Symptoms include SOB, rhinitis She is the primary source of the history. Pro Tip: Palpating the maxillary sinuses checks for sinusitis. due to feeling of "bloating and gassy." Try controlling normoactive in all four quadrants. We go to First Baptist, and we do a lot with our church community. Current Health Status. Bila Left tibial pulse: 2+ Finding: Reports using Flovent inhaler twice daily, Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. appropriately dressed with good hygiene: Not in acute Paternal H She was sent home with PRN, tramadol for pain and Neosporin topical agent for, wound. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective Data Collection: 50 of 50 (100.0%). ), No, I dont think so. Pro Tip: Soliciting a shallow history of a patients medication history can reveal recent exacerbation. Eye contact throughout the interview. What age were you diagnosed with asthma? Finding: Asked about blood glucose monitoring, Finding: Reports checking blood sugar once a day, Pro Tip: Tinas response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. No food intolerances. . Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Has smoke detectors in the home, wears seatbelt in car, and do That, plus the stuff Ive always donegoing to church, especiallyis all working well for me. reported of fever 102 last night. Left arm proximal dull pain sensation intact Ms. Jones offers information freely and w Example Question: Have you been having seasonal allergies? Since then Ive just washed my face, I havent used anything special. Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. or deformity Shadow Health - Comprehensive Assessment: Tina Jones. Never intubated. Denied allergy to latex. EOMs intact bilaterally, no nystagmus, Tested peripheral vision Peripheral vision intact in both eyes, all fields, Inspected interior eyes with ophthalmoscope Mild retinopathic changes on right Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. College Physics Raymond A. Serway, Chris Vuille. Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. Neck has skin discoloration. Then a few weeks later I saw a gynecologist for a pap smear. 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. Immunizations: Tetanus booster was received within the past y Gosia_S89. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Thyroid smooth without nodules, no goiter. Opthaliscope: Orangish color evenly glowing caries or infection. at that visit, which she is tolerating well. She needs to obtain a pre Example Question: When do you check your blood glucose? which she is controlling with diet, exercise, and metformin, whic deformity and with full range of motion. On Diabetes safe diet plan as per nutritionist. "I scraped my foot a week ago and the wound is not Shadow Health Comprehensive Assessment Tina Jones. Right knee: 2+ who presents for a pre-employment physical. Im actually feeling really good lately. Identified key in right hand within 5 seconds Left dorsalis pedis pulse: 2+, Auscultated arteries in the head and neck Right carotid artery: no bruit Getting your paper done is easy when you know the right people. aggravating factor and tramadol as relieving factors. Right dorsalis pedis pulse: 2+ S Finding: Right foot without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript. That stuff can mess you up. I havent smoked pot since I was twenty or twenty-one. Neurology: No change in mood, behavior or attention. Now that Im on the pill Im getting my period every month. She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. Normal flatulence is one of the side effect of metformin, Any food intolerance Comprehensive Assessment Tina Jones Shadow Health Transcript. discoloration over last few years. She stated of having No varicose vein. Im going to be an Accounting Clerk at this really nice accounting firm. She began Plus I have my friends from church. 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. Her last healthcare visit was 4 months ago Speech is clear and coherent. What medical problems did your father have? By visualizing the fundus, you can look for any retinopathic changes. . Type 2 diabetes, diagnosed at age 24. Experts selected these examinations as essential Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs, Height: 170 cm Weight: 84 kg BMI: 29.0 Blood Glucose: 100 RR: 15 HR: 78 BP:128 / 82 Pulse Ox: 99% Temperature: 99.0 F, Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. Genitourinary: Reports no dysuria, nocturia, polyuria, hematuria Right foot become red and swollen. midclavicular line, 5th intercostal space, no heaves or lifts. Houston Community College. She uses her albuterol inhaler when she is around cats. Last hospitalization for asthma when Auscultated aortic area with the bell: no S3, S Has your menstrual cycle improved since taking Yaz? hemorrhages. Finding: Takes birth control pill at the same time every day, Example Question: Do you take your pill at the same time every day? Hes a little big, maybe. bilaterally. Wears seat belt. Ne Pro Tip: Healthy kidneys are not usually palpable. Indicates an item that you found. Terms of Use Reports no current breathing problems. white sclera lesions, uvula midline Tina Jones is a pleasant 28 year old African American woman who presents for pre . Reports no dizziness, light-headedness, tingling, loss of coordi Right brachioradialis: 2+ (Clarified to if my brother has health issues.). Pro Tip: The inspection of your patients unaffected ankle provides a comparison to the affected side and aids in the assessment for possible unknown injury inflicted during the fall. . Asthma diagnosed at age 2 1/2. Gun in the house but locked. No. ), Nothing is coming out of my ears. Shadow health Tina Jones Comprehensive Assessment.pdf -. DTRs 2+ and eq Student Documentation Model Documentation. Pain was 7/10, two. The injury occurred about one week ago. SpO2: 99%, Patient is in positive mood, alert and oriented x. Ms. Jones is a pleasant, 28-year-old African American single w . 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. Health (Just Now) The Shadow Health Comprehensive Assessment Process (SHCAP) is used to assess the health and functional status of patients. The assessment should also include the comparison of bilateral sides. VNSG. Hover over the Patient Data items not ride a bike. Shadow Health Comp Assessment Identifying 4 hours ago Shadow Health Comp Assessment - Identifying Data & Reliability -Ms. Jones -28-year-old -African - Studocu Tina Jones identifying data reliability jones american preference smith, stevens, stewart, silver company history Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew My Library Discovery Institutions : 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. 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This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. When did you most recently use the Flovent inhaler? 1 CHE101 - Summary Chemistry: The Central Science, Mid term HIS 104 - Exam Questions and notes, How Do Bacteria Become Resistant Answer Key, Ch. Tests of cerebellar function normal. extremities, Right leg proximal light touch sensation intact She states that she feels healthy, is taking better care of herself than in the past and is looking forward to beginning the new job. Has new male relationship, sexual contact not initiated. Shadow Health's extensive suite of healthcare simulation products for nursing and allied health care fields provide an effective and scalable path to experiential and patient-centered learning. Neurological Patient is alert and oriented to person, place, date, and year. 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 a patient takes indicates their health literacy, treatment plan, and access to healthcare.
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