This also applies to late DQ replies. 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. 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. PK ! Genitourinary: Reports no dysuria, nocturia, polyuria, hematuria 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. Tonsils 2+ bilaterally. She, denies any food and latex allergies. Tina was, diagnosed with asthma at age 2 1/2. F/U 3 months to For weight status (particularly if youve started the patient on a weight loss regimen). distribution on lashes and eyebrows, lids without lesions, no pto Endocrine: Reported of polydipsia, polyuria and weight She has no medication side effects at this time. 2 deep. White pus pockets and petechiae on the palate are classic signs of strep throat. Did you forget to cite something? 2022 Nursingbay.com. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score. She maintains eye contact throughout the interview. Reports sore throat began about a week ago. gD,~M?Jx Last menstrual period 2 weeks a Health history is a very important part of assessment for practitioners. Asking Tina about the number on inhaler puffs she needs to resolve symptoms can indicate whether her asthma has worsened or point to potential problems like poor inhaler technique. Tympanic throughout to Gastrointestinal: Reports no nausea, vomiting, pain, constipatio Has your vision gotten worse? Learning about a patients family history around ear problems can help you predict risk. She does not appear to be in any distress. I had two doctors appointments earlier this year. She states that her last asthma attack was 3 months ago. Week4 DCE Tina Jones Comprehensive - Documentation / Electronic Health Record Document: Provider - Studocu On Studocu you find all the lecture notes, summaries and study guides you need to pass your exams with better grades. lower extremities. HPV. Patient dressed appropriately for the weather. Pro Tip: Soliciting a shallow medical history relevant to Tinas chief complaint will allow you to assess her condition relative to past concerns. Speech is clear and coherent. Asking Tina if she gets headaches is soliciting information about possible symptoms that she experiences. Establishing a timeline for how long Tinas throat has been sore will also aid in treating her sore throat. Identifying Data & Reliability Have you noticed any changes to your voice? Liver: 1 cm below right costal margin. When, interviewing the patient the practitioner is able to get a health history and the history of, the patients chief complaint. Has smoke detectors in the home, wears seatbelt in car, and do DONT STRESS YOURSELF, JUST CHAT US AT THE RIGHT CORNER BELOW. Asking Tina if she currently has a headache solicits information about how she is feeling now. Review your similarities. stopped darkening and facial and body hair has improved. Asking Tina if she is lightheaded could point to inner ear disturbances. Your paper will be evaluated based on the following criteria: 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. Strength 5/5 bilateral upper and lower extremities. Do you have a history of throat problems? Denied receiving We're available through e-mail, live chat and Facebook. Neck has skin discoloration. One or two sentence responses, simple statements of agreement or good post, and responses that are off-topic will not count as substantive. Model Note: Differential diagnosis includes viral pharyngitis, strep throat, influenza, cold, and sinusitis. Identifies health concerns based on screening assessments and demographic information. Eyes no swelling in eyes, sclera is white, conjunctiva is pink with no exudates. The comprehensive examination is, completed for her pre-employment. Ms. Tina Jones is a 28 years old African American female who came into the clinic for pre-employment assessment. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. Asking whether shes noticed ear discharge could indicate whether she has a ruptured eardrum. Conjunctiva pink, no lesions, white sclera. employment physical prior to initiating employment. Pt stated of eating 2-3 serving of fruits Asked about frequency and duration of runny nose, Reports nose is runny pretty much all day. Pro Tip: Sinusitis can result in dry mouth. encounter at age 18, Sex with men only. Fasting glucose levels and Hgb A1C can be tested to rule out diabetes. Tina has been diagnosed with diabetes, asthma and polycystic ovarian syndrome (PCOS). Patient verbalized sleeping well at night with no pain or discomfort. due to feeling of "bloating and gassy." Try controlling Fluticasone Propionate 88 mcg/spray- BID to manage asthma, YAZ- 1 pill every morning- for birth control and to manage PCOS Tina Jones Comprehensive Assessment Final Paper. Pro Tip: Establishing a timeline for how frequently Tina gets blurry vision will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers. She reports that she believes she is up to date on xxx and received the xxxx for xxx. 03 Education and Empathy No bleeding or bruising. Those are gotten from EBP and clinical guidelines. She uses her XXXwhen she is around cats. Class Stopped taking med without medical advice You must proofread your paper. 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. Asthma: diagnosed at age 2. uses proventil 2-3 times a f [Content_Types].xml ( O0H|W!tr(kOZ=~{I-lh^"%~w5 'n[oO{V$N ]^ZRA.l>pHh diaphoresis. The clicking noises are most likely caused by displacement of the disc between the condyle and fossa (ball and socket) at the temporomandibular joint. Denied exercising. Mild retinopat deformity and with full range of motion. . Lived independently since age 19, currently lives with mother and sister in a single family home, but will move into own apartment in one month. Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, Patient is in positive mood, alert and oriented x3, Ms. Jones is a pleasant, 28-year-old African American single w, who presents for a pre-employment physical. She uses her albuterol inhaler Have you started taking any new medications? O6Ne wN_2fE%!jP)b3`g933$MB5RWU \@% List your Diagnostics ordered: if applicable Reading and studying seem to cause headaches. 31 Comments Please sign inor registerto post comments. inhaler. click here for Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew to pain. A comprehensive exam starts the moment the patient is within view taking, note of signs of distress, habitus, manner of sitting and degree of facial relaxation (Ball et, al, 2020). How would you rate your headache pain on a scale of 0 to 10? today. 90 mcg/spray MDI 2 puff PRN for shortness of breath. Tes Followed up about medications and relieving factors for nose and eye symptoms. Last pap . View full document Referrals (if indicated): If none needed, document: None. Bowel sounds are intubated. grandmother diseased, died at age 73 from stroke, She reports that she believes she is up to date on ch An analysis of Tinas great aunts medications and past medications can be used to rule out ototoxicity. Paper Asking Tina if she has problems with her gums solicits information about possible causes of her symptoms. She states that she, has tightness in her chest and wheezing. What is the conversion factor between ft2ft^{2}ft2 and yd2yd^{2}yd2. Reports typical inhaler use is 2 3 times a week. Recently she is active. Case - Shadow health focused exam chest pain brian foster completed 5. All health issues listed are under control with no complaints from patients. Covered/Right Eye covered. Frontal and maxillary sinuse Participates in mild to moderate exercise four to five times per week consisting of walking, yoga, or swimming. Heart rate is regular, S1, S2, without murmurs, gallops, or rubs Pro Tip: Sinusitis can result in decreased smell or taste. which she is controlling with diet, exercise, and metformin, whic Model Note: A useful diagnostic finding that suggests otitis media is the lack of mobility of the tympanic membrane during insufflation. Brother overweight. Asking Tina if she has ear pain might indicate a possible ear infection and a reason for changes in her hearing. organomegaly. Do you get headaches when you have blurry vision? Pro Tip: Asking about how Tina is recently breathing can provide a comparative baseline for assessing Tinas current condition and previous breathing concerns or conditions. Asking if Tinas sense of taste has changed lately might indicate a sign of sinusitis. (Example: Advised to lock guns up in safe). Tina Jones shadow health. A neurological assessment should be completed to rule out cerebral ischemia. She enjoys spending time with friends, reading, attending Bible study, volunteering in her church, and dancing. PMI at the She is well-developed and dress appropriately with good hygiene. She is excited to start her new jo in the city. Communication is so very important. What is the name of the inhaler you are currently using? is clear and coherent. Questions to Instructor Forum: This is a great place to ask course content or assignment questions. TMs intact and pearly gray bilaterally, positive light refle Pro Tip: Tinas response to a question about managing her headaches will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. Patient verbalized coping well with stress and anxiety by having support from family and friends. Denies increase in recent asthma symptoms. R: 15. 01 Interview Through our natural language conversation engine, students use their own words to gather subjective data and provide therapeutic communication. Allergies Asking Tina if shes had mouth pain might indicate a problem area that has caused infection. Type 2 DM: diagnosed at age 24. was on metformin She is in the clinic today for a physical, exam for her new job. Pro Tip: Nosebleeds are often caused by sinusitis. Mother- (50 years) hypertension and high cholesterol. MS. She has a history of hypertension which normalized when she Pro Tip: Assessing how a patient feels in the current moment can allow you to juxtapose their chief complaint alongside symptoms they experience. No food intolerances. Guns, having belonged to her AV nicking is usually a result of chronic hypertension. Pleasant and cooperative. reports a few moles but no other hair or nail changes. Pro Tip: Pain severity might change for a variety of reasons. Pro Tip: In some cases, infection can spread to a cheekbone through an infection in the mouth. CV: Denied chest discomfort, palpitation, history of Stretch marks on anterior and posterior waist. She has changed her, diet recently to help with her diabetes. Pro Tip: Tinas response to a question about taking any decongestants will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. Never intubated. Cross), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Civilization and its Discontents (Sigmund Freud), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), The Methodology of the Social Sciences (Max Weber), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler). ORDER COMPREHENSIVE SOLUTION PAPERS ON Tina Jones Comprehensive Health Assessment. Asking Tina what medication she takes for her asthma will indicate her treatment plan and the degree to which she complies with it. Do you have any family history of throat problems? Eye Movements: Movement parallel She plans to use condoms with sexual activity. Reports improved acne due to oral contraceptives. Pro Tip: Secondhand smoke can be particularly triggering for asthmatics. The patient is here, for physical assessment for work insurance for a new job. Does not use APA. Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. Do you have any problems with your lymph nodes? She is required to have a physical exam for her health insurance. Allergic to cats and dust. Tina Jones shadow health. discoloration over last few years. Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Assess health history, including environmental exposure, wellness/illness beliefs, values, attitudes, and health promotion practices of individuals, and a focused family health history. Dentition without evide edema. who presents for a pre-employment physical. Uploaded By rockstar1230. o able to find out what the patient believes is most important about their health (Bickley, 2013). Pro Tip: Sinusitis can often lead to tonsil problems. Stevens, Stewart, Silver & Company. Tina's health history was taken, a physical. Pro Tip: Broad, open questions will allow Tina to describe, in her own words, the specific pain and discomfort that she is experiencing. Asking Tina whether she has been wheezing illustrates how her asthma is presenting. and vegetables a week. Alert and oriented to person, place, and time. Lunch Sometimes left-over dinner or wheat bread sandwich. The universitys policy on late assignments is 10% penalty PER DAY LATE. S Asking Tina if she thinks she is having an allergic reaction will give Tina the opportunity to compare her current symptoms with symptoms shes historically had during an allergic reaction. Denied allergy to latex. Tina Jones shadow health. Do you think you are having an allergic reaction? Simply restating someone elses words does not demonstrate an understanding of the content or critical analysis of the content. she does not smoke cigarette or use illicit drugs but once smoked pot as a teen. The paper is focused on designing evidence-, based, culturally competent nursing interventions through the development of an. Case - Tina jones mental health shadow health assessment transcript 4. not ride a bike. So you will need to make reference to these in APA format. Getting your paper done is easy when you know the right people. I discourage overutilization of direct quotes in DQs and assignments at the Masters level and deduct points accordingly. Pro Tip: Establishing a timeline for how long Tinas nose has been running will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages. Pro Tip: Vision problems are often genetic. Pro Tip: Some people who experience chronic asthma may be accustomed to wheezing and thus might not volunteer this information. Pro Tip: Establishing a timeline for how long Tinas vision stays blurry will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers. I mean, I still have asthma and diabetes, but both. Patient has been eating healthy, using recipes from online for diabetes. Verified answer. in here for a check-up, and the nurse practitioner got me on metformin. Determining when Tinas eyes most itch will also aid in treating her itchy eyes. No edema. fao.b*lIrj),l0%b Tina is a 28 year old African American women. she drinks occasionally with friends once or twice a week. She maintains eye contact throughout the interview. Identified knowledge deficit areas/patient education needs (medication teaching etc). Hello, my name is . Retrieved on July 26, 2020 from. Missing information regarding the patients insurance status, ability to pay of medications and other out-of-pocket expenses. No CVA tenderness. Speech is clear and she Reports no dizziness, light-headedness, tingling, loss of coordi Pro Tip: If left untreated, tongue problems, like abscesses, can result in sinusitis. the day i caught my fiance cheating 2 days before our wedding. Anisocoria can be found in about 20% of normal individuals. for menstrual pain and headaches. It is not a focused assessment. Mental Health History Tina Jones Comprehensive Assessment Final Paper. Exam Have you taken anything for your sore throat? with polycystic ovarian syndrome and prescribed oral contracep Pro Tip: In some cases, infection can spread to a cheekbone through an infected tooth. Speech is clear and coherent. Left fundus with sharp disc margins, no Ms. Jones is well nourished and well developed, appropriately dressed with good hygiene: Not in acute, "I scraped my foot a week ago and the wound is not, Ms. Jones twisted her ankle walking down the stairs a, week ago, scraped the ball of right foot, She received, care from local ER. She began If you have a question, there is a good chance one of your peers does as well. Never tested for Patient appears stated age and in good health. She wears a prescription glasses to help with blurry vision and headaches. Pro Tip: Sinusitis can often lead to tonsil problems and voice changes. I encourage you to incorporate the readings from the week (as applicable) into your responses. Asking Tina if she has neck pain is soliciting information about a possible cause of her symptoms. Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. allergy to cat and dust (caused SOB, she monitors her asthma by using the peak flow. Learning about a patients family history around vision can help you predict risk. Thyroid smooth withou lenses. Diabetic Neuropathy as evidence to decreased sensation on both right and left great toes and right heels. Tina is excited about her new job and the idea of moving to the city and living alone. Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. Reports no palpitations, tachycardia, easy bruising, or edema. Denied issues with Reports occasional sho bilaterally. Tina was recently diagnosed with, TINA JONES ASSESSMENTComprehensive Assessment. Patient is obese but practicing healthy eating and physical activity in her daily routine. On Diabetes safe diet plan as per nutritionist. Eye contact throughout the interview. All Rights Reserved. Tina Jones shadow health, Asked about review of systems for dentation. Course Hero is not sponsored or endorsed by any college or university. Asking Tina if she has mold in her house might indicate a possible trigger that she has been exposed to. 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. Asked about review of systems for mouth and jaw. Pro Tip: Asking Tina when her last hearing test was will indicate the degree to which shes seen her hearing as something that has needed medical attention. Reports using 2 3 puffs of inhaler when used. I will ask you a few questions about how youre using each medication.. Asking Tina if she has dry eyes solicits information about one particular symptom. murmur, or arrythmia. Ms. Jones denied history of mental illness, depression, anxiety, and at risk for suicide. Never pregnant. Nasal mucosa moist and pink, septum 1. Symptoms include SOB, rhinitis Take the extra few minutes to review instead of getting counted off for these mistakes. l\}s Never married, no children. N _rels/.rels ( JAa}7 Tina Jones shadow health. 6. Pain was 7/10, two. PCN (caused rash). TSH and T4 levels can rule out hypothyroidism. You will develop differential diagnosis based on the chief complaint and HPI. treat headaches. or sensation, seizures, or sense of disequilibrium. Always document a specific follow-up and reason: Example: f/u 1 week to evaluate antibiotic efficacy. As Masters level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. ;6-SdhFFS$dg(,9oSN[gwvJ;V:3f'7c?xy0{w6z=v. Followed up about character of nasal discharge. * The paper should be written and referenced in APA format and be no longer than 4 pages (excluding cover page and references). Read over your paper in silence and then aloud before handing it in and make corrections as necessary. Asking Tina if she has problems with her jaw solicits information about possible causes of her symptoms. She maintains eye, Ms. Jones is alert and oriented, seated upright on the examinat, table, and is in no apparent distress. Your initial responses to the mandatory DQ do not count toward participation and are graded separately. She is well-nourished, we GU: Pt stated of polydipsia and polyuria. General: Ms. Jones is relaxed sitting on the edge of the examination table. midclavicular line, 5th intercostal space, no heaves or lifts. Mild edema at right ankle. She began XXX months ago and initially had some gastrointestinal side effects which have since dissipated. Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Last xxx months ago. Patient presents with other health issues that is under control. EOMs intact bilaterally, no nystagmus. Vinik, A., Casellini, C., Nevoret, M. R. (2018). She has a documented medical history of, Asthma and Diabetes. were provided in the ED. There are multiple ways to communicate with me: Pro Tip: Asking Tina when her last vision test was will indicate the degree to which shes seen her vision as something that has needed medical attention. NR 509 SHADOW HEALTH CASES COMPILED BUNDLE OFFER!! Shadow Health Tina Jones All Tabs | Complete Tina Jones Shadow Health Cases, SHADOW HEALTH TINA JONES COMPLETE CASES~SHADOW HEALTH. Reports inhaler is albuterol (Proventil) Reports using inhaler no more than 2 times per week. Assessments should include a history of hearing impairment and ear injuries. Maternal grandfather diseased, died at age 78 of stroke. goods, lunch: sandwich, dinner: meatloaf or chicken. Soliciting this information allows you to more accurately treat her symptoms. During a comprehensive assessment, the practitioner is looking at the. Reports typically taking 2 puffs. Looking for palpable nodes, redness, swelling, tenderness, drainage, loss of hearing, and pain. I highly recommend using the APA Publication Manual, 6th edition. of breath, wheezing, and chest tightness. Tina also takes Advil 500mg as needed for menstrual cramps and for headache. Whispered words heard bilaterally. influenza is not current, and human papillomavirus has been Nursing Capstone Project Writing Services, Nursing Annotated Bibliography by Professional, Online Nursing Research Paper writing service, Includes information regarding patients insurance status and ability to afford medications and other out-of-pocket expenses. No Typical breakfast is frozen fruit smoothie with unsweetened yogurt, lunch is vegetables with brown rice or sandwich on wheat bread or low-fat pita, dinner is roasted vegetables and a protein, snack is carrot sticks or an apple. Paternal intake with weight loss, 10lbs in the last 30 days. Current treatment options for acanthosis nigricans. runny nose, itchy eyes), denied other drug allergies. These announcements are made to ensure you understand everything that is due during the week. Sensorineural hearing loss is common in old age and can be caused by heredity, diabetes, cerebrovascular disease, excessive noise, ototoxic medications, hyperlipidemia, hypothyroidism, and renal failure. She states that it feels like, she "cant' get enough air. Tina Jones Comprehensive Health Assessment. XRay of the foot and wound care, were provided in the ED. bilaterally. 02 Physical Exam Students gather and interpret objective data to assess the patient's condition. She stated of having Wound at right ball of foot measured at 2cm by 1, Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew My Library Discovery Institutions Ne developed, and dressed appropriately with good hygiene. aggravating factor and tramadol as relieving factors. denied Last pap 3 years ago. Pro Tip: Seeing a dentist regularly can assure that among other things, tooth infections, which can cause sinusitis, do not go untreated. PPD (negative) ~2 years ag But do not strictly rely on your computers spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. The static temperature and pressure at each section are indicated. Visualization of the throat also gives clues to the diagnosis. For the past four mont Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. Tina is allergic to cats, she states that she tries to avoid cats but when she is around them her, asthma "acts up" (T. Jones, Shadow Health Interview, February 13, 2016). Tina checks her blood sugar once a day, in the, Her diabetes is being treated with metformin 850 mg PO BID. General Clinic. Be sure to include any patient education for other findings in your exam; for medications; for nutrition (if needed); for safety (if indicated); health promotion and disease prevention. Asking Tina if the lozenges help will illustrate the extent of her pain and how effectively OTC treatments works for her throat. Asking Tina if she has dust in her house might indicate a possible trigger that she has been exposed to. The loss of sensation results in the loss of thermal and pain perception. Pro Tip: Ear pain can suggest an ear infection, during which the middle of the ear becomes clogged with fluid and mucous, which can affect hearing. XXXX Denies food and latex allergies XXXXX. Reports no current breathing problems. HR: 78. It is not a focused assessment. vaccines and received the meningococcal vaccine for college. female. Asking Tina if she has problems with her tongue solicits information about possible causes of her symptoms. Family History Have you been recently exposed to any allergens? A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. If palpation elicits pain and purulent nasal discharge is reported over the last 7-10 days, consider sinusitis. Denies adverse effects of asthma medication. Sister asthma. Any assignment submitted after midnight on the last day of class will not be accepted for grading. Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. XXXX. Asking Tina if she has recently smoked can help you to discern whether smoking was a factor in Tinas recent asthma exacerbation. Tina Jones shadow health. Family History Tina Jones Comprehensive Assessment Final Paper. Have you had any changes in your breathing? than in the past, and is looking forward to beginning the new jo, Metaformin (Diabetes); Albuterol (Asthma); Provental (Asthma), Diabetes Mellitis diagnoed two year ago; Wound healing on right Reports that the symptoms dont seem like a common cold. 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