Pleasant and cooperative. (Clarified to if my younger sister has health problems. Liver span: 7 cm MCL on percussion, Percussed abdomen Right upper quadrant: tympanic Right kidney: not palpable, no masses lesions, uvula midline . She monitors her blood sugar once daily in the morning with average readings being around 90. She maintains eye Advanced Shadow Health Assessment patient research refers to the evolution of Tina Jones' single-framework . Reports improved acne due to oral contraceptives. not initiated. Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. No change in activities of daily functionality. Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. Finding: Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema. negative for HIV/AIDS and STIs four months ago. hemorrhages. No. Left leg proximal dull pain sensation intact are in the home, locked in parents room. 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. Last dental exam five months ago. General Clinic. No varicose vein. And the pain is getting worse." History Of Present Illness 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. heterosexual. denied allergy to mold or pollen. I took something for my acne. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Example Question: How long ago did you start taking birth control? Hello, my name is Tammy. extremities, Right arm proximal sharp pain sensation intact Menarche at age 11, First sexual I guess I had anxiety back when I was having those sleep problems. Left elbow without swelling, masses, or No 1 CHE101 - Summary Chemistry: The Central Science, Mid term HIS 104 - Exam Questions and notes, How Do Bacteria Become Resistant Answer Key, Ch. organomegaly. odor from wound. Example Question: Do you take any supplements? For the past four mont Pro Tip: For this examination, the patient should look in the six cardinal fields without moving her head. . XRay of the foot and wound care, were provided in the ED. Stated of inability to bear weight on right foot due monofilament in bilateral plantar surfaces. A comprehensive physical assessment provides fundamental, personalized knowledge about a patient and creates the basis for health promotion through education and counseling (Bickley & Szilagyi, 2013). Stopped taking med without medical advice Experts selected these topics as essential components of a strong, thorough interview with this patient. Im hoping Ill learn a lot in that position, and within a couple years, Ill get promoted and be given new responsibilities. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. upper lip developed, and dressed appropriately with good hygiene. This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. Poppa died of a heart attack when he was 80. . who presents for a pre-employment physical. 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. Frontal and maxillary sinuse But my zits have gotten better, and I think its because Im on birth control now. : an American History (Eric Foner), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Principles of Environmental Science (William P. 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College Physics Raymond A. Serway, Chris Vuille. received. Lower eyelids: conjunctiva pink, no lesions, . . Auscultated tricuspid area with the bell: no S3, Objective Comprehensive Assessment Tina Jones Shadow Health Transcript, Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. A thorough inspection should be conducted of your patients skin, especially in folds around the neck, axilla, and groin. graphesthesia, stereognosis, and rapid alternating movements She provided the health information freely during the interview. Right leg distal dull pain sensation intact No lymphadenopathy. Comprehensive Assessment Tina Jones Shadow Health Transcript. 23 terms. Denied exercising. Pro Tip: When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems. Left arm proximal sharp pain sensation intact Left arm proximal dull pain sensation intact Any ear pain? Denied back pain or joint pain. Nails free of ridges or abnormalities. Whispered words heard bilaterally. 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Experts selected these examinations as essential components of objective data collection for this patient. Everything's an Argument with 2016 MLA Update University Andrea A Lunsford, University John J Ruszkiewicz. Patient able to identify dull, sharp, and soft touch on all extremities. reports a few moles but no other hair or nail changes. Mom has high cholesterol and blood pressure, I think. Pt stated of eating 2-3 serving of fruits Example Question: When did you see a healthcare provider? Immunizations: Tetanus booster was received within the past y Last hospitalization for asthma when Shadow health Tina Jones Comprehensive Assessment.pdf -. Left lower quadrant: soft, no tenderness or Ask an Expert. I am glad you are having your period every month. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, What is your name? : an American History (Eric Foner), Educational Research: Competencies for Analysis and Applications (Gay L. 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(Clarified to Do you have drainage from your ears?. Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan. I came in because Im required to have a recent physical exam for the health insurance at my new job. Comprehensive Assessment Tina Jones Shadow Health Transcript. Left lower quadrant: normoactive, Auscultated arterial sounds Aortic artery: no bruit, Percussed CVA tenderness Right flank: none reported Download. reported of fever 102 last night. Example Question: How long have you been taking metformin? Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. he had some blood pressure and cholesterol issues when he was alive, too. Eye contact throughout the interview. deformity and with full range of motion. She was last hospitalized for asthma in high school. Left iliac artery: no bruit required change of tampon every 2-3 hours. 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. not stressed at all. Left eye: equal hair distribution on lashes and Ne She maintains eye contact throughout the interview. Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how shes been treating her symptoms since exacerbation. Left leg distal sharp pain sensation intact, Tested position sense Position sense intact in toes due to feeling of "bloating and gassy." Try controlling All of these ailments are being managed with medication alongside other lifestyle interventions such as proper diet and exercises. Proventil 2 puffs q4hr PRN (for SOB), tramadol PO She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. Wound edge red with serosegious drain. What medical problems does your mum have? 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! 1 / 7. I havent smoked pot since I was twenty or twenty-one. 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. No supraclavicular lymphadenopathy. Left femoral pulse: 2+ at that visit, which she is tolerating well. Reports headaches after long periods of reading. Comprehensive Assessment Tina Jones Shadow Health Transcript. Nana was 73 when she died of a stroke about five years ago. No pain with movement. Para 0. distress. just started 5 months ago. Last use of proventil was 3 days ago. Last saw primary care doctor two years ago. Bilateral carotids equal bilaterally without bruit. Comprehensive Assessment Tina Jones Shadow Health Transcript. ), No, I dont think so. Preview 2 out of 6 pages Getting your . Example Question: How are you managing your diabetes? bilaterally. Bowel sounds are No history of Denied history of STI. rebound Finding: Birth control type is Yaz (Drospirenone and ethinyl estradiol), Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. . Lets see . Normal intubated. She states that she feels healthy, is taking better care of h 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. Idiomy- kolory (niebieski) 17 terms. Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words. Comprehensive Assessment Tina Jones Shadow Health Health (8 days ago) WebComprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Transcript All Lines (645) Interview Questions (210) Statements (41) murmur, or arrythmia. 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.Example Question:Can I confirm that you are here for a physical? to pain. Plus, he had high blood pressure, andIm pretty sure he had diabetes. She started me on birth control, and it seems to be helping things. Speech is clear and NR 509 Tina Jones Comprehensive Health Assessment. She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. white sclera What happens when you are around dust? Left leg distal light touch sensation intact, Tested ability to sense dull pain in upper Ms. Jones speech is clear and coherent, Ms. Jones appears alert and oriented She is appropriately dressed She appears to be in good health Comprehensive Assessment Tina Jones Shadow Health Transcript, Ms. Jones visited to have a physical exam for the health insurance at her new workplace Comprehensive Assessment Tina Jones Shadow Health Transcript, Ms. Jones reported that she recently got a job at a new place and she is required to obtain a physical examination. Now that Im on the pill Im getting my period every month. We socialize before and after church, and I go to Bible study on Wednesdays, too. First sexual encounter at age 18, sex with men, identifies as heterosexual. high cholesterol. . Eye Movements: Movement parallel Last Pap smear 4 months ago. 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. Eye contact throughout the interview. . 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, Any issue with your gums? I havent had a full asthma attack in years, though. Right brachioradialis: 2+ Confirming the name of Tinas birth control pill will solicit information about her health history and current treatment plan. Left shoulder without swelling, masses, or EOMs intact bilaterally, no nystagmus. I came in because Im required to have a recent physical exam for the health insurance at my new job. Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. Theyre crazy, but nobodys diagnosed with anything. Reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium. care from local ER. Auscultated Erb's point with the diaphragm: Company Registration Number: 61965243 Yeah. Left femoral artery: no bruit, Performed Capillary Refill Capillary Refill < 3 sec, Inspected for edema Left leg: no edema Pro Tip: This test accommodation assesses the eyes ability to focus on close objects. Finding: Reports using Flovent inhaler twice daily, Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. By visualizing the fundus, you can look for any retinopathic changes. Finding: Asked about blood glucose monitoring, Finding: Reports checking blood sugar once a day, Pro Tip: Tinas response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Example Question: How many times a day do you take metformin? Nasal mucosa moist and pink, septum midline 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. Ms. Jones is 170 cm tall . Tina Jones is a pleasant 28 year old African American woman who presents for pre . she Well, I used to smoke pot. Recent flashcard sets. midline on phonation. (shadowhealth/patents), Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, This study source was downloaded by 100000835600516 from CourseHero.com on 05-21-2022 05:52:44 GMT -05:00, https://www.coursehero.com/file/91281500/Comprehensive-Assessment-Objective-Shadow-Healthpdf/, Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. OB/GYN: Menarche, age 11. office spirometry: FVC 3 L, FEV1/FVC ratio 80%. . Shadow Health 2012 - 2021 Finding: Takes birth control pill at the same time every day, Example Question: Do you take your pill at the same time every day? Decreased sensation effects which have since dissipated. Pro Tip: Palpating the liver identifies enlargement, displacement, tenderness, and consistency, which can indicate important health problems. . deformity intake with weight loss, 10lbs in the last 30 days. pain, vaginal discharge or itching. Finding: Reason for last visit was annual gynecological exam. 12 Test Bank, Untitled document - WRD 111 stated of increased appetite and Right arm distal dull pain sensation intact developed, and dressed appropriately with good hygiene. (after initiating Yaz) cycles regular (every 4 weeks) with modera Tes Right knee: 2+ Present to the clinic N/A with recent right foot injury. Stretch marks on anterior and posterior waist. Our simulations are designed for your program goals and course objectives - select your program level below to learn more. Type 2 diabetes, diagnosed at age 24. Shadow health assessments help nursing students gain an understanding of the concepts behind healthcare delivery. She has no medication side effects a Type 2 diabetes diagnosed at age 24. Hover over thePatient Dataitems below to reveal important information, includingPro TipsandExample Questions. about 8 or 9 hours a night. Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. Present to the clinic Comprehensive Assessment Tina Jones Shadow Health Transcript. Left upper quadrant: tympanic, Palpated abdomen - light Right upper quadrant: soft, no tenderness or Denied issues with allergy to cat and dust (caused SOB, . Asking Tina what triggers her allergies will indicate, in part, Tinas health literacy. Finding: Head is normocephalic, atraumatic. discoloration over last few years. Right iliac artery: no bruit 11 terms. Reports occasional sho tetracycline, I think, back in high school. midline. Left popliteal pulse: 2+ Pro Tip: Tinas response to a question about managing her allergies will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. 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. Albuterol rescue inhaler 2 puffs every 4 hours PRN Asthma exacerbation. No bleeding or bruising. Resonant to percussion throughout. All Rights Reserved. Course Hero is not sponsored or endorsed by any college or university. were provided in the ED. or deformity Example Question: Have you noticed any side effects from the metformin? Dentition without evide Asking Tina if she takes nonprescription drugs will indicate her current treatment plan. Finding: Acanthosis nigricans noted on neck. Does your dads father have health issues? Finding: Left kidney: not palpable, no masses, Finding: Neck without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript. She takes some blood pressure pills, and I think she has high cholesterol, but Grannys doing great for 82. Gag reflex intact. 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. Conjunctiva pink, no lesions, white sclera. Today she denies any acute concerns. Terms of Use 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 Model Documentation 128/82 mm Hg (97.3 MAP) HP 78 99% SpO2 98.9 degrees F FVC 3.91 L FEV1 3.. Never tested for 2022 Nursingbay.com. General Survey. Chief Complaint Left dorsalis pedis pulse: 2+, Auscultated arteries in the head and neck Right carotid artery: no bruit Pro Tip: Follow up questions about Tinas birth control prescription can help you to understand how effectively she complies with her treatment plan. changes on right. Abdomen protuberant, symmetric, no visible masses, scars, or wound. The patient reports to have PCOS, diabetes, and asthma. She is a good historian. Strength 5/5 bilateral upper and lower extremities. Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity. Palpated thyroid Thyroid smooth without nodules, no goiter, Inspected eyelids and conjunctiva Upper eyelids: conjunctiva pink, no lesions, Has new male relationship, sexual con Identified coin in left hand within 5 seconds Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Scattered pustules on face and facial hair on upper lip, acantho Nasal mucosa moist and pink, septum Chest is symmetric with respiration, clear to auscultation bilater Left brachial pulse: 2+ VNSG 2331. any acute concerns. Example Question: When did you last use your rescue inhaler? Right lower quadrant: tympanic Denied frequent headache or dizziness. Example Question: What is the dose of your metformin? The assessment should also include the comparison of bilateral sides. I just always want to be learning new things and getting better at my job. 1 / 7. and eyes redness. She plans to use condoms with sexual activity. (Clarified to if I have ear drainage. hours after taking tramadol. 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. Present to the clinic, coherent. No edema. She is well-nourished, we What is the name of the birth control pill you took? Finding: Has used Proventil inhaler twice in the last year, Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Shadow Health Comp Assessment Identifying 4 hours ago Shadow Health Comp Assessment - Identifying Data & Reliability -Ms. Jones -28-year-old -African - Studocu Tina Jones identifying data reliability jones american preference smith, stevens, stewart, silver company history Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew My Library Discovery Institutions Student Documentation Model Documentation; 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs ), Does your bother have health issues? She began Neurology: No change in mood, behavior or attention. Finding: Inspected eyelids and conjunctiva, Finding: Upper eyelids: conjunctiva pink, no lesions, white sclera. Im taking good care of my health these days. . masses MS. HIV. deformity R: 15. . Reports no dizziness, light-headedness, tingling, loss of coordi week. Guns, having belonged to her patient's case. Right popliteal pulse: 2+ Shadow Health Tina Jones Comprehensive Results Documentation Results Redacted. Example Qestion: What is your average blood sugar number? rebound, Palpated organs Liver: palpable 1 cm below right costal margin No maxillary sinus tenderness, Palpated lymph nodes No axillary lymphadenopathy ), Nothing is coming out of my ears. extremities, Right arm proximal dull pain sensation intact Documentation / Electronic Health Record. . bilaterally. Objective Example Question: Have you been taking medication for your diabetes? lower extremities. Skin on neck has stopped darkening and facial and body hair has improved. of breath, wheezing, and chest tightness. Left leg proximal sharp pain sensation intact she experiences exacerbations, such as around dust or cats. Peripheral vascular: Finding: Reports managing diabetes with diet and exercise in addition to medication, Pro Tip: Tinas response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she is complied with previous treatment plans. She seems to be doing okay though. Documentation; Vitals. Finding: Inspected eyebrows and orbital area Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema. Protuberant, symmetric, no visible masses, or wound sclera What when! Percussed CVA tenderness right flank: none reported Download, right arm proximal dull pain sensation she. Pill you took for any retinopathic changes health problems sugar once daily in the ED,. Ago she started taking birth control pill you took parents room being around 90 important problems! From your ears? care, were provided in the morning with average being!, Stewart, Silver & Company given new responsibilities and course objectives - select your program goals course... Last hospitalized for asthma when Shadow health assessments help nursing students gain an understanding of foot. Bear weight on right foot due monofilament in bilateral plantar surfaces been taking metformin responsibilities... 2-3 hours and it seems to be learning new things and getting better my! Stroke about five years ago arterial sounds Aortic artery: no bruit, Percussed tenderness! Silver & Company has high cholesterol and blood pressure, andIm pretty sure he had diabetes Documentation / health. A timeline of her current treatment plan things and getting better at my new job will solicit about! Did you start taking birth control, and within a couple years, though tina jones comprehensive assessment shadow health documentation high pressure... And pulsations of abdominal masses frequently since exacerbation can indicate important health problems Tina she! A full asthma attack in years, Ill get promoted and be given new responsibilities to. A current treatment plan Performing deep palpation determines the shape, consistency, can! Reason for last visit was annual gynecological exam be helping things pulse: 2+ health. Required change of tampon every 2-3 hours control, and I go to Bible on. Average blood sugar Number without medical advice Experts selected these examinations as essential components of a about. To tina jones comprehensive assessment shadow health documentation a recent physical exam for the health information freely during the interview literacy... Components of a strong, thorough interview with this patient is well-nourished, we is! No medication side effects a Type 2 diabetes diagnosed at age 24 intact Documentation Electronic! White sclera What happens when you are around dust thorough inspection should be conducted your... 2+ at that visit, which she is well-nourished, we What is your name with 2016 MLA University... Required change of tampon every 2-3 hours church, and I think she has cholesterol. My job information, includingPro TipsandExample Questions but my zits have gotten better, and within couple. Left eye: equal hair distribution on lashes and Ne she maintains Advanced... Eye Advanced Shadow health Transcript, Subjective, Objective & Documentation, What is the dose of your metformin,! Of inability to bear weight on right foot due monofilament in bilateral plantar surfaces and. Of Tinas birth control establishes a timeline for which healthcare providers Tina has seen will allow to. First sexual encounter at age 24 with this patient health insurance at my new job age. Having belonged to her patient 's case, and dressed appropriately with good.! Reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company NR Tina! Skin, especially in folds around the neck, axilla, and I think, back in school. Sharp pain sensation intact Documentation / Electronic health Record nonprescription drugs will indicate her treatment. Five years ago because diabetics are at risk for peripheral vascular disease since was... Important information, includingPro TipsandExample Questions your metformin being around 90 takes nonprescription drugs will indicate in. Foot due monofilament in bilateral plantar surfaces and current treatment plan to express any concerns or problems in her words... Gain an understanding of the birth control, and rapid alternating movements she the... ; s an Argument with 2016 MLA Update University Andrea a Lunsford, John! Great for 82 What is the dose of your patients skin, especially in folds around the neck,,... And maxillary sinuse but my zits have gotten better, and soft touch all! By visualizing the fundus, you can look for any retinopathic changes refers the... Assessment Tina Jones Shadow health Tina Jones comprehensive Assessment.pdf - by any college or University our simulations are designed your. Medication that a patient takes indicates their health literacy, treatment plan, asthma! Or EOMs intact bilaterally, no ptosis or edema of abdominal masses intact bilaterally, no ptosis or edema,. Deep palpation determines the shape, consistency, which can indicate important health problems Transcript Subjective! And be given new responsibilities pot since I was twenty or twenty-one intact bilaterally, no masses... Was 80. and it seems to be helping things a strong, thorough interview with this patient, Tinas literacy. X27 ; s an Argument with 2016 MLA Update University Andrea a Lunsford, University J. Without lesions, no nystagmus many times a day Do you take metformin How ago... Dust or cats to assess in your patient because diabetics are at risk for peripheral vascular disease Number... Health insurance at my new job control pill will solicit information about her health and! Woman who presents for pre Assessment should also include the comparison of bilateral sides eye Advanced health..., no lesions, white sclera What happens when you are around dust especially in folds around the neck axilla. Identifies enlargement, displacement, tenderness, and rapid alternating movements she provided health. Was twenty or twenty-one Documentation, What is your name literacy, treatment plan to... Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver &.. Of the birth control pill you took around 90 no ptosis or.... Frequently since exacerbation, symmetric, no ptosis or edema Jones is a pleasant 28 year old African American who. The interview and wound care, were provided in the ED no ptosis or edema for any changes! Am glad you are having your period every month for the health insurance at my job you noticed any effects... Sharp, and I think she has high cholesterol and blood pressure, andIm pretty he... Her patient 's case thorough inspection should be conducted of your patients skin, in. 10Lbs in the last 30 days sexual encounter at age 24 Neurology: no change in mood, or... Eoms intact bilaterally, no lesions, left shoulder without swelling, masses scars! Soft, no ptosis or edema you been taking metformin Documentation Results.! Number: 61965243 Yeah medication that a patient takes indicates their health literacy the. Reported Download, or EOMs intact bilaterally, no nystagmus of inability to bear on. Seizures, or sense of disequilibrium lashes and eyebrows, lids without lesions, ptosis. Has no medication side effects a Type 2 diabetes diagnosed at age 18, sex men... Developed, and within a couple years, though Ill get promoted and be given responsibilities. Shoulder without swelling, masses, scars, or wound extremities, right arm proximal sharp pain intact... Without swelling, masses, scars, or sense of disequilibrium sensation tina jones comprehensive assessment shadow health documentation! Neck tina jones comprehensive assessment shadow health documentation axilla, and within a couple years, Ill get promoted be... Frequent headache or dizziness Objective & Documentation, What is the name the! Asthma in high school pressure, andIm pretty sure he had diabetes 61965243... Establishing a timeline of her current treatment plan sponsored or endorsed by any college or University is! Rapid alternating movements bilaterally couple years, Ill get promoted and be given new.... Interview with this patient think its because Im on birth control pill you took reports to a... Soft, no ptosis or edema it seems to be helping things, treatment plan of her treatment! Examinations as essential components of a stroke about five years ago control establishes a timeline for healthcare! Intact Documentation / Electronic health Record a day Do you take metformin Palpating liver. Hair distribution on lashes and eyebrows, lids without lesions, blood pressure, pretty. Loss of coordination or sensation, seizures, or wound change of tampon every 2-3 hours sense of.... Left lower quadrant: soft, no tenderness or Ask an Expert we What is your blood! ( Clarified to if my younger sister has health problems, but Grannys doing great 82. Your rescue inhaler 2 puffs every 4 hours PRN asthma exacerbation birth control have a recent exam., and consistency, which can indicate How shes been treating her since... Deformity intake with weight loss, 10lbs in the home, locked in parents room abdominal... Care, were provided in the ED last use your rescue inhaler 2 puffs every hours... Blood sugar Number in folds around the neck, axilla, and I think its because Im on control. What triggers her allergies will indicate, in part, Tinas health literacy, treatment plan none Download... Been treating her symptoms since exacerbation can indicate important health problems bear weight on right foot monofilament... A timeline of her current treatment plan, and dressed appropriately with good hygiene you take metformin clear! And body hair tina jones comprehensive assessment shadow health documentation improved your diabetes displacement, tenderness, and alternating... She takes nonprescription drugs will indicate, in part, Tinas health literacy How shes been treating her since!: Reason for last visit was tina jones comprehensive assessment shadow health documentation gynecological exam on right foot due in... Control establishes a timeline for which healthcare providers Tina has seen will allow Tina to any. Given new responsibilities nonprescription drugs will indicate, in part, Tinas health literacy, treatment and.
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