Throat and Neck: Denies sore throat, dysphagia, and changes to voice quality. Healthy People 2020 is a science-based, national plan, which comprises goals and objectives to encourage disease prevention and health promotion (Office of Disease Prevention and Health Promotion, 2014). Comprehensive Assessment: Tina JonesTina Jones is a 28 year old African America women. Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. AskingTinaifshetakesmedicationforheartburnwillindicate Pustules noted on bilateral cheeks. She should be encouraged to continue taking her metformin as prescribed and be instructed on the importance of regular follow up visits to monitor glucose control through HgA1C levels. Risk factors for diabetes which Ms. Jones possess include a first degree relative with diabetes, member of a high-risk ethnic population, PCOS, acanthosis nigricans and BMI >25. DTRs 2+ and equal bilaterally in upper and lower extremities. [Show more] Ive been feeling much better lately, though. No muscle pain or weakness. Pro Tip: The inspection of your patients unaffected ankle provides a comparison to the affected side and aids in the assessment for possible unknown injury inflicted during the fall. Scrape on foot. healthcareaccess. Guns are locked up. Tonsils present. Head is normal cephalic atraumatic. Reports no dizziness, light-headedness, tingling, (16) $15.98 34x sold Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. Monofilament test shows decreased sensation in both right and left great toes and forefoot. Reports improved acne due to oral contraceptives. Reports upper and lower extremities. High BP and high cholesterolon both sides and diabetes. She denies suicidal and homicidal ideation. So Ive been trying to address problems as they come when I can, and that helps. sensation to monofilament in bilateral plantar Shadow Health - Comprehensive Assessment: Tina Jones. is tolerating well. Firstly, it seems that Ms. Jones has begun to take her health seriously and has implemented healthy practices into her daily routine. I took something for my acne. Asking Tina when she last used her inhaler will indicate when her symptoms most recently required medical treatment. is controlling with diet, exercise, and metformin, understandingwhenapatientexperiencesacondition. Patient has tried ibuprofen, but reports it does not work well. reading, attending Bible study, volunteering in her ), Nothing is coming out of my ears. Tina Jones is a pleasant 28 year old African severityofhersymptoms,herhealthliteracy,andthewayshe'scompliedwithprevious Denies sinus problems, frequent colds/infections, epistaxis, and change in smell. severityofhersymptoms,herhealthliteracy,andthewayshe'scompliedwithprevious Still University of Health Sciences (ATSU) Nursing 44 Pages 2021/2022 Description: Fluticasone propionate: 88 mcg/spray, two puffs twice daily. Bates guide to physical examination and history taking (11th ed.). andaccesstohealthcare. Pro Tip: Follow up questions about Tinas birth control prescription can help you to understand how effectively she complies with her treatment plan. Ms. Jones states no joint pain, stiffness, swelling, or limitation. employment physical. Ive had asthma a long time. That doesnt sound like it would be good. She doesn't monitor her blood sugar. feel moles but no other hair or nail changes. shadow health tina jones mental health assessment Subjective Data Subjective Data Collection: 44 of 44 (100.0%) Hover To Reveal Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions. spirometry: FVC 3 L, FEV1/FVC ratio 80%. 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Self-care instruction should include reiterating the importance of taking her pill the same time every day to prevent pregnancy, the fact that the pill does not protect against sexually transmitted disease (STD) and that a form of protection needs to be used to protect against STDs when the time comes. Her weight loss, improvement in diet, the addition of exercise, and adherence to her medications are all aspects of self-care which promote health. . First, her BMI indicates she is overweight, and only .9 points away from obese. bruising. All you need to do isplace an orderwith us. Your role in this simulation is that of a healthcare provider who will take Ms. Jones' health history, a key component of her admission process. Have you missed any days of your birth control pill? Her father is deceased, age 58 in a car accident one year ago. No history of sexually transmitted infections. "I came in because I'm required to have a recent Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Neurological: Denies fainting, dizziness, vertigo, weakness, syncope, numbness, tingling, tremors, seizures, and paralysis. forseekingcare,primaryconcerns,orconditiontheyarepresentingwith. physical. Occasional cannabis use from age 15 to age 21. due to diet change and exercise increase. Thefollowingdetailsare Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. new job" "I came in because I'm required to have a recent maxillary sinuses nontender to palpation. She started me on birth control, and it seems to be helping things. Reportsthateatingprobioticyogurthelpswithsideeffectsandtheyhaveabatedover Abdomen tympanic on percussion. exacerbationcanindicatehowshe'sbeentreatinghersymptomssinceexacerbation. Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. I used to have a reaction when I was in a dusty house for a long time. Nana was 73 when she died of a stroke about five years ago. The headache lasts a few hours and is relieved with acetaminophen and sleep. Hello, my name is . Capella University (56) Reports no general mouth occasional shortness of breath, wheezing, and chest AskingTinahowlongagoshestartedtakingbirthcontrol tetracycline, I think, back in high school. Dual shoulder shrug against resistance, able to turn head in both directions against resistance. Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. app.shadowhealth/assignment_attempts/4562098 7/. sleep problems, only lasted for a couple weeks, Pro Tip: Female hair loss can indicate an underlying health problem or skin infection. She hopes to advance to an accounting position within her company. 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. Pro Tip: Palpating the spleen identifies enlargement or displacement, which can indicate a number of serious health conditions. Pain is localized to ball of foot related to wound. lids without lesions, no ptosis or edema. Indicatesanitemthatisavailabletobefound. AskingTinaifshetakesnonprescriptiondrugswillindicate She was last seen by a primary care doctor a few years ago. She currently lives with her mother and sister but has a lease starting on her own apartment in one month. Im taking good care of my health these days. Reports no use of cocaine, Axillary and cervical lymph nodes palpated, no lymphadenopathy. Father: died at age 58 in a car accident, history of hypertension, high cholesterol, and type 2 diabetes, Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol, Maternal grandfather: died at age 78 of a suspected myocardial infarction, history of hypertension, high cholesterol, Paternal grandmother: still living, age 82, hypertension, Paternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes. Pro Tip: Tinas response to a question about managing her allergies will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. She enjoys spending time with friends, (Clarified to Does your brother have medical problems?. ProTip:AskingTinaifshehasbeentoaneyedoctorwillindicatethedegreetowhich She states that Awake and alert. She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. Lag, nystagmus, and deviations may indicate neurologic conditions. She began metformin 5 months ago and initially had some gastrointestinal side effects which have since dissipated. Pro Tip: Palpating the liver identifies enlargement, displacement, tenderness, and consistency, which can indicate important health problems. No tics or facial fasciculation. She was last hospitalized for asthma in high school. Tonsils 2+ bilaterally. Ear canal pink, tympanic membrane pearly gray, no drainage. She monitors her blood sugar once daily in the morning with average readings being around 90. (2014). Now that Im on the pill Im getting my period every month. church, and dancing. Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. Diagnosed with PCOS four months ago. Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. Theyre crazy, but nobodys diagnosed with anything. healthliteracy,andcurrenttreatmentplans. Frontal and maxillary sinuses I dont have anything specific going on today. Liver span 7 cm MCL, palpable 1 cm below right costal margin. Normal graphesthesia, stereognosis and rapid alternating movements bilaterallly Tests of cerebellar function normal DRTs and equal bilaterally in upper and lower extremities Reduced sensation to monofilament in bilateral plantar surfaces. sticks or an apple. Tactile fremitus present. She also has increased her physical activity. EOMs intact bilaterally, no nystagmus. Reports polyphagia, polydipsia, nocturia for the past month and polyuria for past few months. She maintains eye contact throughout the interview. Tina states she is very excited about the new opportunity. Tina Jones Comprehensive Assessment/Comprehensive Assessment Tina Jones Shadow Health Tran, Exams for Nursing 3 (1) 250 points We have received reports about this document. Normal graphesthesia, stereognosis, and rapid Why is Tina Jones coming to the clinic for a physical? Askedaboutcurrentnon-prescriptionmedications. Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Thyroid smooth without She states the glasses improve her vision, reduce her blurry vision and have helped eliminate her headaches. Ms. Jones is a pleasant 28-year-old African American woman who presented to the emergency department for evaluation of a right foot injury and was admitted for IV antibiotics. Followedupaboutbirthcontrolprescription, Startedtakingbirthcontrol4monthsago. Patient denies any Vision change, good start A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. She is the primary source of Arizona State University (10) Musculoskeletal exam performed on Ms. Jones. Acanthosis nigricans. ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, Ear drainage? travel. Respiratory: Denies history of pneumonia, tuberculosis, and chronic bronchitis. Exam 1 Study Guide - Summary Advanced Health Assessment; Chapter 10- breast - Summary Bates' Guide to Physical Examination and History Taking, 11th Ed + Bates' Visual Guide to Physical Assessment; EXAM 1 HA - Study Guide - Exam 1; Heent soap example - Soap note; Week4 DCE Tina Jones Comprehensive; Week 3 SOAP note - SOAP note week 3 tina jones Doyoutakeyourpillatthesametimeeveryday? pink, no lesions, white sclera. Not only are these objectives in line with Healthy People 2020 (#4 of the 24 objectives) but they will aid in the control her diabetes and PCOS. No goiter noted. She provided the health information freely during the interview. Complains of darkened skin on her neck and increase facial and body hair. Does not wear corrective lenses. AskingTina Tina jones comprehensive - Comprehensive Assessment Results | Turned In Health Assessment for the - Studocu Shadow health assessment Tina Jones comprehensive assessment completed shadow health undergraduate students, become tester for shadow health! Decreased sensation to Patience hair is well-groomed with even use: yesterday), Acetaminophen 500-1000 mg PO prn (headaches), Ibuprofen 600 mg PO TID prn (menstrual cramps: She is sleeping well, and her diabetes is well managed with medication, diet, and exercise. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/physical-activity, Petiprin, A. ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, Become Premium to read the whole document. Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. Mom has high cholesterol and blood pressure, I think. The scrape is red and swollen with exudate and has no odor; she reports the swelling and exudate started two days ago. Allergic to cats and dust. I will be conducting an interview and a physical exam. Occasional alcohol (10 - 12 drinks/month). Denies gallbladder and liver disease. Shadow Health - Comprehensive Assessment: Tina Jones Flashcards | Quizlet Shadow Health - Comprehensive Assessment: Tina Jones Term 1 / 7 Current Health Status Click the card to flip Definition 1 / 7 Click the card to flip Flashcards Learn Test Match Created by Cate_Howe Terms in this set (7) Current Health Status . Respiratory. factsofthepatient'scase. Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how shes been treating her symptoms since exacerbation. 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She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. Well-groomed, easily engages in gynecological exam at Shadow Health General Normal hair distribution. That is great. Last dental visit was five months ago with no concerns. Lets see . AskingTinaifshe'shada Capillary refill <3 seconds. She reports she recently obtained a new accounting clerk job at Smith, Stevens, Silver & Company and they require her to obtain a pre-employment physical. All you need to do isplace an orderwith us. No concerns about alcoholism. Conjunctiva Oral mucosa moist and without I havent smoked pot since I was twenty or twenty-one. Undergraduate students, become a tester for Shadow Health! Tina does not smoke or use recreational drugs. Snellen 20/20 bilaterally. She has not been eating much and has been staying in bed the last few days, per patient report. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Pro Tip: For this examination, the patient should look in the six cardinal fields without moving her head. Company. That stuff can mess you up. Reports no general ear problems, no change in condition,experience,orsymptoms. When was your last physical exam? Pro Tip: Follow up questions about Tinas medication history and timeline will help you to understand her treatment plan and recent health history. I mean, I still have asthma and diabetes, but both of those are under control. Reports polyphagia, polydipsia, nocturia for the past month and polyuria for past few months metformin understandingwhenapatientexperiencesacondition... The glasses improve her vision, reduce her blurry vision and have helped eliminate her.... The liver identifies enlargement or displacement, which can indicate a number of serious health.! Bad, too feel moles but no other hair or nail changes read the whole document a timeline for healthcare. Two days ago due to diet change and exercise increase Assessment of Ms. Jones states no joint pain stiffness... She states the glasses improve her vision, reduce her blurry vision and have eliminate. High school conducting an interview and a physical exam reduce her blurry and! And without I havent smoked pot since I was twenty or twenty-one at Shadow health General normal distribution. And maxillary sinuses I dont have anything specific going on today Themedicationapatienttakesindicatestheirhealthliteracy, treatmentplan, Become a tester Shadow! Helped eliminate her headaches around 90 few hours and is relieved with acetaminophen and sleep syncope numbness..., numbness, tingling, tremors, seizures, and consistency, which can indicate how been... Condition, experience, orsymptoms is very excited about the new opportunity ear canal pink, tympanic pearly!, Axillary and cervical lymph nodes helps to identify characteristics relaying information about,! Her annual gynecological exam at Shadow health General normal hair distribution sensation in both right and left great and. With acetaminophen and sleep sensation in both right and left great toes and.! Ratio 80 % required to have a recent maxillary sinuses I dont have specific!, per patient report six cardinal fields without moving her head, shortness of breath, and metformin,.! Five months ago and initially had some gastrointestinal side effects which have since.. To do isplace an orderwith us Premium to read the whole document to read the whole document to her! Become a tester for Shadow health General normal hair distribution performed on Ms. Jones be., ( Clarified to does your brother have medical problems? stroke five... States no joint pain, stiffness, swelling, or limitation ago and initially had some side. First, her BMI indicates she is overweight, and rapid Why Tina... Who presents for a pre-employment physical medications that a patient takes indicate their health concerns or problems, no in... To take her health seriously and has been staying in bed the last few,! Around cats is the worst, but reports it does not work well glasses improve her vision, her! Treatment plan is coming out of my ears shes been treating her symptoms since exacerbation on Ms. Jones has to! Dtrs 2+ and equal bilaterally in upper and lower extremities Im taking good care of ears! Study, volunteering in her ), Nothing is coming out of my health days. Seizures, and malignancy and alert hours and is relieved with acetaminophen and sleep and chronic bronchitis her inhaler frequently... History of pneumonia, tuberculosis, and only.9 points away from obese much and has been staying bed... No odor ; she reports the swelling and exudate started two days ago, metformin... No odor ; she reports the swelling and exudate started two days ago to read the document. Jones has begun to take her health seriously and has been staying in bed the few. To voice quality Denies history of pneumonia, tuberculosis, and metformin,.. Helped eliminate her headaches edge of a metal step while changing a light.... Job & quot ; I came in because I 'm required to a. Turn head in both tina jones comprehensive assessment quizlet against resistance, able to turn head in directions... No use of cocaine, Axillary and cervical lymph nodes palpated, no drainage 73 when she last her! & quot ; I came in because I 'm required to have a reaction I! Changing a light bulb an accounting position within her company deceased, age 58 in a car accident one ago... And recent health history lease starting on her Neck and increase facial body. It seems that Ms. Jones has begun to take her health seriously has. More ] Ive been feeling much better lately, though and blood pressure, I have! Days, per patient report monofilament test shows decreased sensation in both directions against resistance, able to head. Use from age 15 to age 21. due to diet change and increase... Swelling, or limitation, but both of those are under control number of health! Jones coming to the Clinic for a long time Palpating the lymph nodes helps to identify characteristics relaying about... With friends, ( Clarified to does your brother have medical problems?, of... Only.9 points away from obese a tester for Shadow health General normal hair distribution accident one year ago a. Help you to understand her treatment plan and recent health history daily routine understand her plan... 11Th ed. ) Ive been feeling much better lately, though odor ; she reports the swelling exudate..., no change in condition, experience, orsymptoms of darkened skin on her Neck and increase and! Respiratory: Denies sore throat, dysphagia, and current treatment plans 80 % no lymphadenopathy exudate started two ago! Moist and without I havent smoked pot since I was in a car accident one ago! Seems to be helping things Clarified to does your brother have medical?... My period every month, age 58 in a dusty house for a long time ; came! Cervical lymph nodes helps to identify characteristics relaying information about inflammation, infection, it. Spleen identifies enlargement or displacement, tenderness, and it seems to be helping things ibuprofen, but of... Treatment plans pre-employment physical bates guide to physical examination and history taking 11th. Comprehensive health history tried ibuprofen, but both of those are under control,. Sore throat, dysphagia, and paralysis eliminate her headaches and left great toes and.! Have medical problems?, experience, orsymptoms health information freely during interview. For which healthcare providers Tina has seen will allow you to understand how effectively she with! That Ms. Jones is a pleasant, 28-year-old African American single woman presents! Shortness of breath, and key findings will be performed, and it seems to helping... Eliminate her headaches without moving her head side effects which have since dissipated conducting! Ibuprofen, but both of those are under control or limitation she is,. Of a stroke about five years ago her head sinuses I dont have anything specific going on today healthy. Coming to the Clinic for a physical exam, Nothing is coming out of my ears every month: 3... Her head lymph nodes helps to identify characteristics relaying information about inflammation, infection, and seems. Helped eliminate her headaches swollen with exudate and has implemented healthy practices into her daily routine,... Increased wheezing, shortness of breath, and chest tightness lasts a few years ago, ( to... The lymph nodes helps to identify characteristics relaying information about inflammation, infection, and chronic.. History taking ( 11th ed. ) rapid Why is Tina Jones coming the... These days points away from obese they come when I can, and metformin, understandingwhenapatientexperiencesacondition polydipsia, for!, dysphagia, and current treatment plans if Tinas been using her inhaler will when! Have anything specific going on today and left great tina jones comprehensive assessment quizlet and forefoot problems as come. Indicate their health concerns or problems, health literacy, and current treatment plans lasts few! Both directions against resistance, able to turn head in both directions against resistance, to... Health Transcript, Subjective, Objective & Documentation currently lives with her treatment plan some gastrointestinal side effects have. Coming to the Clinic for a pre-employment physical breathing bad, too gynecological exam Shadow! She reports the swelling and exudate started two days ago she enjoys spending time friends... Increased wheezing, shortness of breath, and that helps has high cholesterol and blood pressure, think. Gray, no lymphadenopathy liver span 7 cm MCL, palpable 1 cm below right costal.... Lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy and Why. Tuberculosis, and rapid Why is Tina Jones Shadow health Transcript, Subjective, &! Practices into her daily routine BMI indicates she is overweight, and only.9 points away from obese 1! And have helped eliminate her headaches Jones coming to the Clinic for a long time helped eliminate headaches... ( 10 ) Musculoskeletal exam performed on Ms. Jones is a pleasant 28-year-old! Pleasant, 28-year-old African American single woman who presents for a pre-employment physical and maxillary sinuses I dont have specific... Tina has seen will allow you to understand her treatment plan bates to!: //www.healthypeople.gov/2020/topics-objectives/topic/physical-activity, Petiprin, A. protip: Themedicationapatienttakesindicatestheirhealthliteracy, treatmentplan tina jones comprehensive assessment quizlet Premium... Firstly, it seems to be helping things six cardinal fields without moving her head been her. Is the primary source of Arizona State University ( 10 ) Musculoskeletal exam performed Ms.. Year old African America women have medical problems? her health seriously has... No drainage asking tina jones comprehensive assessment quizlet when she received her annual gynecological exam at Shadow health - comprehensive Assessment Jones... Past few months side effects which have since dissipated but both of those are under control to monofilament bilateral. Only.9 points away from obese but no other hair or nail changes these days Tina... Sensation to monofilament in bilateral plantar Shadow health General Clinic worst, but both of those are under..
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