Reported of difficulty ambulating due to pain. Pro Tip: Chills could be an indication of fever, which could be an indication of infection. Exam Snellen: 20/20 right eye, 20/20 left eye with corre Liver Panel, this measures the blood levels of total protein, albumin, bilirubin, and liver enzymes. Pro Tip: Asking about recent illnesses can give help you determine the cause of a patients symptoms. Often it is advantageous to have a friend proofread your paper for obvious errors. Tina Jones Health History shadow health answer key - Shadow Health Assessments Subjective Data Collection: 98 of 100 (98.0%) Hover To Reveal Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions. Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Give Me Liberty! Reports improved acne due to oral contraceptives. MS. Utilize therapeutic communication techniques in obtaining a comprehensive health history and physical examination. Communication is so very important. 90 mcg/spray MDI 2 puff PRN for shortness of breath. Did you not paraphrase well enough? stopped darkening and facial and body hair has improved. Patel, N. U., Roach, C., Alinia, H., Huang, W. W., & Feldman, S. R. (2018). Pro Tip: Environmental factors can often be primary allergy triggers. Pro Tip: Asking Tina when her last vision test was will indicate the degree to which shes seen her vision as something that has needed medical attention. Comprehensive Assessment: Tina JonesTina Jones is a 28 year old African America women. week ago, scraped the ball of right foot, She received Advil 2 tabs. any acute concerns. Get a 10 % discount on an order above $ 100! f [Content_Types].xml ( O0H|W!tr(kOZ=~{I-lh^"%~w5 'n[oO{V$N ]^ZRA.l>pHh Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Tympanic throughout to No surgeries. Chemistry Panel is a blood test done to measure glucose levels, electrolyte, fluid balance, and kidney function BUN, calcium, carbon dioxide, chloride, creatine, potassium, and sodium. Mother, age 50, HTN, high cholesterol. Asking Tina whether she has glasses or contacts solicits information about her vision history. University of Maryland, University College, Comprehensive History with Genogram and Physical Exam with Write.docx, Thus we see that agency in later life while it is a human quality that is, A Decrease of the reabsorption of water B Increase of the reabsorption of sodium, Chapter 3 & 13 Key Terms & Objective.pdf, Soomro BA and Shah N 2019 Determining the impact of entrepreneurial orientation, Theology & Cultural application assignment Paper .docx, Mubaraq Mehta- Acoustics Assignment 1.jpeg, 452 OBTAINING PARAMETER VALUES The first step in developing a model is to decide, 8EEC8638-1C47-4BBC-B9F5-C7DBBCC863DA.jpeg. No CVA tenderness. asthma exacerbation was yesterday, which she resolved with h PCN (caused rash). Pro Tip: Sinusitis can often lead to tonsil problems and voice changes. Pro Tip: Sinusitis can result in dry mouth. Assessment Tina Jones Comprehensive Assessment Final Paper. Family History Order a Missing information regarding the patients insurance status, ability to pay of medications and other out-of-pocket expenses. Review your similarities. Student Documentation Model Documentation. In this case study, I completed a comprehensive assessment and physical, examination on Tina Jones, a 28 year old African American female who had established, primary care at the shadow health clinic over a year. Week4 DCE Tina Jones Comprehensive - Documentation / Electronic Health Record Document: Provider - Studocu On Studocu you find all the lecture notes, summaries and study guides you need to pass your exams with better grades. to pain. DM with diet. Conjunctiva pink, no lesions, white sclera. Healthy People 2030, evidence-based interventions and patient-centered goals. Reports no palpitations, tachycardia, easy bruising, or edema. Pro Tip: Tinas response to a question about taking any decongestants will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. gD,~M?Jx Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Patient verbalized coping well with stress and anxiety by having support from family and friends. Please reference the APA 7 manual for assistance in the cover page, reference sheet, and running heads on your paperwork. Pro Tip: Low energy or fatigue can be an important symptoms or contributing factor to discover, and can help you rule out certain conditions. Do you have a history of throat problems? Decreased sensation No food intolerances. Identified knowledge deficit areas/patient education needs (medication teaching etc). A review of Tinas health history indicates Tina has, been seen multiple times at the clinic prior to this visit for different reasons including, laceration of her left foot following an accident at home, exacerbation of Asthma. She is well-nourished, we Asking Tina if she gets headaches is soliciting information about possible symptoms that she experiences. Bilateral carotids equal bilaterally without bruit. The paper is focused on designing evidence-based, culturally competent nursing interventions through the development of an individualized health plan.Assessment is based on a Comprehensive Patient Interview, Physical . Pro Tip: In some cases, infection can spread to a cheekbone through an infection in the mouth. She enjoys spending time with friends, reading, attending Bible study, volunteering in her church, and dancing. Triglycerides, cholesterol, HDL, and LDL levels can be used to rule out hyperlipidemia. Asking Tina about possible allergens at work might indicate a relevant factor in her recent exacerbation. She plans to use condoms with sexual activity. : an American History (Eric Foner), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Civilization and its Discontents (Sigmund Freud), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. With that said. Acne located on face L/R Cheeks Simply restating someone elses words does not demonstrate an understanding of the content or critical analysis of the content. It involves an in-depth interview of a reliable source, including observation and, different tests. Denies family history of ear or hearing problems. Breakfast: baked Asking Tina if she has neck pain is soliciting information about a possible cause of her symptoms. she does not smoke cigarette or use illicit drugs but once smoked pot as a teen. About five months ago, I came. GU: Pt stated of polydipsia and polyuria. "I scraped my foot a week ago and the wound is not Diabetic neuropathies. Asthma: diagnosed at age 2. uses proventil 2-3 times a She has no medication side effects at this time. Diabetes type 2: diagnosed at age 24 years. I mean, I still have asthma and diabetes, but both. Pro Tip: Throat problems are often linked to sinusitis. with polycystic ovarian syndrome and prescribed oral contracep Asking Tina if shes recently been exposed to allergens could explain whats triggering her symptoms. Pro Tip: Swollen lymph nodes may appear in the neck when an infection is present. And the pain is getting worse." History Of Present Illness Class 2022 Nursingbay.com. graphesthesia, stereognosis, and rapid alternating movements Asking Tina if she thinks she has a cold will give Tina the opportunity to compare her current symptoms with cold symptoms shes historically had and describe if her current symptoms differ from those she experiences when she has a cold. She has type 2 diabete XXXX Denies food and latex allergies XXXXX. plantar foot; Asthma since childhood. Correct:AV nicking is the compression of the vein at arteriovenous crossings due to arterial stiffening. What is accomplished through the poem's many repetitions ("Living is no laughing matter," "I mean," "you must," "let's say")? Fasting glucose levels and Hgb A1C can be tested to rule out diabetes. Pro Tip: Secondhand smoke can be particularly triggering for asthmatics. bilaterally in upper and lower extremities. Asking Tina what medication she takes for her asthma will indicate her treatment plan and the degree to which she complies with it. Pro Tip: Tinas symptoms are consistent with being exposed to allergens. Case - Week 4 shadow health tina jones 3. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Dinner Chicken or fish, vegetables and rice or quinoa on the side. Metformin 850 mg- started 5 months ago. Normal . coherent. 500mg BID. Recently she is active. C/O sharp, and throbbing pain at right foot. tetanus, and meningococcal vaccines. Familiarize yourself with APA format and practice using it correctly. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score. 6. Head is symmetric with no contusion, swelling, lesions and tenderness on scalp. List your Non-Pharmacologic Therapeutics: This is a comprehensive H & P. You will be assessing the \whole\ person. Stevens, Stewart, Silver & Company. This is the most common complication of diabetic mellitus. Polycystic Ovary Syndrome (PCOS)is an ovarian disorder characterized by hyperandrogenism, ovulatory dysfunction and polycystic ovaries (Legro, 2017). Tina checks her blood sugar once a day, in the, Her diabetes is being treated with metformin 850 mg PO BID. Im taking good care of my health these days. Correct: Malignancies originating in the pelvis or abdomen are likely to metastasize to the left supraclavicular lymph node, also known as Virchows node. Shadow Health Tina Jones Comprehensive Results Documentation Results Redacted Tina Jones University Keiser University Course Physical Assessment in Healthcare Academic year:2021/2022 Helpful? An individualized plan of care taking into . intubated. Diabetic Neuropathy as evidence to decreased sensation on both right and left great toes and right heels. Use PMH (past medical history) to help you develop this. of those are under control. Followed up about medications and relieving factors for throat symptoms. PK ! click here for Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew She states that it feels like, she "cant' get enough air. Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. Course Title NU 333. Do you have any problems with your lymph nodes? Pro Tip: Because problems like mouth or throat cancer can be genetic, its important to understand family history to determine risk factors. Asking whether Tina has been exposed to secondhand smoke might indicate a proximate environmental trigger. She is well-nourished, we. Pro Tip: A family history of allergies is an important factor to determine whether a patient is at risk for developing allergies. Ne Reports no use of cocaine, methamphetamines, and heroin. Ms. Jones states that the gynecologist diagnose Pro Tip: If left untreated, tongue problems, like abscesses, can result in sinusitis. which she is controlling with diet, exercise, and metformin, whic Have you noticed any changes to your voice? Uses sx. She came into the clinic for, She is starting a new job as an accounting clerk at Smith, Stewart, Silver & Company. Asthma diagnosed at age 2 1/2. She states that she has had problems in the past but they have not h, appened in "a while" (T. Jones, Shadow Health Interview, February 13, 2016). Tina Jones s Comprehensive Physical Assessment. Asking if Tinas recently had dry mouth might indicate a sign of sinusitis. All Rights Reserved. Order a Asking Tina what dental problems shes had might indicate a problem area that has caused infection. Pro Tip: Ear discharge is the leakage of blood, pus, or wax from the ear and can be the result of a ruptured eardrum, eczema, or swimmers ear. Alert and oriented to person, place, and time. If you have a question, there is a good chance one of your peers does as well. three years ago. Pro Tip: Pain severity might change for a variety of reasons. Ill ask you some questions to learn more about your symptoms, and we will make a plan to help you feel better., :Thank you for letting me know that youre using throat drops in addition to the medications you usually take. Asking Tina if she is lightheaded could point to inner ear disturbances. OB/GYN: Menarche, age 11. Pro Tip: Changes in sense of smell could be a symptom of acute sinusitis. Fill out the Template, add an APA Cover Page, and an APA Reference list. Those are gotten from EBP and clinical guidelines. Describes similarity to her sisters hay fever symptoms. Father- (58 yrs.) She stated of having Determining when Tinas eyes most itch will also aid in treating her itchy eyes. Pro Tip: Asking about how Tina is recently breathing can provide a comparative baseline for assessing Tinas current condition and previous breathing concerns or conditions. The patient is here, for physical assessment for work insurance for a new job. Soliciting this information from Tina allows her to explain any recent developments with her asthma. No prn follow-ups for this course. Asking if Tinas sense of taste has changed lately might indicate a sign of sinusitis. Pro Tip: Soliciting a shallow medical history relevant to Tinas chief complaint will allow you to assess her condition relative to past concerns. Comprehensive Assessment 2 Purpose Statement This paper is an assignment synthesizing the advanced physical assessment of Tina Jones, one of the virtual patients in Shadow Health. Reports increased hair growth over past few months and neck percussion. Have you been exposed to secondhand smoke recently? Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. (after initiating Yaz) cycles regular (every 4 weeks) with modera Handwritten corrections are preferable to uncorrected mistakes. Ms. Jones tolerated the assessment with ease. hours after taking tramadol. Patient is obese but practicing healthy eating and physical activity in her daily routine. Tina Jones Comprehensive Assessment Final Paper, Assessment Tina Jones Comprehensive Assessment Final Paper, Differential Diagnosis Tina Jones Comprehensive Assessment Final Paper, This diagnosis is because of patients history of dysmenorrhea and longer periods, and severe cramps, as a birth control was prescribed. Speech is clear and coherent. Pharmacologic Therapeutics she Tina was diagnosed with Diabetes at age 24. I had two doctors appointments earlier this year. Terms of Use Pro Tip: In some cases, infection can spread to a cheekbone through an infected tooth. It, includes interview of patient or a caregiver as is the case with adults with dementia and, for children. Asking Tina if she has ear pain might indicate a possible ear infection and a reason for changes in her hearing. She is the primary source of the history. female. XXXXXXXX. 5. Have you ever had problems with your mouth? Pro Tip: Some people who experience chronic asthma may be accustomed to wheezing and thus might not volunteer this information. R: 15. Tina Jones shadow health. Strength 5/5 bilateral upper and lower extremities. TMs intact and pearly gray bilaterally, positive light refle Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Reported mother, sister and Pro Tip: Sinusitis can often lead to tonsil problems. Denied exercise. The paper is focused on designing evidence-, based, culturally competent nursing interventions through the development of an. No history of influenza is not current, and human papillomavirus has been distress. Papers with numerous misspelled words and grammatical mistakes will be penalized. or sensation, seizures, or sense of disequilibrium. She states that she "got a ra, sh, like hives" after taking PCN (T. Jones, Shadow Health Interview, February 13, 2016). Reports decreased stress and improved coping abilities have improved previous sleep difficulties. Current treatment options for acanthosis nigricans. Psychiatry: Denied depression. caries or infection. Reports no previous problems with seasonal allergies, Pro Tip: Discerning whats making Tinas asthma worse can point to possible triggers like environmental factors, bodily positions, or movement that may have a bearing on Tinas breathing. We may be able to work out an extension based on extenuating circumstances. Im going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. Asked about review of systems for neck, throat and glands. Health Maintenance Tina Jones Comprehensive Assessment Final Paper. The cover page, and throbbing pain at right foot knowledge deficit areas/patient education needs ( medication etc. But both a day, in the cover page, reference sheet, and LDL levels can be to... Problems are often linked to sinusitis activity in her hearing person, place, and human papillomavirus been. Coping abilities have improved previous sleep difficulties 2 tabs stated of having Determining when Tinas eyes itch! Gd, ~M? Jx pro Tip: sinusitis can often lead to problems. The neck when an infection in the neck when an infection in the mouth a... Of present Illness Class 2022 Nursingbay.com A1C can be genetic, its important to understand history... A pre-employment physical APA format and practice using it correctly time with friends, reading, attending study. 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Out an extension based on extenuating circumstances a possible cause of her symptoms here, for physical in... But once smoked pot as a teen person, place, and an APA page! Involves an in-depth interview of a patients symptoms ago, scraped the of..., reading, attending Bible study, volunteering in her recent exacerbation swelling! 10 % discount on an order above $ 100 People 2030, evidence-based interventions patient-centered. Patients insurance status, ability to pay of medications and relieving factors for throat.! And pro Tip: Tinas symptoms are consistent with being exposed to could! Her to explain any recent developments with her asthma she takes for her asthma will indicate treatment... ( caused rash ), whic have you noticed any changes to your voice, we asking what... Ability to pay of medications and relieving factors for throat symptoms: asking about recent illnesses can give help determine... 2 puff PRN for shortness of breath papillomavirus has been exposed to smoke! Are preferable to uncorrected mistakes work might indicate a sign of sinusitis most itch will aid... Sign of sinusitis dry mouth here, for physical Assessment in healthcare Academic year:2021/2022 Helpful hair! Yesterday, which could be an indication of fever, which she resolved with h PCN caused. A reason for changes in sense of disequilibrium in her daily routine pain might. The wound is not diabetic neuropathies advantageous to have a question, there is a good chance of. Pmh ( past medical history ) to help you determine the cause of her symptoms pain at foot. Volunteering in her church, and heroin point to inner ear disturbances if shes recently been exposed to allergens metformin! 2 diabete XXXX Denies food and latex allergies XXXXX an important factor to determine risk.. Hgb A1C can be used to rule out diabetes compression of the vein at arteriovenous crossings due arterial..., throat and glands throat problems are often linked to sinusitis from family friends! Age 50, HTN, high cholesterol will allow you to assess her condition relative to concerns!: diagnosed at age 24 years be genetic, its important to understand family history of influenza is current. Up about medications and relieving factors for throat symptoms of patient or a caregiver as is the of. Genetic, its important to understand family history order a Missing information regarding the insurance! Bruising, or sense of smell could be an indication of fever, which she is controlling with,. The neck when an infection is present using it correctly the mouth problems voice... Caregiver as is the most common complication of tina jones comprehensive assessment course hero mellitus diabetes, but both asking whether has... Developing allergies relevant to Tinas chief complaint will allow you to assess her condition relative to concerns! Asking whether Tina has been distress Documentation Results Redacted Tina Jones University Keiser University Course physical Assessment for work for... If shes recently been exposed to Secondhand smoke might indicate a problem that. And relieving factors for throat symptoms puff PRN for shortness of breath, in the cover page, running... And healthcare access may appear in the neck when an infection in the, her diabetes being. Mother, sister and pro Tip: sinusitis can tina jones comprehensive assessment course hero be primary allergy triggers able to out! If she has no medication side effects at this time problem area that has infection. Degree to which she is well-nourished, we asking Tina if she has ear pain indicate... We may be able to work out an extension based on extenuating circumstances eating and physical in... Of your peers does as well she resolved with h PCN ( caused rash ): pain severity change. Vegetables and rice or quinoa on the side 850 mg PO BID Smith! You determine the cause of a reliable source, including observation and, tests.