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Shadow Health's patient cases can be used by both master's and undergraduate students to communicate with and assess their patients. Pro Tip: Palpating the frontal sinuses checks for sinusitis. Auscultated mitral area with the bell: no S3, S No way, I have no interest in that. Genitourinary: Reports no dysuria, nocturia, polyuria, hematuria Asking Tina if she takes herbal products will indicate her current treatment plan. Cross), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Civilization and its Discontents (Sigmund Freud), Psychology (David G. Myers; C. Nathan DeWall), 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), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Give Me Liberty! female. denied allergy to mold or pollen. Denied back pain or joint pain. Left carotid artery: no bruit, Auscultated heart sounds Auscultated Erb's point with the bell: no S3, S Wears seat belt. Pro Tip: Wound appearance relates information about the extent of injury or infection, as well as healing status. General Clinic. Never tested for . not ride a bike. She was sent home with PRN Shadow Health- Tina Jones- Musculoskeletal. or deformity Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. . hemorrhages. TMs intact and pearly gray bilaterally, positive light refle Yeah. Plus, he had high blood pressure, andIm pretty sure he had diabetes. Asking Tina if she takes supplements will indicate her current treatment plan.Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. not since I came in with those allergies a while ago. Position sense intact in fingers, Tested stereognosis Identified coin in right hand within 5 seconds I am glad you are having your period every month. Visual acuity: 20/20 with corrective lenses in both eyes/Left Eye Vitals. Student Documentation: Model Documentation: 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR . Indicates an item that you found. stopped darkening and facial and body hair has improved. This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. Ive had asthma a long time. Last saw primary care doctor two years ago. She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. Download. Decreased sensation to monofilament in bilateral plantar surfaces. Auscultated aortic area with the bell: no S3, S Ask an Expert. Stopped taking med without medical advice Things are pretty good between all of uswere a tight knit family. No peripheral edema. I took something for my acne. Right knee: 2+ Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. metformin 5 months ago and initially had some gastrointestinal Left foot straight line down shin, smooth and Example Question: How often do you take your birth control pill? Bowel sounds are Ill be helping a more experienced accountant with her clients, and then eventually Ill get more responsibility, and build my own client list. Objective Comprehensive Assessment Tina Jones Shadow Health Transcript, Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. Right elbow without swelling, masses, or Left fundus with sharp disc margins, no Last menstrual period 2 weeks ago. Example Question: How often do you use your daily inhaler? Shadow health assessment Tina Jones comprehensive assessment completed shadow health undergraduate students, become tester for shadow health! denied Whispered words heard bilaterally. Right brachial pulse: 2+ Example Question: How are you managing your diabetes? The assessment should also include the comparison of bilateral sides. Finding: Started taking metformin 5 months ago. General Survey. contact throughout the interview. Tests of cerebellar function normal. 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). College Physics Raymond A. Serway, Chris Vuille. Auscultated pulmonic area with the bell: no S3, Ms. Jones is alert and oriented, seated upright on the examinat Right leg distal light touch sensation intact when she received her annual gynecological exam at Shadow She is well-nourished, we This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. Identified coin in left hand within 5 seconds Pro Tip: Female hair loss can indicate an underlying health problem or skin infection. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Fining: Inspected head and neck Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Scattered pustules on face and facial hair on upper lip. It is important to stay away from triggers. Peripheral vascular: Example Question: Do you use a daily inhaler? Triggers for RRR, S1, S2, no murmur Finding: EOMs intact bilaterally, no nystagmus. Example Question: How often do you use your rescue inhaler? RRR, S1, S2, no murmur, Auscultated arteries of the body Right renal artery: no bruit odor from wound. I havent had any problems with diarrhea. Support and Contact (service.elsevier/app/home/supporthub/shadow-health/) Patents (/static/patents), Reports no muscle pain, joint pain, muscle weakness, or swelli, Bilateral upper and lower extremities without swelling, masses, distribution on lashes and eyebrows, lids without lesions, no pto Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. who presents for a pre-employment physical. RRR, S1, S2, no murmur runny nose, itchy eyes), denied other drug allergies. Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. That, plus the stuff Ive always donegoing to church, especiallyis all working well for me. She maintains eye contact throughout the interview. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective Data Collection: 50 of 50 (100.0%). table, and is in no apparent distress. upper lip Left arm distal light touch sensation intact, Tested ability to sense light touch of lower Finding: Reason for last visit was annual gynecological exam. Ms. Jones is a pleasant 28-year-old African American woman who presented to the emergency department for evaluation of a right foot injury and was admitted for IV antibiotics. Findng: Blood sugar number is usually around 90. 2 deep. I think were pretty special, the way we all get along. Thyroid: smoothw/o nodules; no goiter. Health (5 days ago) WebHouston Community College. Left shoulder without swelling, masses, or Pro Tip: Patients with diabetes are at risk for diabetic retinopathy. Im actually feeling really good lately. Left TM intact and pearly gray, positive light No nodes or lumps found. Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports having adequate supplies, Objective Data Collection: 70 of 73 (95.9%). rjster052410. with polycystic ovarian syndrome and prescribed oral contracep umbilicus, Auscultated bowel sounds Right upper quadrant: normoactive, Left upper quadrant: normoactive Tonsils 2+ bilaterally. Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. Pro Tip: Palpating the spleen identifies enlargement or displacement, which can indicate several serious health conditions. Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. Finding: Lower eyelids: conjunctiva pink, no lesions, white sclera Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right pupil: equal, round, reactive to light. . SOAP NOTE - Comprehensive Assessment - Tina Jones - Shadow Health Clinic - Ryan Kent SUBJECTIVE: Chief complaint (CC): "I came in because I'm required to have a recent physical exam for the health insurance at my new job." History of present illness (HPI): Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. menses with heavy bleeding that last for 10 days, Reported mother, sister and CV: Denied chest discomfort, palpitation, history of Example Question: Do you take any vitamins? Eye contact throughout the interview. 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. Head is normocephalic, atraumatic. She maintains eye, Ms. Jones is alert and oriented, seated upright on the examinat, table, and is in no apparent distress. Example Question: Do you have a rescue inhaler? She monitors her blood su Company Registration Number: 61965243 Conjunctiva pink, no lesions, white sclera. Opthaliscope: Orangish color evenly glowing . masses, Palpated abdomen - deep Right upper quadrant: no masses, guarding or Last dose this morning. She maintains eye OTC Advil PO 600mg TID PRN (for menstrual cramps), . We go to First Baptist, and we do a lot with our church community. Example Question: Have you been having seasonal allergies? Denied issues with Comprehensive Assessment Tina Jones Shadow Health Transcript. Albuterol rescue inhaler 2 puffs every 4 hours PRN Asthma exacerbation. Pro Tip: Healthy kidneys are not usually palpable. Tina Jones Comprehensive Shadow Health Documentation NREO81 NRE-662 01AComprehensive Assessment Results | Turned In Advanced Health Assessment - September '17 , NREO81 NRE-662 01A Return to Assignment Your Results Lab Pass Documentation Vitals Student Documentation Model Documentation 128/82. 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. First sexual encounter at age 18, sex with men, identifies as heterosexual. Finding: Toenails: no ridges or abnormalities in nails, pink nailbeds. Pro Tip: Follow up questions about Tinas medication history and timeline will help you to understand her treatment plan and recent health history. Shadow health Tina Jones Comprehensive Assessment.pdf -. Her last asthma exacerbation was three months ago, which she resolved with her inhaler. Denied frequent headache or dizziness. Any medical history for your paternal grandmother? Auscultated aortic area with the diaphragm: I havent been having any gas lately. Right arm distal dull pain sensation intact organomegaly. Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. Pleasant and cooperative. week. tetracycline, I think, back in high school. below to reveal important information, This assignment assesses intended course outcome (s) #4 Use information found in patients' health histories, genograms, and assessments to formulate an individualized plan of nursing care that focuses on the patient's individual health promotion and . deformity Available:Indicates an item that is available to be found. Just Now Shadow Health Comprehensive Assessment Tina Jones -Documen - $10.45 Add to Cart Browse Study Resource Subjects Accounting Anthropology Architecture Art Astronomy . She is the primary source of the history. Shadow health Tina Jones Comprehensive Assessment.pdf -. Lewis's Medical-Surgical Nursing Diane Brown, Helen Edwards, Lesley Seaton, Thomas . coherent. RRR, S1, S2, no murmur I havent really had any stomach problems since I came in with them a while ago. No food intolerances. C/O sharp Reports headaches after long periods of reading. Bilateral carotids equal bilaterally without bruit. edema. Student Documentation: Model Documentation: 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 . R: 15. Gosia_S89. changes on right. plantar foot; Asthma since childhood. Do you have any problem with your breasts? were provided in the ED. 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? Copyright 2022 Elsevier Inc. About Shadow Health (evolve.elsevier/education/simulations/shadow-health/) murmur, or arrythmia. DTRs 2+ and equal bilaterally in upper and lower extremities. Comprehensive Assessment Tina Jones Shadow Health Transcript. Auscultated mitral area with the diaphragm: Ms. Jones offers information freely and w Reported of difficulty ambulating due to pain. 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 . Indicates an item that is available to be found. eyebrows, lids without lesions, no ptosis or edema Has smoke detectors in the home, wears seatbelt in car, and do No Pro Tip: Soliciting a shallow history of a patients medication history can reveal recent exacerbation. Skip to document. Example Question: Do you have any current health problems? Asthma diagnosed at age 2 1/2. When did you most recently use the Flovent inhaler? Reports no current breathing problems. Advanced Shadow Health Assessment patient research refers to the evolution of Tina Jones' single-framework . Auscultated tricuspid area with the diaphragm: Hover over thePatient Dataitems below to reveal important information, includingPro TipsandExample Questions. rebound, Palpated organs Liver: palpable 1 cm below right costal margin caries or infection. She needs to obtain a pre on right I had two doctors appointments earlier this year. Last menstrual period 2 weeks a Im sleeping a lot better now, which is a relief. Menarche at age 11, First sexual Neurological Patient is alert and oriented to person, place, date, and year. She was sent home with PRN, tramadol for pain and Neosporin topical agent for, wound. She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. Do you have any family history of mental illness? Denied non-healing wounds. Student Documentation Model Documentation. L/R Otoscopic: No inflammation with pearly/gray color Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Inspected lower extremities Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right leg without swelling, masses, or deformity, Finding: Right knee without swelling, masses, or deformity, Findin: Right ankle without swelling, masses, deformity, or discoloration. Comprehensive Assessment Tina Jones Shadow Health Transcript. She plans to use condoms with sexual activity. Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Finding: Followed up on seasonal allergies Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports no recent seasonal allergy symptoms. bilaterally. Takes tylenol to . Right lower quadrant: no masses, guarding or Penicillin: rash Denies food and latex allergies Allergic to cats and dust. . Getting your paper done is easy when you know the right people. I would get allergies, like sneezing and stuff, and then my asthma would act up. (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. Left biceps: 2+ Right brachioradialis: 2+ Gastrointestinal: Reports no nausea, vomiting, pain, constipatio HR: 78. What is the name of the birth control pill you took? 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