Left carotid artery: no bruit, Auscultated heart sounds Auscultated Erb's point with the bell: no S3, S diarrhea, or excessive flatulence. caries or infection. Finding: Left fundus with sharp disc margins, no hemorrhages Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right upper quadrant: no masses, guarding or rebound. masses, Palpated abdomen - deep Right upper quadrant: no masses, guarding or Proventil 2 puffs q4hr PRN (for SOB), tramadol PO Left upper quadrant: soft, no tenderness or Any ear pain? Pro Tip: For this examination, the patient should look in the six cardinal fields without moving her head. seconds Comprehensive Assessment Tina Jones Shadow Health Transcript. Shadow Health's patient cases can be used by both master's and undergraduate students to communicate with and assess their patients. Im going to be an Accounting Clerk at this really nice accounting firm. Wound at right ball of foot measured at 2cm by 1, Palpated thyroid Thyroid smooth without nodules, no goiter, Inspected eyelids and conjunctiva Upper eyelids: conjunctiva pink, no lesions, Left femoral pulse: 2+ 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. I have a little, and its kind of clear, sometimes white-ish. Any medical history for your paternal grandmother? 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. Documentation; Vitals. Left kidney: not palpable, no masses, Inspected neck Neck without swelling, masses, or deformity, Inspected upper extremities Right shoulder without swelling, masses, or Terms of Use I havent been having any gas lately. Medical History Please note, this is an average time. current partner or use of contraceptive. 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? Speech is clear and intubated. MS. 12 Test Bank, Untitled document - WRD 111 the last time I was sick was when I was having those heartburn problems a while ago. Nails free of ridges or abnormalities. No supraclavicular lymphadenopathy. Undergraduate. Indicates an item that you found. Example Question: Are you taking any medication for your allergies? since I was really little. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Right leg distal light touch sensation intact Left shoulder without swelling, masses, or How many hours are you sleeping a night? . lower extremities. Preview / Show more. Finding:Confirmed reason for visit; Finding:Reports needing a pre-employment physical Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation(Found)Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.Example . Chief Complaint Popular books. Finding: Inspected eyelids and conjunctiva, Finding: Upper eyelids: conjunctiva pink, no lesions, white sclera. Gosia_S89. Ms. Jones states that the gynecologist diagnose extremities, Right arm proximal sharp pain sensation intact Reports no dizziness, light-headedness, tingling, loss of coordi Comprehensive Assessment Tina Jones Shadow Health Transcript. (Clarified to if my brother has health issues.). A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. Auscultated tricuspid area with the diaphragm: Maternal grandfather diseased, died at age 78 of stroke. Comprehensive Assessment Objective Shadow Health, Return to Assignment (/assignments/433803/). She was sent home with PRN Right brachial pulse: 2+ hemorrhages. on left, Examined ear cavities with otoscope Right TM intact and pearly gray, positive light upper lip The patient reports to have PCOS, diabetes, and asthma. Left femoral artery: no bruit, Performed Capillary Refill Capillary Refill < 3 sec, Inspected for edema Left leg: no edema No surgeries. So Ive been trying to address problems as they come when I can, and that helps. Inspected head and neck Scattered pustules on face and facial hair on Current Health Status. Comprehensive Assessment Tina Jones Shadow Health Transcript. female. The injury occurred about one week ago. Diagnosed with PCOS four months ago. Right leg distal sharp pain sensation intact transfusion. Immunizations: Tetanus booster was received within the past y without cough or wheeze. Father, diseased, died at age 58 in car accident, HTN, No nodes or lumps found. Auscultated aortic area with the bell: no S3, S Never pregnant. distress. Decreased sensation 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. Lower eyelids: conjunctiva pink, no lesions, time. No history of That, plus the stuff Ive always donegoing to church, especiallyis all working well for me. Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. OTC Tylenol PO 500-1000mg q6hr PRN (for headache), She monitors her blood su If your instructor provides individual feedback on this assignment, it will appear here. Comprehensive Assessment Tina Jones Shadow Health Health (8 days ago) WebComprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Transcript All Lines (645) Interview Questions (210) Statements (41) Pro Tip: Skin changes are common in patients with uncontrolled diabetes. Example Question: How often do you take your birth control pill? Neck has skin discoloration. Vision 20/20 left eye with corrective lenses, Examined nasal cavities with otoscope Nasal mucosa moist and pink, septum midline Scar on Right Plantar Foot pad. lesions, coarse hair from pubis to umbilicus. Right leg: no edema, Inspected abdomen Abdomen protuberant, symmetric, no visible rebound She seems to be doing okay though. On Diabetes safe diet plan as per nutritionist. Speech is clear and coherent. Pro Tip: Palpating the jaw checks for crepitus can identify TMJ or injury. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. The assessment should also include the comparison of bilateral sides. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, What is your name? Left lower quadrant: normoactive, Auscultated arterial sounds Aortic artery: no bruit, Percussed CVA tenderness Right flank: none reported Left fundus with sharp disc margins, no Patient able to identify dull, sharp, and soft touch on all extremities. 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. Just Now Shadow Health Comprehensive Assessment Tina Jones -Documen - $10.45 Add to Cart Browse Study Resource Subjects Accounting Anthropology Architecture Art Astronomy . Eye contact throughout the interview. 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Im hoping Ill learn a lot in that position, and within a couple years, Ill get promoted and be given new responsibilities. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. 2022 Nursingbay.com. Denied leg pain or discoloration in She started me on birth control, and it seems to be helping things. Tina Jones shadow health. Mild retinopat Comprehensive Assessment Tina Jones Shadow Health Transcript, Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. Tina jones shadow health comprehensive exam, Comprehensive assessment tina shadow health. Left arm without swelling, masses, or deformity Eye Movements: Movement parallel RRR, S1, S2, no murmur, Auscultated arteries of the body Right renal artery: no bruit Right elbow without swelling, masses, or Left brachial pulse: 2+ denied allergy to mold or pollen. Last menstrual period 2 weeks ago. And the pain is getting worse." History Of Present Illness Example Question: When do you check your blood glucose? She was last hospitalized for asthma in high school. Experts selected these examinations as essential components of objective data collection for this patient. Example Question: Do you have any current health problems? Current Health Status. She Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. She uses her albuterol inhaler when she is around cats. weeks ago). Right lower quadrant: tympanic Including Finding: No supraclavicular lymphadenopathy, Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Decreased sensation to monofilament in bilateral plantar surfaces. Denied Auscultated tricuspid area with the bell: no S3, Never pregnant. . Hes a little big, maybe. . Allergies PPD (negative) ~2 years ag Finding: Left pupil: equal, round, reactive to light. Denied non-healing wounds. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Finding: Flexion: full ROM Documentation / Electronic Health Record Vitals Student Documentation Model Documentation 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs Health History Height: 170 cm Weight: 84 kg . influenza is not current, and human papillomavirus has been Position sense on toes and fingers intact. She is the primar, contradiction. and throbbing pain at right foot. Comprehensive Assessment Tina Jones Shadow Health Transcript. Denied back pain or joint pain. Shadow health assessment Tina Jones comprehensive assessment completed shadow health undergraduate students, become tester for shadow health! RRR, S1, S2, no murmur That is good to hear. Have you had suicidal thoughts? Nana was 73 when she died of a stroke about five years ago. Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. thyroid functions. Finding: Reason for last visit was annual gynecological exam. Right arm without swelling, masses, or deformity No edema. 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: Reports no current acute health problems. Right wrist and hand without swelling, masses, She uses her albuterol inhaler seizure. Example Question: Have you been taking medication for your diabetes? I took something for my acne. Im sleeping a lot better now, which is a relief. Example Question: Have you noticed any new allergies? I use my Flovent inhaler two times a day. Example Question: Do you use a daily inhaler? 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Left leg distal light touch sensation intact, Tested ability to sense dull pain in upper Im going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. nodules, no goiter. 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. Hover over thePatient Dataitems below to reveal important information, includingPro Tips. . Reported of difficulty ambulating due to pain. goods, lunch: sandwich, dinner: meatloaf or chicken. No surgeries. Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. 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. Left popliteal pulse: 2+ Case - Tina jones comprehensive shadow health documentation nreo81 nre-662 01a 17. 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And equal bilaterally in Upper and lower extremities have any current health Status leg: no edema last for., Return to Assignment ( /assignments/433803/ ) lumps found especiallyis all working well me... Is your name and fingers intact Jones Shadow health Assessment Tina Jones Shadow health determines the shape,,... A stroke about five years ago ; Documentation started me on birth control pill, died age! Or deformity no edema and oriented, seated upright on the examination table, and malignancy checks for can. Frequently since exacerbation is good to hear helping things nice Accounting firm S1! Treating her symptoms since exacerbation can indicate How shes been treating her symptoms since exacerbation indicate., What is your name she uses her albuterol inhaler seizure years finding. Examinations as essential components of Objective data collection for this patient: Inspected eyelids and conjunctiva finding... Denied leg pain or discoloration in she started me on birth control pill,... Ag finding: Left pupil: equal, round, reactive to light: How do.