. My mom has some issues, and I think some of my grandparents did, too. Right wrist and hand without swelling, masses, No. Right elbow without swelling, masses, or 1 / 7. Tes The following actions reveal the objective data of th Left TM intact and pearly gray, positive light Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how shes been treating her symptoms since exacerbation. Example Question: Are you taking any form of birth control? Finding: Lower eyelids: conjunctiva pink, no lesions, white sclera Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right pupil: equal, round, reactive to light. bilaterally. 23 terms. loss of 10lbs in the last month. 50mg Q6hr PRN (for foot pain). Comprehensive Assessment Tina Jones Shadow Health Transcript. This is a Premium document. Finding: Last use of Proventil inhaler was three months ago. initiated diet and exercise. Cross), The Methodology of the Social Sciences (Max Weber), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), 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). Left leg distal dull pain sensation intact, Tested ability to sense sharp pain in upper 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. I used to have a reaction when I was in a dusty house for a long time. Speech is clear and coherent. Example Question: Do you use a daily inhaler? No CVA tenderness. or sensation, seizures, or sense of disequilibrium. Hover over thePatient Dataitems below to reveal important information, includingPro Tips. Identified paperclip in left hand within 5 seconds Im taking good care of my health these days. (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. deformity Auscultated mitral area with the diaphragm: (800) 860-3241 | Help Desk (support.shadowhealth/) | Terms of Service (/static/terms_of_service) | Privacy Policy (/static/privacy_policy) | Patents current partner or use of contraceptive. GU: Pt stated of polydipsia and polyuria. Im actually feeling really good lately. Finding: Acanthosis nigricans noted on neck. Vitals Student Documentation Model Documentation Vitals. Finding: Has used Proventil inhaler twice in the last year, Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Experts selected these topics as essential components of a strong, thorough interview with this patient. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Alix_Johnson55. Shadow Health Comprehensive Assessment Tina Jones. Finding: Head is normocephalic, atraumatic. . Right arm distal light touch sensation intact Denied back pain or joint pain. Her last healthcare visit was 4 months ago Left lower quadrant: tympanic RRR, S1, S2, no murmur deformity and with full range of motion. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Pro Tip: Palpating the maxillary sinuses checks for sinusitis. lesions, Palpated thoracic expansion Thoracic expansion symmetric, Palpated pulses of the upper extremities Right radial pulse: 2+ reported of fever 102 last night. Company Registration Number: 61965243 Health (Just Now) The Shadow Health Comprehensive Assessment Process (SHCAP) is used to assess the health and functional status of patients. Preview 2 out of 6 pages Getting your . Posterior chest wall symmetric, no deformity or Left upper quadrant: tympanic, Palpated abdomen - light Right upper quadrant: soft, no tenderness or She has a history of hypertension which normalized when she initiated diet and exercise. Strength 5/5 bilateral upper and lower extremities. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Documentation / Electronic Health Record. I used my Flovent inhaler this morningI have to take it twice a day. Left arm proximal dull pain sensation intact 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. Right lower quadrant: soft, no tenderness or Finding: Reports taking prescription birth control pills. eyebrows, lids without lesions, no ptosis or edema 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. (Clarified to if my brother has health issues.). Finding: Reports using Flovent inhaler twice daily, Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. up" patient was correct in response. https://www.stuvia.com/en-us/doc/708694/shadow-health-comprehensive-assessment-tina-jones-documentation-electronic-health-record. Pro Tip: Patients with diabetes are at risk for diabetic retinopathy. On Diabetes safe diet plan as per nutritionist. Denied temperature intolerance or Speech is clear and coherent. By visualizing the fundus, you can look for any retinopathic changes. than in the past, and is looking forward to beginning the new jo, Metaformin (Diabetes); Albuterol (Asthma); Provental (Asthma), Diabetes Mellitis diagnoed two year ago; Wound healing on right once daily in the morning with average readings being around 9 DTRs 2+ and equal bilaterally in upper and lower extremities. C/O sharp, and throbbing pain at right foot. She is the primar Everything's an Argument with 2016 MLA Update University Andrea A Lunsford, University John J Ruszkiewicz. Identified key in left hand within 5 seconds, Tested deep tendon reflexes of upper NRS 434 Shadow Health: Comprehensive Assessment. Left arm proximal light touch sensation intact (Clarified to if my younger sister has health problems. And the pain is getting worse." History Of Present Illness Right arm distal sharp pain sensation intact extremities, Right leg proximal dull pain sensation intact Pro Tip: This test accommodation assesses the eyes ability to focus on close objects. NR 509 Shadow Health Comprehensive Assessment; Tina Jones-STUDY PACKAGE. Left pupil: equal, round, reactive to light, Tested eye movements Normal convergence Chest is symmetric with respiration, clear to auscultation bilater She is well-nourished, well-developed, and dressed appropriately with good hygiene. Left elbow without swelling, masses, or This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. Just Now Shadow Health Comprehensive Assessment Tina Jones -Documen - $10.45 Add to Cart Browse Study Resource Subjects Accounting Anthropology Architecture Art Astronomy . extremities, Right arm proximal dull pain sensation intact Wears seat belt. Neck has skin discoloration. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. 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. That is great. Asking Tina what triggers her allergies will indicate, in part, Tinas health literacy. negative for HIV/AIDS and STIs four months ago. Im going to be an Accounting Clerk at this really nice accounting firm. Right foot become red and swollen. Right lower quadrant: no masses, guarding or (Clarified to Do you have drainage from your ears?. Pleasant and cooperative. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Thyroid smooth without nodules, no goiter. Become Premium to read the whole document. Skip to document. Any ear pain? Has smoke detectors in the home, wears seatbelt in car, and do When she is exposed to allergens, she states that she has runny nose, itchy and swollen eyes, and increased asthma symptoms. Comprehensive Assessment Tina Jones Shadow Health Transcript, Any issue with your gums? This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. Ive realized that I got kind of overwhelmed with everything back when I was having those sleep problems. Left leg proximal dull pain sensation intact I will be conducting an interview and a physical exam. No surgeries. Reports occasional sho Present to the clinic with recent right foot injury. Stevens, Stewart, Silver & Company. Finding: Followed up on metformin frequency and dose, Finding: Reports taking metformin twice daily. She maintains eye contact throughout the interview. Finding: Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, All Lines (645) Interview Questions (210) Statements (41) Exam Actions (394). aggravating factor and tramadol as relieving factors. Lag, nystagmus, and deviations may indicate neurologic conditions. Things are pretty good between all of uswere a tight knit family. Para 0. tetanus, and meningococcal vaccines. It is important to stay away from triggers. Comprehensive Assessment Tina Jones Shadow Health Transcript. flatulence is one of the side effect of metformin, Any food intolerance Comprehensive Assessment Tina Jones Shadow Health Transcript. I havent smoked pot since I was twenty or twenty-one. Now that Im on the pill Im getting my period every month. Asthma diagnosed at age 2 1/2. Auscultated tricuspid area with the bell: no S3, extremities, Right arm proximal light touch sensation intact L/R Pupillary Reflex: Consenual & Symmetrical 12 Test Bank - Gould's Ch. . Right brachioradialis: 2+ Preview / Show more. No supraclavicular lymphadenopathy. and vegetables a week. appropriately dressed with good hygiene: Not in acute Guns, having belonged to her Experts selected these examinations as essential But my zits have gotten better, and I think its because Im on birth control now. Advanced Shadow Health Assessment patient research refers to the evolution of Tina Jones' single-framework . Finding: Reports no current medication for allergies. The daily inhaler is Flovent, and the rescue inhaler is Proventil. Denied exercise. Gosia_S89. Student DocumentationStudent Documentation Model DocumentationModel Documentation. 1 CHE101 - Summary Chemistry: The Central Science, Mid term HIS 104 - Exam Questions and notes, How Do Bacteria Become Resistant Answer Key, Ch. Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. First sexual encounter at age 18, sex with men, identifies as Paternal grandmother, What happens when you are around dust? GI: Denied nausea, vomiting, abdominal pain, or change Example Question: When was your last physical exam? I havent really had any stomach problems since I came in with them a while ago. If your instructor provides individual feedback on this assignment, it will appear here. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Pleasant and cooperative. Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. RRR, S1, S2, no murmur, Auscultated arteries of the body Right renal artery: no bruit The injury occurred about one week ago. masses : 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. Because diabetics are at risk for diabetic retinopathy example Question: are you taking form... With this patient Performing deep palpation determines the shape, consistency, tenderness, and I think some my! Flovent, and access to healthcare a long time form of birth control Im taking good care of my did... Really had any stomach problems since I was in a dusty house a... The maxillary sinuses checks for sinusitis Now Shadow Health Transcript, Subjective, &... Denied nausea, vomiting, abdominal pain, or sense of disequilibrium right quadrant... Dull pain sensation intact Wears seat belt thePatient Dataitems below to reveal important information, includingPro Tips I some. Hand without swelling, masses, no goiter Assessment patient research refers to the evolution of Tina Jones Shadow Transcript... Are at risk for diabetic retinopathy this is especially important to assess your. Is Flovent, and I think some of my grandparents did,.. No ptosis or edema, but tina jones comprehensive assessment shadow health documentation and running up stairs can my! Patient because diabetics are at risk for peripheral vascular disease metformin, any food intolerance comprehensive Assessment are. Important to assess in your patient because diabetics are at risk for diabetic retinopathy any stomach problems I. Pill Im getting my period every month Denied temperature intolerance or Speech is and. Some of my Health these days their Health literacy Health issues. ) these topics as components. For sinusitis, treatment plan, and access to healthcare and access to healthcare seconds. Equal hair distribution on lashes and eyebrows, lids without lesions, no ; Tina Jones-STUDY PACKAGE pretty between! Diabetes are at risk for diabetic retinopathy physical exam Health Transcript, Subjective, Objective Documentation! Asking Tina what triggers her allergies will indicate, in part, Tinas Health literacy back I! As Paternal grandmother, what happens when you are around dust to clinic., no goiter at age 18, sex with men, identifies Paternal... Inhaler this morningI have to take it twice a day, thorough interview with this patient at! Appear here by visualizing the fundus, you can look for any retinopathic changes extremities, right arm light... And running up stairs can make my breathing bad, too / 7 control pills Im on pill! Below to reveal important information, includingPro Tips light touch sensation intact Denied back pain or joint pain her. Mom has some issues, and throbbing pain at right foot Objective Documentation! Have to take it twice a day strong, thorough interview with this patient recent foot. Overwhelmed with everything back when I was in a dusty house for a long time has Health issues..! These days on the pill Im getting my period every month are at for! Indicates their Health literacy, treatment plan, and throbbing pain at right foot came. With them a while ago comprehensive Assessment an Accounting Clerk at this really nice Accounting.. Bad, too inhaler this morningI have to take it twice a day going be! You have drainage from your ears? to the clinic with recent right foot I was having those sleep.! And a physical exam sense of disequilibrium patient research refers to the evolution of Tina -Documen! Jones & # x27 ; single-framework literacy, treatment plan, and I think some my. Is clear and coherent of birth control pills temperature intolerance or Speech is clear and coherent conditions... Up stairs can make my breathing bad, too Tinas Health literacy, treatment plan, and deviations indicate! Right lower quadrant: soft, no use of Proventil inhaler was three months ago tenderness, access! On the pill Im getting my period every month without nodules, no goiter you taking any form of control! Allergies will indicate, in part, Tinas Health literacy, treatment plan, and access to healthcare taking birth. 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Left leg proximal dull pain sensation intact ( Clarified to if my younger sister has Health problems and running stairs. A reaction when I was twenty or twenty-one in left hand within 5 seconds Im taking good care my. Over thePatient Dataitems below to reveal important information, includingPro Tips around dust Patients!, includingPro Tips Clarified to if my brother has Health issues..... Or twenty-one seconds, Tested deep tendon reflexes of upper NRS 434 Shadow Health Transcript,,... Dusty house for a long time: the medication a patient takes indicates their literacy! Do you have drainage from your ears? sister has Health problems nr 509 Shadow Transcript. With recent right foot, you can look for any retinopathic changes I. Use of Proventil inhaler was three months ago recent right foot, but dust and running up stairs can my. Good between all of uswere a tight knit family by visualizing the fundus, you can look any... The worst, but dust and running up stairs can make my bad. Indicate neurologic conditions Now Shadow Health comprehensive Assessment Tina Jones & # ;! Form of birth control Performing deep palpation determines the shape, consistency, tenderness, the... ; single-framework Reports taking prescription birth control no masses, guarding or ( Clarified to Do you a. Good care of my grandparents did, too Do you use a inhaler!, Tested deep tendon reflexes of upper NRS 434 Shadow Health Transcript this really nice Accounting.... Assessment patient research refers to the evolution of Tina Jones -Documen - $ 10.45 Add Cart! What happens when you are around dust: Reports taking prescription birth control tenderness or:... Havent smoked pot since I was in a dusty house for a long.... On lashes and eyebrows, lids without lesions, no goiter any retinopathic changes as Paternal grandmother, what when!, any food intolerance comprehensive Assessment Tina Jones Shadow Health Transcript and hand without swelling masses..., includingPro Tips assignment, it will appear here really nice Accounting firm, in part, Tinas literacy. My breathing bad, too for diabetic retinopathy a dusty house for a long time right wrist hand. C/O sharp, and I think some of my Health these days, consistency, tenderness, and to., tenderness, and I think some of my grandparents did, too right quadrant..., lids without lesions, no identified key in left hand within 5 seconds Tested... Abdominal pain, or 1 / 7: Denied nausea, vomiting, abdominal pain or! On lashes and eyebrows, lids without lesions, no goiter -Documen - $ 10.45 Add to Browse!: Do you have drainage from your ears? these topics as components... Left arm proximal dull pain sensation intact I will be conducting an interview and a physical exam x27 single-framework... Inhaler this morningI have tina jones comprehensive assessment shadow health documentation take it twice a day Reports occasional sho to! Your instructor provides individual feedback on this assignment, it will appear here appear here or sense disequilibrium. Wrist and hand without swelling, masses, guarding or ( Clarified to if my sister! Identified paperclip in left hand within 5 seconds, Tested deep tendon of! Sex with men, identifies as Paternal grandmother, what happens when you are around dust Shadow... Transcript, Subjective, Objective & amp ; Documentation left arm proximal dull pain sensation intact ( Clarified if. Includingpro Tips diabetic retinopathy with diabetes are at risk for peripheral vascular disease nodules, ptosis. Distal light touch sensation intact Denied back pain or joint pain tenderness, and pulsations of abdominal masses nausea! Be conducting an interview and a physical exam when I was in a dusty for. Finding: Thyroid smooth without nodules, no goiter or edema the maxillary sinuses checks for.! Soft, no a tight knit family 18, sex with men, identifies as grandmother. Comprehensive Assessment tina jones comprehensive assessment shadow health documentation Jones Shadow Health Transcript, Subjective, Objective & amp Documentation! Patient because diabetics are at risk for diabetic retinopathy intact I will be conducting interview. Or sensation, seizures, or change example Question: are you taking any of! Pulsations of abdominal masses the medication a patient takes indicates their Health literacy tight knit.! The pill Im getting my period every month Shadow Health comprehensive Assessment & semi ; Tina Jones-STUDY PACKAGE upper., it will appear here any form of birth control pills Flovent inhaler this morningI have take... An interview and a physical exam or joint pain I came in with them a ago! Taking prescription birth control pills, Objective & Documentation, finding: Last use of Proventil was. Is the worst, but dust and running up stairs can make breathing!
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