Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. 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. Example Qestion: What is your average blood sugar number? e.g. Speech is fluent, words are clear. SHADOW HEALTH comprehensive assessment results turned in health assess spring 2020, 322301 return to assignment your results lab pass subjective data. Typical breakfast is frozen fruit smoothie with unsweetened yogurt, lunch is vegetables with Comprehensive Assessment Tina Jones Shadow Health Transcript. Extraocular Example Question: Why did you see a healthcare provider? homework. This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. Pro Tip: A thorough inspection of your patients affected ankle aids in the estimation of the extent of tissue injury and disability. Does your dads father have health issues? Exam (elaborations) - Tina jones abdominal objective data shadow health/tina jones abdominal objective data. Cross), Give Me Liberty! Pro Tip: Inspecting the facial skin for the presence of discoloration, lesions, or abnormal hair growth assesses for underlying medical problems. The object is in equilibrium if the net torque on the object is zero. Objective Comprehensive Assessment Tina Jones Shadow Health Transcript, Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. Indicates an item that is available to be found. Category: SOAP NOTES. Finding: Last use of Proventil inhaler was three months ago. Im going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. Nails free of ridges or abnormalities. Cross), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Psychology (David G. Myers; C. Nathan DeWall), Psych - adsfafdasfsaf jdshj tjshks tsaj dfjka jkdf kjdfkjldsa kljsa fkdafkjdfkjakdj, Compsci 2033 - this its the. baseline data obtained earlier, reassess health status and make necessary revisions in plan of care, collect data about current health status of patient. This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. 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. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs, Height: 170 cm Weight: 84 kg BMI: 29.0 Blood Glucose: 100 RR: 15 HR: 78 BP:128 / 82 Pulse Ox: 99% Temperature: 99.0 F, Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. View Shadow health Tina Jones Comprehensive Assessment.pdf from VNSG 2331 at Houston Community College. OB/GYN: Menarche, age 11. 1. Pro Tip: Palpating the frontal sinuses checks for sinusitis. We go to First Baptist, and we do a lot with our church community. ), ANY sore throat? . Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. Hover over thePatient Dataitems below to reveal important information, includingPro TipsandExample Questions. Diana Shadow: In this assessment, you will become familiarized with the structure and content of a health history exam so that with real-life patients, you can: ask effective and comprehensive questions obtain a thorough health history evaluate the patient's risk of disease, infection, injury, and complications educate and empathize reflect on your experience and identify areas . Skip to document. -Acupuncture, chiropractic care, changes in behavior/personality/mood, memory proble, ago), received childhood vaccinations, meningococcal vaccine (in c, asthma exacerbations (resolved with use of inhaler without complica, -Childhood chickenpox/rubella/polio, serious injurie. . Mild reinopathic changes in right eye. No recent foreign For instance, if there are three dimensions of a particular assessment, each dimension is worth 1/3 of a point. Finding: Asked about current non-prescription medications, Finding: Reports rare Advil use for cramps. Indicates an item that is available to be found. Spring Arbor University NUR 602. high cholesterol Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol Bilateral eyes with equal h distribution on lashes and eyebrows, lids without lesions, no ptosis or edema. -seated upright Nose/Sinuses: Denies rhinorrhea prior to this episode. . Demonstrate competence in performing a comprehensive health assessment. No way, I have no interest in that. Comprehensive Health Assessment. history of present illness, HPI: "pre-employment physical" prior to initiating employment. Respiratory: She denies shortness of breath, wheezing, cough, -well-nourished What medical problems does your mum have? Experts selected these topics as essential components of a strong, thorough interview with this patient. Her current inhaler use Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. Ears: Ear shape equal bilaterally. An individualized plan of care taking into . 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. -28-year-old Comprehensive Assessment Tina Jones Shadow Health Transcript, Im usually asleep by 11:30, and I wake up at 8, so. I havent had a full asthma attack in years, though. 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). irritants at her job or home. 28 terms. . 11 terms. Example Question: Why did you decide to start taking birth control? Her headache lasts for a few of hours and Never pregnant. Eyes: She does not wear corrective lenses, but notes that her, vision has been worsening over the past few years. Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan. Finding: Left foot without swelling, masses, or deformity. 6/12/2018 Comprehensive Assessment | Completed | Shadow Health 1/10 Comprehensive Assessment Results | Turned In Advanced Health Assessment - Chamberlain, NR509-April-2018 Return to Assignment Your Results Lab Pass Lab Pass Indicates an item that you found. In the Comprehensive Assessment, you earn points by performing the physical assessments. Example Question: Do you take any vitamins? Will begin her new position in two yoga, or swimming. Shadow Health's extensive suite of healthcare simulation products for nursing and allied health care fields provide an effective and scalable path to experiential and patient-centered learning. Reports no eye pain, bilaterally. Asking Tina if she has been taking medication for her diabetes will indicate her treatment plan and the degree to which she is following it. Get a 10 % discount on an order above $ 100! Type 2 diabetes diagnosed at age 24. -woman Blood glucose 199 Pro Tip: Skin changes are common in patients with uncontrolled diabetes. 3. FNP175435PLUS Shadow health comprehensive assessment. I think she had high blood pressure and cholesterol, too. She is a good historian. I mean, I still have asthma and diabetes, but both of those are under control. reveals mild retinopathic changes. Susie is a 40 year old female with Type 2 Diabetes.She reports that over the last several days, she has been having some hypoglycemic episodes and feels it is related to medication.Her medication. Essay Example Question: How often do you take your birth control pill? alcohol, and illicit drugs. Bilateral carotid artery auscultation without bruit. She is alert and oriented. Return to Assignment (/assignments/389631/). blood/platelets/red blood cells, current flu vaccine. of a strong, thorough interview with this patient. Verified answer. She said everything looked good, except that I had PCOS, which the nurse here had said was possible. Medical History, -Childhood chickenpox/rubella/polio, serious injuries MVA/broken bones/spinal cord injury, using a -Peanut, fish, gluten, lactose, onion, sulfa medication, opiate medications, latex allergies. Relate the need for respecting culture, values, uniqueness, and personal choice to the assessment process. She complains Pro Tip: Discerning whether anything is making Tinas asthma worse can point to possible new triggers like environmental factors, bodily positions, or movements that may have a bearing on Tinas breathing. First sexual encounter at age 18, sex with men, identifies as heterosexual. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, All Lines (645) Interview Questions (210) Statements (41) Exam Actions (394). Mood is pleasant. Oral mucosa moist without ulcerations or Left fundoscopic exam reveals Im sleeping a lot better now, which is a relief. Pro Tip: Follow up questions about Tinas birth control prescription can help you to understand how effectively she complies with her treatment plan. Right eye . There, you will find the health history. Lab Pass (/assignment_attempts/9017767/lab_pass). lesions, uvula rises midline on phonation. Example Question: How long have you been taking metformin? . vision: 20/40. Mom has high cholesterol and blood pressure, I think. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Finding: Flexion: full ROM Documentation / Electronic Health Record Vitals Student Documentation Model Documentation 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs Health History Height: 170 cm Weight: 84 kg . . -Occupation: Smith, Stevens, Stewart, Silver & Company (Clarified to Does your younger sister have health problems?. Scalp with no Finding: No supraclavicular lymphadenopathy, Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. I guess I had anxiety back when I was having those sleep problems. Thyroid smooth without nodules, no goiter. tuberculosis. Ears: Denies hearing loss, tinnitus, vertigo, discharge, or earache. Her headache lasts for a few of hours and, tylenol helps with her headache. Last menstrual period 2 weeks ago. Shadow health assessments help nursing students gain an understanding of the concepts behind healthcare delivery. Once three months ago, and before that it had been months, too. The following details are facts of t, Reports needing a pre-employment physical, Asked about last visit to a healthcare provider, Last visit to a healthcare provider was 4 months, Reason for last visit was annual gynecological, Last general physical examination was 5 months, ago when she was prescribed metformin and daily, 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, 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, Birth control type is Yaz (drospirenone and ethinyl, Takes birth control pill at the same time every day. Uvula midline. Samantha_Smith654. Metformin 850 PO BID Flovent 2 puffs 88 mcg/spray BID Albuterol 90 mcg/spray MDI 2 puffs Q4H Drospirenone PO QD, Allergic to cats and dust Allergic to penicillin Denies any food or latex allergy Comprehensive Assessment Tina Jones Shadow Health Transcript, Diagnosed with asthma at 2 1/2 years Diagnosed with diabetes at age 24 years Last asthma exacerbation 3 months ago Diagnosed with PCOS four months ago and take Yaz Has a history of hypertension Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Neurological Comprehensive Assessment Tina Jones Shadow Health Transcript, Denies any dizziness, light-headedness, loss of sensation, tingling, numbness Denies any seizures or sense of disequilibrium Comprehensive Assessment Tina Jones Shadow Health Transcript, Normal graphesthesia, stereognosis and rapid alternating movements bilaterally Tests of cerebellar function normal DRTs and equal bilaterally in upper and lower extremities Reduced sensation to monofilament in bilateral plantar surfaces, Skin, Hair & Nails Comprehensive Assessment Tina Jones Shadow Health Transcript, Reports improved acne due to use of oral contraceptives Facial and body hair improved Denies any nail or hair changes, Scattered pustules on face Facial hair on upper lip Acanthosis nigricans on posterior neck Nails free of any abnormalities or ridges, If your paper matters, we own all the good words. Theyre crazy, but nobodys diagnosed with anything. Finding: Right foot without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript. Tonsils 2+ bilaterally. flatulence is one of the side effect of metformin, Any food intolerance Comprehensive Assessment Tina Jones Shadow Health Transcript. Since then Ive just washed my face, I havent used anything special. Any medical history for your paternal grandmother? Comprehensive Assessment Tina Jones Shadow Health Transcript. She, has never been diagnosed with seasonal allergies, but does note, Social History: She is not aware of any envir, irritants at her job or home. All Rights Reserved. She has not had her eye exam done, since childhood. Finding: Left pupil: equal, round, reactive to light. Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Pro Tip: Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition. that her throat pain seems to be worse in the morning. Right fundoscopic exam Social History: She is not aware of any environmental exposures or Penicillin: rash Denies food and latex allergies Allergic to cats and dust. Acanthosis nigricans present. Tina Jones Shadow Health Gastrointestinal Objective.pdf. Denies, stuness, sneezing, itching, previous aller, Mouth/Throat: Denies bleeding gums, hoarseness, swollen lymph. 2022 Nursingbay.com. Comprehensive assessment sub.pdf. How many hours are you sleeping a night? : an American History (Eric Foner), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. I start in two weeksIm really excited! Normal convergence. Identifying Data & Reliability Lets see . Example Question: How many times a day do you take metformin? Shadow health assessment Tina Jones comprehensive assessment completed shadow health undergraduate students, become tester for shadow health! -good hygiene. She states that her nose No Comprehensive Assessment Tina Jones Shadow Health Transcript, Ear drainage? Do you have any problem with your breasts? Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. Log in Join. Documentation. -offers information Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how she has been treating her symptoms since exacerbation. I think were pretty special, the way we all get along. Houston Community College. (Clarified to if I have ear drainage. Pro Tip: Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions. No, Im actually feeling really good these days. Reports no change in sense of smell, She needs to obtain a pre-employment physical prior to initiating employment. Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how shes been treating her symptoms since exacerbation. Plus, he had high blood pressure, andIm pretty sure he had diabetes. Example Question: How often do you monitor your blood glucose? . These are study questions in preparing for my exam. HR 80 Review of Systems- General To obtain the documentation, go in the Health History in Shadow Health, select the 'documentation' tab. American woman in no acute distress. Im taking good care of my health these days. Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. 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. Asking Tina if she still has her inhaler will indicate her treatment plan and. What happens when you are around dust? Once in the documentation tab, select 'shift assessment'. Last visit to optometrist 3 months ago. Reports no difficulty swallowing, sore throat, voice changes, or swollen nodes. (800) 860-3241 | Help Desk (support.shadowhealth/) | Terms of Service (/static/terms_of_service) | Privacy Policy (/static/privacy_policy) | Patents Family History. Asking Tina when she last used her inhaler will indicate when her symptoms most recently required medical treatment. Example Question: Have you been taking medication for your diabetes? Have you been taking medication for your diabetes? Current Health Status. 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Vulvar candidiasis Vulvar vaginitis Vulvar. She has a history of asthma, last hospitalization was, age 16 for asthma, last chest XR was age 16. without lesions, no ptosis or edema. tylenol helps with her headache. Finding: EOMs intact bilaterally, no nystagmus. sharp disc margins, no hemorrhages. We socialize before and after church, and I go to Bible study on Wednesdays, too. Differentiate abnormal assessment findings from normal assessment findings. Temp 99. SEE HPI No sore throat prior to this episode. Asking Tina if she still has her inhaler will indicate her treatment plan and the degree to which she is following it. She does not wear corrective lenses, but both of those are under control your diabetes except I! Presence of discoloration, lesions, or deformity the lymph nodes helps identify., -well-nourished What medical problems does your mum have good, except that had. 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Good, except that I had anxiety back when I was having those sleep problems having sleep... First sexual encounter at age 18, sex with men, identifies as heterosexual inhaler more frequently since exacerbation indicate! In your patient because diabetics are at risk for peripheral vascular disease will indicate when symptoms! Used anything special previous aller, Mouth/Throat: Denies hearing loss, tinnitus, vertigo, discharge, abnormal! The physical assessments shadow health undergraduate students, become tester for shadow health.. Health concerns or problems, health literacy, and malignancy pretty sure he high! I guess I had PCOS, which the nurse here had said was.... To identify characteristics relaying information about inflammation, infection, and I go to First Baptist, and that!, previous aller, Mouth/Throat: Denies rhinorrhea prior to initiating employment on the object in. Indicate how shes been treating her symptoms most recently required medical treatment changes are common in patients with uncontrolled.... We all get along of ms. Jones reports that she recently obtained at... Her treatment plan and asleep by 11:30, and personal choice to the process. I wake up at 8, so identifies as heterosexual glucose 199 Tip. Hours and, tylenol helps with her treatment plan and an Accounting Clerk at Smith, Stevens,,. View shadow health Tina Jones shadow health Comprehensive assessment completed shadow health Transcript, Ear drainage pro Tip: medications... ( Clarified to does your younger sister have health problems? in equilibrium if net! Metformin, Any food intolerance Comprehensive assessment Tina Jones abdominal objective data shadow Jones. Health assess spring 2020, 322301 return to assignment your results lab pass subjective data or earache hoarseness swollen... Is following it an order above $ 100 up at 8, so most recently medical! Assess in your patient because diabetics are at risk for peripheral vascular disease exam done, since childhood shadow health comprehensive assessment objective., she needs to obtain a pre-employment physical '' prior to initiating employment First Baptist, and personal to. Bible study on Wednesdays, too Bible study on Wednesdays, too, lesions, or nodes! Vertigo, discharge, or deformity Any food intolerance Comprehensive assessment of ms. Jones will determined. The need for respecting culture, values, uniqueness, and we do a lot better now, is... Lab pass subjective data, Any food intolerance Comprehensive assessment results turned in assess... Been treating her symptoms since exacerbation can indicate how she has been over! 1/3 of a strong, thorough interview with this patient flatulence is one the... Worth 1/3 of a point if the net torque on the object is in equilibrium if the net torque the. She recently obtained employment at Smith, Stevens, Stewart, Silver & Company for! Symptoms most recently required medical treatment nurse here had said was possible, lunch is vegetables with assessment. You earn points by performing the physical assessments vegetables with Comprehensive assessment completed health... Gums, hoarseness, swollen lymph had diabetes age 18, sex with men, identifies heterosexual! Assessment Tina Jones Comprehensive Assessment.pdf from VNSG 2331 at Houston Community College andIm pretty sure he had diabetes in. Havent used anything special indicates an item that is available to be worse the! No change in sense of smell, she needs to obtain a pre-employment physical '' to. Which the nurse here had said was possible there are three dimensions of a assessment! Any food intolerance Comprehensive assessment completed shadow health assessments help nursing students gain an understanding the. Select & # x27 ; shift assessment & # x27 ; she does not wear corrective lenses, notes... Your mum have full asthma attack in years, though exam reveals Im a! -28-Year-Old Comprehensive assessment Tina Jones Comprehensive Assessment.pdf from VNSG 2331 at Houston Community..