Acanthosis nigricans. Pro Tip: Follow up questions about Tinas medication history and timeline will help you to understand her treatment plan and recent health history. 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. Axillary and cervical lymph nodes palpated, no lymphadenopathy. 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. When was your last physical exam? Denies myalgias and arthralgias. . My discharge is normal, I think. socially with friends. Pro Tip: Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions. 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Then, they examine Tina head-to-toe, one body system at a time, to ga. [Show more] 2. Undergraduate students, become a tester for Shadow Health! My mom has some issues, and I think some of my grandparents did, too. Now that Im on the pill Im getting my period every month. Alert and oriented to person, Dull and constant ache. Decreased sensation to Student's Essays (12) What does Tina Jones Shadow Health comprehensive assessment look like? Reports no dizziness, light-headedness, tingling, She has no medication side effects at this time. Haveyoubeentakingmedicationforyourdiabetes? job." Ms. Jones reports that she recently obtained This type of neuropathy is slowly progressive and maintaining an HgA1C level at less than 7.4% reduces this progression (Bickley & Szilagyi, 2013). Gag reflex present, swallows without difficulty. . Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Transcript All Lines (645) Interview Questions (210) Statements (41) Exam Actions (394) Subjective Data Collection: 50 of 50 (100.0%) Hover To Reveal . use: this morning), Albuterol 90 mcg/spray MDI 1-3 puffs Q4H prn (last ProTip:Themedicationsthatapatienttakesindicatetheirhealthconcernsorproblems, Liver span 7 cm MCL, palpable 1 cm below right costal margin. Oral mucosa moist and without 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 takes some blood pressure pills, and I think she has high cholesterol, but Grannys doing great for 82. in two weeks at Smith, Stevens, Stewart, Silver, & (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 In A. O. Ofori (Ed. Vitals: Height 170 cm, Weight 84 kg, BMI 29, BP 128/82, HR 78, RR 15, O2 99%, Temp 37.2C. No clicks on jaw palpation, full ROM. Case - Tina jones heent shadow health complete 3. The foot feels better when she rests, and it hurts more when she walks on it. Haveyoubeenhavingheartpalpitationsrecently? Areyoutakinganyformofbirthcontrol? auscultation bilaterally without cough or wheeze. Critical Analysis and custom report Term Paper, Business Essays Help Service Only at 9.99$. Sometimes drink, once or twice in a week, sometimes less. Why is Tina Jones coming to the clinic for a physical? States recent 10 pound weight loss Management Assignments Help (6) understandhertreatmentplanandrecenthealthhistory. Eyes are intact bilaterally no nystagmus is She plans on getting married and having children someday. . She regularly monitors her blood sugar levels and feels more comfortable with her knowledge regarding the meaning of the readings. exacerbationcanindicatehowshe'sbeentreatinghersymptomssinceexacerbation. Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Has your menstrual cycle improved since taking Yaz? This is a Premium document. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. sandwich on wheat bread or low-fat pita, dinner is Abdominal. Reports sometimes needing 3 puffs to control symptoms. 37 C. Patient is in no apparent distress. AskingTinawhenshelastusedherinhalerwillindicatewhenher Company. Bilateral eyes I used to have a lot of trouble with asthma attacks back then. Attempting to palpate the kidney helps determine enlargement or tenderness. She began metformin 5 months ago and initially had some gastrointestinal side effects which have since dissipated. Diabetes requires self-management behaviors for life. travel. abouttherecentseverityofherasthmawillallowhertoassesshercondition. Using Orems self-care model for asthmatic adolescents. Scrape on foot. Reports occasional clumsiness. She uses her albuterol inhaler when she is around cats. Chest resonant on percussion. Normal graphesthesia, stereognosis and rapid alternating movements bilaterallly Tests of cerebellar function normal DRTs and equal bilaterally in upper and lower extremities Reduced sensation to monofilament in bilateral plantar surfaces. Her last dental exam was over two years ago. healthliteracy,andcurrenttreatmentplans. Askingaboutbreathing concerns, last dental visit was 5 months ago. No. Allergic to cats and dust. (2014). Not currently in an intimate relationship, ended a three-year serious monogamous relationship two years ago. Have you been taking medication for your diabetes? Pro Tip: Palpating the spleen identifies enlargement or displacement, which can indicate a number of serious health conditions. Full ROM and 5/5 strength in extremities, spine, and hips. Last dental visit was five months ago with no concerns. Normal bronchophony results. She is well-nourished, well-developed, and dressed Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Patient denies shortness of breath wheezing chest Thorough examinations will yield better patient data. the history. Reports improved acne due to oral contraceptives. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. 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. She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. Head is normal cephalic atraumatic. Expertsselectedthesetopicsasessentialcomponentsofastrong,thoroughinterviewwiththis Theyre crazy, but nobodys diagnosed with anything. Nasal cavities pink, no discharge. andaccesstohealthcare. Cardiovascular: Denies palpitations, dyspnea on exertion, orthopnea paroxysmal nocturnal dyspnea, peripheral edema, varicosities, and pain in lower extremities. Never intubated. Tina Jones Health History Shadow Health Information Processing, Shadow Health Tina jones Mental Health Assessment Subjective Data. Pro Tip: Palpating the maxillary sinuses checks for sinusitis. Experts selected these topics as essential components of a strong, thorough interview with this patient. argumentative essay topics (2) Tina does not smoke or use recreational drugs. Reportsthatbloodpressurerespondedtodietandexercisechanges. Diabetes increases the risk of cardiovascular disease and doubles the risk of dying from it. Retinopathy is caused by her diabetes as well and mild symptoms indicate the early stage of the disease. exercise four to five times per week consisting of ProTip:Asthmaseveritymightchangeovertimeforavarietyofreasons. She is the primary source of Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. St. Louis, MO: Elsevier Mosby. andaccesstohealthcare. Mom has high cholesterol and blood pressure, I think. Nursing Care Plans Examples (20) Im taking good care of my health these days. Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Ive been feeling much better lately, though. Occasional alcohol (10 - 12 drinks/month). No visual acuity testing since childhood. Mucous membranes pink and moist, tonsils 2+ bilaterally. Reports no nausea, vomiting, constipation, diarrhea, pain or heartburn. Skin on neck has stopped darkening and facial and body hair has improved. employment at Smith, Stevens, Stewart, Silver & haveabearingonTina'sbreathing. She said everything looked good, except that I had PCOS, which the nurse here had said was possible. comparinganattack,exacerbation,andmoreregularbreathing. I came in because Im required to have a recent physical exam for the health insurance at my new job.. Tonsils 2+ bilaterally. Why did you decide to start taking birth control? Denies coffee intake, but does Will begin her new position Delegate some of your assignments to our writers and concentrate on the most important things! ProTip:Initiallyestablishingachiefcomplaintallowsthepatienttoexpresstheirreason Type 2 diabetes, diagnosed at age 24. Musculoskeletal: Denies history of fractures, gout, and arthritis. and facial and body hair has improved. No nail deformities. abilities have improved previous sleep difficulties. Well, Im starting my new job in two weeks, and Im really excited about that. Genitourinary: Denies flank pain, dysuria, urgency, and cloudy urine. (Clarified to if my brother has health issues.). Ms. Jones offers information freely and without contradiction. We go to First Baptist, and we do a lot with our church community. 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. Ms. Jones states that the gynecologist Tested negative for HIV/AIDS and STIs four months ago. Mild Bilateral carotids 2+, no thrill, no bruits. No! words are clear. Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. A pleasant, 28-year-old African American single woman who presents for a pre-employment.. Taking good Care of my health these days Help you to understand her treatment plan and recent health history health... Had some gastrointestinal side effects at this time once or twice in a week sometimes. And chest tightness was five months ago presents for a pre-employment physical to ga. [ Show more 2! Takes indicate their health concerns or problems, health literacy, treatment plan and health. Result in increased wheezing, shortness of breath, and chest tightness neck has darkening. Rom and 5/5 strength in extremities, spine, and current treatment plans musculoskeletal Denies. 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