Tina Jones Neuro documentation; Neuro Subjective TINA Jones; Neurological Shadow Health Objective tina jones; Musculoskeletal Objective; Decreased sensation to monofilament in bilateral plantar surfaces. . Pro Tip: Female hair loss can indicate an underlying health problem or skin infection. My doctor told me when I was pretty little I think I was about two and a half? the examination table, and is in no apparent distress. She regularly monitors her blood glucose levels, checking once a day in the morning. Im taking good care of my health these days. . No obvious injuries lacerations rashes dandruff or Not currently in an intimate relationship, ended a three-year serious monogamous relationship two years ago. She currently lives with her mother and sister but has a lease starting on her own apartment in one month. Topics (15) SHADOW HEALTH TINA JONES COMPLETE CASES~SHADOW HEALTH $ 293.01 $ 18.49 23 items 1. HEENT. healthcareaccess. since age 19, currently lives with mother and sister ProTip:Themedicationsthatapatienttakesindicatetheirhealthconcernsorproblems, but I dont do that anymore. ProTip:Conditions,likepalpitations,mightchangeovertime. Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. I will be conducting an interview and a physical exam. Expertsselectedthesetopicsasessentialcomponentsofastrong,thoroughinterviewwiththis Eyes: Complains of blurred vision associated with "reading and studying," which has worsened over the past few years. feel moles but no other hair or nail changes. Reports inhaler is albuterol (Proventil) Reports using inhaler no more than 2 times per week. Left disc round with sharp margins. Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how shes been treating her symptoms since exacerbation. Never married, no children. She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. Reports sometimes needing 3 puffs to control symptoms. mucosa moist and pink, septum midline. Gag reflex intact. . Although Ms. Jones is not sexually active, she states she probably will be soon. I havent really had any stomach problems since I came in with them a while ago. Delegate some of your assignments to our writers and concentrate on the most important things! She began metformin 5 months ago and initially had some gastrointestinal side effects which have since dissipated. . By visualizing the fundus, you can look for any retinopathic changes. methamphetamines, and heroin. Hes a little big, maybe. Coarse hair growth noted from pubis to umbilicus. Occasional alcohol (10 - 12 drinks/month). Howoftendoyouuseyourrescueinhaler? Lastly, due to her age and the recent start of a new relationship, Ms. Jones should be educated on reproductive health. : an American History, Med Surg Nursing Cheat Sheets 76 Cheat Sheets for Nursing Students nodrm pdf, Philippine Politics and Governance W1 _ Grade 11/12 Modules SY. Inspecting the scalp and hair for texture, distribution, and quantity helps to identify lesions or masses. Ms. Jones states her acne has improved due to oral contraceptive use. Pain is localized to ball of foot related to wound. She denies any acute concerns at this visit. Allergic to penicillin, and also allergic to cats. Patient denies any dizziness lightheadedness She hopes to advance to an accounting position within her company. Strength 5/5 bilateral upper and lower extremities. ProTip:Themedicationthatapatienttakesrevealsacurrenttreatmentplanand Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Patient is seated upright on the examination ), Shes pretty healthy. He had hypertension, high cholesterol, and type 2 diabetes. Reports decreased stress and improved coping Denies myalgias and arthralgias. AskingifTina'sbeenusingherinhalermorefrequentlysince Will begin her new position Vision 20/20 bilateral with corrective lenses. ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Albuterol: 90mcg/spray MDI, two puffs every four hours as needed. I use my Flovent inhaler two times a day. Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. of disequilibrium. Tina jones comprehensive questions to ask, Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, Psychology (David G. Myers; C. Nathan DeWall), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. She has recently started a new relationship but denies she is sexually active. out with friends, 2-3 times per month, reports Eyes are andaccesstohealthcare. abouttherecentseverityofherasthmawillallowhertoassesshercondition. She reports diarrhea overnight. table, she is well nourished, and dressed As you continue, thestudycorp.com has the top and most qualified writers to help with any of your assignments. Flashcards. Snellen 20/20 bilaterally. OB/GYN: Menarche, age 11. Denies head and neck trauma. She works 32 hours/week as a supervisor at a printing and shipping company and is in her last semester of a bachelor's of accounting program. ProTip:Tina'sresponsetoaquestionaboutmanagingherallergieswillrevealthe Ms. Jones is alert and oriented, seated upright on Scattered pustules on face and facial hair on upper Reports no dizziness, tingling, or loss of sensation. I havent had a full asthma attack in years, though. Scattered pustules on face Facial hair on upper lip Acanthos nigricans on posterior neck Nails free of any abnormalities or ridges, Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. Has a car, cell phone, and computer. Reports she smoked marijuana when she was younger but has not for many years. A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. Skin, Hair, and Nails: Reports acne since puberty and occasional dry skin. Does not exercise regularly. Neurological. Reports needing a pre-employment physical, Asked about last visit to a healthcare provider, Last visit to a healthcare provider was 4 months ago, Reason for last visit was annual gynecological exam, Last general physical examination was 5 months ago when she was prescribed metformin and daily inhaler, Asked about current prescription medications, Reports taking prescription birth control pills, Reports that eating probiotic yogurt helps with side effects and they have abated over time, Followed up on metformin frequency and dose, Reports using Flovent inhaler twice daily, Last use of Proventil inhaler was three months ago, Has used Proventil inhaler twice in the last year, Followed up about birth control prescription, Started taking birth control 4 months ago, Reason for birth control was to manage PCOS symptoms, Birth control type is Yaz (drospirenone and ethinyl estradiol), Takes birth control pill at the same time every day, Asked about current non-prescription medications, Reports no recent seasonal allergy symptoms, Reports no current medication for allergies, Reports managing diabetes with diet and exercise in addition to medication. Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, Tina Jones comes into the clinic for a general physical exam. Musculoskeletal: Denies history of fractures, gout, and arthritis. Normal graphesthesia, sterognosis, and able to Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Attempting to palpate the kidney helps determine enlargement or tenderness. (7 days ago) WebA 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. 2. Denies fatigue, fever, chills, or night Heart rate is regular, S1, S2, no murmurs, gallops or rubs. with equal hair distribution on lashes and eyebrows, Pro Tip: Healthy kidneys are not usually palpable. . Asthma is one of the most prevalent chronic illnesses in children, but it may also affect adults. ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, allergens she states that she has runny nose, itchy Denies history of traumatic brain injury and meningitis. She is well-nourished, well-developed, and dressed Thorough examinations will yield better patient data. Patient reports an improve in acne due to oral Lets see . Head is normal cephalic atraumatic. Anterior and posterior chest walls are symmetric with respiration, no deformities, rashes, or lesions. Pro Tip: This test accommodation assesses the eyes ability to focus on close objects. She offers information freely and without : an American History (Eric Foner), Psychology (David G. Myers; C. Nathan DeWall), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Tina jones comprehensive questions to ask, Week 1 Discussion- pregnant woman on reserve, Ch 03 Examination Techniques and Equipment, https://app.shadowhealth.com/assignment_attempts/4562098. diagnosed her with polycystic ovarian syndrome and She should be encouraged to continue taking her metformin as prescribed and be instructed on the importance of regular follow up visits to monitor glucose control through HgA1C levels. roasted vegetables and a protein, snack is carrot andchesttightness. healthliteracy,andcurrenttreatmentplans. The following actions reveal the objective data of the patients case. I start in two weeksIm really excited! Conjunctiva AskingTinaifshestillhasherinhalerwill An individualized plan of care taking into consideration Ms. Jones age, physical examination results, nursing theory, and Healthy People 2020 objectives will be discussed. Pain improved with oxycodone. AskingTina No peripheral edema. Her weight loss, improvement in diet, the addition of exercise, and adherence to her medications are all aspects of self-care which promote health. How many times a day do you take metformin? Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. since I was really little. Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. What is the name of your diabetes medication? She needs to obtain a pre-employment AskingTinaifshehasarescueinhalerforherasthmawillindicate Skin, hair, and nails. Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. No muscle pain or weakness. We socialize before and after church, and I go to Bible study on Wednesdays, too. Hover over thePatient Dataitems below to reveal important information, includingPro Tips. Has your menstrual cycle improved since taking Yaz? ), No, I dont think so. and pearly gray bilaterally, positive light reflex. (16) $15.98 34x sold Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. new job. ProTip:AskingTinaifshehasbeentoaneyedoctorwillindicatethedegreetowhich Asking Tina if she takes supplements will indicate her current treatment plan. Capillary refill <3 seconds. Do you take your pill at the same time every day? Once three months ago, and before that it had been months, too. Capella University (56) 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. She needs to be educated and understand the importance of testing her blood sugar regularly. How often do you take your birth control pill? She states she can cope well with upcoming life changes. NR 509 Tina Jones Comprehensive Health Assessment 100% non-plagiarized Papers 24/7 /365 Service Available Affordable Prices Any Paper, Urgency, and Subject On time Delivery Money-back and Privacy guarantees Unlimited Amendments upon request Satisfaction guarantee (Clarified to Does your younger sister have health problems?. AskingTinaifshetakesvitaminswillindicatehercurrent Still University of Health Sciences (ATSU) Nursing 44 Pages 2021/2022 Description: I used to have a lot of trouble with asthma attacks back then. Able to perform repetitive alternating movements, finger to nose smooth, able to run heel down shin with no deviation. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. hertreatmentplanandthedegreetowhichshecomplieswithit. She reports she recently obtained a new accounting clerk job at Smith, Stevens, Silver & Company and they require her to obtain a pre-employment physical. The foot feels better when she rests, and it hurts more when she walks on it. Throat and Neck: Denies sore throat, dysphagia, and changes to voice quality. In A. O. Ofori (Ed. 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. Never pregnant. Has new male relationship, sexual contact not initiated. Company. healthliteracy,andcurrenttreatmentplans. AskingTinaifshetakesnonprescriptiondrugswillindicate Ms. Jones offers information freely and treatmentplan. She is the primary source of the history. . Drospirenone and ethinyl estradiol: one pill every day. Patient denies any Vision change, good start I just always want to be learning new things and getting better at my job. She started me on birth control, and it seems to be helping things. DTRs 2+ and equal bilaterally in Asking Tina if she has been taking medication for her diabetes will indicate her treatment plan and the degree to which she is following it. Thefollowingdetailsare I used to have a reaction when I was in a dusty house for a long time. Ear drainage? Things are pretty good between all of uswere a tight knit family. Skin on neck has stopped darkening This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. . rises midline on phonation. She was exposed to cats a few days ago and had to use her inhaler once; she reports having to use three puffs instead of the prescribed two. use: this morning), Albuterol 90 mcg/spray MDI 1-3 puffs Q4H prn (last Tympanic throughout to percussion. About Press Copyright Contact us Creators Advertise Developers Terms Privacy Policy & Safety How YouTube works Test new features Press Copyright Contact us Creators . . Scattered pustules What is your new job? She came into the clinic for a physical exam. She is required to have a physical exam for her health insurance. She is starting a new job as an accounting clerk at Smith, Stewart, Silver & Company. No history of sexually transmitted infections. Assessment Tina Jones comes in for a follow-up/general physical exam. Ms. Jones has a penicillin allergy with a reaction of rash. Essay Topics (13) physical prior to initiating employment. She was last hospitalized for asthma in high school. 1). She provided the health information freely during the interview. Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, https://www.coursehero.com/file/38245035/Comprehensive-Assessment-Completed-Shadow-Healthpdf/, The Methodology of the Social Sciences (Max Weber), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), 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), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Civilization and its Discontents (Sigmund Freud), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. Chest is symmetric with respiration, clear to Asthma diagnosed at age 2 1/2. Reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium. She seems to be doing okay though. Her gait is smooth with equal stride. https://doi.org/10.1111/jspn.12032. Ms. Jones reports no muscle pain or weakness. socially with friends. Fluticasone propionate: 88 mcg/spray, two puffs twice daily. Journal for Specialists in Pediatric Nursing. Buy best Assignments with zero plagiarism. No. Patient denies any current pain. Yeah. indicatehertreatmentplanandthedegreetowhichsheisfollowingit. Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. Pro Tip: Skin changes are common in patients with uncontrolled diabetes. Tina Jones comes into the clinic for a general physical exam. Comprehensive Assessment Of Tina Jones A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. Since then Ive just washed my face, I havent used anything special. ProTip:Initiallyestablishingachiefcomplaintallowsthepatienttoexpresstheirreason A referral to a podiatrist is important to monitor her peripheral neuropathy and for foot care. . function normal. Full ROM and 5/5 strength in extremities, spine, and hips. She denies any food allergies. 3. "I came in because I'm required to have a recent Click here for more informationClick here for more information, BP: 142/82; HR: 68; RR: 16; O2: 98%; Temperature: physical examination for the health insurance at my distribution. Pro Tip: Inspecting the facial skin for the presence of discoloration, lesions, or abnormal hair growth assesses for underlying medical problems. Normal bronchophony results. Complains of darkened skin on her neck and increase facial and body hair. Asthma is a lung condition that affects people of all ages. Asking Tina if she takes non prescription drugs will indicate her current treatment plan. in sense of smell, sneezing, epistaxis, sinus pain or . Tonsils present. PAST MEDICAL HISTORY Diabetes PCOS Asthma Allergies Medications Metformin: 850 mg BID Flovent: 2 puffs 88 mcg/spray BID Albuterol: 90 mcg/spray MDI 2 puffs denies any acute concerns. Indicates an item that is available to be found. How often do you use your rescue inhaler? There is no family history of other cancers, mental illness. Gastrointestinal: Denies digestive problems, reflux, dysphagia, nausea, vomiting, diarrhea, constipation, changes in bowel habits, jaundice, abdominal pain, and bloody stools. I mean, I still have asthma and diabetes, but both of those are under control. Reports improved acne due to oral contraceptives. She enjoys spending time with friends, My mom has some issues, and I think some of my grandparents did, too. ProTip:Solicitingashallowhistoryofapatient'smedicationhistorycanrevealrecent ProTip:FollowupquestionsaboutTina'smedicationhistoryandtimelinewillhelpyouto Pro Tip: Discerning whats making Tinas asthma worse can point to possible triggers like environmental factors, bodily positions, allergies, or movement that may have a bearing on Tinas breathing. She is very active in her Baptist church, faith is important to her, and church community is a large part of her social network. Poppa died of a heart attack when he was 80. . Ive had asthma a long time. That doesnt sound like it would be good. No tics or facial fasciculation. ProTip:Themedicationsthatapatienttakesindicatetheirhealthconcernsorproblems, nontender to palpation. Case - Tina jones subjective heent | completed | shadow health 2 4. employment at Smith, Stevens, Stewart, Silver & She is the primary source of information and is reliable.
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