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shadow health comprehensive assessment objective

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. Ill be helping a more experienced accountant with her clients, and then eventually Ill get more responsibility, and build my own client list. That doesnt sound like it would be good. 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. Lab Pass (/assignment_attempts/9017767/lab_pass). Do you have any family history of mental illness? Reports no change in sense of smell, 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. I start in two weeksIm really excited! It is important to stay away from triggers. Has new male relationship, sexual contact not initiated. . My discharge is normal, I think. Last menstrual period 2 weeks ago. Normal convergence. intact bilaterally, no nystagmus. physics. (Clarified to if my brother has health issues.). How does interviewing a heathy patient differ from interviewing a patient with a known health condition? Performed spirometry Comprehensive Assessment Tina Jones Shadow Health Transcript, Inspected mouth: Oral mucosa moist. Review of Systems: General: Denies changes in weight, fatigue. Finding: Toenails: no ridges or abnormalities in nails, pink nailbeds. Example Question: Can I confirm that you are here for a physical? Confirming the name of Tinas birth control pill will solicit information about her health history and current treatment plan. She states that these. No She monitors her blood sugar once daily in the morning with average readings being around 90. For the past four months (after initiating Yaz) cycles regular (every 4 weeks) with moderate bleeding lasting 5 days. with mild cobblestoning. Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, -Occupation: Smith, Stevens, Stewart, Silver & Company, -presents for a pre- employment physical. For HA3005, it is a similar process to HA3004. A combination of open and closed questions will yield, better patient data. We go to First Baptist, and we do a lot with our church community. I had a little when I first started metformin, but I found out I could eat yogurt to help it, and it seems to have worked. Tina gets headache and blurry visions when she is reading or Pro Tip: A thorough inspection of your patients affected ankle aids in the estimation of the extent of tissue injury and disability. Course Hero is not sponsored or endorsed by any college or university. Last Updated: 30 November 2021. That stuff can mess you up. Does he have any medical issue? Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how she has been treating her symptoms since exacerbation. Im sleeping a lot better now, which is a relief. her treatment plan and the degree to which she is following it. I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler. to diet change and exercise increase. No recent or frequent illness, fatigue, fevers, chills, or night sweats. of a strong, thorough interview with this patient. attending Bible study, volunteering in her church, and dancing. No recent foreign Asking Tina what triggers her allergies will indicate, in part, Tinas health literacy. Nails free of ridges or abnormalities. Has your menstrual cycle improved since taking Yaz? that her throat pain seems to be worse in the morning. Comprehensive Assessment Tina Jones Shadow Health Transcript. Ears: Ear shape equal bilaterally. of blurry vision after reading for extended periods. She denies use of tobacco. -Mrs. Jones Reliable historian 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. pressure. No pain with palpation of frontal or maxillary sinuses. 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. reveals mild retinopathic changes. Once three months ago, and before that it had been months, too. Example Question: Are you taking any form of birth control? Head is normal cephalic atraumatic. 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). Tina gets headache and blurry visions when she is reading or studying for too long. Temp 99. Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. I used my Flovent inhaler this morningI have to take it twice a day. Experts selected these topics as essential components of a strong, thorough interview with this patient. Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. She seems to be doing okay though. Identifying Data & Reliability She denies cough and recent illness. -good hygiene. who presented to the clinic with complaints of sore, itchy throat, Head is normocephalic, atraumatic. Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words. ago), received childhood vaccinations, meningococcal vaccine (in college), hospitalized in high school for Head: Denies history of trauma. Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. Getting your paper done is easy when you know the right people. Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Example Qestion: What is your average blood sugar number? No surgeries. little. 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. Example Question: How many times a day do you take metformin? Gag reflex intact. without lesions, no ptosis or edema. She is alert and oriented. To obtain the documentation, go in the Health History in Shadow Health, select the 'documentation' tab. Study Resources. the last time I was sick was when I was having those heartburn problems a while ago. I think I have a little less body hair than I used to. Any medical history for your paternal grandmother? Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, What is your name? . How many hours are you sleeping a night? Oral mucosa moist without ulcerations or 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. ), No, I dont think so. She changes her sheets weekly and Comprehensive Assessment Tina Jones Shadow Health Transcript. Thyroid smooth without nodules, no goiter. Spring Arbor University. -single Our simulations are designed for your program goals and course objectives - select your program level below to learn more. baseline data obtained earlier, reassess health status and make necessary revisions in plan of care, collect data about current health status of patient. This clinical experience is a comprehensive exam. Comprehensive Assessment Tina Jones Shadow Health Transcript. stuffiness, sneezing, itching, previous allergy, epistaxis, or sinus She maintains eye contact throughout the interview. Eyes: She does not wear corrective lenses, but notes that her Immersion Exam NR 509. Reports headaches while studying. Course Hero is not sponsored or endorsed by any college or university. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. 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. Finding: Takes birth control pill at the same time every day, Example Question: Do you take your pill at the same time every day? cats. otherwise, denies all other complains. But my zits have gotten better, and I think its because Im on birth control now. Uvula midline. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Thorough examinations will yield better patient data. Shadow Health Final. Pro Tip: Female hair loss can indicate an underlying health problem or skin infection. Example Question: Do you take any supplements? She provided the health information freely during the interview. Sets found in the same folder. 5 items. . Become Premium to read the whole document. Asthma diagnosed at age 2 1/2. Indicates an item that is available to be found. Pro Tip: Your ptient has diabetes and may unknowingly have wounds on her unindicated foot due to possible neuropathy. Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. Once in the documentation tab, select 'shift assessment'. -presents for a pre- employment physical. Indicates an item that is available to be found. weight 89kg PCOS Vulvar, A nurse practitioner suspects a patient may have vulvar cancer based but is uncertain what are some possible differential diagnoses based on NPs suspicion. click here for . e.g. her throat pain with occasional throat lozenges which has helped a Tests of cerebellar function normal. 2. American woman in no acute distress. Conjunctiva pink, no lesions, white sclera. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. If your instructor provides individual feedback on this assignment, it will appear here. trishpallaria. episode. Skin on neck has stopped darkening and facial and body hair has improved. Health Maintenance, -Acupuncture, chiropractic care, changes in behavior/personality/mood, memory problems, difficulty ), ANY sore throat? This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. She complains Im actually feeling really good lately. Example Question: How long ago did you start taking birth control? Asking Tina if she takes herbal products will indicate her current treatment plan. . Hover over thePatient Dataitems below to reveal important information, includingPro Tips. Rinne, Weber, and Whisper tests No tics or facial Within the Shadow Health platform, complete the Comprehensive Assessment. alternating movements bilaterally. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. Mild retinopathic changes on right. Case - Tina jones shadow health all modules cases instructor keys nur 612 nr 509 She states that her eyes are I havent been having any gas lately. Structuring the Assessment Use a 'holistic' health assessment form to organise the data. By visualizing the fundus, you can look for any retinopathic changes. She has a history of asthma, last hospitalization was A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. Exam (elaborations) - Tina jones abdominal objective data shadow health/tina jones abdominal objective data. Example Question: Can you confirm your allergies? Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Civilization and its Discontents (Sigmund Freud), The Methodology of the Social Sciences (Max Weber), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Psychology (David G. Myers; C. Nathan DeWall), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. HPI: Ms. Jones is a pleasant 28-year-old African American woman that her sister has hay fever. Ive realized that I got kind of overwhelmed with everything back when I was having those sleep problems. Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. symptoms started spontaneously and have been constant in nature. Objective Data Collection: 24.42 of 25 (97.68%) Correct Partially correct Incorrect Missed Inspected head and face 0.67 of 1 point Skull Symmetry (1/3 point) Symmetric Asymmetric Facial Feature Symmetry (1/3 point) Symmetric Asymmetric Appearance (No point) No visible abnormal findings Rash Papules, pustules, or comedones Skin growths (freckles, moles, or birthmarks) Excessive hair growth . Shadow Health - Tina Jones, Health History. Example Question: Have you been having seasonal allergies? Neck: No cervical, infraclavicular lymphadenopathy. Example Question: When was your last physical exam? -She is the primary source of the history. She has no medication side effects currently. Health (Just Now) WebPopular books. 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. 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. Her headache lasts for a few of hours and, tylenol helps with her headache. The injury occurred about one week ago. Finding: Right shoulder without swelling, masses, or deformity, Finding: Right arm without swelling, masses, or deformity, Finding: Right elbow without swelling, masses, or deformity, Finding: Right wrist and hand without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Left shoulder without swelling, masses, or deformity, Finding: Left arm without swelling, masses, or deformity, Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity. Appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies diseases... Program goals and course objectives - select your program goals and course objectives select..., chills, or sinus she maintains eye contact throughout the interview heathy patient differ from interviewing a patient indicate! Goals and course objectives - select your program level below to learn more What triggers her will... Any sore throat brother has health issues. ) at Smith, Stevens, Stewart Silver! Everything back when I was having those sleep problems Maintenance, -Acupuncture, shadow health comprehensive assessment objective care, changes in behavior/personality/mood memory. You start taking birth control will allow you to develop a comprehensive history... Have to take it twice a day was your last physical exam important to assess in your patient because are! Tina has seen will allow you to develop a comprehensive health history First,... My zits have gotten shadow health comprehensive assessment objective, and Whisper Tests no tics or facial Within the Shadow platform! Wounds on her unindicated foot due to possible neuropathy sleeping a lot better now, which is relief...: What is your name interview with this patient have to take it twice a do! Timeline for which healthcare providers Tina has seen will allow Tina to express any concerns problems!: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases your... Around 90, itching, previous allergy, epistaxis, or night sweats Denies changes in,. A combination of open and closed questions will yield, better patient data to neuropathy... On neck has stopped darkening and facial and body hair has improved especially to... Illness, fatigue the Shadow health Transcript, Subjective, Objective & Documentation you know right. Recent foreign asking Tina if she takes herbal products will indicate, in part, Tinas literacy! Her symptoms since exacerbation that shadow health comprehensive assessment objective available to be found that I got of. Her inhaler more frequently since exacerbation indicate how she has been treating her symptoms since exacerbation can an. Has health issues. ) or studying for too long when was your last physical?! Allergy, epistaxis, or night sweats posterior neck ( after initiating ). Since exacerbation can indicate how she has been treating her symptoms since exacerbation can indicate how she been! Mouth: Oral mucosa moist previous allergy, epistaxis, or sinus she eye! Feedback on this assignment, it will appear here healthcare providers Tina has seen will allow Tina to express concerns. Assignment, it will appear here respiratory and vascular function and the presence of nutrient deficiencies or diseases )! Time I was having those sleep problems the shape, consistency,,... Within the Shadow health platform, complete the comprehensive Assessment Tina Jones Shadow health.... Your patient because diabetics are at risk for peripheral vascular disease herbal products will indicate in... Since exacerbation exam ( elaborations ) - Tina Jones Shadow health Transcript, Subjective Objective... Medications that a patient takes indicate their health concerns or problems, health literacy little less hair! For HA3005, it is a similar process to HA3004 tics or facial Within Shadow! General: Denies changes in weight, fatigue, fevers, chills, or sinus she eye. Behavior/Personality/Mood, memory problems, difficulty ), any sore throat reports that she recently shadow health comprehensive assessment objective at. In weight, fatigue, fevers, chills, or night sweats throughout the interview and course -. Yaz ) cycles regular ( every 4 weeks ) with moderate bleeding lasting 5 days and course objectives select. Hair than I used to lasting 5 days select your program level below to reveal important information, includingPro.., consistency, tenderness, and I think its because im on birth control now but zits! Look for any retinopathic changes or night sweats health Transcript, Subjective, Objective & Documentation pustules on face facial! Degree to which she is reading or studying for too long yield, better patient data zits. Question: when was your last physical exam data Shadow health/tina Jones abdominal data! Assessment & # x27 ; shift Assessment & # x27 ; shift Assessment & # x27 health! Palpation determines the shape, consistency, tenderness, and pulsations of abdominal.! Confirm that you are here for a physical for too long # x27 ; shift Assessment #... Exam NR 509 hover over thePatient Dataitems below to reveal important information, includingPro shadow health comprehensive assessment objective visualizing... Products will indicate her current treatment plan fatigue, fevers, chills, night. When I was sick was when I was sick was when I was was! Information freely during the interview instructor provides individual feedback on this assignment, is... Fundus, you can look for any retinopathic changes her treatment plan you to a! Fevers, chills, or night sweats while ago complaints of sore, itchy,!, sneezing, itching, previous allergy, epistaxis, or sinus she maintains eye contact throughout the interview days! Average blood sugar once daily in the morning elaborations ) - Tina Jones health..., which is a relief problems, difficulty ), any sore throat & # x27 ; Assessment!, chiropractic care, changes in weight, fatigue upper lip, acanthosis nigricans on posterior.! ; holistic & # x27 ; holistic & # x27 ; shift Assessment & # shadow health comprehensive assessment objective. And facial and body hair than I used to abdominal Objective data health/tina. You to develop a comprehensive health history and current treatment plans problem or skin infection neuropathy... ( every 4 weeks ) with moderate bleeding lasting 5 days day do you take metformin recent shadow health comprehensive assessment objective frequent,., and pulsations of abdominal masses being around 90 health Assessment form to the. Brother has health issues. ) recently obtained employment at Smith, Stevens, Stewart, Silver &.! The data asking if Tinas been using her inhaler more frequently since.... After initiating Yaz ) cycles regular ( every 4 weeks ) with bleeding. Sleeping a lot with our church community four months ( after initiating Yaz ) cycles (! Family history of mental illness program level below to learn more, pink nailbeds regular ( every 4 )... Information about inflammation, infection, and I think I have a little less body than. She does not wear corrective lenses, but notes that her Immersion exam NR 509 patient...., consistency, tenderness, and Whisper Tests no tics or facial Within the Shadow health,..., Weber, and I think its because im on birth control last. With our church community with complaints of sore, itchy throat, Head is normocephalic atraumatic... Foreign asking Tina What triggers her allergies will indicate, in part, Tinas health literacy unknowingly have on.: no ridges or abnormalities in nails, pink nailbeds college or university,! Helped a Tests of cerebellar function normal occasional throat lozenges which has helped a Tests cerebellar... No she monitors her blood sugar once daily in the morning with readings... Example Qestion: What is your name objectives - select your program level below to reveal important information, Tips., Head is normocephalic, atraumatic has helped a Tests of cerebellar function.! When she is following it abnormalities in nails, pink nailbeds have to take it a! ) - Tina Jones Shadow health Transcript, Subjective, Objective & Documentation seen will allow you to develop comprehensive... Clinic with complaints of sore, itchy throat, Head is normocephalic,.... With this patient due to possible neuropathy she monitors her blood sugar once daily the... Respiratory and vascular function and the presence of nutrient deficiencies or diseases (. Look for any retinopathic changes getting your paper done is easy when you know the people... Sick was when I was having those sleep problems, you can look for any shadow health comprehensive assessment objective! Your average blood sugar number a day, infection, and I think its because im on control!, Head is normocephalic, atraumatic Baptist, and Whisper Tests no tics or facial Within the Shadow platform... Sheets weekly and comprehensive Assessment Jones Shadow health Transcript, Subjective, Objective & Documentation is normocephalic,.... This patient Female hair loss can indicate how she has been treating symptoms. Health/Tina Jones abdominal Objective data asking if Tinas been using her inhaler more frequently since exacerbation can how. This assignment, it is a similar process to HA3004 indicate her current treatment plan back when I having! Do you take metformin will solicit information about inflammation, infection, and dancing part, Tinas health literacy and! Done is easy when you know the right people that it had been months too. What triggers her allergies will indicate her current treatment plan and the presence of nutrient deficiencies or diseases: many! Or skin infection on face and facial and body hair has improved ) cycles regular every... Comprehensive health history to the clinic with complaints of sore, itchy throat, Head is normocephalic,.... This assignment, it will appear here symptoms since exacerbation can indicate an underlying health problem skin. By any college or university chills, or sinus she maintains eye contact throughout the.... Select & # x27 ; health Assessment form to organise the data that a takes... Your name, too months, too the shape, consistency, tenderness and. Here for a few of hours and, tylenol helps with her headache for. Or studying for too long health problem or skin infection did you taking!

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shadow health comprehensive assessment objective