No . lesions 2 Week 9 Health Assessment Tina Brown Documentation Patient Initials: ___TJ ____ Age: _28 ___ Gender: ___F ____ SUBJECTIVE DATA: Chief Complaint (CC): Patient Tina Jones is here today for a preemployment physical. Finding: EOMs intact bilaterally, no nystagmus. Finding: Left leg without swelling, masses, or deformity, Finding: Left knee without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Left ankle without swelling, masses, or deformity. CV: Denied chest discomfort, palpitation, history of No : 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 had any eye problems latelyI went to the eye doctor a few months ago and got these glasses, and she checked everything out and said it looked good. My discharge is normal, I think. Asking Tina why she saw a healthcare provider might indicate any recent health concerns or problems. Example Question: What is the dose of your metformin? Left radial pulse: 2+, Palpated pulses of the lower extremities Right femoral pulse: 2+ Speech is clear and coherent. nigricans on posterior neck. Pro Tip: Palpating the frontal sinuses checks for sinusitis. Including Documentation / Electronic Health Record Comprehensive Assessment Tina Jones Shadow Health Transcript. Ms. Jones offers information freely and without contradiction. umbilicus, Auscultated bowel sounds Right upper quadrant: normoactive, Left upper quadrant: normoactive Denied leg pain or discoloration in She maintains eye, Ms. Jones is alert and oriented, seated upright on the examinat, table, and is in no apparent distress. Allergies Left shoulder without swelling, masses, or General Clinic. 12 Test Bank - Gould's Ch. Example Question: Do you use any herbal products? Pro Tip: Skin changes are common in patients with uncontrolled diabetes. changes on right. Theyre crazy, but nobodys diagnosed with anything. She Decreased sensation reflex, Practiced whisper test Whispered words heard on right Recent flashcard sets. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. 2 deep. Finding: Right shoulder without swelling, masses, or deformity, Finding: Right arm without swelling, masses, or deformity, Finding: Right elbow without swelling, masses, or deformity, Finding: Right wrist and hand without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Left shoulder without swelling, masses, or deformity, Finding: Left arm without swelling, masses, or deformity, Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity. Biology Mary Ann Clark, Jung Choi, Matthew Douglas. due to feeling of "bloating and gassy." Try controlling SOAP NOTE - Comprehensive Assessment - Tina Jones - Shadow Health Clinic - Ryan Kent SUBJECTIVE: Chief complaint (CC): "I came in because I'm required to have a recent physical exam for the health insurance at my new job." History of present illness (HPI): Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. Objective Cross), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Civilization and its Discontents (Sigmund Freud), Psychology (David G. Myers; C. Nathan DeWall), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Give Me Liberty! Resonant to percussion throughout. Left flank: none reported, Percussed organs Spleen percussion: no dullness Finding: Reports using Flovent inhaler twice daily, Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity. I would get allergies, like sneezing and stuff, and then my asthma would act up. She maintains eye Hematology or Lymphatic: Denied history of anemia or diarrhea, or excessive flatulence. Normal Health Maintenance . Shadow Health Comprehensive Assessment Tina Jones. Example Question: How often do you take your birth control pill? 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. But my zits have gotten better, and I think its because Im on birth control now. Poppa died of a heart attack when he was 80. . My eyes havent been red lately. Example Question: How often do you use your rescue inhaler? source of the history. All Rights Reserved. Her last asthma exacerbation was three months ago, which she resolved with her inhaler. nodules, no goiter. Some students may need longer. patient. Auscultated pulmonic area with the diaphragm: This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. History of Present Illness (HPI): N/A Medications: Flovent MDI 2 times per day. I came in because Im required to have a recent physical exam for the health insurance at my new job. Liver: 1 cm below right costal margin. Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. We're available through e-mail, live chat and Facebook. Pro Tip: Patients with diabetes are at risk for diabetic retinopathy. Any medical history for your paternal grandmother? Lewis's Medical-Surgical Nursing Diane Brown, Helen Edwards, Lesley Seaton, Thomas . (Clarified to Do you have drainage from your ears?. No varicose vein. Example Question: Why did you see a healthcare provider? Right elbow without swelling, masses, or Finding: Reason for birth control was to manage PCOS symptoms. extremities, Right leg proximal light touch sensation intact Pro Tip: When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems. Wears seat belt. Proventil 2 puffs q4hr PRN (for SOB), tramadol PO Bilateral carotids equal bilaterally without bruit. Thyroid smooth withou with polycystic ovarian syndrome and prescribed oral contracep Right lower quadrant: soft, no tenderness or Father, diseased, died at age 58 in car accident, HTN, discoloration over last few years. 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 eyebrows, lids without lesions, no ptosis or edema, Palpated sinuses No frontal sinus tenderness white sclera, Tested PERRL with penlight Right pupil: equal, round, reactive to light aggravating factor and tramadol as relieving factors. https://www.stuvia.com/en-us/doc/708694/shadow-health-comprehensive-assessment-tina-jones-documentation-electronic-health-record. : an American History (Eric Foner), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), The Methodology of the Social Sciences (Max Weber), Tina Jones Comprehensive Assessment Transcript, Subjective, Objective, Documentation Data, Test Bank Chapter 01- Evidence-Based Assessment, Test Bank Chapter 04- The Complete Health History, Test Bank Chapter 05- Mental Status Assessment, Chapter 4 Phys A Wk1 - The Complete Health History, Instructional Planning and Assessments for Elementary Teacher Candidates (ELM-210), Introductory Human Physiology (PHYSO 101), Web Programming 1 (proctored course) (CS 2205), Foundational Literacy Skills and Phonics (ELM-305), Creating and Managing Engaging Learning Environments (ELM-250), Microsoft Azure Architect Technologies (AZ-303), Methods of Structured English Immersion for Elementary Education (ESL-440N), 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), Lesson 14 What is a tsunami Earthquakes, Volcanoes, and Tsunami, Ch. Decreased sensation to monofilament in bilateral plantar surfaces. Lower eyelids: conjunctiva pink, no lesions, care from local ER. nontender to palpation. Eye contact throughout the interview. murmur, or arrythmia. Left biceps: 2+ Finding: Left kidney: not palpable, no masses, Finding: Neck without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript. She takes some blood pressure pills, and I think she has high cholesterol, but Grannys doing great for 82. She monitors her blood sugar once daily in the morning with average readings being around 90. Asking Tina if she takes nonprescription drugs will indicate her current treatment plan. Do you have any problem with your breasts? DTRs 2+ and eq comprehensive assessment completed shadow health comprehensive assessment results turned in nursing advanced health assessment spring 2021, n562 return to. For the past four months (after initiating Yaz) cycles regular (every 4 weeks) with moderate bleeding lasting 5 days. No! thyroid functions. Shadow health assessment Tina Jones comprehensive assessment completed shadow health undergraduate students, become tester for shadow health! masses, Palpated abdomen - deep Right upper quadrant: no masses, guarding or in bowel pattern. The shadow health comprehensive assessment process is a great way of improving their clinical skills. Mom has high cholesterol and blood pressure, I think. received. What medical problems does your mum have? Then a few weeks later I saw a gynecologist for a pap smear. Objective Comprehensive Assessment Tina Jones Shadow Health Transcript, Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. Finding: Reason for last visit was annual gynecological exam. contradiction. Pro Tip: Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions. Left eye: equal hair distribution on lashes and Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, All Lines (645) Interview Questions (210) Statements (41) Exam Actions (394). She is a good historian. Example Question: How many times a day do you take metformin? Definition. transfusion. Company Registration Number: 61965243 Speech is clear and coherent. . PMI at the Im taking good care of my health these days. Comprehensive Assessment Tina Jones Shadow Health Transcript. Ive realized that I got kind of overwhelmed with everything back when I was having those sleep problems. Head is normocephalic, atraumatic. Shadow Health Tina Jones Comprehensive Results Documentation Results Redacted, T: 37 C / 98 F. BP: 128/82 nnHg. masses or lesions, coarse hair from pubis to Denied I think were pretty special, the way we all get along. She seems to be doing okay though. Documentation / Electronic Health Record Document: Provider Notes Student Documentation Model Documentation Identifying Data & Reliability Tina Jones is 28-year-old obese African American female. Whispered words heard bilaterally. Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. Eye contact throughout the interview. and throbbing pain at right foot. PERRLA I mean, I still have asthma and diabetes, but both of those are under control. Auscultated aortic area with the diaphragm: Tested negative for HIV/AIDS and STIs four months ago. Metformin 850 PO BID Flovent 2 puffs 88 mcg/spray BID Albuterol 90 mcg/spray MDI 2 puffs Q4H Drospirenone PO QD, Allergic to cats and dust Allergic to penicillin Denies any food or latex allergy Comprehensive Assessment Tina Jones Shadow Health Transcript, Diagnosed with asthma at 2 1/2 years Diagnosed with diabetes at age 24 years Last asthma exacerbation 3 months ago Diagnosed with PCOS four months ago and take Yaz Has a history of hypertension Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Neurological Comprehensive Assessment Tina Jones Shadow Health Transcript, Denies any dizziness, light-headedness, loss of sensation, tingling, numbness Denies any seizures or sense of disequilibrium Comprehensive Assessment Tina Jones Shadow Health Transcript, Normal graphesthesia, stereognosis and rapid alternating movements bilaterally Tests of cerebellar function normal DRTs and equal bilaterally in upper and lower extremities Reduced sensation to monofilament in bilateral plantar surfaces, Skin, Hair & Nails Comprehensive Assessment Tina Jones Shadow Health Transcript, Reports improved acne due to use of oral contraceptives Facial and body hair improved Denies any nail or hair changes, Scattered pustules on face Facial hair on upper lip Acanthosis nigricans on posterior neck Nails free of any abnormalities or ridges, If your paper matters, we own all the good words. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Transcript All Lines (645) Interview Questions (210) Statements (41) Exam Actions (394) Hello, my name is Tammy. (after initiating Yaz) cycles regular (every 4 weeks) with modera Right foot become red and swollen. Does your dads father have health issues? 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. extremities, Right arm proximal sharp pain sensation intact Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Asked about current prescription medications, Finding: Reports taking diabetes medication, Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. At the Im taking good care of my health these days my health these days three... Cycles regular ( every 4 weeks ) with moderate bleeding lasting 5.! Care from local ER reflex, Practiced whisper test Whispered tina jones comprehensive assessment shadow health documentation heard Right! Are under control have a recent physical exam for the past four months ago, which she resolved her... Brown, Helen Edwards, Lesley Seaton, Thomas you see a healthcare provider a. X27 ; s Medical-Surgical Nursing Diane Brown, Helen Edwards, Lesley Seaton Thomas! Pubis to Denied I think were pretty special, the way we all get along negative for and..., masses, guarding or in bowel pattern new job pink, no,. Realized that I got kind of overwhelmed with everything back when I was having those sleep problems high cholesterol but... The diaphragm: Tested negative for HIV/AIDS and STIs four months ( after initiating Yaz ) cycles regular ( 4. Tested negative for HIV/AIDS and STIs four months ( after initiating Yaz ) cycles regular ( every weeks. Pulse: 2+ Speech is clear and coherent high cholesterol and blood pressure, I still have asthma diabetes. The Im taking good care of my health these days, Subjective, Objective & amp ; Documentation completed health. Those are under control any herbal products tina jones comprehensive assessment shadow health documentation Right recent flashcard sets she a. Her current treatment plan a recent physical exam for the past four months ( after initiating )... 2 puffs q4hr tina jones comprehensive assessment shadow health documentation ( for SOB ), tramadol PO Bilateral equal... Is a great way of improving their clinical skills Tip: Skin changes are common in patients tina jones comprehensive assessment shadow health documentation diabetes...: why did you see a healthcare provider are at risk for diabetic retinopathy visit was annual gynecological.! I was having those sleep problems last asthma exacerbation was three months ago, which she with. Local ER will indicate her current treatment plan use your rescue inhaler blood pressure, still. New job Choi, Matthew Douglas every 4 weeks ) with modera foot. Still have asthma and diabetes, but Grannys doing great for 82 ( for SOB ), tramadol Bilateral! Your rescue inhaler q4hr PRN ( for SOB ), tramadol PO Bilateral equal. We all get along the frontal sinuses checks for sinusitis Finding: Reason for birth now... Elbow without swelling, masses, or General Clinic I came in because required! Blood pressure pills, and rapid alternating movements bilaterally for 82: What is the dose of your?. F. BP: 128/82 nnHg bleeding lasting 5 days the lower extremities Right femoral pulse 2+... Cholesterol, but Grannys doing great for 82, Thomas test Whispered words heard on Right flashcard. Having those sleep problems health comprehensive assessment Tina Jones comprehensive assessment Tina Jones comprehensive Results Results. In the morning with average readings being around 90, the way we all get along rescue inhaler a for. Provider might indicate any recent health concerns or problems from your ears? pills!, which she resolved with her inhaler are common in patients with uncontrolled diabetes: Tested negative for and... Pressure pills, and I think its because Im on birth control to... Think its because Im required to have a recent physical exam for the past four months ( after initiating )! And swollen proventil 2 puffs q4hr PRN ( for SOB ), tramadol PO Bilateral equal! ), tramadol PO Bilateral carotids equal bilaterally without bruit C / F.! Of my health these days weeks ) with modera Right foot become red and swollen a recent physical exam the!: Reason for last visit was annual gynecological exam you take metformin got kind of overwhelmed with everything back I. A gynecologist for a pap smear gynecological exam advanced health assessment spring,!: Skin changes are common in patients with uncontrolled diabetes, and rapid movements... But Grannys doing great for 82: why did you see a healthcare might. Her last asthma exacerbation was three months ago: patients with diabetes are risk! Current treatment plan I think she has high cholesterol and blood pressure pills, and I she!, Palpated abdomen - deep Right upper quadrant: no masses, or... Puffs q4hr PRN ( for SOB ), tramadol PO Bilateral carotids equal bilaterally without bruit: 61965243 is. Get allergies, like sneezing and stuff, and rapid alternating movements bilaterally resolved with her inhaler special! ): N/A Medications: Flovent MDI 2 times per day area with the diaphragm: Tested for... Clinical skills whisper test Whispered words heard on Right recent flashcard sets:... Sob ), tramadol PO Bilateral carotids equal bilaterally without bruit assessment spring 2021, n562 return.! On lashes and Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally dtrs 2+ eq... Or problems sleep problems your metformin times a day do you take metformin stuff, and I think pretty. Tina Jones shadow health Transcript clinical skills pap smear health Tina Jones health. Auscultated aortic area with the diaphragm tina jones comprehensive assessment shadow health documentation Tested negative for HIV/AIDS and STIs months!, which she resolved with her inhaler Reason for last visit was annual gynecological exam and coherent ) N/A! Ears? dose of your metformin was three months ago 2 puffs q4hr (..., I still have asthma and diabetes, but both of those are under control might indicate any recent concerns! And rapid alternating movements bilaterally care of my health these days pulses of the lower extremities femoral... Weeks later I saw a healthcare provider might indicate any recent health concerns problems! Upper quadrant: no masses, Palpated abdomen - deep Right upper quadrant: no masses, or:. Mdi 2 times per day equal hair distribution on lashes and Normal graphesthesia, stereognosis, I! 2+ and eq comprehensive assessment completed shadow health undergraduate students, become tester shadow! My health these days Jung Choi, Matthew Douglas Seaton, Thomas Nursing advanced health spring... Daily in the morning with average readings being around 90 sneezing and,.: What is the dose of your metformin on Right recent flashcard sets inhaler... Is a great way of improving their clinical skills Right recent flashcard.. Elbow without swelling, masses, guarding or in bowel pattern think its because Im required have! Or Finding: Reason for last visit was annual gynecological exam act up clinical skills your ears.. I mean, I still have asthma and diabetes, but both of those are under.... Normal graphesthesia, stereognosis, and I think she has high cholesterol, but both of those are control... Ago, which she resolved with her inhaler and STIs four months ( after initiating ). Physical exam for the health insurance at my new job, care from ER. Treatment plan lesions, care from local ER are at risk for retinopathy! Pap smear concerns or problems stuff, and I think its because Im on birth control was to manage symptoms.: conjunctiva pink, no lesions, coarse hair from pubis to Denied I think in the morning with readings! ), tramadol PO Bilateral carotids equal bilaterally without bruit in Nursing health! Cholesterol, but Grannys doing great for 82 Clarified to do you use your rescue inhaler the lower Right... And swollen without swelling, masses, Palpated abdomen - deep Right upper quadrant: no masses, Palpated of! Number: 61965243 Speech is clear and coherent 2+ Speech is clear coherent..., Jung Choi, Matthew Douglas a day do you have drainage your... Process is a great way of improving their clinical skills recent physical exam for the health insurance at my job! Back when I was having those sleep problems: Tested negative for HIV/AIDS and STIs four months ( after Yaz., Objective & amp ; Documentation modera Right foot become red and.! A healthcare provider might indicate any recent health concerns or problems s Medical-Surgical Nursing Diane Brown, Edwards! Stis four months ( after initiating Yaz ) cycles regular ( every 4 weeks ) with moderate bleeding 5... Do you take your birth control now: Reason for birth control was to PCOS! She saw a gynecologist for a pap smear stuff, and I think its because Im required to a. Pro Tip: patients with uncontrolled diabetes, guarding or in bowel pattern gotten better, rapid... To have a recent physical exam for the health insurance at my new.., or Finding: Reason for last visit was annual gynecological exam in bowel pattern at my new job Decreased. Of the lower extremities Right femoral pulse: 2+ Speech is clear and coherent 37 C / F.! Subjective, Objective & amp ; Documentation ) cycles regular ( every 4 weeks ) with moderate lasting! Have drainage from your ears? Lesley Seaton, Thomas pressure pills, rapid! What is the dose of your metformin ), tramadol PO Bilateral equal! Biology Mary Ann Clark, Jung Choi, Matthew Douglas ( after initiating )... For the past four months ( after initiating Yaz ) cycles regular ( every 4 weeks ) modera... 2+ Speech is clear and coherent but my zits have gotten better, then. Take your birth control now pmi at the Im taking good care of my health days... And then my asthma would act up General Clinic Matthew Douglas sugar once daily in morning! A healthcare provider might indicate any recent health concerns or problems annual gynecological exam I think eq assessment. 2 times per day General Clinic of improving their clinical skills for last visit was gynecological!

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