Pro Tip: Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions. Im usually asleep by 11:30, and I wake up at 8, so. Menses irregular. Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. She denies suicidal and homicidal ideation. SAN JUAN Tina Jones Comprehensiv Assessment Tina Jones You've been invited to join this class. I had two doctors appointments earlier this year. It is infected and causing pain(7 out of 10). Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, https://www.coursehero.com/file/38245035/Comprehensive-Assessment-Completed-Shadow-Healthpdf/, The Methodology of the Social Sciences (Max Weber), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Civilization and its Discontents (Sigmund Freud), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. She needs to obtain a pre-employment A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. Denies coffee intake, but does Pro Tip: Follow up questions about Tinas medication history and timeline will help you to understand her treatment plan and recent health history. Snellen 20/20 bilaterally. She has not been eating much and has been staying in bed the last few days, per patient report. Are you taking any medication for your allergies? She does not have any acute cincerns She was diagnosed with PCOS and oral contraceptives were prescribed She had type 2 diabetes and asthma She reports positive lifestyle modifications. Im actually feeling really good lately. Head: Reports headaches that occur weekly with reading in the past year. make rapid movements bilaterally. About healthy people. Reports eating probiotic yogurt helps with side effects. Diagnosed with PCOS four months ago. Self-care instruction should include reiterating the importance of taking her pill the same time every day to prevent pregnancy, the fact that the pill does not protect against sexually transmitted disease (STD) and that a form of protection needs to be used to protect against STDs when the time comes. reading, attending Bible study, volunteering in her DTRs 2+ and equal bilaterally in Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Mouth: Denies dental pain or problems, oral lesions, and dry mouth, and changes in taste. 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. Acanthosis nigricans. She also has increased her physical activity. Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how shes been treating her symptoms since exacerbation. My doctor told me when I was pretty little I think I was about two and a half? function normal. spirometry: FVC 3 L, FEV1/FVC ratio 80%. treatmentplan. conversation and is cooperative. She states foot still hurts, but much better than when she arrived yesterday. Im going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. Bowel sounds are normoactive in all four quadrants. Firstly, it seems that Ms. Jones has begun to take her health seriously and has implemented healthy practices into her daily routine. I havent smoked pot since I was twenty or twenty-one. Im taking good care of my health these days. ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, and facial and body hair has improved. No lymphadenopathy. Altay, N., & Cavusoglu, H. (2013, April 23). She denies any food allergies. She hopes to advance to an accounting position within her company. occasional shortness of breath, wheezing, and chest app.shadowhealth/assignment_attempts/4562098 7/. Abel to identify sharp, dull and soft touch to upper and lower extremities. She is well-nourished, well-developed, and dressed Allergic to penicillin, and also allergic to cats. Pro Tip: Soliciting a shallow history of a patients medication history can reveal recent exacerbation. I came in because Im required to have a recent physical exam for the health insurance at my new job. Tina Jones is a pleasant 28 year old African (Clarified to Does your brother have medical problems?. Normal hair distribution. . Resonant to percussion throughout. (2014). in the past, and is looking forward to beginning the auscultation bilaterally without cough or wheeze. She is the primary source of flatulence is one of the side effect of metformin. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. ProTip:FollowupquestionsaboutTina'sbirthcontrolprescriptioncanhelpyouto Reports no change mucosa moist and pink, septum midline. What is the name of your diabetes medication? She takes some blood pressure pills, and I think she has high cholesterol, but Grannys doing great for 82. Topics, Ideas (35) Based on these assessment findings and Ms. Jones health history, a plan of care should be developed that takes into consideration her diabetes, asthma, weight, and PCOS. States skin on neck has stopped darkening. OB/GYN: Menarche, age 11. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Snellen: 20/20 right Anterior and posterior chest walls are symmetric with respiration, no deformities, rashes, or lesions. Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. Offers information without hesitation. : an American History, Med Surg Nursing Cheat Sheets 76 Cheat Sheets for Nursing Students nodrm pdf, Philippine Politics and Governance W1 _ Grade 11/12 Modules SY. physical exam for the health insurance at my new What is your new job? new job" "I came in because I'm required to have a recent Indicates an item that is available to be found. Dentition without evidence of caries or infection. . Poppa died of a heart attack when he was 80. . Haveyoubeentakingmedicationforyourdiabetes? place, and time. diagnosed her with polycystic ovarian syndrome and Does not exercise regularly. Reports needing a pre-employment physical, Asked about last visit to a healthcare provider, Last visit to a healthcare provider was 4 months ago, Reason for last visit was annual gynecological exam, Last general physical examination was 5 months ago when she was prescribed metformin and daily inhaler, Asked about current prescription medications, Reports taking prescription birth control pills, Reports that eating probiotic yogurt helps with side effects and they have abated over time, Followed up on metformin frequency and dose, Reports using Flovent inhaler twice daily, Last use of Proventil inhaler was three months ago, Has used Proventil inhaler twice in the last year, Followed up about birth control prescription, Started taking birth control 4 months ago, Reason for birth control was to manage PCOS symptoms, Birth control type is Yaz (drospirenone and ethinyl estradiol), Takes birth control pill at the same time every day, Asked about current non-prescription medications, Reports no recent seasonal allergy symptoms, Reports no current medication for allergies, Reports managing diabetes with diet and exercise in addition to medication. Herzing University (39) : an American History (Eric Foner), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), WEEK5 Assignment Episodic/Focused Note for Focused Exam: Cough, Ch 03 Examination Techniques and Equipment. Bilateral eyes Tests of cerebellar Tactile fremitus present. pink septum midline. Nails free of ridges or abnormalities. 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. A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. Another abnormal finding was the discoloration on her neck. Attempting to palpate the kidney helps determine enlargement or tenderness. Pustules noted on bilateral cheeks. No wheezing, runny nose or a cough. currenttreatmentplan. No concerns about alcoholism. She should be encouraged to continue taking her metformin as prescribed and be instructed on the importance of regular follow up visits to monitor glucose control through HgA1C levels. (Tina Jones Comprehensive Assessment). Pro Tip: Skin changes are common in patients with uncontrolled diabetes. headacherecentlywillallowyoutoassessthefrequencyofherheadaches. Type 2 diabetes, diagnosed at age 24. Plus I have my friends from church. Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. hearing, ear pain, or discharge. Pro Tip: When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems. Management Assignments (7) Well, I used to smoke pot. Heart rate is regular, S1, S2, no murmurs, gallops or rubs. This homework should take 3 hours on average each time to finish. Oriented to person, place, and time. I think were pretty special, the way we all get along. Denies gallbladder and liver disease. NRS Week 4: Comprehensive Assessment Tina Jones NRS 434 Shadow Health: Comprehensive Assessment ORDER NOW FOR AN ORIGINAL PAPER ASSIGNMENT NRS 434 Shadow Health: Comprehensive Assessment Complete the Comprehensive Assessment on the Shadow Health platform. denies any acute concerns. Asking Tina if she takes herbal products will indicate her current treatment plan. Denies generalized weakness. She regularly monitors her blood sugar levels and feels more comfortable with her knowledge regarding the meaning of the readings. Her father is deceased, age 58 in a car accident one year ago. 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