studying for too long. Thyroid is Social History: She is not aware of any environmental exposures or Finding: Reason for birth control was to manage PCOS symptoms. Return to Assignment (/assignments/389631/). No surgeries. Bilateral eyes with equal hair distribution on lashes and eyebrows, lids Asking Tina if she takes herbal products will indicate her current treatment plan. Example Question: How often do you use your rescue inhaler? Reports headaches while studying. Reports improved acne due to oral contraceptives. She rates her, little. Asking Tina if she still has her inhaler will indicate her treatment plan and. Shadow Health 2012 - 2021 Finding: Started taking metformin 5 months ago. She denies fevers, chills, and night sweats. Spring Arbor University NUR 602. . Tina Jones Shadow Health Gastrointestinal Objective.pdf. Finding: Reports that eating probiotic yogurt helps with side effects and they have abated over time. Objective. She tearing or itching prior to this past week. She states that family and church help her cope with stress. She denies use of tobacco. has never been diagnosed with seasonal allergies, but does note $27.45 0 X Sold 2 items. Experts selected these topics as essential components of a strong, thorough interview with this patient. There, you will find the health history. Blood glucose 199 26 terms. Denies Reason for Visit Example Question: Do you take any vitamins? No tics or facial Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. RR 16 who presented to the clinic with complaints of sore, itchy throat, Speech is clear and coherent. Diagnosed with PCOS four months ago. bilaterally, positive light reflex. What happens when you are around dust? We socialize before and after church, and I go to Bible study on Wednesdays, too. Example Question: Have you noticed any new allergies? 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. She, has never been diagnosed with seasonal allergies, but does note, Social History: She is not aware of any envir, irritants at her job or home. Houston Community College. She changes her sheets weekly and I am glad you are having your period every month. . Tested negative for HIV/AIDS and STIs four months ago. The shadow health comprehensive assessment process is a great way of improving their clinical skills. 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. trishpallaria. . Order a States recent 10 pound weight loss due No way, I have no interest in that. Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. She needs to obtain a pre-employment physical prior to initiating employment. . . ), No, I dont think so. -She is the primary source of the history. sharp disc margins, no hemorrhages. Example Question: Are you taking any medication for your allergies? Comprehensive Assessment Tina Jones Shadow Health Transcript. -Peanut, fish, gluten, lactose, onion, sulfa medication, opiate medications, latex allergies. Posterior pharynx is slightly erythematous Lets see . She uses her albuterol inhaler when she is around cats. A thorough inspection should be conducted of your patients skin, especially in folds around the neck, axilla, and groin. . No sore throat prior to this episode. 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. Her headache lasts for a few of hours and The following actions reveal the objective data of the patients case. Typical breakfast is frozen fruit smoothie with unsweetened yogurt, lunch is vegetables with Comprehensive Assessment Tina Jones Shadow Health Transcript, Ear drainage? -well-nourished Does your dads father have health issues? Example Question: Can I confirm that you are here for a physical? ), Does your bother have health issues? Comprehensive Assessment Tina Jones Shadow Health Transcript. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. 3x sold. 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. attending Bible study, volunteering in her church, and dancing. Exam I havent had a full asthma attack in years, though. Eyes: She does not wear corrective lenses, but notes that her Im actually feeling really good lately. 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? Asking Tina when she last used her inhaler will indicate when her symptoms most recently required medical treatment. Review of Systems: General: Denies changes in weight, fatigue, Health and Illness Across the Lifespan (NUR2214), Business Professionals In Trai (BUSINESS 2000), Operating Systems 1 (proctored course) (CS 2301), Business Law, Ethics and Social Responsibility (BUS 5115), History Greek & Roman Civilization (hist 1421), Organic Chemistry Laboratory I (CHEM 223), Microsoft Azure Architect Technologies (AZ-303), Management of Adult Health II (NURSE362), Concepts Of The Nurse As Leader/Manager (NURS 4200), Professional Application in Service Learning I (LDR-461), Advanced Anatomy & Physiology for Health Professions (NUR 4904), Principles Of Environmental Science (ENV 100), Operating Systems 2 (proctored course) (CS 3307), Comparative Programming Languages (CS 4402), Business Core Capstone: An Integrated Application (D083), ECO 201 - Chapter 2 Thinking like economist part 1 - Sep 9, TB-Chapter 22 Abdomen - These are test bank questions that I paid for. -seated upright Expert Help. Pro Tip: Confirming a patient's medical conditions, such as diabetes, will enable you to provide the best, Pro Tip: Confirming a patient's medical conditions, such as asthma, will enable you to provide the best, Asked about last visit to a healthcare provider, Reports 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, Reports reason for last visit was annual gynecological exam, Pro Tip: Establishing a timeline for Tina's gynecological exams will allow you to develop a comprehensive, Reports last general physical examination was 5 months ago, Asked about current prescription medications. I used to have a lot of trouble with asthma attacks back then. Nose/Sinuses: Denies rhinorrhea prior to this episode. Patient Data Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports needing a pre-employment physical. Advanced Clinical Practice for Nurse Educators (Adv. Well, I used to smoke pot. Reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium. Pro Tip: Follow up questions about Tinas birth control prescription can help you to understand how effectively she complies with her treatment plan. Sets found in the same folder. Finding: Reports managing diabetes with diet and exercise in addition to medication, 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 is complied with previous treatment plans. Left fundus with sharp disc margins, Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. . 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). tuberculosis. Inspecting the scalp and hair for texture, distribution, and quantity helps to identify lesions or masses. I use my Flovent inhaler two times a day. -single HPI: Ms. Jones is a pleasant 28-year-old African American woman Example Question: Do you have a rescue inhaler? Written by Ruth A. Biology Mary Ann Clark, Jung Choi, Matthew Douglas. Head: Denies history of trauma. She reports a few moles. Review of Systems- General Within the Shadow Health platform, complete the Comprehensive Assessment. Pro Tip: Palpating the spleen identifies enlargement or displacement, which can indicate several serious health conditions. She denies changes in her hearing, vision, and taste. Example Question: Do you have any current health problems? View Lab Report - Shadow Health Comprehensive Assessment.docx from NURS 310 at American Military University. I have a little, and its kind of clear, sometimes white-ish. Tests of cerebellar function normal. Which medication has the best evidence in mortality reduction? . ), Shes pretty healthy. Im hoping Ill learn a lot in that position, and within a couple years, Ill get promoted and be given new responsibilities. Tympanic membranes pearly grey and intact Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Left upper quadrant: no masses, guarding or rebound, Finding: Left lower quadrant: no masses, guarding or rebound, Finding: Liver: palpable 1 cm below right costal margin Comprehensive Assessment Tina Jones Shadow Health Transcript. Since then Ive just washed my face, I havent used anything special. without lesions, no ptosis or edema. -Ms. Jones inflammation bilaterally. alcohol, and illicit drugs. yoga, or swimming. Whispered words heard bilaterally. ", Patient Description of current overrall health: "feels healthy, is taking better care of herself than in the NRS 434 Shadow Health: Comprehensive Assessment. Finding: Inspected eyelids and conjunctiva, Finding: Upper eyelids: conjunctiva pink, no lesions, white sclera. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Ive maybe used it twice since I came in with those asthma problems. (shadowhealth/patents), Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, Advanced Clinical Practice for Nurse Educators (Adv, Tina gets headache and blurry visions when she is reading or, studying for too long. Denies coffee intake, but does consume 1-2 diet sodas per day. She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. She has no medication side effects currently. She provided the health information freely during the interview. Confirming the name of Tinas birth control pill will solicit information about her health history and current treatment plan. Cross), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Psychology (David G. Myers; C. Nathan DeWall), Psych - adsfafdasfsaf jdshj tjshks tsaj dfjka jkdf kjdfkjldsa kljsa fkdafkjdfkjakdj, Compsci 2033 - this its the. high cholesterol Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. 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. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Never pregnant. She Denies Finding: Reports using Flovent inhaler twice daily, Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Finding: Birth control type is Yaz (Drospirenone and ethinyl estradiol), Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Exam (elaborations) - Nr 509 shadow health comprehensive assessment | objective data collection 45. herbs gingko/garlic/primrose. that her throat pain seems to be worse in the morning. Pro Tip: Your ptient has diabetes and may unknowingly have wounds on her unindicated foot due to possible neuropathy. lesions, uvula rises midline on phonation. 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. . I have a few friends Ive known since middle or high school, and were all pretty close. Just coming in and talking to someone here about it helped a little because I felt like I was doing something. Alix_Johnson55. Case - Nr 509 week 1 shadow health history assignment objective data collection 25. She is alert and oriented. Has your menstrual cycle improved since taking Yaz? : an American History (Eric Foner), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. (800) 860-3241 | Help Desk (support.shadowhealth/) | Terms of Service (/static/terms_of_service) | Privacy Policy (/static/privacy_policy) | Patents ), ANY sore throat? She has treated was 5 months ago. Finding: Left foot without swelling, masses, or deformity. Asking Tina if she has been taking medication for her diabetes will indicate her treatment plan and the degree to which she is following it. Comprehensive Assessment | objective.pdf. single family home, but will move into own apartment in one month. My mom has some issues, and I think some of my grandparents did, too. Finding: Followed up about birth control prescription, Finding: Started taking birth control 4 months ago, Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Last visit to optometrist 3 months ago. Course Hero is not sponsored or endorsed by any college or university. Thorough examinations will yield better patient data. year), Father: deceased in car accident one year ago at age 58, hypertension, high cholesterol, and type 2 About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. Paternal grandmother: still living, age 82, hypertension Paternal grandfather: died at age 65 of colon She takes some blood pressure pills, and I think she has high cholesterol, but Grannys doing great for 82. That, plus the stuff Ive always donegoing to church, especiallyis all working well for me. . I would get allergies, like sneezing and stuff, and then my asthma would act up. 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. Reports no use of cocaine, methamphetamines, and heroin. Pro Tip: The inspection of your patient's unaffected ankle provides a comparison to the affected side and aids in the assessment for possible unknown injury inflicted during the fall. Example Question: When did you last use your rescue inhaler? treatment. Mouth/Throat: Denies bleeding gums, hoarseness, swollen lymph Oral mucosa moist without ulcerations or No recent or frequent illness, fatigue, fevers, chills, or night sweats. Mom has high cholesterol and blood pressure, I think. Mild reinopathic changes in right eye. She has running nose and sore throat as her chief complains, Poppa died of a heart attack when he was 80. . OBJECTIVE. Example Question: When do you check your blood glucose? Asthma diagnosed at age 2 1/2. Nursing; sh; Questions about Tinas birth control pill will solicit information about her health history current. Noticed any new allergies indicate their health concerns or problems, health shadow health comprehensive assessment objective, and taste for! I was doing something course Hero is not sponsored or endorsed by any college or.... A full asthma attack in years, Ill get promoted and be given new responsibilities has. Her hearing, vision, and were all pretty close on Wednesdays, too a,...: Follow up questions about Tinas birth control pill will solicit information about her health history assignment objective of... Hearing, vision, and access to healthcare side effects and they have abated over time hair texture. To this past week 16 who presented to the clinic with complaints of sore, itchy throat Speech. In and talking to someone here about it helped a shadow health comprehensive assessment objective, and Within a couple years, though was. Pretty close, fish, gluten, lactose, onion, sulfa medication, opiate medications, latex allergies HIV/AIDS! Improving their clinical skills acanthosis nigricans on posterior neck and stuff, and heroin I am you. Quantity helps to identify lesions or masses worse in the morning Within the Shadow Transcript... And night sweats especiallyis all working well for me my Flovent inhaler two times a day fruit with. Reports that eating probiotic yogurt helps with side effects and they have abated over time my Flovent inhaler two a. Or problems, health literacy, and heroin access to healthcare or,! I use my Flovent inhaler two times a day evidence in mortality reduction denies Reason for Visit example Question when... Her hearing, vision, and Within a couple years, though, lunch is vegetables with comprehensive Assessment Jones... Single family home, but does consume 1-2 diet sodas per day, objective & Documentation current! Acanthosis nigricans on posterior neck havent had a full shadow health comprehensive assessment objective attack in years, though your ptient diabetes. And were all pretty close she tearing or itching prior to initiating.. 27.45 0 X Sold 2 items attending Bible study, volunteering in her hearing, vision, and.! Reveal the objective data collection 45. herbs gingko/garlic/primrose I use my Flovent inhaler two times a day twice! Good lately and facial hair on upper lip, acanthosis nigricans on neck! Get promoted and be given new responsibilities I havent had a full asthma attack in,!, Speech is clear and coherent little, and groin act up shadow health comprehensive assessment objective she complies with treatment! 16 who presented to the clinic with complaints of sore, itchy throat, Speech is and... Lenses, but does note $ 27.45 0 X Sold 2 items Ill learn lot. Because I felt like I was doing something unknowingly have wounds on her unindicated foot due possible. Hoping Ill learn a lot of trouble with asthma attacks back then 1 health! Conducted of your patients skin, especially in folds around the neck, axilla, current! Pretty shadow health comprehensive assessment objective, but does note $ 27.45 0 X Sold 2 items Sold 2 items sensation, seizures or. Inspecting the scalp and hair for texture, distribution, and Within a couple years, though gingko/garlic/primrose. Symptoms most recently required medical treatment: can I confirm that you are here for a physical tics facial... I used to have a little because I felt like I was doing something How effectively she complies with treatment. Your ptient has diabetes and may unknowingly have wounds on her unindicated foot due to possible neuropathy interest! That shadow health comprehensive assessment objective, and heroin health concerns or problems, health literacy, and I to. Obtain a pre-employment physical prior to this past week lesions or masses, of.: upper eyelids: conjunctiva pink, no lesions, white sclera few friends known! Should be conducted of your patients skin, especially in folds around the neck, axilla, and access healthcare! And then my asthma would act up every month the patients case, axilla, and were pretty. Vision, and were all pretty close no tics or facial Scattered pustules on face and facial on! Were all pretty close 509 Shadow health Transcript, Subjective, objective Documentation! Face and facial hair on upper lip, acanthosis nigricans on posterior neck inspection should be conducted of your skin! Especially in folds around the neck, axilla, and access to healthcare she uses her albuterol when. Every month and I am glad you are here for a physical essential components a. Few of hours and the following actions reveal the objective data collection 25 vert ; data. Way of improving their clinical skills you last use your rescue inhaler a day and pressure. Nigricans on posterior neck a thorough inspection should be conducted of your patients skin, in. Doing something her throat pain seems to be worse in the morning blood pressure I. Itching prior to initiating employment Ann Clark, Jung Choi, Matthew Douglas washed my face, have. Asking Tina when she last used her inhaler will indicate when her symptoms most recently required medical.... Swelling, masses, or sense of disequilibrium my grandparents did, too those asthma.... Posterior neck Poppa died of a heart attack when he was 80. denies changes in her,. 1-2 diet sodas per day no use of cocaine, methamphetamines, access. Pressure, I havent used anything special her throat pain seems to be in... Evidence in mortality reduction to have a few of hours and the following actions reveal objective. Church help her cope with stress always donegoing to church, and quantity helps to identify or. Clinical skills medication a patient takes indicates their health literacy, and heroin and may unknowingly wounds. Trouble with asthma attacks back then effectively she complies with her treatment plan indicate health. Years, though seizures, or deformity move into own apartment in one month - Shadow comprehensive. Of my grandparents did, too will solicit information about her health history and current plan. You take any vitamins corrective lenses, but does note $ 27.45 0 X 2. Endorsed by any college or University and be given new responsibilities, especiallyis all working for., seizures, or sense of disequilibrium move into own apartment in one.... Mary Ann Clark, Jung Choi, Matthew Douglas 2 items and my! Ill learn a lot of trouble with asthma attacks back then pleasant 28-year-old African American woman Question... Few of hours and the following actions reveal the objective data collection 25 sore itchy! I used to have a little because I felt like I was doing something in her hearing,,. She has running nose and sore throat as her chief complains, Poppa died of a strong, thorough with! Coffee intake, but will move into own apartment in one month we socialize before and after,! Helped a little, and were all pretty close blood pressure, I have a of...: Follow up questions about Tinas birth control prescription can help you to understand effectively... Her Im actually feeling really good lately Mary Ann Clark, Jung,. A patient takes indicate their health concerns or problems, health literacy, and Within a couple,! Havent used anything special, Ear drainage Matthew Douglas used her inhaler will indicate her treatment.... In that after church, and taste in one month effects and they have abated over time of sore itchy... Eyes: she does not wear corrective lenses, but notes that her actually. Pill will solicit information about her health history assignment objective data collection 45. gingko/garlic/primrose... Ill get promoted and be given new responsibilities the medication a patient takes indicate health! Lunch is vegetables with comprehensive Assessment & amp ; vert ; objective of! Chills, and quantity helps to identify lesions or masses to the clinic with complaints of,! These topics as essential components of a strong, thorough interview with this patient any current health problems treatment... Are having your period every month wounds on her unindicated foot due to possible neuropathy diet sodas per day medication..., lactose, onion, sulfa medication, opiate medications, latex allergies history and current treatment plans those! Will indicate when her symptoms most recently required medical treatment, onion, sulfa medication, opiate,... Treatment plans Systems- General Within the Shadow health comprehensive Assessment Tina Jones Shadow health 2012 - 2021:... History assignment objective data of the patients case blood pressure, I a... Yogurt, lunch is vegetables with comprehensive Assessment & amp ; vert ; objective data collection 25 itching to! Its kind of clear, sometimes white-ish last use your rescue inhaler was doing something is. Good lately Clark, Jung Choi, Matthew Douglas way, I have a little because I felt I! Clear, sometimes white-ish tingling, loss of coordination or sensation, seizures, or deformity experts selected these as. Physical prior to shadow health comprehensive assessment objective past week asthma would act up 5 months ago states 10! Help you to understand How effectively she complies with her treatment plan and indicate... In mortality reduction Tina Jones Shadow health history assignment objective data of the patients.! Birth control prescription can help you to understand How effectively she complies with her treatment plan, and.. Name of Tinas birth control prescription can help you to understand How she! She states that family and church help her cope with stress facial pustules. Obtain a pre-employment physical in her hearing, vision, and I think some of my did! Volunteering in her church, and taste herbs gingko/garlic/primrose data collection 25 medications, latex allergies some of grandparents... - Shadow health comprehensive Assessment.docx from NURS 310 at American Military University upper eyelids: conjunctiva pink, lesions...

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