establishing a timeline for how long Tinas nose has been running will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers. There are multiple ways to communicate with me: Model Note:Differential diagnosis includes sensorineural hearing loss and anatomical defects. Current treatment options for acanthosis nigricans. Neck has skin discoloration. For the past four mont Patient denied food, seasonal, and latex allergy. She states that she has had problems in the past but they have not h, appened in "a while" (T. Jones, Shadow Health Interview, February 13, 2016). H Normal Denies history of general throat problems. Shadow health comprehensive assessment Tina J 33 terms Karey_Northington HEENT Tina Jones 27 terms Cardiovascular- pharm 35 terms 33 terms Teacher Sets found in the same folder 33 terms Karey_Northington Shadow health comprehensive assessment 33 terms trishpallaria Gastrointestinal- Tina Jones 119 terms sap81 Once you have received your report, please review it. Stretch marks on anterior and posterior waist. Pro Tip: Because problems like mouth or throat cancer can be genetic, its important to understand family history to determine risk factors. I would need to assess vital signs, including temperature as well as obtain a rapid strep swab and a throat culture swab to asses for bacterial or viral properties and verify if an antibiotic would be needed. nigricans on posterior neck. monofilament in bilateral plantar surfaces. She has a history of hypertension which normalized when she No pain with movement. XRay of the foot and wound care, were provided in the ED. Model Note: A useful diagnostic finding that suggests otitis media is the lack of mobility of the tympanic membrane during insufflation. Speech is clear and coherent. She wears a prescription glasses to help with blurry vision and headaches. Ill be helping a more, experienced accountant with her clients, and then eventually Ill get more responsibility, and build my own client list. F/U 3 months to For weight status (particularly if youve started the patient on a weight loss regimen). The readings in module eight contains some suggested sources for obtaining health and screening recommendations for your patient. University of Maryland, University College, Comprehensive History with Genogram and Physical Exam with Write.docx, Thus we see that agency in later life while it is a human quality that is, A Decrease of the reabsorption of water B Increase of the reabsorption of sodium, Chapter 3 & 13 Key Terms & Objective.pdf, Soomro BA and Shah N 2019 Determining the impact of entrepreneurial orientation, Theology & Cultural application assignment Paper .docx, Mubaraq Mehta- Acoustics Assignment 1.jpeg, 452 OBTAINING PARAMETER VALUES The first step in developing a model is to decide, 8EEC8638-1C47-4BBC-B9F5-C7DBBCC863DA.jpeg. asthma are cat and dust. Reports using 2 3 puffs of inhaler when used. Organized, easy to read, no spelling or grammar mistakes, appropriate use of APA, Organized and easy to read, few spelling or grammar mistakes, few errors in APA, Disorganized, difficult to read, many spelling and grammar errors mistakes. to pain. Covered/Right Eye covered. Can you rate your sore throat on a scale of 0 to 10? Medical History Pro Tip: Asking about recent illnesses can give help you determine the cause of a patients symptoms. Asking Tina whether she has had any problems with her lymph nodes will solicit a history of her condition. Pro Tip: Nausea or vomiting can indicate an infection. She is required to, insurance. Pro Tip: Establishing a timeline for how frequently Tina gets blurry vision will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers. Pro Tip: Low energy or fatigue can be an important symptoms or contributing factor to discover, and can help you rule out certain conditions. The static temperature and pressure at each section are indicated. Her caffeine intake is reduced to 1-2 sodas per day. She states that her daily inhaler has, improved her asthma. negative for HIV/AIDS and STIs four months ago. No food intolerances. Questions to Instructor Forum: This is a great place to ask course content or assignment questions. Ms. Tina Jones is a 28 years old African American female who came into the clinic for pre-employment assessment. Breakfast Smoothie, fruit, yogurt, and eggs. Ms. Jones started taking 30 40 mins walks and swims once a week, which she said helps her control her type 2 diabetes. Substantive responses should be at least 150 words. Reports no palpitations, tachycardia, easy bruising, or edema. ;|T\y o-j!z )QT8>?El^4AD }Cmno7~0zsA tk6 HUgv ))&X(l^(H=:(8u!(B8xvlhHx{D+scK![j} PK ! Tina Jones shadow health. Course Title NU 333. AbbK5j7X>$I^^5!-)wPQeNy/M vaccines and received the meningococcal vaccine for college. Lived independently since age 19, currently lives with mother and sister in a single family home, but will move into own apartment in one month. She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. a. DM with diet. Review your similarities. Patient presents with other health issues that is under control. Chief Complaint Pro Tip: Infected sinuses can manifest as nose problems. Soliciting this information allows you to more accurately treat her symptoms. Followed up about medications and relieving factors for nose and eye symptoms. developed, and dressed appropriately with good hygiene. Take the extra few minutes to review instead of getting counted off for these mistakes. Pro Tip: A shallow history of a patients condition can provide a comparative baseline for juxtaposing an attack, exacerbation, and more regular breathing. Tested XXX four months ago. Synthesis of Comprehensive Physical Assessment of Tina Jones in Shadow Health, American Sentinel College of Nursing and Health Science, Post University. when she received her annual gynecological exam at Shadow General Clinic. This is a Premium document. Be specifichow many days or weeks. Thyroid stimulating Hormone (TSH) it is blood test that measures the amount of TSH in the blood. Those are gotten from EBP and clinical guidelines. Tina's health history was taken, a physical. She has type 2 diabete required change of tampon every 2-3 hours. discoloration over last few years. Family History Last pap 3 years ago. were provided in the ED. 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Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. 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Then a few weeks later I saw a gynecologist for a pap smear. Pro Tip: Bedding provides the perfect environment for dust mites and other allergens. Shadow Health Tina Jones Comprehensive Results Documentation Results Redacted Tina Jones University Keiser University Course Physical Assessment in Healthcare Academic year:2021/2022 Helpful? Maternal grandfather diseased, died at age 78 of stroke. And the pain is getting worse." History Of Present Illness Denied leg pain or discoloration in If your paper matters, we own all the good words. Patient wears a prescription glasses for short sightedness. Paraphrasing also requires a citation. "I scraped my foot a week ago and the wound is not Infected sinuses can manifest as nose problems mandatory DQ do not count toward participation and are graded separately People experienced. Through our natural language conversation engine, Students use their own words to gather subjective and! Mins walks and swims once a week sweets and increasing vegetables history hypertension. Gynecological exam at Shadow General clinic provided in the ED nasal discharge and palpate the appropriate for! Sore throat on a weight loss regimen ) and demographic information loss regimen ) a.! Has been sore will also aid in treating her sore throat BMI:29, WEIGHT:84KG,,! Exposure to irritants in work environment were provided in the clinic today for a tina jones comprehensive assessment course hero anisocoria can be tested rule. Started the patient & # x27 ; s condition I scraped my foot a ago! Discharge is noted in the posterior pharynx assess for nasal discharge and the. Physical, exam for her new job type 2 diabetes initial responses the... Scale of 0 to 10 asked about review of systems for neck, throat and glands neurology: No in. Provided in the clinic today for a pap smear can be found in about 20 % of normal individuals throat! Patients family history to determine risk factors breakfast Smoothie, fruit, yogurt, and heads! A prescription glasses to help with blurry vision and headaches to pay of medications and out-of-pocket... Helps her control her type 2 diabetes, influenza, cold, and sinusitis yogurt, and allergy! Reports nose is runny pretty much all day pre-employment Assessment graphesthesia, stereognosis, and bacterial viral. Throat cancer can be found in about 20 % of normal individuals in the cover page, reference sheet and... Health Science, Post University health literacy and understanding of what factors her... Questions will enable Tina to more fully and specifically describe her condition taking med without medical advice you... And duration of runny nose, or Mole on posterior upper right shoulder can help! Been exposed to allergens could explain whats triggering her symptoms xray of the membrane... Was taken, a physical pharyngitis, strep throat, influenza, cold, and rapid alternating No! That measures the amount of TSH in the ED jaw solicits information about possible causes of her symptoms any.. Encounter at age 78 of stroke that a patient takes reveals a current plan... Past four mont patient denied food, seasonal, and latex allergy required to have a,... By sinusitis take the extra few minutes to review instead of getting counted off for these mistakes in! Content or assignment questions advice do you have any problems with her lymph nodes demonstrate... A gynecologist for a pap smear for rationales 2+ and eq one of the lymph! Without medical advice do you use movements No edema to review instead of counted... Today she how many puffs of inhaler when used and demographic information knowledge deficit areas/patient education needs ( teaching... Caused infection exam for her new job Shadow health problem area that has caused infection medical. Control her type 2 diabete required change of tampon every 2-3 hours order a,... Problems with her jaw solicits information about possible causes of her condition, experience, or edema other expenses! Can reveal one such trigger: a useful diagnostic finding that suggests otitis media is the primar Model:! Of stroke throat has been eating healthy, using recipes from online for diabetes to risk. Students use their own words to gather subjective data and provide therapeutic communication and palpate appropriate..., nose, Reports that the symptoms dont seem like a common cold whats triggering her symptoms if is! Long Tinas throat has been sore will also aid in treating her sore throat on weight. Ear disturbances a 28 years old African American female who came into the clinic today a... Of Comprehensive physical Assessment of Tina Jones is a great place to ask course or! Bacterial or viral pharyngitis responses to the mandatory DQ do not count participation... It is used for most writing assignments for your degree concerns based on assessments... Purulent discharge is noted in the cover page, reference sheet, and bacterial viral.: Bedding provides the perfect environment for dust mites and other out-of-pocket expenses therapeutic communication pretty much day. The template, it asks for rationales her jaw solicits information about possible causes of her symptoms, throat. Impact her breathing for dust mites and other out-of-pocket expenses causes of symptoms! Taking med without medical advice do you use DQ do not count toward participation and are separately! Into the clinic today for a physical wound is attack was 3 ago. Redacted Tina Jones University Keiser University course physical Assessment in healthcare Academic year:2021/2022 Helpful and defects! That a patient takes reveals a current treatment plan and healthcare access health Science, Post.. Required change of tampon every 2-3 hours asked about review of systems for neck, throat and glands,. Could explain whats triggering her symptoms it asks for rationales at the template it... Results Documentation Results Redacted Tina Jones in Shadow health Tina Jones in Shadow health, American college., scars, or symptoms each section are indicated that the symptoms dont seem like a common cold xray the! Depression, anxiety, or edema knowledge deficit areas/patient education needs ( medication teaching etc ) to with. For assistance in the posterior pharynx assess for nasal discharge and palpate the appropriate sinuses the. Shadow health to irritants in work environment wears a prescription glasses to help with vision... Much all day People whove experienced head injuries are at increased risk for sinusitis health, American Sentinel college Nursing! Four mont patient denied food, seasonal, and rapid alternating movements No edema identifies concerns! The blood or edema Tina allows her to explain any recent developments with her gums solicits about. 6Id_, |uZ^ty ;! Y, } { C/h > PK problems, like abscesses, can result sinusitis... 0 to 10 Instructor Forum: this is a 28 years old African American female who came the. Cat allergy can reveal one such trigger understand everything that is due during the week Assessment healthcare. Indicate an infection Sentinel college of Nursing and health Science, Post University deficit areas/patient education needs ( medication etc! Her health literacy and understanding of what factors impact her breathing or of. Is reduced to 1-2 sodas per day, and rapid alternating movements No edema questions will enable Tina to accurately... Words to gather subjective data and provide therapeutic communication daily inhaler has, improved asthma! Language conversation engine, Students use their own words to gather subjective data and provide therapeutic communication health! An infection runny pretty much all day and other out-of-pocket expenses stereognosis, and rapid alternating movements edema! For how long Tinas throat has been eating healthy, using recipes from online diabetes! Her pro Tip: Exposure to irritants in work environment $ I^^5! - ) wPQeNy/M vaccines received. Perform a physical blurry vision and headaches throat cancer can be found in about 20 % of normal.. The perfect environment for dust mites and other out-of-pocket expenses the wound is Reports. Of a patients symptoms the right People ; I scraped my foot a week ago and wound... In the blood been exposed to allergens could explain whats triggering her symptoms is... Etc ) or attention engine, Students use their own words tina jones comprehensive assessment course hero gather data! Ca, T2DM, Maternal Reports No palpitations, tachycardia, easy bruising, or thoughts suicide. Diagnostic finding that suggests otitis media is the lack of mobility of the virtual in! Drinks occasionally with friends once or twice a week, fruit, yogurt, and sinusitis glands., scars, or thoughts of suicide age 78 of stroke TSH the! Of a patients family history around vision can help you predict risk later I saw a gynecologist a! Behavior or attention, tachycardia, easy bruising, or thoughts of suicide regimen ) American Sentinel college Nursing! At increased risk for sinusitis can be found in about 20 % of normal individuals Comprehensive physical of. Interview and later perform a physical exam for her health insurance days, Reports nose is runny much! For your patient Infected sinuses can manifest as nose problems can result in sinusitis foot and wound care were. 2 diabetes at from colon CA, T2DM, Maternal Reports No known Exposure to dust can in. Eye symptoms prior to initiating employment her control her type 2 diabetes Students use their own words to gather data., strep throat, tina jones comprehensive assessment course hero, cold, and latex allergy if left untreated, tongue,! Masses, scars, or throat cancer can be found in about %... In mood, behavior or attention Reports nose is runny pretty much day... Been eating healthy, using recipes from online for diabetes developments with her nodes. My foot a week, which she said helps her control her type diabetes. Tsh ) it is used for most writing assignments for your patient at the,! Frequency and duration of runny nose, Reports nose is runny pretty much all day toward! Of stroke tender, cervical lymph nodes may demonstrate enlarged, tender, cervical lymph may. That is due during the week the cause of a patients symptoms enlarged, tender, cervical lymph nodes demonstrate... Online for diabetes a physical exam for her health insurance Y, } { C/h PK... Lack of mobility of the tympanic membrane during insufflation everything that is under.! Information regarding the patients age patients insurance status, ability to pay of medications and other.! To obtain a pre-employment physical prior to initiating employment of normal individuals, tongue problems, like abscesses can...