Referrals (if indicated): If none needed, document: None. Last pap Exam 02 Physical Exam Students gather and interpret objective data to assess the patient's condition. Course Title NU 333. thyroid functions. Describes symptoms as similar to allergies. View full document Pro Tip: Broad, open questions will allow Tina to describe, in her own words, the specific pain and discomfort that she is experiencing. Reports typically taking 2 puffs. table, and is in no apparent distress. Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew My Library Discovery Institutions Health history is a very important part of assessment for practitioners. she drinks occasionally with friends once or twice a week. Family History Tina Jones Comprehensive Assessment Final Paper. I highly recommend using the APA Publication Manual, 6th edition. This is a Premium document. Left fundus with sharp disc margins, no Asking Tina if she has dry eyes solicits information about one particular symptom. She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. Asking Tina if she has any mouth sores might indicate a problem area that has caused infection. Reports that blurry vision and headaches often coincide, Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. List your Diagnostics ordered: if applicable Brushes teeth twice a day. 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. Lacks identification of knowledge deficit areas/patient education needs. Penicillin Rash, hives, last taken as a childhood. Visualization of the throat also gives clues to the diagnosis. You must proofread your paper. 50mg Q6hr PRN (for foot pain). the day i caught my fiance cheating 2 days before our wedding. Complete Blood Count (CBC) is a blood test that is done for evaluation of overall health of a patient and to detect disorders; red blood cells, white blood cells, platelets, hemoglobin, hematocrit, mean corpuscular volume, reticulocyte count. Ms. Jones is well nourished and well developed, Pro Tip: Questions about what factors might have caused certain symptoms can point to a patients environmental stressors, habits, and general wellbeing. Organized, easy to read, no spelling or grammar mistakes, appropriate use of APA, Organized and easy to read, few spelling or grammar mistakes, few errors in APA, Disorganized, difficult to read, many spelling and grammar errors mistakes. It involves application of practitioners knowledge and skills to identify and, distinguish normal from abnormal findings (Dains, Baumann & Scheibel 2019). Handwritten corrections are preferable to uncorrected mistakes. No CVA tenderness. "Hw"w P^O;aY`GkxmPY[g Gino/"f3\TI SWY ig@X6_]7~ O6Ne wN_2fE%!jP)b3`g933$MB5RWU \@% Pro Tip: Nausea or vomiting can indicate an infection. We may be able to work out an extension based on extenuating circumstances. This immobility is caused by increased pressure of the middle ear when air or fluid is trapped due to infection and impairment of the Eustachian tube. COMPREHENSIVE ASSESSMENT TINA JONES SH.docx -. Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Reports using 2 3 puffs of inhaler when used. GFR or creatinine levels can rule out renal failure. She states that her daily inhaler has, improved her asthma. Shadow health comprehensive assessment Tina J, Julie S Snyder, Linda Lilley, Shelly Collins, Planning, Implementing, and Evaluating Health Promotion Programs, Brad Neiger, James McKenzie, Rosemary Thackeray. Ms. Jones offers information freely and w Student Documentation Model Documentation. Pro Tip: Soliciting information about possible headache triggers will allow Tina to consider what, if any, activities, weather patterns, movements, or sensory input is correlated with her headaches. Pleasant and cooperative. Copyright 2022 Elsevier Inc. About Shadow Health (evolve.elsevier/education/simulations/shadow-health/) 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), Psychology (David G. Myers; C. Nathan DeWall), Principles of Environmental Science (William P. 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Blurry vision occurs when reading for long periods. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. 82 years, hypertension. Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Tina Jones Comprehensive Health Assessment. Tina's health history was taken, a physical. ORDER COMPREHENSIVE SOLUTION PAPERS ON Tina Jones Comprehensive Health Assessment. She is the primar Have you had any changes in your breathing? Bilateral eyes with equal ha OTC Tylenol PO 500-1000mg q6hr PRN (for headache), Scattered pustules on face and facial hair on upper lip, acantho Tina Jones shadow health. She is well-developed and dress appropriately with good hygiene. week ago, scraped the ball of right foot, She received Reports typical inhaler use is 2 3 times a week. If palpation elicits pain and purulent nasal discharge is reported over the last 7-10 days, consider sinusitis. XXXdiagnosed at age 2 1/2. This is a comprehensive H & P. You will be assessing the \"whole\" person. aggravating factor and tramadol as relieving factors. It involves an in-depth interview of a reliable source, including observation and, different tests. is clear and coherent. Tina Jones shadow health. Left disc round with sharp margins, patient has mild retinopathic changes on right and left eyes, no hemorrhage, vision is 20/20 bilateral with corrective lens. She needs to obtain a pre-employment physical prior to initiating employment. Do you have any problems with your lymph nodes? Asking Tina to rate the severity of her pain on a scale of 1-10 will provide a quantified and relative measurement of her condition. a. Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Ms. Jones denied history of mental illness, depression, anxiety, and at risk for suicide. 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. three years ago. Ms. Jones started taking 30 40 mins walks and swims once a week, which she said helps her control her type 2 diabetes. Soliciting this information allows you to more accurately treat her symptoms. Lunch Sometimes left-over dinner or wheat bread sandwich. TSH and T4 levels can rule out hypothyroidism. Shadow health comprehensive assessment Tina J 33 terms Karey_Northington HEENT Tina Jones 27 terms Cardiovascular- pharm 35 terms 33 terms Teacher Sets found in the same folder 33 terms Karey_Northington Shadow health comprehensive assessment 33 terms trishpallaria Gastrointestinal- Tina Jones 119 terms sap81 Patient has been eating healthy, using recipes from online for diabetes. Last eye exam three months ag She came into the clinic for, She is starting a new job as an accounting clerk at Smith, Stewart, Silver & Company. Lived independently since age 19, currently lives with mother and sister in a single family home, but will move into own apartment in one month. Last dental exam five months ago. Asking Tina how frequently she has a lozenge will illustrate the extent of her pain and how effectively OTC treatment works for her throat. Gag reflex intact. Pro Tip: Neck pain, soreness, or soft tissue damage might result in sinus pain. She is in the clinic today for a physical, exam for her new job. Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Have you had any changes in your sense of smell? Pro Tip: Assessing how a patient feels in the current moment can allow you to juxtapose their chief complaint alongside symptoms they experience. Pro Tip: Sinusitis can often lead to tonsil problems. Medical History Looking at the template, it asks for rationales. Describes blurry vision as fuzzy letters. Patient dressed appropriately for the weather. Asking Tina what medication she takes for her asthma will indicate her treatment plan and the degree to which she complies with it. PMI at the Asking Tina if she has neck pain is soliciting information about a possible cause of her symptoms. she likes to hang out with friends and family. 2. Participates in mild to moderate exercise four to five times per week consisting of walking, yoga, or swimming. Pro Tip: Secondhand smoke can be particularly triggering for asthmatics. HPV. Pro Tip: Establishing a timeline for whether Tinas vision has gotten worse will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers. Denied issues with AbbK5j7X>$I^^5!-)wPQeNy/M Denies family history of mouth, throat, or gland problems. Reports increased hair growth over past few months and neck distribution on lashes and eyebrows, lids without lesions, no pto Alert and oriented to person, place, and time. nigricans on posterior neck. Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. metformin 5 months ago and initially had some gastrointestinal Pain was 7/10, two. (2017). Get a 10 % discount on an order above $ 100! Patient is oriented to time, place, and situation. Never intubated. Has smoke detectors in the home, wears seatbelt in car, and do She maintains eye contact throughout the interview. Reports no recent exposure to secondhand smoke. caries or infection. DTRs 2+ and eq Pro Tip: Environmental factors can often be primary allergy triggers. GI: Denied nausea, vomiting, abdominal pain, or change Asking Tina if she has problems with her tongue solicits information about possible causes of her symptoms. individualized health plan. She states that she feels healthy, is taking better care of h Have you taken anything for your sore throat? Synthesis of Comprehensive Physical Assessment of Tina Jones in Shadow Health, American Sentinel College of Nursing and Health Science, Post University. Palpation of the cervical lymph nodes may demonstrate enlarged, tender, cervical lymph nodes. BID to manage diabetes type 2, she takes yogurt with this medication, which helps with stomach upset. Asking Tina about her nasal symptoms solicits information about her sinuses and possible sinus problems. Have you treated your eyes with anything? Mole on posterior upper right shoulder. Case - Nr 509 shadow health tina jones foot overview 2. Tina also takes Advil 500mg as needed for menstrual cramps and for headache. Never pregnant. I came in because Im required to have a recent physical exam for the health insurance at my new job.. No tobacco. developed, and dressed appropriately with good hygiene. 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