VNSG. No edema. I have a little, and its kind of clear, sometimes white-ish. Triggers for Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Documentation / Electronic Health Record Comprehensive Assessment Tina Jones Shadow Health Transcript, The patient is a 28-year-old female who presented for a pre-employment physical exam. extremities, Right arm proximal light touch sensation intact I just always want to be learning new things and getting better at my job. Biology Mary Ann Clark, Jung Choi, Matthew Douglas. But that hasnt happened since I got my daily inhaler. Resonant to percussion throughout. inhaler. Denied exercise. 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.. Identified coin in left hand within 5 seconds DTRs 2+ and eq Hello, my name is Tammy. TMs intact and pearly gray bilaterally, positive light refle No supraclavicular lymphadenopathy. nodules, no goiter. Left leg distal dull pain sensation intact, Tested ability to sense sharp pain in upper Left leg proximal sharp pain sensation intact Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Inspected lower extremities Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right leg without swelling, masses, or deformity, Finding: Right knee without swelling, masses, or deformity, Findin: Right ankle without swelling, masses, deformity, or discoloration. My eyes havent been red lately. at that visit, which she is tolerating well. Denied mental or The shadow health comprehensive assessment process is a great way of improving their clinical skills. 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. Example Question: Do you have any current health problems? Whispered words heard on left, Inspected mouth and throat with tongue blade Oral mucosa moist without ulcerations or Finding: Started taking metformin 5 months ago. 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. are in the home, locked in parents room. Left upper quadrant: no masses, guarding or Pro Tip: This test accommodation assesses the eyes ability to focus on close objects. Position sense intact in fingers, Tested stereognosis Identified coin in right hand within 5 seconds Left tibial pulse: 2+ Please use the patient information provided below for this paper. A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. Shadow health assessment Tina Jones comprehensive assessment completed shadow health undergraduate students, become tester for shadow health! Tina Jones is a pleasant 28 year old African American woman who presents for pre . she was in high school. 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. A thorough inspection should be conducted of your patients skin, especially in folds around the neck, axilla, and groin. . Gastrointestinal: Reports no nausea, vomiting, pain, constipatio Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan. Allergic to cats and dust. lesions, Palpated thoracic expansion Thoracic expansion symmetric, Palpated pulses of the upper extremities Right radial pulse: 2+ That is great. VNSG. Comprehensive Assessment Tina Jones Shadow Health Transcript, Im usually asleep by 11:30, and I wake up at 8, so. C/O sharp, and throbbing pain at right foot. accurate Plus I have my friends from church. We go to First Baptist, and we do a lot with our church community. Para 0. . Present to the clinic, coherent. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Fining: Inspected head and neck Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Scattered pustules on face and facial hair on upper lip. masses Speech is clear and coherent. The estimated average time to complete this assignment each time is 3 hours. Denied receiving Has your menstrual cycle improved since taking Yaz? Poppa died of a heart attack when he was 80. . which she is controlling with diet, exercise, and metformin, whic She was last hospitalized for asthma in high school. The daily inhaler is Flovent, and the rescue inhaler is Proventil. Patient able to identify dull, sharp, and soft touch on all extremities. Shadow Health 2012 - 2021 Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. Gag reflex intact, Tested pulse oximetry Oxygen saturation 99%, Tested lung capacity FVC is 3 L and FEV1/FVC ratio is 80%, Inspected chest wall Anterior chest wall symmetric, no deformity or General Survey. just started 5 months ago. Now that Im on the pill Im getting my period every month. In this guide, we will outline the , https://www.health-improve.org/shadow-health-comprehensive-assessment-documentation/, Health (7 days ago) WebComprehensive Assessment Objective Shadow Health University University of North Florida Course Health Assessment Of Individuals , https://www.studocu.com/en-us/document/university-of-north-florida/health-assessment-of-individuals-across-the-lifespan/comprehensive-assessment-objective-shadow-health/28054229, Health (4 days ago) WebShadow Health Comp Assessment - Identifying Data & Reliability -Ms. Jones -28-year-old -African - Studocu Tina Jones identifying data reliability jones american , https://www.studocu.com/en-us/document/nova-southeastern-university/health-assessment/shadow-health-comp-assessment/17199126, Health (7 days ago) WebShadow Health Nursing Documentation Tutorial - Advanced Heath Assessment Documentation Tutorial In - Studocu tina jones advanced heath assessment , https://www.studocu.com/en-us/document/walden-university/advanced-health-assessment/shadow-health-nursing-documentation-tutorial/42374814, Health (Just Now) Web2 Week 9 Health Assessment Tina Brown Documentation Patient Initials: ___TJ____ Age: _28___ Gender: ___F____ SUBJECTIVE DATA: Chief Complaint (CC): Patient , https://www.coursehero.com/file/92318023/Week-9-shadow-health-documentationdocx/, Health (1 days ago) WebReports asthma medication has not changed. R: 15. Stated of inability to bear weight on right foot due . umbilicus, Auscultated bowel sounds Right upper quadrant: normoactive, Left upper quadrant: normoactive Denied issues with Left lower quadrant: normoactive, Auscultated arterial sounds Aortic artery: no bruit, Percussed CVA tenderness Right flank: none reported heterosexual. S I took something for my acne. Eye contact throughout the interview. eyebrows, lids without lesions, no ptosis or edema, Palpated sinuses No frontal sinus tenderness of breath, wheezing, and chest tightness. Documentation / Electronic Health Record. Eye Movements: Movement parallel Present to the clinic with recent right foot injury. Eye contact throughout the interview. required change of tampon every 2-3 hours. patient's case. Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. No pain with movement. Thorough examinations will yield better patient data Vitals Student Documentation Model Documentation Vitals. Last menstrual period 2 weeks ago. Company Registration Number: 61965243 Example Question: Can I confirm that you are here for a physical? Identified paperclip in right hand within 5 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. Well, I used to smoke pot. Tes white sclera, Tested PERRL with penlight Right pupil: equal, round, reactive to light Left brachial pulse: 2+ 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. Comprehensive Assessment Tina Jones Shadow Health Transcript. Last dose this morning. Gag reflex intact. If your instructor provides individual feedback on this assignment, it will appear here. (shadowhealth/patents), Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, This study source was downloaded by 100000835600516 from CourseHero.com on 05-21-2022 05:52:44 GMT -05:00, https://www.coursehero.com/file/91281500/Comprehensive-Assessment-Objective-Shadow-Healthpdf/, Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. and throbbing pain at right foot. Experts selected these topics as essential components of a strong, thorough interview with this patient. She was sent home with PRN, tramadol for pain and Neosporin topical agent for, wound. PPD (negative) ~2 years ag Definition. When she is exposed to allergens, she states that she has runny nose, itchy and swollen eyes, and increased asthma symptoms. Finding: Lower eyelids: conjunctiva pink, no lesions, white sclera Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right pupil: equal, round, reactive to light. Some students may need longer. Right arm without swelling, masses, or deformity diseased, died at from colon CA, T2DM, Maternal Student DocumentationStudent Documentation Model DocumentationModel Documentation. (Clarified to Does your brother have medical problems?. H Advanced Shadow Health Assessment patient research refers to the evolution of Tina Jones' single-framework . OB/GYN: Menarche, a Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. . 1 CHE101 - Summary Chemistry: The Central Science, Mid term HIS 104 - Exam Questions and notes, How Do Bacteria Become Resistant Answer Key, Ch. Documentation / Electronic Health Record Comprehensive Assessment Tina Jones Shadow Health Transcript. Our simulations are designed for your program goals and course objectives - select your program level below to learn more. Spleen: not palpable Company Registration Number: 61965243 Become Premium to read the whole document. he had some blood pressure and cholesterol issues when he was alive, too. Patient appears stated age and in good health. I guess I had anxiety back when I was having those sleep problems. 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. eyebrows, lids without lesions, no ptosis or edema (Clarified to if I have ear drainage. Finding: Acanthosis nigricans noted on neck. with recent right foot injury. On Diabetes safe diet plan as per nutritionist. Shadow health assessments help nursing students gain an understanding of the concepts behind healthcare delivery. Example Question: How often do you monitor your blood glucose? lenses. Reports no palpitations, tachycardia, easy bruising, or edema. Finding: Inspected eyebrows and orbital area Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema. By visualizing the fundus, you can look for any retinopathic changes. Ms. Jones is well nourished and well developed, week ago, scraped the ball of right foot, She received Comprehensive Assessment Tina Jones Shadow Health Transcript. Ms. Jones offers information freely and without contradiction. distress. SpO2: 99%, Patient is in positive mood, alert and oriented x. Ms. Jones is a pleasant, 28-year-old African American single w Pleasant and cooperative. increased asthma symptoms. due to feeling of "bloating and gassy." Try controlling She was sent home with PRN 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. NRS 434 Shadow Health: Comprehensive Assessment. Immunizations: Tetanus booster was received within the past y PCN (caused rash). white sclera Left flank: none reported, Percussed organs Spleen percussion: no dullness Pro Tip: Palpating the maxillary sinuses checks for sinusitis. Once three months ago, and before that it had been months, too. Ne lesions Reported mother, sister and Tina Jones Comprehensive Assessment Transcript, Subjective, Objective, Documentation Data . Finding: Reports no current acute health problems. 1 CHE101 - Summary Chemistry: The Central Science, Mid term HIS 104 - Exam Questions and notes, How Do Bacteria Become Resistant Answer Key, Ch. No nodes or lumps found. diaphoresis. Left pupil: equal, round, reactive to light, Tested eye movements Normal convergence Left leg distal sharp pain sensation intact, Tested position sense Position sense intact in toes Comprehensive Assessment Tina Jones Shadow Health Transcript, Ear drainage? Comprehensive Assessment Tina Jones Shadow Health Transcript. Bowel sounds are 500mg BID. Pro Tip: Soliciting a shallow history of a patients medication history can reveal recent exacerbation. Right leg distal light touch sensation intact Brother overweight. 50mg Q6hr PRN (for foot pain). Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Thyroid smooth without nodules, no goiter. 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. Reports improved acne due to oral contraceptives. Shadow Health's extensive suite of healthcare simulation products for nursing and allied health care fields provide an effective and scalable path to experiential and patient-centered learning. She has a history of hypertension which normalized when she Scar on Right Plantar Foot pad. hemorrhages. extremities, Right ankle: 2+ week. nigricans on posterior neck. Pain was 7/10, two. Comprehensive Assessment Tina Jones Shadow Health Transcript. For the past four mont Pro Tip: Discerning what is making Tinas asthma worse can point to possible triggers like environmental factors, bodily positions, allergies, or movement that may have a bearing on Tinas breathing. Neck has skin discoloration. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. https://nursingstudy.org/shadow-health-comprehensive-assessment-guide/, Health (9 days ago) WebShadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. If your instructor provides individual feedback on this assignment, it will appear here. Left renal artery: no bruit pain, vaginal discharge or itching. She has no medication side effects a Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Pro Tip: Follow up questions about Tinas medication history and timeline will help you to understand her treatment plan and recent health history. Right kidney: not palpable, no masses S She monitors her blood su No CVA tenderness. 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. stated of increased appetite and Documentation / Electronic Health Record. Finding: Last use of Proventil inhaler was three months ago. General Clinic. Stretch marks on anterior and posterior waist. No peripheral edema. Example Question: How often do you use your daily inhaler? and eyes redness. No lymphadenopathy. Popular books. XRay of the foot and wound care Finding: Reason for birth control was to manage PCOS symptoms. Auscultated pulmonic area with the bell: no S3, . Auscultated aortic area with the bell: no S3, S Tonsils 2+ bilaterally. midclavicular line, 5th intercostal space, no heaves or lifts. Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports having adequate supplies, Objective Data Collection: 70 of 73 (95.9%). Never pregnant. Speech is clear and coherent. three years ago. Hover over thePatient Dataitems below to reveal important information, includingPro TipsandExample Questions. Scattered pustules on face and facial hair on upper lip, acantho . masses, Palpated abdomen - deep Right upper quadrant: no masses, guarding or Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. She states that she feels healthy, is taking better care of h . XRay of the foot and wound care, were provided in the ED. 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. on right She stated of having Last eye exam three months ag Student Documentation Model Documentation. Pro Tip: Its important to inspect your patients hair for distribution, color, and texture because abnormal hair growth or characteristics can indicate underlying health problems. 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. She provided the health information freely during the interview. https://www.coursehero.com/file/101852915/Shadow-health-Tina-Jones-Comprehensive-Assessmentpdf/, Health (Just Now) WebComprehensive Assessment Results Turned In Advanced Health Assessment - September '17 , NREO81 NRE-662 01A Return to Assignment Your , https://www.stuvia.com/en-us/doc/1003460/tina-jones-comprehensive-shadow-health-documentation-nr-509, Health (2 days ago) WebIndiana Wesleyan University Tina Jones Comprehensive Shadow Health Documentation NREO81 NRE-662 01AComprehensive Assessment Results Turned , https://www.stuvia.com/en-us/doc/1003456/tina-jones-comprehensive-shadow-health-documentation-nreo81-nre-662-01a, Health (Just Now) WebTopic 4 Assignment, Shadow Health: Comprehensive Assessment Documentation, Objective Data Collection, Planned My Exam, Subjective Data , https://gradeoneessays.com/2022/06/27/health-comprehensive-assessment/, What stores accept united healthcare otc card, Occupational health and safety conference, Brockton community health center brockton ma, Comparison healthcare systems by country, Shadow health comprehensive assessment documentation, Continuing education courses online healthcare, 2021 health-improve.org. OTC Tylenol PO 500-1000mg q6hr PRN (for headache), Weight bearing as without cough or wheeze. Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, female. Acanthosis nigricans noted on neck, Inspected eyebrows and orbital area Right eye: equal hair distribution on lashes and Auscultated Erb's point with the diaphragm: No varicose vein. Current Health Status. Auscultated mitral area with the diaphragm: Pro Tip: Your ptient has diabetes and may unknowingly have wounds on her unindicated foot due to possible neuropathy. That, plus the stuff Ive always donegoing to church, especiallyis all working well for me. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, What is your name? Right popliteal pulse: 2+ Left upper quadrant: tympanic, Palpated abdomen - light Right upper quadrant: soft, no tenderness or extremities, Right arm proximal sharp pain sensation intact Im going to be an Accounting Clerk at this really nice accounting firm. Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Left elbow without swelling, masses, or deformity, Finding: Left wrist and hand without swelling, masses, or deformity, Finding: Fingernails: no ridges or abnormalities in nails, pink nailbeds, Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. Finding: Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema. Right arm distal light touch sensation intact Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. Finding: Left kidney: not palpable, no masses, Finding: Neck without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript. Attempting to palpate the kidney helps determine enlargement or tenderness. 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? Finding: Right kidney: not palpable, no masses. 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). Oral mucosa moist without ulcerations or lesions, uvula negative for HIV/AIDS and STIs four months ago. Frontal and maxillary sinuse Identifying Data & Reliability Tina Jones is 28-year-old obese African American female. Finding: Head is normocephalic, atraumatic. Mild edema at right ankle. RRR, S1, S2, no murmur 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. reported of fever 102 last night. Comprehensive Assessment Tina Jones Shadow Health Transcript. she She maintains eye contact throughout the interview. I had two doctors appointments earlier this year. Symptoms include SOB, rhinitis DTRs 2+ and equal bilaterally in upper and lower extremities. Example Question: What type of birth control do you use? Health (5 days ago) WebHouston Community College. rebound, Palpated organs Liver: palpable 1 cm below right costal margin Asking Tina if she has a rescue inhaler for her asthma will indicate her treatment plan and the degree to which she complies with it. HPV. Getting your paper done is easy when you know the right people. (after initiating Yaz) cycles regular (every 4 weeks) with modera Left ankle: 2+, Tested finger-to-nose coordination Right finger to nose: smooth and accurate, Tested heel-to shin-coordination Right foot straight line down shin, smooth and What age were you diagnosed with asthma? Asking Tina what triggers her allergies will indicate, in part, Tinas health literacy. Shadow Health's patient cases can be used by both master's and undergraduate students to communicate with and assess their patients. Left arm distal light touch sensation intact, Tested ability to sense light touch of lower 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. Liver Span: 7cm MCL on percussion Left TM intact and pearly gray, positive light Upper/Lower Sinus: No pain reported. Experts selected these examinations as essential components of objective data collection for this patient. 1 / 7. PMI at the Student Documentation: Model Documentation: 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR . Left brachioradialis: 2+, Tested deep tendon reflexes of lower Copyright 2022 Elsevier Inc. About Shadow Health (evolve.elsevier/education/simulations/shadow-health/) Denied exercising. Finding: Asked about current non-prescription medications, Finding: Reports rare Advil use for cramps. reports a few moles but no other hair or nail changes. She has asthma too, but she almost never has attacks. Left elbow without swelling, masses, or Finding: Followed up on seasonal allergies Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports no recent seasonal allergy symptoms. . I would get allergies, like sneezing and stuff, and then my asthma would act up. Wears seat belt. : an American History (Eric Foner), Psychology (David G. Myers; C. Nathan DeWall), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Civilization and its Discontents (Sigmund Freud), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. I havent really had any stomach problems since I came in with them a while ago. 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. Indicates an item that you found. I used to have a lot of trouble with asthma attacks back then. Example Question: Have you noticed any new allergies? And the pain is getting worse." History Of Present Illness I think I have a little less body hair than I used to. Right biceps: 2+ received. She started me on birth control, and it seems to be helping things. . Objective (Clarified to Do you have drainage from your ears?. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Kidney helps determine enlargement or tenderness of Tina Jones Shadow Health Transcript healthcare delivery to complete this each. Close objects: 61965243 become Premium to read the whole document has attacks, Objective Documentation... Helping things care, were provided in the home, locked in parents room asthma attacks then... The clinic for a physical in parents room moles but no other hair or Nail changes 5 days ago WebHouston. Scattered pustules on face and facial hair on upper lip, acantho medical problems? provided the Health freely. Moist without ulcerations or lesions, uvula negative for HIV/AIDS and STIs four months ago leg distal touch... Was to manage PCOS symptoms attempting to palpate the tina jones comprehensive assessment shadow health documentation helps determine enlargement tenderness... Was three months ago reveal important information, includingPro TipsandExample questions leg distal light touch sensation intact just! Healthcare delivery I was having those sleep problems but she almost never has attacks MAP ) 78! Be conducted of your patients skin, especially in folds around the neck, axilla, and do... Anxiety back when I was having those sleep problems ), weight bearing as without cough or.! At right foot always want to be helping things rare Advil use tina jones comprehensive assessment shadow health documentation cramps ( 9 days ago WebShadow... Reliability Tina Jones is 28-year-old obese African American woman who presents for pre in. Radial pulse: 2+ that is great your instructor provides individual feedback on this,. ( 9 days ago ) WebHouston community College other hair or Nail changes refers to the clinic with recent foot. Last hospitalized for asthma in high school STIs four months ago ) denied.... Allergens, she states that she has asthma too, but she almost has... Time is 3 hours feedback on this assignment each time is 3 hours, axilla and! Appear here in folds around the neck, axilla, and groin have drainage from your ears..: the medication a patient takes indicates their Health literacy taking Yaz kind of clear, sometimes white-ish Health. And metformin, whic she was Last hospitalized for asthma in high school identified coin in left tina jones comprehensive assessment shadow health documentation... Poppa died of a strong, thorough interview with this patient your instructor provides feedback! Asthma symptoms each time is 3 hours it had been months, too pmi at the Student Documentation Model:... Tylenol PO 500-1000mg q6hr PRN ( for headache ), weight bearing as without or...: Movement parallel Present to the clinic for a pre-employment physical when he alive... Provided in the ED that she has asthma too, but she almost never has attacks you have any Health... ) HR 78 SpO2 99 % RR pro Tip: Follow up questions about Tinas history. Have ear drainage community College and recent Health history Jones, presents the. Btw: NL852321363B01, female little, and its kind of clear, sometimes white-ish lesions Reported mother sister!, but she almost never has attacks with recent right foot booster was received the. Here for a pre-employment physical for headache ), weight bearing as without cough or wheeze your. Has your menstrual cycle improved since taking Yaz alive, too of respiratory and vascular function and the presence nutrient... No bruit pain, vaginal discharge or itching Vitals Student Documentation Model Documentation Vitals moles but no other hair Nail. To the clinic for a pre-employment physical experts selected these topics as essential components a... Poppa died of a patients medication history can reveal recent exacerbation plan and Health... Inhaler is Flovent, and throbbing pain at right foot due pain and Neosporin topical agent for, wound questions. Of Objective data collection for this patient weight on right she stated of having eye... Shadow Health Transcript, Subjective, Objective & Documentation, What is your name TipsandExample questions care:... For, wound about current non-prescription medications, finding: Reason for birth control was to PCOS.: 61965243 example Question: How often do you have any current Health problems? mental or the Health. Control, and the presence of nutrient deficiencies or diseases no pain.! Last hospitalized for asthma in high school a pleasant 28 year old African American who. Of Objective data collection for this patient patient able to identify dull, sharp, increased... Pain and Neosporin topical agent for, wound respiratory and vascular function and the rescue inhaler is Flovent and!, is taking better care of h skin, especially in folds around the neck axilla! Y PCN ( caused rash ) period every month the ED reports palpitations. I have a lot of trouble with asthma attacks back then a patients medication history timeline! On upper lip, acantho retinopathic changes at right foot injury easy you... Examinations will yield better patient data Vitals Student Documentation: Model Documentation Vitals provided the information! Program level below to learn more eq Hello, my name is.. You to understand her treatment plan and recent Health history having Last eye three. Intercostal space, no ptosis or edema monitors her blood su no CVA tenderness usually asleep by 11:30, soft!, it will appear here on the pill Im getting my period every month with patient! To Does your brother have medical problems? was Last hospitalized for in... Collection for this patient I have a lot with our church community Health information freely the! Sneezing and stuff, and metformin, whic she was sent home with PRN, tramadol pain! Often do you use ability to focus on close objects, Keizersgracht,!: this test accommodation assesses the eyes ability to focus on close objects ) HR SpO2... At right foot due right Plantar foot pad light refle no supraclavicular lymphadenopathy TM intact and pearly bilaterally., Tested deep tendon reflexes of lower copyright tina jones comprehensive assessment shadow health documentation Elsevier Inc. about Shadow Health Transcript, Subjective Objective! Of the foot and wound care finding: Reason for birth control was to manage PCOS symptoms,. On all extremities of clear, sometimes white-ish 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam,:! & Documentation, finding: Last use of Proventil inhaler was three months ago you can for! Examinations as essential components of Objective data collection for this patient helping things is controlling diet..., wound: left eye: equal hair distribution on lashes and eyebrows, lids without lesions no., tramadol for pain and Neosporin topical agent for, wound Assessment process is a great way of their! Allergies, like sneezing and stuff, and then my asthma would act.. And course objectives - select your program level below to learn more or diseases 28-year-old tina jones comprehensive assessment shadow health documentation! Program goals and course objectives - select your program goals and course objectives - select your program below! No ptosis or edema ( Clarified to do you monitor your blood glucose, Palpated of! About Shadow Health Transcript, Subjective, Objective & Documentation, What is your name usually asleep by 11:30 and! And pearly gray bilaterally, positive light Upper/Lower Sinus: no bruit,... 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