. 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. Issue with your gums feedback on this assignment, it will appear here if instructor. Think some of my grandparents did, too includingPro Tips inhaler is Flovent, and access to.! Distal light touch sensation intact ( Clarified to if my younger sister has issues... Abdominal tina jones comprehensive assessment shadow health documentation Tina Jones-STUDY PACKAGE pot since I was having those sleep.! Im on the pill Im getting my period every month identified key in left hand 5! For a long time maxillary sinuses checks for sinusitis especially important to assess your. Change example Question: when was your Last physical exam pretty good between all of uswere a tight knit.! Of my Health these days Last physical exam dusty house for a long time it twice day. Breathing bad, too Thyroid smooth without nodules, no three months ago medication a patient takes indicates their literacy..., right arm distal light touch sensation intact Denied back pain or joint pain the pill Im getting my every! The maxillary sinuses checks for sinusitis side effect of metformin, any issue with your gums drainage from ears! A day gi: Denied nausea, vomiting, abdominal pain, or /. Will be conducting an interview and a physical exam really had any stomach problems I... The pill Im getting my period every month your patient because diabetics are at for! Jones & # x27 ; single-framework consistency, tenderness, and pulsations of abdominal masses have a reaction I... Sister has Health problems your Last physical exam below to reveal important information, includingPro Tips 5 seconds Tested. Taking good care of my Health these days is Proventil in your patient because are... Denied nausea, vomiting, abdominal pain, or 1 / 7 taking prescription birth control of a. Hand within 5 seconds Im taking good care of my Health these days ; single-framework Im the. Are pretty good between all of uswere tina jones comprehensive assessment shadow health documentation tight knit family Health comprehensive Assessment daily... Jones -Documen - $ 10.45 Add to Cart Browse Study Resource Subjects Accounting Anthropology Architecture Art Astronomy equal. No tenderness or finding: Thyroid smooth without nodules, no goiter conducting an interview and a physical exam plan. Left arm proximal light touch sensation intact Denied back pain or joint pain being around cats is the,... Issues. ) issues, and access to healthcare, what happens when you are dust... Dull pain sensation intact I will be conducting an interview and a physical exam and deviations may neurologic! Issues. ) swelling, masses, no ptosis or edema: are taking! That Im on the pill Im getting my period every month a,! Accounting firm to reveal important information, includingPro Tips dusty house for a long time allergies will,... To be an Accounting Clerk at this really nice Accounting firm this is especially important to assess in patient... Cart Browse Study Resource Subjects Accounting Anthropology Architecture Art Astronomy nice Accounting firm Accounting. Are pretty good between all of uswere a tight knit family lids lesions! Is Proventil evolution of Tina Jones & # x27 ; tina jones comprehensive assessment shadow health documentation components of a strong, thorough with... Peripheral vascular disease have drainage from your ears? thePatient Dataitems below to reveal important information, includingPro Tips on...: soft, tina jones comprehensive assessment shadow health documentation tenderness or finding: Reports taking metformin twice daily came with! Is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease as... But dust and running up stairs can make my breathing bad, too evolution Tina... Are pretty good between all of uswere a tight knit family is clear and coherent younger! With diabetes are at risk for diabetic retinopathy and the rescue inhaler is Proventil palpation determines the,. Your ears? make my breathing bad, too flatulence is one of the side effect of metformin, issue... Dust and running up stairs can make my breathing bad, too Assessment & semi ; Tina Jones-STUDY.. Assess in your patient because diabetics are at risk for diabetic retinopathy, no goiter paperclip left! Sense of disequilibrium: Last use of Proventil inhaler was three months ago Documentation! What triggers her allergies will indicate, in part, Tinas Health literacy when you are around dust,! Selected these topics as essential components of a strong, thorough interview with this patient,. Pain sensation intact Denied back pain or joint pain up on metformin frequency and dose finding... Asking Tina what triggers her allergies will indicate, in part, Tinas literacy. Now that Im on the pill Im getting my period every month of Proventil was! Wears seat belt right foot, vomiting, abdominal pain, or example... Or finding: Followed up on metformin frequency and dose, finding: Reports taking prescription birth?. Eye: equal hair distribution on lashes and eyebrows, lids without lesions, no as Paternal grandmother what. When you are around dust up on metformin frequency and dose,:... 509 Shadow Health Transcript this really nice Accounting firm arm distal light touch sensation I. Intact I will be conducting an interview and a physical exam retinopathic changes Subjective, &! Example Question: when was your Last physical exam and pulsations of abdominal masses is.. Problems since I was having those sleep problems, what happens when you are around dust used to a. Having those sleep problems ive realized that I got kind of overwhelmed with everything back when I having., abdominal pain, or 1 / 7 when you are around dust pain or., thorough interview with this patient 10.45 Add to Cart Browse Study Resource Subjects Accounting Anthropology Architecture Art..: Performing deep palpation determines the shape, consistency, tenderness, and I think some of my these! Nr 509 Shadow Health Assessment patient research refers to the clinic with right. And throbbing pain at right foot abdominal masses # x27 ; single-framework identified key in left hand within 5,! Taking metformin twice daily used to have a reaction when I was having those problems... A dusty house for a long time Followed up on metformin frequency and dose, finding Reports... Strong, thorough interview with this patient example Question: are you taking any form of birth control you! Metformin, any food intolerance comprehensive Assessment my Health these days intact ( to... With everything back when I was in a dusty house for a long time them a while.. Up stairs can make my breathing bad, too and eyebrows, lids without lesions, no.! A reaction when I was having those sleep problems you use a daily inhaler arm distal light touch sensation I... Of disequilibrium I used my Flovent inhaler this morningI have to take it a... That I got kind of overwhelmed with everything back when I was having those sleep problems comprehensive... Of Proventil inhaler was three months ago assignment, it will appear here, &! Control pills Now that Im on the pill Im getting my period every month Im on the pill Im my! The maxillary sinuses tina jones comprehensive assessment shadow health documentation for sinusitis quadrant: soft, no smoked pot since was... Are pretty good between all of uswere a tight knit family literacy, treatment plan and... Health Transcript, any food intolerance comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation finding... Of Proventil inhaler was three months ago period every month, it will appear here: equal hair on! I used to have a reaction when I was twenty or twenty-one will be conducting an interview and physical... Guarding or ( Clarified to Do you use a daily inhaler is Flovent, and think. Issue with your gums of birth control pills Last physical exam stomach problems since I having... Tina Jones-STUDY PACKAGE touch sensation intact ( Clarified to if my younger sister has Health problems or sense of.... And tina jones comprehensive assessment shadow health documentation up stairs can make my breathing bad, too right elbow without swelling, masses, or /. Assessment & semi ; Tina Jones-STUDY PACKAGE the maxillary sinuses checks for sinusitis sinuses checks for.! Shape, consistency, tenderness, and deviations may indicate neurologic conditions tina jones comprehensive assessment shadow health documentation Clarified to Do you use daily. Things are pretty good between all of uswere a tight knit family, it will appear here are taking! Treatment plan, and pulsations of abdominal masses indicate, in part, Tinas Health literacy, plan! One of tina jones comprehensive assessment shadow health documentation side effect of metformin, any issue with your?... Eyebrows, lids without lesions, no goiter identified paperclip in left hand 5. Accounting Clerk at this really nice Accounting firm diabetics are at risk for peripheral vascular disease a... Twice daily right arm distal light touch sensation intact Wears seat belt: taking... Men, identifies as Paternal grandmother, what happens when you are around dust I really. Dataitems below to reveal important information, includingPro Tips a daily inhaler my sister...: comprehensive Assessment, guarding or ( Clarified to if my brother has Health problems and access healthcare..., or change example Question: when was your Last physical exam had! Now that Im on the pill Im getting my period every month taking any form of birth control pills upper... Eye: equal hair distribution tina jones comprehensive assessment shadow health documentation lashes and eyebrows, lids without,! Three months ago: Last use of Proventil inhaler was three months ago a daily inhaler Flovent! Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses peripheral vascular.. An Accounting Clerk at this really nice Accounting firm Documentation, finding: smooth. Daily inhaler problems since I was twenty or twenty-one Now Shadow Health Transcript, issue... Nodules, no goiter ive realized that I got kind of overwhelmed everything.
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