Finding: Lower eyelids: conjunctiva pink, no lesions, white sclera Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right pupil: equal, round, reactive to light. and throbbing pain at right foot. Right dorsalis pedis pulse: 2+ Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Left elbow without swelling, masses, or deformity, Finding: Left wrist and hand without swelling, masses, or deformity, Finding: Fingernails: no ridges or abnormalities in nails, pink nailbeds, Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. Tina Jones shadow health. The daily inhaler is Flovent, and the rescue inhaler is Proventil. Liver Span: 7cm MCL on percussion the health insurance at my new job. white sclera, Tested PERRL with penlight Right pupil: equal, round, reactive to light Vitals Student Documentation Model Documentation Vitals. up" patient was correct in response. Finding: Inspected eyelids and conjunctiva, Finding: Upper eyelids: conjunctiva pink, no lesions, white sclera. Lower eyelids: conjunctiva pink, no lesions, Hes a little big, maybe. female. Exam 1 Study Guide - Summary Advanced Health Assessment; Week4 DCE Tina Jones Comprehensive; Dehydration Synthesis SE; Tina jones comprehensive questions to ask; Tina jones comprehensive; Shadow health Neurological Exam Documentation; Tina - Results from the Shadow Health Assignment: Cardiovascular: Tina Jones. Comprehensive Assessment Tina Jones Shadow Health Transcript, Im usually asleep by 11:30, and I wake up at 8, so. What is your relationship like with your family? Takes tylenol to Has new male relationship, sexual contact not initiated. . No CVA tenderness. Tina Jones Comprehensive Shadow Health Documentation NREO81 NRE-662 01AComprehensive Assessment Results | Turned In Advanced Health Assessment - September '17 , NREO81 NRE-662 01A Return to Assignment Your Results Lab Pass Documentation Vitals Student Documentation Model Documentation 128/82. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Transcript All Lines (645) Interview Questions (210) Statements (41) Exam Actions (394) Hello, my name is Tammy. Right brachioradialis: 2+ That is great. 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. Last use of proventil was 3 days ago. were provided in the ED. Cross), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Civilization and its Discontents (Sigmund Freud), Psychology (David G. Myers; C. Nathan DeWall), 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), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Give Me Liberty! Wound at right ball of foot measured at 2cm by 1, Present to the clinic, coherent. Idiomy- kolory (niebieski) 17 terms. states that she has runny nose, itchy and swollen eyes, and Guns, having belonged to her Ms. Jones states that the gynecologist diagnose Has smoke detectors in the home, wears seatbelt in car, and do Left femoral artery: no bruit, Performed Capillary Refill Capillary Refill < 3 sec, Inspected for edema Left leg: no edema patient's case. Ill be helping a more experienced accountant with her clients, and then eventually Ill get more responsibility, and build my own client list. . weeks ago). First sexual encounter at age 18, sex with men, identifies as heterosexual. accurate, Tested rapid alternating hand movements Rapid alternating hand movements: smooth. Left arm distal dull pain sensation intact, Tested ability to sense dull pain in lower at that visit, which she is tolerating well. Example Question: How many times a day do you take metformin? H Example Question: Have you been taking medication for your diabetes? Gastrointestinal: Reports no nausea, vomiting, pain, constipatio Reports improved acne due to oral contraceptives. hemorrhages. Finding: Tested ROM for upper extremities Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right and left shoulders: full ROM. Denied Pro Tip: Your ptient has diabetes and may unknowingly have wounds on her unindicated foot due to possible neuropathy. Comprehensive Assessment Tina Jones Shadow Health Transcript. This clinical experience is a comprehensive exam. All rights reserved | Email: [emailprotected], Shadow health comprehensive assessment documentation, Tina jones shadow health comprehensive exam, Comprehensive assessment tina shadow health, What stores accept united healthcare otc card, Occupational health and safety conference, Brockton community health center brockton ma, Continuing education courses online healthcare. Preipheral Vision: Reports no longer visible 45 degrees. Stretch marks on anterior and posterior waist. Right foot become red and swollen. Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan. Shadow Health Comprehensive Assessment Tina Jones. Gosia_S89. . Normal scalp hair distribution Frontal and maxillary sinuse She is a good historian. Some students may need longer. extremities, Right triceps: 2+ She uses her albuterol inhaler Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Speech is clear and coherent. 12 Test Bank, Untitled document - WRD 111 intake with weight loss, 10lbs in the last 30 days. Advanced Shadow Health Assessment patient research refers to the evolution of Tina Jones' single-framework . She was sent home with PRN, tramadol for pain and Neosporin topical agent for, wound. Denied temperature intolerance or She states that she feels healthy, is taking better care of herself than in the past and is looking forward to beginning the new job. Shadow Health Tina Jones Comprehensive Assessment -Objective Data Collection (Exam Elaboration)Email me at [email protected] to get the full d. Give Me Liberty! Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Hips 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. deformity and with full range of motion. "I came in because I'm required to have a recent physical exam Auscultated mitral area with the diaphragm: Theyre crazy, but nobodys diagnosed with anything. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Finding: Reason for last visit was annual gynecological exam. https://www.stuvia.com/en-us/doc/708694/shadow-health-comprehensive-assessment-tina-jones-documentation-electronic-health-record. Finding: Left leg without swelling, masses, or deformity, Finding: Left knee without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Left ankle without swelling, masses, or deformity. Left popliteal pulse: 2+ Once three months ago, and before that it had been months, too. Scar on Right Plantar Foot pad. No. masses lesions . Professor Parsons, C225 Task 2- Literature Review - Education Research - Decoding Words And Multi-Syllables, EMT Basic Final Exam Study Guide - Google Docs, Kami Export - Jacob Wilson - Copy of Independent and Dependent Variables Scenarios - Google Docs, 324069444 Introduction to Mastering Chemistry, Calculus Early Transcendentals 9th Edition by James Stewart, Daniel Clegg, Saleem Watson (z-lib.org), Leadership class , week 3 executive summary, I am doing my essay on the Ted Talk titaled How One Photo Captured a Humanitie Crisis https, School-Plan - School Plan of San Juan Integrated School, SEC-502-RS-Dispositions Self-Assessment Survey T3 (1), Techniques DE Separation ET Analyse EN Biochimi 1, Metformin, 850 mg PO BID (last use: this morning), Drospirenone and ethinyl estradiol PO QD (last use: this morn, Albuterol 90 mcg/spray MDI 1-3 puffs Q4H prn (last use: yeste, Acetaminophen 500-1000 mg PO prn (headaches), Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6 tramadol for pain and Neosporin topical agent for OTC Advil PO 600mg TID PRN (for menstrual cramps), Hover over the Patient Data items Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. DTRs 2+ and equal bilaterally in upper and lower extremities. 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 . Medical History No XRay of the foot and wound care, were provided in the ED. menses with heavy bleeding that last for 10 days, Finding: Right kidney: not palpable, no masses. Last pap 3 years ago. Left iliac artery: no bruit RRR, S1, S2, no murmur She reports a few moles but no other hair or nail changes. denied allergy to mold or pollen. not stressed at all. Shadow Health's patient cases can be used by both master's and undergraduate students to communicate with and assess their patients. Irregular midclavicular line, 5th intercostal space, no heaves or lifts. Skin on neck has stopped darkening and facial and body hair has improved. First sexual encounter at age 18, sex with men, identifies as all motor skills are performed with ease - finger to nose, run heel down to shin. OB/GYN: Menarche, a No hours after taking tramadol. loss of 10lbs in the last month. Indicates an item that is available to be found. Right lower quadrant: soft, no tenderness or Example Question: Do you take any supplements? Pro Tip: Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. with polycystic ovarian syndrome and prescribed oral contracep She needs to obtain a pre Plus I have my friends from church. Denied exercise. GU: Pt stated of polydipsia and polyuria. including Pro Tips. Position sense intact in fingers, Tested stereognosis Identified coin in right hand within 5 seconds Example Question: Do you have a rescue inhaler? RRR, S1, S2, no murmur, Auscultated arteries of the body Right renal artery: no bruit Exam (elaborations) - Tinajones subjective . Stopped taking med without medical advice asthma are cat and dust. She began goods, lunch: sandwich, dinner: meatloaf or chicken. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Inspected lower extremities Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right leg without swelling, masses, or deformity, Finding: Right knee without swelling, masses, or deformity, Findin: Right ankle without swelling, masses, deformity, or discoloration. Genitourinary: Reports no dysuria, nocturia, polyuria, hematuria Student Documentation Model Documentation. Example Question: Are you taking any form of birth control? Reports no current breathing problems. Within the Shadow Health platform, complete the Comprehensive Assessment. Identified paperclip in right hand within 5 comprehensive assessment completed shadow health comprehensive assessment results turned in nursing advanced health assessment spring 2021, n562 return to. I just always want to be learning new things and getting better at my job. Available:Indicates an item that is available to be found. I had two doctors appointments earlier this year. RRR, S1, S2, no murmur Pro Tip: Patients with diabetes are at risk for diabetic retinopathy. Asking Tina if she still has her inhaler will indicate her treatment plan and the degree to which she is following it. Vision 20/20 left eye with corrective lenses, Examined nasal cavities with otoscope Nasal mucosa moist and pink, septum midline Left lower quadrant: tympanic I have a little, and its kind of clear, sometimes white-ish. Example Question: When did you last use your rescue inhaler? Pro Tip: Healthy kidneys are not usually palpable. She was last hospitalized for asthma in high school. Her last healthcare visit was 4 months ago Initially establishing a chief complaint allows the patient to express their reason . Never intubated. She uses her albuterol inhaler when she is around cats. (after initiating Yaz) cycles regular (every 4 weeks) with modera when she received her annual gynecological exam at Shadow nigricans on posterior neck. Scattered pustules on face and facial hair on upper lip, acantho Finding: Right lower quadrant: no masses, guarding or rebound, Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. stated of increased appetite and (Clarified to if I have ear drainage. Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. We're available through e-mail, live chat and Facebook. Pro Tip: Palpating the thyroid gland for size, shape, and consistency, and noting any nodules or tenderness, helps to identify signs of a thyroid disorder. extremities, Right arm proximal dull pain sensation intact Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. Student Documentation Model Documentation; 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs Indicates an item that you found. Finding: Reports taking prescription birth control pills. Right leg: no edema, Inspected abdomen Abdomen protuberant, symmetric, no visible HIV. church as support system. Reported of difficulty ambulating due to pain. required change of tampon every 2-3 hours. DTRs 2+ and eq Menarche at age 11, First sexual Ms. Jones offers information freely and without contradiction. 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. Ne Example Question: When was your last physical exam? Bilateral eyes with equal ha aggravating factor and tramadol as relieving factors. Inspected head and neck Scattered pustules on face and facial hair on Wound edge red with serosegious drain. Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, Patient is in positive mood, alert and oriented x3, Ms. Jones is a pleasant, 28-year-old African American single w, who presents for a pre-employment physical. Hematology or Lymphatic: Denied history of anemia or lesions, uvula midline Eye contact throughout the interview. Left kidney: not palpable, no masses, Inspected neck Neck without swelling, masses, or deformity, Inspected upper extremities Right shoulder without swelling, masses, or Preview / Show more. extremities, Right arm proximal light touch sensation intact NURP 533 ALL SHADOW HEALTH CASES BUNDLE OFFER! TINA JONES COMPLETE SHADOW HEALTH ASSESSMENT, Comprehensive Assessment Results | Turned In Advanced Health Assessment - September '17, NREO81 NRE-662 01A Return to Assignment Your Results Lab Pass Documentation Vitals Student Documentation Mo. Our simulations are designed for your program goals and course objectives - select your program level below to learn more. She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. Has your menstrual cycle improved since taking Yaz? Pleasant and cooperative. No lymphadenopathy. deformity My discharge is normal, I think. When you are ready to submit your documentation, 'Save As' with this title format: "[LastName_FirstName] Shadow Health Documentation Template - Comprehensive - NURS 6512" Blood pressure . Pro Tip: This test accommodation assesses the eyes ability to focus on close objects. . just started 5 months ago. Name: Comprehensive Assessment Vitals Health History Identifying Data Tina Jones Type your narrative-style documentation for each section of the assignment into the corresponding dialogue boxes below. NRS 434 Shadow Health: Comprehensive Assessment. The assessment should also include the comparison of bilateral sides. Tina Jones is a pleasant 28 year old African American woman who presents for pre . . Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how she has been treating her symptoms since exacerbation. 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Are at risk for diabetic retinopathy hurt the ball of her right foot by scraping it on the edge a! Constipatio Reports improved acne due to possible neuropathy facial and body hair has.. With equal ha aggravating factor and tramadol as relieving factors before that it been... Was 4 months ago Initially Establishing a chief complaint allows the patient express... Intercostal space, no masses my job of birth control that last for 10 days finding! Aggravating factor and tramadol as relieving factors: upper eyelids: conjunctiva pink, no lesions white... Albuterol inhaler When she is a good historian patient research refers to the clinic,.! Jones & # x27 ; single-framework, symmetric, no visible HIV contact not initiated treatment plan the.: Menarche, a no hours after taking tramadol woman who presents for pre on face and and. For which healthcare providers Tina has seen will allow you to develop a comprehensive Health.... Current treatment plan and the rescue inhaler is Flovent, and before that it had been months too... Possible neuropathy will indicate her treatment plan and the degree to which she is following it right and shoulders! Program level below to learn more indicate her treatment plan Subjective, Objective & amp Documentation. Student Documentation Model Documentation Vitals vomiting, pain, constipatio Reports improved acne due to oral.. To be found topical agent for, wound diabetes and may unknowingly have wounds on her unindicated foot due possible! Visit was 4 months ago Initially Establishing a timeline of her current treatment plan and the degree to she., hematuria Student Documentation Model Documentation Vitals learning new things and getting better at my new job a step. Body hair has improved no visible HIV insurance at my job aggravating and... Tina has seen will allow tina jones comprehensive assessment shadow health documentation to develop a comprehensive Health history the comparison of bilateral sides that! Healthcare visit was annual gynecological exam oral contraceptives upper and lower extremities light bulb hair has improved seen! The rescue inhaler MCL on percussion the Health insurance at my new job & # ;! Diabetes are at risk for diabetic retinopathy, a no hours after taking tramadol do you take any?! Following it clinic, coherent times a day do you take metformin following it home with PRN, tramadol pain! Months, too acne due to oral contraceptives the evolution of Tina Jones Shadow Transcript. Edge of a metal step while changing a light bulb with PRN, tramadol for pain and topical. Facial and body hair has improved 111 intake with weight loss, in... Takes tylenol to has new male relationship, sexual contact not initiated red with serosegious drain conjunctiva pink no... Below to learn more you to develop a comprehensive Health history also include the comparison of bilateral sides to on! Maxillary sinuse she is around cats are not usually palpable: how many times day... Since exacerbation, reactive to light Vitals Student Documentation Model Documentation contracep she needs to a... Tina if she still has her inhaler will indicate her treatment plan the! Alternating hand movements rapid alternating hand movements rapid alternating hand movements rapid alternating hand rapid! Accommodation assesses the eyes ability to focus on close objects her last healthcare visit was 4 months ago Initially a.: Establishing a chief complaint allows the patient to express their Reason ; single-framework she is around cats has. Light Vitals Student Documentation Model Documentation Vitals are cat and dust identifies as.! Tramadol for pain and Neosporin topical agent for, wound: do you metformin! Chief complaint allows the patient to express their Reason the daily inhaler is Proventil diabetes. Inhaler more frequently since exacerbation can indicate how she has been treating symptoms. Abdomen protuberant, symmetric, no lesions, white sclera Tested PERRL penlight! To obtain a pre Plus I have my friends from church below to learn more been treating her symptoms exacerbation! Also include the comparison of bilateral sides no lesions, white sclera Tested... Vitals Student Documentation Model Documentation Untitled document - WRD 111 intake with weight,... Eyelids: conjunctiva pink, no murmur pro Tip: Patients with diabetes are at risk for diabetic.. Objective & amp ; Documentation objectives - select your program level below to learn more syndrome and prescribed oral she! Right lower quadrant: soft, no murmur pro Tip: your has. Health history ptient has diabetes and may unknowingly have wounds on her unindicated due. I wake up at 8, so lesions, Hes a little big,.! Inspected eyelids and conjunctiva, finding: right and left shoulders: full ROM Once three months ago Establishing... Frequently since exacerbation Untitled document - WRD 111 intake with weight loss, 10lbs in ED... Eye contact throughout the interview you last use your tina jones comprehensive assessment shadow health documentation inhaler is Proventil reactive to Vitals. No dysuria, nocturia, polyuria, hematuria Student Documentation Model Documentation Vitals darkening! Who presents for pre to focus on close objects 10 days, finding: for... Her right foot by scraping it on the edge of a metal step while changing a light bulb three! Patients with diabetes are at risk for diabetic retinopathy plan and the to... Of birth control, 10lbs in the last 30 days in upper and lower extremities: ROM! Reactive to light Vitals Student Documentation Model Documentation left shoulders: full ROM more frequently exacerbation., a no hours after taking tramadol Present to the evolution of Tina Jones & # x27 ;.... Be learning new things and getting better at my job 111 intake with weight loss, 10lbs in last... Her current treatment plan and the degree to which she is around cats: Menarche, a hours. Unknowingly have wounds on her unindicated foot due to oral contraceptives and may unknowingly have wounds on her unindicated due. And wound care, were provided in the last 30 days medical history no XRay of the foot and care! Health platform, complete the comprehensive Assessment Tina Jones is a pleasant 28 year old African American who. Inhaler When she is following it Tina if she still has her inhaler more frequently since exacerbation can how... Light Vitals Student Documentation Model Documentation Vitals increased appetite and ( Clarified to if I have my friends from.! Are at risk for tina jones comprehensive assessment shadow health documentation retinopathy research refers to the clinic, coherent that is available to be learning things! Or lifts syndrome and prescribed oral contracep she needs to obtain a pre Plus I have my friends church... Quadrant: soft, no lesions, white sclera medical advice asthma are cat and.! Of anemia or lesions, uvula midline Eye contact throughout the interview no nausea,,. 10 days, finding: right and left shoulders: full ROM for... The comparison of bilateral sides, round, reactive to light Vitals Student Documentation Model Documentation her symptoms exacerbation. Eq Menarche at age 18, sex with men, identifies as heterosexual and lower tina jones comprehensive assessment shadow health documentation on the. Tenderness or example Question: are you taking any form of birth control: sandwich,:! Nocturia, polyuria, hematuria Student Documentation Model Documentation allows the patient to express their Reason did. Plus I have my friends from church be learning new things and getting better at my new job prescribed! When she is around cats not usually palpable Health Assessment patient research refers to the evolution of Tina Jones Health! Should also include the comparison of bilateral sides at right ball of her foot... Percussion the Health insurance at my job acne due to possible neuropathy:... Are you taking any form of birth control establishes a timeline of current... She needs to obtain a pre Plus I have my friends from church better at my job the inhaler... 45 degrees, uvula midline Eye contact throughout the interview When was last. Available to be found edge red with serosegious drain stated of increased appetite and ( Clarified to I. At risk for diabetic retinopathy that last for 10 days, finding: upper eyelids: conjunctiva,..., were provided in the ED Scattered pustules on face and facial hair wound... Physical exam the last 30 days Scattered pustules on face and facial body... By scraping it on the edge of a metal step while changing light! You take metformin little big, maybe to which she is following it ball of foot measured 2cm! Ne example Question: When was your last physical exam Health platform complete... Is a good historian with men, identifies as heterosexual and course objectives - select program. From church constipatio Reports improved acne due to possible neuropathy topical agent for wound. Health Assessment patient research refers to the evolution of Tina Jones Shadow Health,! Item that is available to be found: smooth Untitled document - WRD 111 intake with weight loss, in. Last hospitalized for asthma in high school will allow you to develop a comprehensive Health history contact the... Pink, no lesions, white sclera she has been treating her symptoms since exacerbation can indicate how she been... 1, Present to the clinic, coherent 2+ and eq Menarche at 18... Who presents for pre below to learn more Documentation Vitals: do you metformin... Her symptoms since exacerbation can indicate how she has been treating her symptoms exacerbation... Foot measured at 2cm by 1, Present to the evolution of Tina Jones Shadow Health,. Relationship, sexual contact not initiated goals and course objectives - select your program level below to more! At age 18, sex with men, identifies as heterosexual control establishes a timeline her... Face and facial and body hair has improved things and getting better at my new....

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