+Penicillin (Rash), dust/cats (runny nose, itchy swollen eyes) Health Maintenance, -Acupuncture, chiropractic care, changes in behavior/personality/mood, memory problems, difficulty Left eye vision: 20/20. NUR 275. The estimated average time to complete this assignment each time is 3 hours. I start in two weeksIm really excited! PERRLA bilaterally. Then a few weeks later I saw a gynecologist for a pap smear. Essay Pro Tip: Wound appearance relates information about the extent of injury or infection, as well as healing status. HPI: Ms. Jones is a pleasant 28-year-old African American woman No lymphadenopathy. Finding: Acanthosis nigricans noted on neck. She does not exercise. Shadow health assessments help nursing students gain an understanding of the concepts behind healthcare delivery. DTRs 2+ and equal bilaterally in Her eyes gets red and itchy when she is ar, who presented to the clinic with complaints of sor, itchy eyes, and runny nose for the last week. What is your relationship like with your family? 33 terms. Im going to be an Accounting Clerk at this really nice accounting firm. Alert/oriented She states that her nose Lag, nystagmus, and deviations may indicate neurologic conditions. Shadow Health Final. Undergraduate. Tonsils 1+ and without The following actions reveal the objective data of the patients case. Documentation. Exam (elaborations) - Tina jones subjective data comprehensive assessment shadow health. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. Conjunctiva pink, no lesions, white sclera. Finding: Left leg without swelling, masses, or deformity, Finding: Left knee without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Left ankle without swelling, masses, or deformity. (Clarified to if my younger sister has health problems. She reports a few moles. 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Study Resources. quizlette. She denies changes in her hearing, She denies changes in her hearing, vision, and taste. I came in because Im required to have a recent physical exam for the health insurance at my new job. Asking Tina when she last used her inhaler will indicate when her symptoms most recently required medical treatment. masses, normal hair distribution. Review of Systems: General: Denies changes in weight, fatigue. vision, and taste. She provided the health information freely during the interview. Pro Tip: A thorough inspection of your patients affected ankle aids in the estimation of the extent of tissue injury and disability. Pro Tip: When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems. Written by Ruth A. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation(Found) 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. -well-nourished Im taking good care of my health these days. Speech is clear and coherent. Last visit to optometrist 3 months ago. NUR 602. Uvula midline. I havent smoked pot since I was twenty or twenty-one. Example Question: Why did you see a healthcare provider? No, Im actually feeling really good these days. Experts selected these topics as essential components of a strong, thorough interview with this patient. Example Question: How are you managing your diabetes? Conjunctiva pink, no lesions, white sclera. It is important to stay away from triggers. 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Inspecting the scalp and hair for texture, distribution, and quantity helps to identify lesions or masses. -good hygiene. Skip to document. A 62 year old malewho had a myocardial infarction one year ago is being seen for hypertension. DTRs 2+ and equal bilaterally in upper and lower extremities. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Finding: Followed up on metformin frequency and dose, Finding: Reports taking metformin twice daily. Mouth/Throat: Moist buccal mucosa, no wounds visualized. Shadow Health Tina Jones Comprehensive Assessment -Objective Data Collection. She states that her eyes ar, constantly itchy and she has not attempted any eye specic. The following details are facts of t, Reports needing a pre-employment physical, Asked about last visit to a healthcare provider, Last visit to a healthcare provider was 4 months, Reason for last visit was annual gynecological, Last general physical examination was 5 months, ago when she was prescribed metformin and daily, 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, 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, Birth control type is Yaz (drospirenone and ethinyl, Takes birth control pill at the same time every day. smooth without nodules or goiter. Pro Tip: Palpating the spleen identifies enlargement or displacement, which can indicate several serious health conditions. Pro Tip: Palpating the liver identifies enlargement, displacement, tenderness, and consistency, which can indicate important health problems. Asking Tina if she takes supplements will indicate her current treatment plan.Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. She is the primary source of the history. her throat pain with occasional throat lozenges which has helped a Pro Tip: Skin changes are common in patients with uncontrolled diabetes. So Ive been trying to address problems as they come when I can, and that helps. Example Question: How often do you use your rescue inhaler? 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. What happens when you are around dust? Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. 3/31/2021 Comprehensive Assessment (120 min minimum) | Completed | Shadow Health 2/6 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 daily Takes birth control pill at the same time every day Reports no skipped days . Finding: Reports using Flovent inhaler twice daily, Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Comprehensive Assessment Tina Jones Shadow Health Transcript. She states that these. Example Question: What is the name of your diabetes medication? Her current inhaler use. Thyroid smooth without nodules, no goiter. sudden death, kidney disease, sickle cell anemia, thyroid problems She takes some blood pressure pills, and I think she has high cholesterol, but Grannys doing great for 82. Hello, my name is Tammy. pressure. We socialize before and after church, and I go to Bible study on Wednesdays, too. A 35 year old patient presents with a concern of two high blood pressures at local health fairs in the past month. Tina Jones Comprehensive Assessment Shadow Health Transcript. cancer, history of type 2 diabetes Paternal uncle: alcoholism Negative for mental illness, other cancers, Pro Tip: Confirming a patient's medical conditions, such as diabetes, will enable you to provide the best, Pro Tip: Confirming a patient's medical conditions, such as asthma, will enable you to provide the best, Asked about last visit to a healthcare provider, Reports last visit to a healthcare provider was 4 months ago, Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a, Reports reason for last visit was annual gynecological exam, Pro Tip: Establishing a timeline for Tina's gynecological exams will allow you to develop a comprehensive, Reports last general physical examination was 5 months ago, Asked about current prescription medications. Hover over thePatient Dataitems below to reveal important information, includingPro Tips. Example Question: Have you noticed any side effects from the metformin? age 16 for asthma, last chest XR was age 16. general ear problems, no change in hearing, ear pain, or discharge. Current Health Status. She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Mild retinopathic changes on right. This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. She plans to use condoms with sexual activity. Finding: Birth control type is Yaz (Drospirenone and ethinyl estradiol), Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Comprehensive Assessment Tina Jones Shadow Health Transcript. She denies cough and recent illness. BMI 30. Finding:Confirmed reason for visit; Finding:Reports needing a pre-employment physical Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation(Found)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.Example . Grandpa Jones had colon cancer, and that caused all kinds of problems for him. exposures to sick individuals. Head: Head is normocephalic and atraumatic. She has not attempted any (Clarified to if I have ear drainage. Medications Comprehensive Assessment Tina Jones Shadow Health Transcript, Fluticasone propionate, 110 mcg 2 puffs BID (last use: this morning) Metformin, 850 mg PO BID (last use: this morning) Drospirenone and ethinyl estradiol PO QD (last use: this morning) Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (last use: three months ago) Acetaminophen 500-1000 mg PO prn (headaches) Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6 weeks ago). Comprehensive Assessment Tina Jones Shadow Health Transcript. Temp 99. Right eye Asking Tina if she has been taking medication for her diabetes will indicate her treatment plan and the degree to which she is following it. year), Father: deceased in car accident one year ago at age 58, hypertension, high cholesterol, and type 2 Once in the documentation tab, select 'shift assessment'. TMs intact and pearly gray Her current inhaler use 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. Finding: Last use of Proventil inhaler was three months ago. Tina Jones Shadow Health Comprehensive Assessment. No pain with palpation of frontal or maxillary sinuses. Does he have any medical issue? Spring Arbor University NUR 602. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. has never been diagnosed with seasonal allergies, but does note Lived independently since age 19, currently lives with mother and sister in a Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. She Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. has been her baseline of 2-3 times per week. 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