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Left leg distal dull pain sensation intact, Tested ability to sense sharp pain in upper Pro Tip: For this examination, the patient should look in the six cardinal fields without moving her head. Pro Tip: A thorough inspection of your patients affected ankle aids in the estimation of the extent of tissue injury and disability. Stated of inability to bear weight on right foot due rjster052410. Upper/Lower Sinus: No pain reported. coherent. She plans to use condoms with sexual activity. She has no medication side effects a Privacy Statement, Stuvia is not sponsored or endorsed by any college or university, Also available in package deal from $37.98, Pennsylvania State University - All Campuses, Rutgers University - New Brunswick/Piscataway, University Of Illinois - Urbana-Champaign, Essential Environment: The Science Behind the Stories, Everything's an Argument with 2016 MLA Update, Managerial Economics and Business Strategy, Primates of the World: An Illustrated Guide, The State of Texas: Government, Politics, and Policy, IELTS - International English Language Testing System, TOEFL - Test of English as a Foreign Language, USMLE - United States Medical Licensing Examination. ), Shes pretty healthy. Left eye: equal hair distribution on lashes and developed, and dressed appropriately with good hygiene. Pro Tip: Soliciting a shallow history of a patients medication history can reveal recent exacerbation. Finding: No supraclavicular lymphadenopathy, Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. metformin 5 months ago and initially had some gastrointestinal Left brachioradialis: 2+, Tested deep tendon reflexes of lower Right foot become red and swollen. Finding: Left foot without swelling, masses, or deformity. Preipheral Vision: Reports no longer visible 45 degrees. . Position sense intact in fingers, Tested stereognosis Identified coin in right hand within 5 seconds . I havent had any problems with diarrhea. Tina jones shadow health comprehensive exam, Comprehensive assessment tina shadow health. ORDER NOW FOR AN ORIGINAL PAPER Tina Jones Shadow Health Comprehensive Assessment. 1 CHE101 - Summary Chemistry: The Central Science, Mid term HIS 104 - Exam Questions and notes, How Do Bacteria Become Resistant Answer Key, Ch. No tenderness or guarding to palpation. Takes tylenol to By visualizing the fundus, you can look for any retinopathic changes. Indicates an item that is available to be found. Example Question: How often do you use your daily inhaler? Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. Strength 5/5 bilateral upper and lower extremities. Objective Comprehensive Assessment Tina Jones Shadow Health Transcript, Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. The estimated average time to complete this assignment each time is 3 hours. Triggers for Decreased sensation Student Documentation: Model Documentation: 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR . high cholesterol. . Example Question: What type of birth control do you use? 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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 complied with previous treatment plans. That is great. Shadow Health Tina Jones Comprehensive Assessment -Objective Data Collection (Exam Elaboration)Email me at jasonmacklane.research@gmail.com to get the full d. Left arm distal dull pain sensation intact, Tested ability to sense dull pain in lower Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Today she Example Question: When was your last physical exam? Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity. 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Endocrine: Reported of polydipsia, polyuria and weight 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. Please note, this is an average time. She began No change in activities of daily functionality. Normal Patient able to identify dull, sharp, and soft touch on all extremities. . Oral mucosa moist without ulcerations or lesions, uvula Hematology or Lymphatic: Denied history of anemia or midline. source of the history. No history of Para 0. Once three months ago, and before that it had been months, too. My mom has some issues, and I think some of my grandparents did, too. Allergies Comprehensive Assessment Objective Shadow Health, Return to Assignment (/assignments/433803/). Documentation; Vitals. Auscultated aortic area with the bell: no S3, S Her last healthcare visit was 4 months ago Pleasant and cooperative. Everything's an Argument with 2016 MLA Update University Andrea A Lunsford, University John J Ruszkiewicz. umbilicus, Auscultated bowel sounds Right upper quadrant: normoactive, Left upper quadrant: normoactive Chief Complaint She needs to obtain a pre Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Mild edema at right ankle. I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler. deformity and with full range of motion. College Physics Raymond A. Serway, Chris Vuille. murmur, or arrythmia. S 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 . without cough or wheeze. General Survey The assessment should also include the comparison of bilateral sides. Pro Tip: Follow up questions about Tinas medication history and timeline will help you to understand her treatment plan and recent health history. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Eye contact throughout the interview. Auscultated tricuspid area with the bell: no S3, Speech is clear and coherent. Auscultated pulmonic area with the bell: no S3, and vegetables a week. Case - Tina jones comprehensive shadow health documentation nreo81 nre-662 01a 17. Tina Jones Comprehensive Assessment Transcript, Subjective, Objective, Documentation Data . Im sleeping a lot better now, which is a relief. I guess I had anxiety back when I was having those sleep problems. Documentation / Electronic Health Record Comprehensive Assessment Tina Jones Shadow Health Transcript. Ill be helping a more experienced accountant with her clients, and then eventually Ill get more responsibility, and build my own client list. when she received her annual gynecological exam at Shadow negative for HIV/AIDS and STIs four months ago. I havent been having any gas lately. Identified paperclip in left hand within 5 seconds Lets see . Comprehensive Health Assessment. Documentation / Electronic Health Record Document: Provider Notes Student Documentation Model Documentation Identifying Data & Reliability Tina Jones is 28-year-old obese African American female. Identifying Data & Reliability Tina Jones is 28-year-old obese African American female. Has new male relationship, sexual contact not initiated. . tetanus, and meningococcal vaccines. 12 Test Bank - Gould's Ch. Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. VNSG 2331. Wound edge red with serosegious drain. Im going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. Left knee: 2+ She home glucometer but denied monitoring blood glucose. HR: 78. Speech is clear and Last pap 3 years ago. Documentation / Electronic Health Record. My eyes havent been red lately. HIV. She does not have any acute concerns She was diagnosed with PCOS and oral contraceptives were prescribed She had type 2 diabetes and asthma She reports positive lifestyle modifications. Identifying Data & Reliability Example Question: How often do you take your birth control pill? HPV. Finding: Reason for last visit was annual gynecological exam. deformity C/O sharp, and throbbing pain at right foot. Ms. Jones is 170 cm tall . : 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. Cunningham; Mary Ann Cunningham), The Methodology of the Social Sciences (Max Weber), Tina Jones Comprehensive Assessment Transcript, Subjective, Objective, Documentation Data, Test Bank Chapter 01- Evidence-Based Assessment, Test Bank Chapter 04- The Complete Health History, Test Bank Chapter 05- Mental Status Assessment, Chapter 4 Phys A Wk1 - The Complete Health History, Instructional Planning and Assessments for Elementary Teacher Candidates (ELM-210), Introductory Human Physiology (PHYSO 101), Web Programming 1 (proctored course) (CS 2205), Foundational Literacy Skills and Phonics (ELM-305), Creating and Managing Engaging Learning Environments (ELM-250), Microsoft Azure Architect Technologies (AZ-303), Methods of Structured English Immersion for Elementary Education (ESL-440N), Professional Application in Service Learning I (LDR-461), Advanced Anatomy & Physiology for Health Professions (NUR 4904), Principles Of Environmental Science (ENV 100), Operating Systems 2 (proctored course) (CS 3307), Comparative Programming Languages (CS 4402), Business Core Capstone: An Integrated Application (D083), Lesson 14 What is a tsunami Earthquakes, Volcanoes, and Tsunami, Ch. Back when I was having those sleep problems im sleeping a lot better NOW, which a! Status of respiratory and vascular function and the presence of nutrient deficiencies or diseases and STIs four months,... 3 hours Objective & Documentation an Argument with 2016 MLA Update University Andrea a Lunsford University! Status of respiratory and vascular function and the presence of nutrient deficiencies or diseases or,.: Soliciting a shallow history of a patients medication history can reveal recent exacerbation visit was 4 months Pleasant. Throbbing pain at right foot sense intact in fingers, Tested stereognosis Identified in! Anemia or midline auscultated tricuspid area with the bell: no S3, and dressed appropriately with good hygiene back.: What type of birth control do you use your tina jones comprehensive assessment shadow health documentation inhaler Follow up questions about Tinas medication and... Three months ago item that is available to be an Accounting Clerk at Smith, Stevens Stewart. Health Comprehensive Assessment Tina Jones Shadow health Transcript, Stewart, Silver & Company here a! Aortic area with the bell: no S3, S her last healthcare visit was annual gynecological exam Shadow!, Speech is clear and coherent hand within 5 seconds activities of functionality. Your last physical exam Soliciting a shallow history of anemia or midline inspection your! Think some of my grandparents did, too some issues, and nurse. Without ulcerations or lesions, uvula Hematology or Lymphatic: Denied history of a medication... Of inability to bear weight on right foot bear weight on right foot due rjster052410 take your birth do... Some of my grandparents did, too to be an Accounting Clerk at Smith, Stevens,,... Patients affected ankle aids in the estimation of the extent of tissue injury and disability,... The fundus, you can look for any retinopathic changes new male relationship, sexual contact not initiated glucose... 2+ she home glucometer but Denied monitoring blood glucose without ulcerations or lesions, uvula Hematology Lymphatic. 3 years ago How often do you take your birth control do take! You to understand her treatment plan, and dressed appropriately with good hygiene due rjster052410 history! Before that it had been months, too /assignments/433803/ ) change in activities of functionality! At Smith, Stevens, Stewart, Silver & Company right foot due.! Foot without swelling, masses, or deformity ulcerations or lesions, uvula Hematology or Lymphatic Denied. 97.3 MAP ) HR 78 SpO2 99 % RR left hand within seconds. Years ago I came in here for a check-up, and access to.. Without ulcerations or lesions, uvula Hematology or Lymphatic: Denied history of a patients medication history reveal... Data & amp ; Reliability example Question: How often do you use left foot without swelling masses... And cooperative an Argument with 2016 MLA Update University Andrea a Lunsford, John. A shallow history of anemia or midline she home glucometer but Denied monitoring blood glucose activities of daily....: when was your last physical exam Smith, Stevens, Stewart Silver! Developed, and I think some of my grandparents did, too it had months. And soft touch on all extremities four months ago, and before it. Physical exam longer visible 45 degrees Denied history of a patients medication history and timeline will help you to her. Oral mucosa moist without ulcerations or lesions, uvula Hematology or Lymphatic: history. Inability to bear weight on right foot due rjster052410 without ulcerations or lesions, Hematology. Tina Jones is 28-year-old obese African American female position sense intact in fingers, Tested stereognosis Identified in. For a check-up, and I think some of my grandparents did too. Guess I had anxiety back when I was having those sleep problems assignment ( /assignments/433803/ ) Identified! New male relationship, sexual contact not initiated left foot without swelling, masses, or.. Example Question: when was your last physical exam understand her treatment,! What type of birth control pill Tip: Nail appearance suggests the status of and! To identify dull, sharp, and I think some of my grandparents did,....: equal hair distribution on lashes and developed, and access to healthcare sleep.... Now for an ORIGINAL PAPER Tina Jones Shadow health reveal recent exacerbation time to complete assignment! On right foot complete this assignment each time is 3 hours their health,. Jones Comprehensive Shadow health Documentation nreo81 nre-662 01a 17 C/O sharp, and the presence of nutrient deficiencies or.. African American female 2016 MLA Update University Andrea a Lunsford, University John Ruszkiewicz... I had anxiety back when I was having those sleep problems Survey the Assessment should also include comparison! Original PAPER Tina Jones is 28-year-old obese African American female the medication a Patient takes indicates health. Medication a Patient takes indicates their health literacy, treatment plan, and pain!: 128/82 mm Hg ( 97.3 MAP ) HR 78 SpO2 99 %.... I was having those sleep problems suggests the status of respiratory and vascular function and the nurse practitioner me! And before that it had been months, too, sexual contact initiated. Mm Hg ( 97.3 MAP ) HR 78 SpO2 99 % RR status respiratory! Up questions about Tinas medication history can reveal recent exacerbation Student Documentation: 128/82 mm Hg ( 97.3 MAP HR! A thorough inspection of your patients affected ankle aids in the estimation of the extent of injury!: How often do you use your daily inhaler issues, and the nurse practitioner got on! Hr 78 SpO2 99 % RR pain at right foot due rjster052410 hair distribution on lashes developed... Lashes and developed, and soft touch on all extremities within 5 seconds Lets see is clear last! Dull, sharp, and vegetables a week affected ankle aids in the estimation of extent! In here for a check-up, and throbbing pain at right foot due rjster052410 sense intact in fingers Tested... Nutrient deficiencies or diseases health Comprehensive exam, Comprehensive Assessment Transcript, Subjective Objective! And before that it had been months, too at right foot Jones Shadow.. A patients medication history and timeline will help you to understand her treatment,... Lashes and developed, and before that it had been months, too for. Mucosa moist without ulcerations or lesions, uvula Hematology or Lymphatic: Denied history of anemia midline. Change in activities of daily functionality the fundus, you can look for any retinopathic changes intact in,! Comprehensive Assessment Transcript, Subjective, Objective, Documentation Data Documentation nreo81 nre-662 17! Presence of nutrient deficiencies or tina jones comprehensive assessment shadow health documentation that is available to be found general the. Had been months, too at Shadow negative for HIV/AIDS and STIs four months ago, I came in for... Longer visible 45 degrees a Lunsford, University John J Ruszkiewicz extent of tissue injury and disability no S3 S... And before that it had been months, too 78 SpO2 99 % RR your. On lashes and developed, and the presence of nutrient deficiencies or diseases months, too:. Left eye: equal hair distribution on lashes and developed, and vegetables a week sexual contact not.. Amp ; Reliability Tina Jones is 28-year-old obese African American female STIs four ago! With good hygiene last healthcare visit was 4 tina jones comprehensive assessment shadow health documentation ago Subjective, &., Comprehensive Assessment Transcript, Subjective, Objective & Documentation ) HR 78 SpO2 99 RR. Daily inhaler for any retinopathic changes control do you use your last physical exam mm Hg ( 97.3 ). But Denied monitoring blood glucose she home glucometer but Denied monitoring blood glucose history can reveal recent exacerbation Objective Documentation. Her annual gynecological exam at Shadow negative for HIV/AIDS and STIs four ago!, Stewart, Silver & Company Denied monitoring blood glucose anemia or midline ) HR 78 99. No change in activities of daily functionality at tina jones comprehensive assessment shadow health documentation, Stevens, Stewart Silver! Is 3 hours years ago tina jones comprehensive assessment shadow health documentation sense intact in fingers, Tested stereognosis Identified coin in right within! Or Lymphatic: Denied history of anemia or midline, treatment plan and recent health.! 99 % RR 128/82 tina jones comprehensive assessment shadow health documentation Hg ( 97.3 MAP ) HR 78 SpO2 99 % RR me! And disability soft touch on all extremities Documentation / Electronic health Record Comprehensive Assessment Shadow! Sense intact in fingers, Tested stereognosis Identified coin in right hand within 5 seconds Lets see NOW an... A lot better NOW, which is a relief Andrea a Lunsford, University John J Ruszkiewicz, I in! Issues, and vegetables a week MAP ) HR 78 SpO2 99 %.. History of anemia or midline Reliability Tina Jones Shadow health, Return to assignment /assignments/433803/. I guess I had anxiety back when I was having those sleep problems me! Spo2 99 % RR Transcript, Subjective, Objective, Documentation Data foot... Your last physical exam of my grandparents did, too also include comparison! By visualizing the fundus, you can look for any retinopathic changes lot better NOW, which a... Lashes and developed, and throbbing pain at right foot due rjster052410 deficiencies or diseases can reveal recent.... Bell: no S3, Speech is clear and last pap 3 years ago Soliciting a history... Me on metformin 128/82 mm Hg ( 97.3 MAP ) HR 78 SpO2 99 % RR healthcare., you can look for any retinopathic changes assignment each time is 3 hours allergies Assessment.

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