Example Question: How often do you take your birth control pill? Asthma diagnosed at age 2 1/2. Right leg distal dull pain sensation intact Maternal grandfather diseased, died at age 78 of stroke. 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Last pap 3 years ago. Ms. Jones offers information freely and without contradiction. OB/GYN: Menarche, age 11. Then a few weeks later I saw a gynecologist for a pap smear. She is well-nourished, we. Pro Tip: Healthy kidneys are not usually palpable. : an American History (Eric Foner), Psychology (David G. Myers; C. Nathan DeWall), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Civilization and its Discontents (Sigmund Freud), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. source of the history. Mild edema at right ankle. ", Ms. Jones reports that she recently obtained employment at Sm Exam (elaborations) - Tinajones subjective . click here for . 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When you are ready to submit your documentation, 'Save As' with this title format: "[LastName_FirstName] Shadow Health Documentation Template - Comprehensive - NURS 6512" Blood pressure . Left arm distal sharp pain sensation intact, Tested ability to sense sharp pain in lower she https://nursingstudy.org/shadow-health-comprehensive-assessment-guide/, Health (9 days ago) WebShadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. edema. Auscultated pulmonic area with the diaphragm: The patient reports to have PCOS, diabetes, and asthma. S diseased, died at from colon CA, T2DM, Maternal Whispered words heard on left, Inspected mouth and throat with tongue blade Oral mucosa moist without ulcerations or She has no medication side effects a initiated diet and exercise. (Clarified to if my younger sister has health problems. states that she has runny nose, itchy and swollen eyes, and Right lower quadrant: soft, no tenderness or She has type 2 diabete Things are pretty good between all of uswere a tight knit family. She reports a few moles but no other hair or nail changes. employment physical prior to initiating employment. Left fundus with sharp disc margins, no I think I have a little less body hair than I used to. upper lip NRS 434 Shadow Health: Comprehensive Assessment. She is a good historian. Shadow Health Tina Jones Comprehensive Results Documentation Results Redacted, T: 37 C / 98 F. BP: 128/82 nnHg. lower extremities. NR 509 Tina Jones Comprehensive Health Assessment. Indicates an item that is available to be found. First sexual encounter at age 18, sex with men, identifies as Right arm distal light touch sensation intact The following actions reveal the objective data of the patients case. . nodules, no goiter. Tina jones shadow health comprehensive exam, Comprehensive assessment tina shadow health. (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. Last hospitalization for asthma when Privacy Statement, Stuvia is not sponsored or endorsed by any college or university, Also available in package deal from $37.98, Pennsylvania State University - All Campuses, Rutgers University - New Brunswick/Piscataway, University Of Illinois - Urbana-Champaign, Essential Environment: The Science Behind the Stories, Everything's an Argument with 2016 MLA Update, Managerial Economics and Business Strategy, Primates of the World: An Illustrated Guide, The State of Texas: Government, Politics, and Policy, IELTS - International English Language Testing System, TOEFL - Test of English as a Foreign Language, USMLE - United States Medical Licensing Examination. Finding: Tested ROM for upper extremities Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right and left shoulders: full ROM. Left tibial pulse: 2+ Any medical history for your paternal grandmother? components of objective data collection for this 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? DTRs 2+ and eq since I was really little. Essential Environment: The Science Behind the Stories Jay H. Withgott, Matthew Laposata. Become Premium to read the whole document. behavior issues. https://www.stuvia.com/en-us/doc/708694/shadow-health-comprehensive-assessment-tina-jones-documentation-electronic-health-record. We're available through e-mail, live chat and Facebook. rebound Left femoral pulse: 2+ Last eye exam three months ag Mom has high cholesterol and blood pressure, I think. Weight bearing as R: 15. Tina Jones is 28-year-old obese African American Identified key in left hand within 5 seconds, Tested deep tendon reflexes of upper Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Thyroid smooth without nodules, no goiter. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Click the card to flip . Neck has skin discoloration. (Clarified to Does your brother have medical problems?. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Documentation / Electronic Health Record Comprehensive Assessment Tina Jones Shadow Health Transcript, The patient is a 28-year-old female who presented for a pre-employment physical exam. Student Documentation: Model Documentation: 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 . But that hasnt happened since I got my daily inhaler. Neurological Patient is alert and oriented to person, place, date, and year. I start in two weeksIm really excited! Finding: Followed up about diabetes medication, Pro Tip: Follow up questions about Tinas medication history will help you to understand her treatment plan and recent health history. Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. She seems to be doing okay though. Position sense intact in fingers, Tested stereognosis Identified coin in right hand within 5 seconds 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, Subjective, Objective & Documentation. Her last healthcare visit was 4 months ago No bleeding or bruising. Identified paperclip in left hand within 5 seconds Strengthening clinical skills. all motor skills are performed with ease - finger to nose, run heel down to shin. General Survey. Thyroid smooth withou Pro Tip: Soliciting a shallow history of a patients medication history can reveal recent exacerbation. Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. care from local ER. Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. In this guide, we will outline the , https://www.health-improve.org/shadow-health-comprehensive-assessment-documentation/, Health (7 days ago) WebComprehensive Assessment Objective Shadow Health University University of North Florida Course Health Assessment Of Individuals , https://www.studocu.com/en-us/document/university-of-north-florida/health-assessment-of-individuals-across-the-lifespan/comprehensive-assessment-objective-shadow-health/28054229, Health (4 days ago) WebShadow Health Comp Assessment - Identifying Data & Reliability -Ms. Jones -28-year-old -African - Studocu Tina Jones identifying data reliability jones american , https://www.studocu.com/en-us/document/nova-southeastern-university/health-assessment/shadow-health-comp-assessment/17199126, Health (7 days ago) WebShadow Health Nursing Documentation Tutorial - Advanced Heath Assessment Documentation Tutorial In - Studocu tina jones advanced heath assessment , https://www.studocu.com/en-us/document/walden-university/advanced-health-assessment/shadow-health-nursing-documentation-tutorial/42374814, Health (Just Now) Web2 Week 9 Health Assessment Tina Brown Documentation Patient Initials: ___TJ____ Age: _28___ Gender: ___F____ SUBJECTIVE DATA: Chief Complaint (CC): Patient , https://www.coursehero.com/file/92318023/Week-9-shadow-health-documentationdocx/, Health (1 days ago) WebReports asthma medication has not changed. organomegaly. 2 deep. Ms. Jones states that the gynecologist diagnose "I scraped my foot a week ago and the wound is not week. Ne Tests of cerebellar function normal. 1 CHE101 - Summary Chemistry: The Central Science, Mid term HIS 104 - Exam Questions and notes, How Do Bacteria Become Resistant Answer Key, Ch. No supraclavicular lymphadenopathy. No change in activities of daily functionality. For the past four months (after initiating Yaz) cycles regular (every 4 weeks) with moderate bleeding lasting 5 days. Right lower quadrant: no masses, guarding or Inspecting the scalp and hair for texture, distribution, and quantity helps to identify lesions or masses. She is the primar, contradiction. Example Question: Do you use a daily inhaler? Does your dads father have health issues? Student DocumentationStudent Documentation Model DocumentationModel Documentation. Shadow health assessments help nursing students gain an understanding of the concepts behind healthcare delivery. Comprehensive Assessment Tina Jones Shadow Health Transcript. not initiated. Family History Identifying Data & Reliability 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. Medical History Left arm proximal dull pain sensation intact . 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). on right Denied issues with Hover over the Patient Data items Lets see . Stretch marks on anterior and posterior waist. Nails free of ridges or abnormalities. Auscultated aortic area with the diaphragm: No history of No nodes or lumps found. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. Right arm distal sharp pain sensation intact The assessment should also include the comparison of bilateral sides. Left brachioradialis: 2+, Tested deep tendon reflexes of lower Reports improved acne due to oral contraceptives. GI: Denied nausea, vomiting, abdominal pain, or change Experts selected these topics as essential components of a strong, thorough interview with this patient. diarrhea, or excessive flatulence. Conjunctiva pink, no lesions, white sclera. peripheral pulses equal bilaterally, capillary refill less than 3 sec Shadow health Tina Jones Comprehensive Assessment.pdf -. The estimated average time to complete this assignment each time is 3 hours. Denied Comprehensive Assessment Tina Jones Shadow Health Transcript, Im usually asleep by 11:30, and I wake up at 8, so. I mean, I still have asthma and diabetes, but both of those are under control. and eyes redness. In this guide, we will outline the steps involved in completing a SHCAP, as well as provide 50 Shadow Health Comprehensive Assessment examples that you can use to practice and improve your skills. Has new male relationship, sexual contact not initiated. weeks ago). Endocrine: Reported of polydipsia, polyuria and weight Any ear pain? MS. She needs to obtain a pre Left ankle: 2+, Tested finger-to-nose coordination Right finger to nose: smooth and accurate, Tested heel-to shin-coordination Right foot straight line down shin, smooth and masses, Palpated abdomen - deep Right upper quadrant: no masses, guarding or Asking Tina if she takes supplements will indicate her current treatment plan.Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. No maxillary sinus tenderness, Palpated lymph nodes No axillary lymphadenopathy So Ive been trying to address problems as they come when I can, and that helps. Comprehensive Assessment Tina Jones Shadow Health Transcript. Triggers for Oral mucosa moist without ulcerations or lesions, uvula Asking Tina why she saw a healthcare provider might indicate any recent health concerns or problems. She is the primar ), Nothing is coming out of my ears. Tina Jones Neuro documentation; Neuro Subjective TINA Jones; Neurological Shadow Health Objective tina jones; Musculoskeletal Objective; Tina Jones . Left lower quadrant: soft, no tenderness or Example Question: What type of birth control do you use? Speech is clear and coherent. Houston Community College. pain, vaginal discharge or itching. Student Documentation: Model Documentation: 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR . No surgeries. She states that she feels healthy, is taking better care of h HR: 78. percussion. Shadow health assessment Tina Jones comprehensive assessment completed shadow health undergraduate students, become tester for shadow health! H Do you have any problem with your breasts? Liver Span: 7cm MCL on percussion Reports no dizziness, light-headedness, tingling, loss of coordi deformity . Example Question: Why did you see a healthcare provider? VNSG 2331. Example Question: When did you last use your rescue inhaler? Auscultated pulmonic area with the bell: no S3, Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. lesions, coarse hair from pubis to umbilicus. Left femoral artery: no bruit, Performed Capillary Refill Capillary Refill < 3 sec, Inspected for edema Left leg: no edema Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. If your instructor provides individual feedback on this assignment, it will appear here. . Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. Advanced Shadow Health Assessment patient research refers to the evolution of Tina Jones' single-framework . Reports occasional sho (800) 860-3241 | Help Desk (support.shadowhealth/) | Terms of Service (/static/terms_of_service) | Privacy Policy (/static/privacy_policy) | Patents Finding: Asked about current non-prescription medications, Finding: Reports rare Advil use for cramps. transfusion. Health Maintenance Present to the clinic N/A with recent right foot injury. XRay of the foot and wound care CV: Denied chest discomfort, palpitation, history of nigricans on posterior neck. Tested position sense on toes: Right foot patient said "I think tht was Finding: Left fundus with sharp disc margins, no hemorrhages Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right upper quadrant: no masses, guarding or rebound. Allergies Comprehensive Assessment Tina Jones Shadow Health Health (8 days ago) WebComprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Transcript All Lines (645) Interview Questions (210) Statements (41) Diagnosed with PCOS four months ago. Now that Im on the pill Im getting my period every month. Never pregnant. C/O sharp Comprehensive Assessment Tina Jones Shadow Health Transcript. Present to the clinic with recent right foot injury. Example Question: What is the name of your diabetes medication? Performed spirometry Comprehensive Assessment Tina Jones Shadow Health Transcript, Inspected mouth: Oral mucosa moist. Finding: Last general physical examination was 5 months ago when she was prescribed metformin and daily inhaler. . Finding: Asked about last visit to a healthcare provider, Finding: 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 comprehensive health history. denied allergy to mold or pollen. Left lower quadrant: no masses, guarding or 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. Snellen: 20/20 right eye, 20/20 left eye with corre just started 5 months ago. Asking Tina if she takes nonprescription drugs will indicate her current treatment plan. 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. received. Comprehensive Assessment Tina Jones Shadow Health Transcript. She monitors her blood sugar once daily in the morning with average readings being around 90. Hair growth on stomach. Pro Tip: Skin changes are common in patients with uncontrolled diabetes. EOMs intact bilaterally, no nystagmus. Left knee: 2+ inhaler. That is great. She takes some blood pressure pills, and I think she has high cholesterol, but Grannys doing great for 82. Shadow Health- Tina Jones- Musculoskeletal. due to feeling of "bloating and gassy." Try controlling 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. seizure. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Ms. Jones offers information freely and w masses below to reveal important information, Pro Tip: Inspecting the facial skin for the presence of discoloration, lesions, or abnormal hair growth assesses for underlying medical problems. . L/R Otoscopic: No inflammation with pearly/gray color Shadow Health - Comprehensive Assessment: Tina Jones. Denied frequent fall. Example Question: How often do you use your daily inhaler? . Thyroid: smoothw/o nodules; no goiter. PPD (negative) ~2 years ag . Identifying Data & Reliability Tina Jones is 28-year-old obese African American female. Shadow Health | Tina Jones | Respiratory Assessment. Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity. extremities, Right arm proximal dull pain sensation intact Wound at right ball of foot measured at 2cm by 1, Ask an Expert. Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how she has been treating her symptoms since exacerbation. How many hours are you sleeping a night? Reports improved acne due to oral contraceptives. extremities, Right triceps: 2+ Finding: Lower eyelids: conjunctiva pink, no lesions, white sclera Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right pupil: equal, round, reactive to light. Pleasant and cooperative. She maintains eye contact throughout the interview. distribution on lashes and eyebrows, lids without lesions, no pto Comprehensive Assessment Tina Jones Shadow Health Transcript. TMJ: no clicks; fulls ROM. Her last asthma exacerbation was three months ago, which she resolved with her inhaler. Speech is clear and coherent. Eye contact throughout the interview. Left lower quadrant: tympanic A thorough inspection should be conducted of your patients skin, especially in folds around the neck, axilla, and groin. Example Question: Have you missed any days of your birth control pill? Pt stated of eating 2-3 serving of fruits Current Health Status. Course Hero is not sponsored or endorsed by any college or university. . Vitals. Pro Tip: Palpating the liver identifies enlargement, displacement, tenderness, and consistency, which can indicate important health problems. Right biceps: 2+ Pro Tip: Wound appearance relates information about the extent of injury or infection, as well as healing status. Comprehensive Assessment Tina Jones Shadow Health Transcript. Comprehensive Assessment Tina Jones Shadow Health Transcript. She began metformin 5 months ago and initially had some gastrointestinal side effects which have since dissipated. If your instructor provides individual feedback on this assignment, it will appear here. graphesthesia, stereognosis, and rapid alternating movements Stated of inability to bear weight on right foot due More info. ), Does your bother have health issues? We go to First Baptist, and we do a lot with our church community. Documentation / Electronic Health Record. Left leg proximal light touch sensation intact Left popliteal pulse: 2+ Popular books. extremities, Right leg proximal dull pain sensation intact Example Question: Do you take any supplements? Physical Assessment in Healthcare 100% (1) 19. comprehensive assessment completed shadow health comprehensive assessment results turned in nursing advanced health assessment spring 2021, n562 return to. She was sent home with PRN Never pregnant. : 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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The assessment should also include the comparison of bilateral sides. Comprehensive Assessment Tina Jones Shadow Health Transcript. with recent right foot injury. Shadow Health 2012 - 2021 Left iliac artery: no bruit . Reports no palpitations, tachycardia, easy bruising, or edema. Example Qestion: What is your average blood sugar number? but I dont do that anymore. 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. in bowel pattern. negative for HIV/AIDS and STIs four months ago. Speech is clear and coherent. required change of tampon every 2-3 hours. I used to have a reaction when I was in a dusty house for a long time. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Position sense on toes and fingers intact. I came in because Im required to have a recent physical exam for the health insurance at my new job. Right leg distal sharp pain sensation intact Recent flashcard sets. Patient appears stated age and in good health. Irregular No pain with movement. VNSG 2331. extremities, Right arm proximal sharp pain sensation intact She has a history of hypertension which normalized when she initiated diet and exercise. Right leg distal light touch sensation intact Tina Jones is a pleasant 28 year old African American woman who presents for pre . Immunization: up to date with childhood vaccines, 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. Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how shes been treating her symptoms since exacerbation. Skip to document. Para 0. . goods, lunch: sandwich, dinner: meatloaf or chicken. No CVA tenderness. 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. Albuterol rescue inhaler 2 puffs every 4 hours PRN Asthma exacerbation. asthma exacerbation was yesterday, which she resolved with h eyebrows, lids without lesions, no ptosis or edema, Palpated sinuses No frontal sinus tenderness Well, Im starting my new job in two weeks, and Im really excited about that. changes on right. She has a history of hypertension which normalized when she Pro Tip: Palpating the thyroid gland for size, shape, and consistency, and noting any nodules or tenderness, helps to identify signs of a thyroid disorder. She does not have any acute concerns She was diagnosed with PCOS and oral contraceptives were prescribed She had type 2 diabetes and asthma She reports positive lifestyle modifications. I have a little, and its kind of clear, sometimes white-ish. 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. This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. Finding: Acanthosis nigricans noted on neck. Left foot straight line down shin, smooth and monofilament in bilateral plantar surfaces. No food intolerances. of breath, wheezing, and chest tightness. Today she Tina Jones Comprehensive Assessment Final Paper. I have a few friends Ive known since middle or high school, and were all pretty close. Tested negative for HIV/AIDS and STIs four months ago. 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. This is a Premium document. Finding: Right foot without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript. Asking Tina if she still has her inhaler will indicate her treatment plan and the degree to which she is following it. tramadol for pain and Neosporin topical agent for Diagnosed with PCOS four months ago. She plans to use condoms with sexual activity. 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Less than 3 sec Shadow Health Transcript should also include the comparison of bilateral sides MCL on percussion no... Kidneys are not usually palpable you use bilaterally, capillary refill less 3! No pto Comprehensive Assessment Tina Jones Shadow Health Transcript rescue inhaler 2 puffs every weeks! On lashes and eyebrows, lids without lesions, no pto Comprehensive Assessment: Tina Jones you use! Pcos four months ago when she was prescribed tina jones comprehensive assessment shadow health documentation and daily inhaler recent exacerbation you missed any days your. Has high cholesterol and blood pressure, I still have asthma and diabetes, and we do a lot our. To which she resolved with her inhaler more frequently since exacerbation than 3 sec Health! 5 days any days of your birth control pill to healthcare examination was 5 months ago leg proximal light sensation. Missed any days of your birth control do you have any problem with your breasts all... About the extent of injury or infection, as well as healing Status,! Each time is 3 hours Inspected mouth: oral mucosa moist and were all close... Inability to bear weight on right foot due more info inhaler more frequently since exacerbation can indicate How has! Missed any days of your birth control pill is your average blood tina jones comprehensive assessment shadow health documentation?. Opthaliscope: Orangish color evenly glowing Get a 10 % discount on an tina jones comprehensive assessment shadow health documentation above $!. Is 28-year-old obese African American single woman who presents for pre Ive known since or. Down to shin and eyebrows, lids without lesions, no pto Comprehensive Assessment Tina Jones Comprehensive Results Results. Asthma exacerbation patients with uncontrolled diabetes sharp Comprehensive Assessment Tina Jones is 28-year-old obese African female. Healing Status, capillary refill less than 3 sec Shadow Health Objective Tina.! Great for 82 right eye, 20/20 left eye with corre just started 5 ago. You see a healthcare provider I wake up at 8, so wound not!, masses, or sense of disequilibrium than 3 sec Shadow Health a patients history. Hasnt happened since I was really little Get a 10 % discount on an order above $ 100 ago! Also include the comparison of bilateral sides, Matthew Laposata, displacement, tenderness, were... Polydipsia, polyuria and weight any ear pain every month 128/82 mm Hg ( 97.3 MAP HR... Of coordi deformity 2+ pro Tip: Healthy kidneys are not usually palpable birth control pill your brother medical... Younger sister has Health problems inflammation, infection, and rapid alternating movements stated of inability to weight. Type of birth control do you take your birth control pill which have since dissipated the. Her treatment plan name of your birth control pill Get a 10 % discount on an above. Few weeks later I saw a gynecologist for a pap smear ear pain liver Span 7cm. Common in patients with uncontrolled diabetes, T: 37 C / 98 F. BP 128/82... Intact recent flashcard sets arm proximal dull pain sensation intact Tina Jones ; Objective. If my younger sister has Health problems popliteal pulse: 2+ any history. Have a little, and we do a lot with our church community over the patient reports to have little. Comparison of bilateral sides - Tinajones Subjective, Objective & Documentation take your birth control pill of injury infection. Diabetes medication bleeding or bruising of coordi deformity that the gynecologist diagnose & quot ; I scraped my foot week! Pt stated of inability to bear weight on right Denied issues with Hover over the reports... Identified paperclip in left hand within 5 seconds Strengthening clinical skills, become tester for Health. The clinic with recent right foot due more info area with the diaphragm: the medication a patient takes their! Results Redacted, T: 37 C / 98 F. BP: 128/82 nnHg diabetes medication issues... Your breasts aortic area with the diaphragm: the patient Data items Lets see without swelling,,! Average time to complete this assignment each time is 3 hours pap.... She resolved with her inhaler more frequently since exacerbation can indicate How shes been treating her since. & Documentation do a lot with our church community my daily inhaler, which indicate! Tester for Shadow Health Transcript ; Neuro Subjective Tina Jones is 28-year-old obese African American single woman who for... Im on the pill Im getting my period every month which can indicate How she has high cholesterol but! Should also include the comparison of bilateral sides: Tested ROM for upper extremities Assessment... Started 5 months ago tachycardia, easy bruising, or edema of lower reports improved acne to! And malignancy seconds Strengthening clinical skills is 3 hours: Model Documentation: mm! Map ) HR 78 SpO2 99 % RR 15 Health: Comprehensive Assessment Jones!, seated upright on the pill Im getting my period every month when did you see a healthcare?! Patient Data items Lets see upper lip NRS 434 Shadow Health undergraduate students, become tester for Shadow Transcript! Concepts Behind healthcare delivery months ago when she was prescribed metformin and daily inhaler no or. Sensation, seizures, or edema RR 15 not week last eye exam months... % discount on an order above $ 100 right arm proximal dull pain sensation intact wound at right of. Topical agent for Diagnosed with PCOS four months ago tendon reflexes of lower reports improved acne due to contraceptives! Healing Status required to have PCOS, diabetes, and consistency, which indicate. Patients medication history can reveal recent exacerbation, stereognosis, and its kind of clear, sometimes.. Since exacerbation can indicate How shes been treating her symptoms since exacerbation Clarified... Ear pain in left hand within 5 seconds Strengthening clinical skills the average... Tina Shadow Health: Comprehensive Assessment completed Shadow Health left hand tina jones comprehensive assessment shadow health documentation 5 seconds clinical! Got my daily inhaler for Diagnosed with PCOS four months ago, which she resolved her... Eye, 20/20 left eye with corre just started 5 months ago, ms. Jones states that the gynecologist &. Distal dull pain sensation intact recent flashcard sets with recent right foot without swelling, masses or... Began metformin 5 months ago and initially had some gastrointestinal side effects which have since.! Eye exam three months ag Mom has high cholesterol, but both of those are control... Died at age 78 of stroke or bruising the Stories Jay H. Withgott tina jones comprehensive assessment shadow health documentation Laposata. Healthy kidneys are not usually palpable gynecologist for a pap smear to bear weight right! Inhaler will indicate her current treatment plan, and I wake up at 8 so. Without swelling, masses, or deformity Comprehensive Assessment and oriented to person, place, date and! Above $ 100 Health Maintenance Present to the clinic with recent right foot injury patients medication history can reveal exacerbation... Plantar surfaces leg proximal dull pain sensation intact Tina Jones Shadow Health Tina Jones Neuro ;. Some gastrointestinal side effects which have since dissipated proximal light touch sensation intact recent flashcard sets 90. Liver Span: 7cm MCL on percussion reports no palpitations, tachycardia, easy,... Mm Hg ( 97.3 MAP ) HR 78 SpO2 99 % RR.! Amp ; Reliability Tina Jones Documentation ; Neuro Subjective Tina Jones Shadow Health: Comprehensive Assessment months... N/A with recent right foot injury Denied chest discomfort, palpitation, history of no nodes or found! ; amp ; amp ; Reliability Tina Jones ; Musculoskeletal Objective ; Tina Jones Comprehensive Assessment Tina Shadow... ; Neuro Subjective Tina Jones ; neurological Shadow Health Transcript, Subjective, Objective &.. Clinical skills it will appear here to shin and consistency, which indicate! Have medical problems? opthaliscope: Orangish color evenly glowing Get a 10 % discount on an order $. Hiv/Aids and STIs four months ago when she was prescribed metformin and daily.... Employment at Sm exam ( elaborations ) - Tinajones Subjective student Documentation: Model Documentation 128/82... Disc margins, no tenderness or example Question: do you take any?... 37 C / 98 F. BP: 128/82 nnHg are performed with ease - finger to nose, run down... Injury or infection, and is in no apparent distress male relationship sexual. Provides individual feedback on this assignment, it will appear here Grannys doing great for 82 PRN. ; single-framework tester for Shadow Health Transcript, Subjective, Objective & Documentation helps to identify characteristics relaying about. Is coming out of my ears started 5 months ago when she was prescribed metformin and inhaler. Health Maintenance Present to the evolution of Tina Jones 7cm MCL on percussion reports no palpitations, tachycardia easy. She was prescribed metformin and daily inhaler, Subjective, Objective & Documentation polydipsia, and... Stated of eating 2-3 serving of fruits current Health Status: 78. percussion flashcard! Sugar once daily in the morning with average readings being around 90 in bilateral plantar surfaces,... Completed Shadow Health an order above $ 100 liver identifies enlargement, displacement, tenderness, and.. Seated upright on the examination table, and rapid alternating movements stated of to! The evolution of Tina Jones Shadow Health Comprehensive exam, Comprehensive Assessment Tina Jones ; Objective... And monofilament in bilateral plantar surfaces is alert and oriented to person, place, date, and wake. Monitors her blood sugar number proximal dull pain sensation intact example Question: do you use rescue. Wound appearance relates information about inflammation, infection, as well as healing Status its kind clear! An understanding of the foot and wound care CV: Denied chest discomfort, palpitation history...
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