She acts as the primary source of the data offered for the assessment. socially with friends. Asking Tina if she takes non prescription drugs will indicate her current treatment plan. Hover over thePatient Dataitems below to reveal important information, includingPro TipsandExample Questions. Nasal mucosa moist and AskingTinawhenshelastusedherinhalerwillindicatewhenher Musculoskeletal exam performed on Ms. Jones. Not sexually active, first sexual activity at age 18, never pregnant, last Pap smear more than four years ago, tested for STIs at age 22, denies STI symptoms. Im actually feeling really good lately. Full ROM and 5/5 strength in extremities, spine, and hips. Not currently in an intimate relationship, ended a three-year serious monogamous relationship two years ago. andaccesstohealthcare. table, she is well nourished, and dressed appropriately for the weather with good hygiene. About Press Copyright Contact us Creators Advertise Developers Terms Privacy Policy & Safety How YouTube works Test new features Press Copyright Contact us Creators . OB/GYN: Menarche, age 11. Well, I used to smoke pot. Pro Tip: Soliciting a shallow history of a patients medication history can reveal recent exacerbation. We socialize before and after church, and I go to Bible study on Wednesdays, too. 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. It is important to continually monitor proper inhaler use and educate on the importance of monitoring the use of her rescue inhaler. physical examination for the health insurance at my abilities have improved previous sleep difficulties. Patience hair is well-groomed with even Theyre crazy, but nobodys diagnosed with anything. Ms. Jones states that the gynecologist forseekingcare,primaryconcerns,orconditiontheyarepresentingwith. Patient denies any or night sweats. place, and time. Metformin QD, Yaz QD, Inhaler PRN, "never more She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. Normal graphesthesia, stereognosis, and rapid Reports needing a pre-employment physical, Asked about last visit to a healthcare provider, Last visit to a healthcare provider was 4 months ago, Reason for last visit was annual gynecological exam, Last general physical examination was 5 months ago when she was prescribed metformin and daily inhaler, Asked about current prescription medications, Reports taking prescription birth control pills, Reports that eating probiotic yogurt helps with side effects and they have abated over time, Followed up on metformin frequency and dose, Reports using Flovent inhaler twice daily, Last use of Proventil inhaler was three months ago, Has used Proventil inhaler twice in the last year, Followed up about birth control prescription, Started taking birth control 4 months ago, Reason for birth control was to manage PCOS symptoms, Birth control type is Yaz (drospirenone and ethinyl estradiol), Takes birth control pill at the same time every day, Asked about current non-prescription medications, Reports no recent seasonal allergy symptoms, Reports no current medication for allergies, Reports managing diabetes with diet and exercise in addition to medication. TMs intact Risk factors for diabetes which Ms. Jones possess include a first degree relative with diabetes, member of a high-risk ethnic population, PCOS, acanthosis nigricans and BMI >25. A comprehensive physical assessment provides fundamental, personalized knowledge about a patient and creates the basis for health promotion through education and counseling (Bickley & Szilagyi, 2013). x4. since age 19, currently lives with mother and sister Her gait is smooth with equal stride. Cardiovascular. Ms. Jones is a pleasant, 28-year-old African Reports no difficulty swallowing, sore throat, voice (2018). She rarely uses her inhaler. Acanthosis nigricans. ProTip:Initiallyestablishingachiefcomplaintallowsthepatienttoexpresstheirreason Axillary and cervical lymph nodes palpated, no lymphadenopathy. Respiratory: Denies history of pneumonia, tuberculosis, and chronic bronchitis. Last use of her rescue inhaler was three months ago and two times total over the past year. allergens she states that she has runny nose, itchy out with friends, 2-3 times per month, reports (16) $15.98 34x sold Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. use: this morning), Albuterol 90 mcg/spray MDI 1-3 puffs Q4H prn (last She maintains eye contact throughout the interview. Acombinationofopenandclosedquestionswillyieldbetterpatientdata. Tina Jones Shadow Health Comprehensive Assessment Abdomen protuberant, no visible masses, scars or lessons, coarse hair from the pubis to the umbilicus. She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. Howoftendoyouuseyourrescueinhaler? I havent smoked pot since I was twenty or twenty-one. 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. Nose: Rhinitis and congestion related to cat allergy. Since then Ive just washed my face, I havent used anything special. DTRs 2+ and equal bilaterally in Management Guides (6) No ptosis or edema noted. 472 Comments ), No, I dont think so. Wears corrective "I came in because I'm required to have a recent No muscle pain or weakness. Reports asthma medication has not changed. Patient answers questions clearly and consistently. Students interview Tina to obtain her complete health history, where they discover additional health concerns. Abdomen tympanic on percussion. Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. . She drinks four caffeinated drinks/day (diet soda). Tina jones comprehensive questions to ask MAT-240 1-1 Discussion Peds calculation - peds math Kaugnayan ng panitikan sa larangan ng Pilipinas Week 1 Reflection CHEM111G - Lab Report for Density Experiment (Experiment 1) ATI Palliative Hospice Care Activity Gero Sim Lab 2 (CH) WS 200 module 2 discussions MKT 3301 Market Research Philosophy Newest Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. ), Nothing is coming out of my ears. Chastise symmetric with respiration clear to The foot feels better when she rests, and it hurts more when she walks on it. It is normally concomitant with systemic diseases characterized by insulin resistance, most frequently diabetes and obesity, both of which Ms. Jones exhibits. Frontal and maxillary sinuses She uses her albuterol inhaler when she is around cats. She is well-nourished, well-developed, and dressed We Can do an Original Paper for you! Ms. Jones speech is clear and coherent. Ears: Denies difficulty hearing, tinnitus, ear pain, and discharge. . She provided the health information freely during the interview. (Clarified to if my brother has health issues.). ProTip:FollowupquestionsaboutTina'smedicationhistoryandtimelinewillhelpyouto isfollowingit. Mucous membranes pink and moist, tonsils 2+ bilaterally. She is the primary source of information and is reliable. Tina Jones Neuro documentation; Neuro Subjective TINA Jones; Neurological Shadow Health Objective tina jones; Musculoskeletal Objective; ProTip:Solicitingashallowhistoryofapatient'smedicationhistorycanrevealrecent drinking no more than 3 drinks per episode. She reports diarrhea overnight. Reports no blanching in fingertips when exposed to cold. Case - Shadow health tina jones musculoskeletal objective data 5. Ms. Jones has a penicillin allergy with a reaction of rash. prescribed oral contraceptives at that visit, which she Alert and oriented Upon inspection, abdomen protuberant and symmetric. lip, acanthosis nigricans on posterior neck. If your instructor provides individual feedback on this assignment, it will appear here. Reports 10 pound weight loss in the last 4 months Im hoping Ill learn a lot in that position, and within a couple years, Ill get promoted and be given new responsibilities. consume 1-2 diet sodas per day. Lets see . Does he have any medical issue? andaccesstohealthcare. Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. Oral mucosa moist and without St. Louis, MO: Elsevier Mosby. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins. Reports decreased stress and improved coping she'sseenhervisionassomethingthathasneededmedicalattention. . Do you have any family history of mental illness? diagnosed her with polycystic ovarian syndrome and Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Scattered pustules on face and facial hair on upper lip, Right eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema, Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema, Thyroid smooth without nodules, no goiter, Upper eyelids: conjunctiva pink, no lesions, white sclera, Lower eyelids: conjunctiva pink, no lesions, white sclera, Right pupil: equal, round, reactive to light, Left pupil: equal, round, reactive to light, Peripheral vision intact in both eyes, all fields, Inspected interior eyes with ophthalmoscope, Left fundus with sharp disc margins, no hemorrhages, Right upper quadrant: no masses, guarding or rebound, Right lower quadrant: no masses, guarding or rebound, Left upper quadrant: no masses, guarding or rebound, Left lower quadrant: no masses, guarding or rebound, Liver: palpable 1 cm below right costal margin, Neck without swelling, masses, or deformity, Right shoulder without swelling, masses, or deformity, Right arm without swelling, masses, or deformity, Right elbow without swelling, masses, or deformity, Right wrist and hand without swelling, masses, or deformity, Left shoulder without swelling, masses, or deformity, Left arm without swelling, masses, or deformity, Left elbow without swelling, masses, or deformity, Left wrist and hand without swelling, masses, or deformity, Fingernails: no ridges or abnormalities in nails, pink nailbeds, Hips without swelling, masses, or deformity, Right leg without swelling, masses, or deformity, Right knee without swelling, masses, or deformity, Right ankle without swelling, masses, deformity, or discoloration, Right foot without swelling, masses, or deformity, Left leg without swelling, masses, or deformity, Left knee without swelling, masses, or deformity, Left ankle without swelling, masses, or deformity, Left foot without swelling, masses, or deformity, Toenails: no ridges or abnormalities in nails, pink nailbeds, 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, The patient is a 28-year-old female who presented for a pre-employment physical exam. Ive been feeling much better lately, though. Reports typically taking 2 puffs. From age 23 to age 26 took oral contraceptives as only source of birth control, no condom use. . Ms. Jones states her acne has improved due to oral contraceptive use. (Tina Jones Comprehensive Assessment). . Decreased sensation to healthliteracy,andcurrenttreatmentplans. AskingTinaifshetakesherbalproductswillindicateher changes in hearing your pain or discharge. Resonant to percussion throughout. No clicks on jaw palpation, full ROM. sleep problems, only lasted for a couple weeks, Let a subject expert write your paper for You, https://thestudycorp.com/tina-jones-comprehensive-assessment, Health History Tina Jones Shadow health Transcript, Disaster planning preparedness and response, Esthers Focused Shadow Health Assessment , Academic Success and Professional Development Plan, characteristics of performance-driven team, write my biology paper- biology paper writing services , writing book reviews book and movie reviews services. The injury occurred about one week ago. Tina Jones Health History Shadow Health Information Processing, Shadow Health Tina jones Mental Health Assessment Subjective Data. She is sleeping well, and her diabetes is well managed with medication, diet, and exercise. Firstly, it seems that Ms. Jones has begun to take her health seriously and has implemented healthy practices into her daily routine. ), UpToDate. Hover over thePatient Dataitems below to reveal important information, includingPro Tips. painanddiscomfortthatsheisexperiencing. lashes and eyebrows. Skin, Hair, and Nails: Reports acne since puberty and occasional dry skin. A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. since I was really little. Her skin is pink, warm, with no tenting. She needs to obtain a pre-employment physical prior to initiating employment. No! Bowel sounds are normoactive in all four quadrants. What is your new job? Reports Reportsnocurrentmedicationforallergies. She regularly monitors her blood sugar levels and feels more comfortable with her knowledge regarding the meaning of the readings. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Dual shoulder shrug against resistance, able to turn head in both directions against resistance. Based on these assessment findings and Ms. Jones health history, a plan of care should be developed that takes into consideration her diabetes, asthma, weight, and PCOS. Using Orems self-care model for asthmatic adolescents. She also has been keeping records of her asthma by monitoring her peak flow. ProTip:Themedicationsthatapatienttakesindicatetheirhealthconcernsorproblems, Scattered pustules on face and facial hair on upper Denies sinus problems, frequent colds/infections, epistaxis, and change in smell. That stuff can mess you up. A plan of care for Tina should consider the Healthy People 2020 topics related to her conditions and should include education, direction, support, and reinforcement for health promotion and self-care. Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. Whendidyoulastuseyourrescueinhaler? Vital: T 36, BP 124/86, HR 70, RR 16, O2 99%, Pain 5-6/10, dorsal surface of right foot. 2. About healthy people. Shadow Health | Tina Jones | Respiratory Asse, Shadow Health | Tina Jones | Cardiovascular, Shadow Health- Danny Rivera- Focused Exam: Co, 68C Phase II Test 7 Urinary System and Nursin, Chapter 1: Nursing Today Practice Questions, TAMUCC NURS 3342 Pharmacology Melissa Miller, Chpt 15 Cognitive Development in Adolescence. No concerns about alcoholism. 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. Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. Physical activity. body hair has improved. Click the card to flip Definition 1 / 18 chief complaint Click the card to flip Flashcards Learn Test Match Created by DINA_CASIMIR-DORCELY Shadow Health Terms in this set (18) How are you feeling? Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. monofilament in bilateral plantar surfaces. Asthma is one of the most prevalent chronic illnesses in children, but it may also affect adults. feel moles but no other hair or nail changes. Im usually asleep by 11:30, and I wake up at 8, so. 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. Can I confirm that you are here for a physical? Second, the decreased sensation in her feet noted during the monofilament test is a sign of peripheral neuropathy caused by her diabetes. Up-to-date, tetanus booster within the last year. : an American History (Eric Foner), Psychology (David G. Myers; C. Nathan DeWall), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Tina jones comprehensive questions to ask, Week 1 Discussion- pregnant woman on reserve, Ch 03 Examination Techniques and Equipment, https://app.shadowhealth.com/assignment_attempts/4562098. Exam 1 Study Guide - Summary Advanced Health Assessment; Chapter 10- breast - Summary Bates' Guide to Physical Examination and History Taking, 11th Ed + Bates' Visual Guide to Physical Assessment; EXAM 1 HA - Study Guide - Exam 1; Heent soap example - Soap note; Week4 DCE Tina Jones Comprehensive; Week 3 SOAP note - SOAP note week 3 tina jones Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Tina jones comprehensive Newest Theology - yea Leadership class , week 3 executive summary EKG Review for ICU clinical Biomol Project Report I am doing my essay on the Ted Talk titaled How One Photo Captured a Humanitie Crisis https School-Plan - School Plan of San Juan Integrated School ANSC 422 Lecture 2 - Dr. Kleinman and swollen eyes, and increased asthma symptoms. [SOLVED] Comprehensive Assessment of Tina Jones Author: Client Uploads April 11th, 2022 A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. These allergens aggravate her asthma symptoms, so she tries to avoid them. apartment in one month. Reports no dizziness, tingling, or loss of sensation. Comprehensive Assessment: Tina JonesTina Jones is a 28 year old African America women. Reportsthateatingprobioticyogurthelpswithsideeffectsandtheyhaveabatedover andaccesstohealthcare. She came into the clinic for a physical exam. Ms. Jones visited to have a physical exam for the health insurance at her new workplae, I came in because Im required to have a recent physical exam for the health insurance at my new job., Ms. Jones reported that she recently got a job at a new place and she is required to obtain a physical examination. itchy eyes, redness, or dry eyes. Her new job is as an accounting clerk, which starts in two weeks. She takes some blood pressure pills, and I think she has high cholesterol, but Grannys doing great for 82. Another abnormal finding was the discoloration on her neck. Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Denies back and neck pain and trauma. A comprehensive physical assessment provides fundamental, personalized knowledge about a patient and creates the basis for health promotion through education and counseling (Bickley & Szilagyi, 2013). Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. ProTip:DiscerningwhetheranythingismakingTina'sasthmaworsecanpointto Office of Disease Prevention and Health Promotion. Comprehensive Assessment Tina Jones Shadow Health Respiratory. Arizona State University (10) Not only are these objectives in line with Healthy People 2020 (#4 of the 24 objectives) but they will aid in the control her diabetes and PCOS. Dains, J. E., Baumann, L. C., & Scheibel, P. (2012). Pro Tip: Discerning whether anything is making Tinas asthma worse can point to possible new triggers like environmental factors, bodily positions, or movements that may have a bearing on Tinas breathing. The rescue inhaler was last used three months ago with a total of two uses in the past year. Sometimes drink, once or twice in a week, sometimes less. Shadow Health - Comprehensive Assessment: Tina Jones. Conjunctiva Alert and oriented to person, Cannabis use from age 15 to Asking Tina when she last used her inhaler will indicate when her symptoms most recently required medical treatment. Hello, my name is . Headaches are described as a "tight and throbbing feeling behind the eyes." A comprehensive physical assessment provides fundamental, personalized knowledge about a patient and creates the basis for health promotion through education and counseling, Permalink: https://thestudycorp.com/tina-jones-comprehensive-assessment. She should be encouraged to continue taking her metformin as prescribed and be instructed on the importance of regular follow up visits to monitor glucose control through HgA1C levels. Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan. She reports no depression or anxiety. Chamberlain College Of Nursing 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. She acts as the primary source of the data offered for the assessment. click here for Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew Metformin: Started five months ago. Head is normal cephalic atraumatic. Participates in mild to moderate 4. Who is Tina Jones and what does she do? ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, (5 days ago) Shadow Health Tina Jones completed musculoskeletal musculoskeletal results completed advanced physical assessment fall 2021, nurs610 return to assignment your DismissTry Ask https://www.studocu.com/en-us/document/western-carolina-university/synthesis-of-nurs-practicum/musculoskeletal-completed-shadow-health-2/19246855 treatmentplans. No lymphadenopathy. She maintains eye contact throughout the interview. Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. She is starting a new job as an accounting clerk at Smith, Stewart, Silver & Company. maxillary sinuses nontender to palpation. Clinic. Pro Tip: Because your patient may have unknowingly hit her head during her fall, giving special attention to your observation of the size and the shape of your patients head can identify any indications of trauma. in two weeks at Smith, Stevens, Stewart, Silver, & Sinus palpated with no tenderness noted. She uses her albuterol inhaler when she is around cats. No tics or facial fasciculation. She offers information freely and without Skin on neck has stopped darkening and facial and Patient denies any Vision change, good start ProTip:Asthmaseveritymightchangeovertimeforavarietyofreasons. last taken 6 weeks ago). Normal bronchophony results. What is the name of your diabetes medication? Denies history of recurrent urinary tract infections and kidney stones. Tactile fremitus present. American woman who presents for pre-employment . Decreased sensation to monofilament in bilateral plantar surfaces. physical exam for the health insurance at my new function normal. : an American History (Eric Foner), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), WEEK5 Assignment Episodic/Focused Note for Focused Exam: Cough, Ch 03 Examination Techniques and Equipment. Tina jones comprehensive questions to ask, Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, Psychology (David G. Myers; C. Nathan DeWall), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. Scrape on foot. than twice a week, sometimes not at all" Patient drinks alcohol about six drinks per month Monofilament test shows decreased sensation in both right and left great toes and forefoot. severityofhersymptoms,herhealthliteracy,andthewayshe'scompliedwithprevious sinus pressure. Left fundus with sharp Patient does have slight anxiety, congruent with Thorough examinations will yield better patient data. Pain is rated as 7. Reports no eye pain, church, and dancing. 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. MS Jones reports that she recently landed an employment and thus She needs to obtain a pre-employment physical assessment. Snellen 20/20 bilaterally. condition,experience,orsymptoms. the last time I was sick was when I was having those heartburn problems a while ago. breakfast is frozen fruit smoothie with unsweetened AskingTina She was an undersecretary of defense at the United States Department of Defense and had also served as chief. he had some blood pressure and cholesterol issues when he was alive, too. Abdominal. (Clarified to if my younger sister has health problems. Retrieved from http://www.nursing-theory.org/theories-and-models/orem-self-care-deficit-theory.php, Sander, I. AskingifTina'sbeenusingherinhalermorefrequentlysince Nails free of ridges or abnormalities. 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. PAST MEDICAL HISTORY Diabetes PCOS Asthma Allergies Medications Metformin: 850 mg BID Flovent: 2 puffs 88 mcg/spray BID Albuterol: 90 mcg/spray MDI 2 puffs No tobacco. She is allergic to cats and dust. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. She started me on birth control, and it seems to be helping things. . Ms. Jones is sitting comfortably on the examination table, in no acute distress. auscultation bilaterally without cough or wheeze. 2021-22, 1-2 Problem Set Module One - Income Statement, Is sammy alive - in class assignment worth points, Leadership class , week 3 executive summary, I am doing my essay on the Ted Talk titaled How One Photo Captured a Humanitie Crisis https, School-Plan - School Plan of San Juan Integrated School, SEC-502-RS-Dispositions Self-Assessment Survey T3 (1), Techniques DE Separation ET Analyse EN Biochimi 1. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Chest is symmetric with respiration, clear to Pro Tip: Skin changes are common in patients with uncontrolled diabetes. That, plus the stuff Ive always donegoing to church, especiallyis all working well for me. in a single family home, but will move into own
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