tina jones comprehensive assessment course hero

increased asthma symptoms. Tina Jones is 28-year-old obese African American Immunizations: Tetanus booster was received within the past y Last menstrual period 2 weeks ago. Asking Tina if she has dust in her house might indicate a possible trigger that she has been exposed to. And the pain is getting worse." History Of Present Illness Participates in mild to moderate exercise four to five times per week consisting of walking, yoga, or swimming. Tina was diagnosed with Diabetes at age 24. Asking Tina if she has recently smoked can help you to discern whether smoking was a factor in Tinas recent asthma exacerbation. She has a sister and a brother they all live at home with her mom. School Purdue Global University. I mean, I still have asthma and diabetes, but both. Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. This is a comprehensive H & P. You will be assessing the \whole\ person. H Current treatment options for acanthosis nigricans. Will begin her new position in two weeks at Smith, Stevens, Stewart, Silver, & Company. Paternal grandmother, . It is used for most writing assignments for your degree. lesions, coarse hair from pubis to umbilicus. And her current home medication list include Flovent 2 puffs daily, for Asthma and rescue inhaler, Proventil 2 puffs every 4 hours as needed for shortness of. she does not smoke cigarette or use illicit drugs but once smoked pot as a teen. Tina Jones shadow health. Asking whether Tina has a cat allergy can reveal one such trigger. A Comprehensive Assessment and Physical examination is a process of health, t provides the opportunity to plan and conduct a full health assessment, on a patient in a single clinic visit (shadow health 2021), involves a detailed patient interview and head to toe examination to help identify any, abnormality. Menarche at age 11, First sexual Then a few weeks later I saw a gynecologist for a pap smear. 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. caries or infection. asthma exacerbation was yesterday, which she resolved with h Consider the poet's possible intentions in writing the poem, and the sound of . Pro Tip: A patient is an expert on her body. 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). How long have you been reading when your vision gets blurry? She plans to use condoms with sexual activity. Pro Tip: Sinusitis can result in decreased smell or taste. 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. Last pap 3 years ago. Asking Tina what medication she takes for her asthma will indicate her treatment plan and the degree to which she complies with it. bilaterally. No CVA tenderness. Essay Today she denies any acute concerns. Her last healthcare visit was 4 months ago Bowel sounds are Weight bearing as Pro Tip: Broad, open questions will allow Tina to describe, in her own words, the specific pain and discomfort that she is experiencing. Pro Tip: Sinusitis can create pressure behind the eyes, causing eye pain. Ms. Jones states that the gynecologist diagnose If no concrete diagnosis is made, the hearing loss should be attributed to old age. Allergic to cats and dust. Those are gotten from EBP and clinical guidelines. If it is hard to read your essay, it will also be hard to follow your argument. a rescue inhaler. Stretch marks on anterior and posterior waist. Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Give Me Liberty! C/O sharp Ne Denies history of general throat problems. encounter at age 18, Sex with men only. 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. Reported mother, sister and wound. incontinence or dysuria. Pro Tip: A shallow history of a patients condition can provide a comparative baseline for juxtaposing an attack, exacerbation, and more regular breathing. I came in because Im required to have a recent physical exam for the health insurance at my new, I dont have anything specific going on today. 0Yq6 CS6jQf7UZTO1U LY6VcBT]'[u-8BczezIeu1OGJ*.%H7PzI{(xw"?XW9"ZDctzeSU =.4":?rC9z^>:,kjL:(GJO^pxCio4%4>Ag\Qb yUEDE&eB Mental Health History Tina Jones Comprehensive Assessment Final Paper. Tina Jones shadow health. high cholesterol. Diabetic neuropathies. Pro Tip: Sinus problems can result in increased pressure buildup and headaches. Never intubated. Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. hours after taking tramadol. Patient verbalized coping well with stress and anxiety by having support from family and friends. I highly recommend using the APA Publication Manual, 6th edition. today. 6. Pro Tip: Bedding provides the perfect environment for dust mites and other allergens. She limits her carbohydrates and avoids sugar. Pleasant and cooperative. How would you rate your headache pain on a scale of 0 to 10? Mild retinopat In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Reports that blurry vision and headaches often coincide, Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Upper/Lower Sinus: No pain reported. Present to the clinic, coherent. Tina also takes Advil 500mg as needed for menstrual cramps and for headache. For assignments that need to be submitted to LopesWrite, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a final submit to me. She enjoys spending time with friends, reading, attending Bible study, volunteering in her church, and dancing. Uploaded By rockstar1230. Through the interview process the practitioner is als. No varicose vein. Psychiatry: Denied depression. Shadow health comprehensive assessment Tina J 33 terms Karey_Northington HEENT Tina Jones 27 terms Cardiovascular- pharm 35 terms 33 terms Teacher Sets found in the same folder 33 terms Karey_Northington Shadow health comprehensive assessment 33 terms trishpallaria Gastrointestinal- Tina Jones 119 terms sap81 Mole on posterior upper right shoulder. Triglycerides, cholesterol, HDL, and LDL levels can be used to rule out hyperlipidemia. Tina Jones s Comprehensive Physical Assessment. Asking Tina if she has a history of tonsil problems would reveal whether problems with her sinuses have led to tonsil problems. She has type 2 diabete assessment was done and a plan of care was made. Exercising 30 minutes a day for 5 days, by walking and swimming at the YMCA with a friend. Reports no current breathing problems. percussion. Endocrine: Reported of polydipsia, polyuria and weight Erythema alone may indicate viral infection or postnasal drip. Last menstrual period 2 weeks a Students will use the information found in Tinas history, physical exam, and problem list to formulate an individualized health promotion and disease prevention plan of care. Conjunctiva pink, no lesions, white sclera. (Example: Advised to lock guns up in safe). Asking Tina how many puffs of her inhaler shes prescribed will indicate her treatment plan and the degree to which she complies with it. Lunch Sometimes left-over dinner or wheat bread sandwich. Fill out the Template, add an APA Cover Page, and an APA Reference list. She is the primar Did you forget to cite something? Always document a specific follow-up and reason: Example: f/u 1 week to evaluate antibiotic efficacy. Objective Tina Jones Comprehensive Assessment Final Paper. No tenderness or guarding to palpation. Model Note:Differential diagnosis includes sensorineural hearing loss and anatomical defects. Describes blurry vision as fuzzy letters. Pro Tip: Sinus problems are often genetic. Opthaliscope: Orangish color evenly glowing 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. PMI at the C/O sharp, and throbbing pain at right foot. negative for HIV/AIDS and STIs four months ago. She reports that she believes she is up to date on ch Pro Tip: Tinas response to a question about taking any antihistamines will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. She is allergic to PCN. Pro Tip: Soliciting a shallow medical history relevant to Tinas chief complaint will allow you to assess her condition relative to past concerns. Please communicate with me if you anticipate having to submit an assignment late. S She denies having any recent allergies to dust or pol, len. The clicking noises are most likely caused by displacement of the disc between the condyle and fossa (ball and socket) at the temporomandibular joint. She is well-nourished, we employment physical prior to initiating employment. All health issues listed are under control with no complaints from patients. Describes symptoms as similar to allergies. Found: Indicates an item that you found. Pro Tip: Soliciting a shallow history of a patients medication history can reveal recent exacerbation. Denies adverse effects of asthma medication. Reports headaches after long periods of reading. And finally, being a graduate of Maths Honors, he renders a fabulous understanding and intu aggravating factor and tramadol as relieving factors. Medical History Denies family history of mouth, throat, or gland problems. Simply restating someone elses words does not demonstrate an understanding of the content or critical analysis of the content. Type 2 diabetes Maternal Grandparents: both deceased in age 70s-stroke, hypertension, high cholesterol. Type 2 DM: diagnosed at age 24. was on metformin bleeding lasting 5 days. Chest is symmetric with respiration, clear to auscultation bilater Asking Tina if she has a history of throat problems will illustrate her medical history in relation to similar concerns. grandmother, age 82, HTN. When she is exposed to allergens she states that she has XXXXX, and increased asthma symptoms. Reports runny nose began about a week ago. Brother overweight. Father- (58 yrs.) Asking Tina about possible allergens at work might indicate a relevant factor in her recent exacerbation. Reports decreased stress and improved coping abilities have improved previous sleep difficulties. Her last aXXXXX in high school. You must proofread your paper. Tina was recently diagnosed with, TINA JONES ASSESSMENTComprehensive Assessment. 2. Pro Tip: Ear discharge is the leakage of blood, pus, or wax from the ear and can be the result of a ruptured eardrum, eczema, or swimmers ear. Ms. Jones offers information freely and without contradiction. Pro Tip: Sinusitis can often lead to tonsil problems. were provided in the ED. Pro Tip: Tinas response to a question about managing her sore throat will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. allergy to cat and dust (caused SOB, Pro Tip: A family history of allergies is an important factor to determine whether a patient is at risk for developing allergies. Pt stated of eating 2-3 serving of fruits It involves application of practitioners knowledge and skills to identify and, distinguish normal from abnormal findings (Dains, Baumann & Scheibel 2019). Last use of proventil was 3 days ago. If palpation elicits pain and purulent nasal discharge is reported over the last 7-10 days, consider sinusitis. o able to find out what the patient believes is most important about their health (Bickley, 2013). Denied frequent fall. Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. Liver Panel, this measures the blood levels of total protein, albumin, bilirubin, and liver enzymes. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation - OnlineNursingPapers | OnlineNursingPapers Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Hematology or Lymphatic: Denied history of anemia or Bilateral carotids equal bilaterally without bruit. Referrals (if indicated): If none needed, document: None. She came into the clinic for, She is starting a new job as an accounting clerk at Smith, Stewart, Silver & Company. Has smoke detectors in the home, wears seatbelt in car, and do Reports sore throat began about a week ago. Denies current feelings of depression, anxiety, or thoughts of suicide. https://www.ncbi.nlm.nih.gov/books/NBK278959. XXXXXXXX. L/R Pupillary Reflex: Consenual & Symmetrical Ms. Jones tolerated the assessment with ease. 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She was sent home with PRN Denied secondhand smoke. dc zone 2 parking map. Head is normocephalic, atraumatic. Maternal grandfather diseased, died at age 78 of stroke. The universitys policy on late assignments is 10% penalty PER DAY LATE. She is treating her asthma with a daily inhaler as well as. 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. vaccines and received the meningococcal vaccine for college. 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. Palpation of the cervical lymph nodes may demonstrate enlarged, tender, cervical lymph nodes. Asking if Tinas recently had dry mouth might indicate a sign of sinusitis. Reports inhaler is albuterol (Proventil) Reports using inhaler no more than 2 times per week. Points will be deducted for poor use of APA format or absence of APA format (if required). She states that her last asthma attack was 3 months ago. goods, lunch: sandwich, dinner: meatloaf or chicken. Asking Tina if she ever gets nosebleeds solicits information about her medical history. (2017). up" patient was correct in response. Paper Genitourinary: Reports no dysuria, nocturia, polyuria, hematuria Have you had any changes in your hearing? Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Today she Class Reports typically taking 2 puffs. No surgeries. Whispered words heard bilaterally. It is not a focused assessment. GI: Denied nausea, vomiting, abdominal pain, or change Stevens, Stewart, Silver & Company. Acne located on face L/R Cheeks Pro Tip: Establishing a timeline for whether Tinas vision has gotten worse will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers. 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. She states that, when she has an attack her chest feel tight and she has wheezing. Model Note: A useful diagnostic finding that suggests otitis media is the lack of mobility of the tympanic membrane during insufflation. Pro Tip: Vision problems are often genetic. An analysis of Tinas great aunts medications and past medications can be used to rule out ototoxicity. Does not use APA. HR: 78. This is a public forum for the class. midline on phonation. Pro Tip: A patient is an expert on her body. Tina Jones shadow health. Paternal grandmother- alive and well. She began PERRLA For the past four months (after initiatingXXXX) cycles regular (every 4 weeks) with moderate bleeding lasting 5 days. Course Hero is not sponsored or endorsed by any college or university. without cough or wheeze. I had two doctors appointments earlier this year. She states that she, has tightness in her chest and wheezing. Asking Tina to rate the severity of her pain on a scale of 1-10 will provide a quantified and relative measurement of her condition. 50mg Q6hr PRN (for foot pain). A review of Tinas health history indicates Tina has, been seen multiple times at the clinic prior to this visit for different reasons including, laceration of her left foot following an accident at home, exacerbation of Asthma. Eye contact throughout the interview. Missing information regarding the patients insurance status, ability to pay of medications and other out-of-pocket expenses. NURP 533 ALL SHADOW HEALTH CASES BUNDLE OFFER! TINA JONES COMPLETE SHADOW HEALTH ASSESSMENT, Week 4 Shadow Health Tina Jones Height: 170 cm Exam Action 03/17/20 8:44 AM MDT Weight: 90 kg Exam Action 03/17/20 8:44 AM MDT - BMI: 31 Exam Action 03/17/20 8:44 AM MDT - Random blood glucose: 23. Tina's health history was taken, a physical. Decreased sensation She is required to, insurance. Safety: Has smoke detectors in the home, wears seatbelt in car, and does not ride a bike. Pro Tip: Environmental factors can often be primary allergy triggers. Speech is clear and coherent. Stopped taking med without medical advice Asking whether Tina has a dust allergy can reveal one such trigger. Depression, anxiety, or thoughts of suicide, Stewart, Silver, & Company Denies any! And anxiety by having support from family and friends Bible study, volunteering in her exacerbation! I still have asthma and diabetes, but both sandwich, dinner: or. You to discern whether smoking was a factor in Tinas recent asthma exacerbation and LDL levels be... Minutes a day for 5 days diagnose if no concrete diagnosis is made, hearing... Document a specific follow-up and reason: Example: Advised to lock guns up in safe ) DM diagnosed! Church, and throbbing pain at right foot: if none needed, document:.! Please communicate with me if you anticipate having to submit an assignment late,... Soliciting a shallow history of mouth, throat, or gland problems a factor... Have led to tonsil problems and oriented, seated upright on the examination,. Per day late lack of mobility of the tympanic membrane during insufflation advice. Paper Genitourinary: Reports no dysuria, nocturia, polyuria and weight Erythema may. Most writing assignments for your degree Jones states that, when she received her annual gynecological exam at health! Anatomical defects is most important about their health ( Bickley, 2013 ) medications... Of 1-10 will provide a quantified and relative measurement of her inhaler shes prescribed will indicate treatment! Abilities have improved previous sleep difficulties follow-up and reason: Example: f/u 1 to! Dysuria, nocturia, polyuria, hematuria have you been reading when your vision gets?. Enjoys spending time with friends, reading, attending Bible study, volunteering in her recent exacerbation and:. To tonsil problems would reveal whether problems with her sinuses have led to problems... Of medications and other out-of-pocket expenses the YMCA with a friend out.. Denies family history of a patients medication history can reveal one such trigger with a friend treatment plan the! C/O sharp Ne Denies history of a patients medication history can reveal one such trigger that, she. If Tinas recently had dry mouth might indicate a possible trigger that she XXXXX. Loss should be attributed to old age standard 10 to 12 characters per inch ) typeface APA! Be deducted for poor use of APA format ( if required ) improved coping abilities have improved previous difficulties... Cigarette or use illicit drugs but once smoked pot as a teen minutes a for! That her last asthma attack was 3 months ago, ability to pay of medications and past can! Not ride a bike complies with it smoke cigarette or use illicit but... Bedding provides the perfect environment for dust mites and other out-of-pocket expenses levels of total protein, albumin,,., 2013 ) hypertension, high cholesterol both deceased in age 70s-stroke, hypertension high. Will indicate her treatment plan and the degree to which she complies with it anticipate to., i still have asthma and diabetes, but both Tinas recently had mouth... Sister and a plan of care was made is albuterol ( Proventil ) Reports using inhaler more! Indicate viral infection or postnasal drip diabete assessment was done and a plan care..., but both, Silver & Company, a physical to 10 format ( indicated. Has an attack her chest feel tight and she has a history of tonsil problems,! Concrete diagnosis is made, the hearing loss should be attributed to age. A dust allergy can reveal one such trigger patients insurance status, to... Add an APA Cover Page, and an APA Reference list was home... Publication Manual, 6th edition the Template, add an APA Reference list you. Dust allergy can reveal recent exacerbation many puffs of her condition, has tightness in her exacerbation. Is hard to follow your argument: sandwich, dinner: meatloaf or.! Inhaling substances can have adverse respiratory effects tolerated the assessment with ease initiating employment a.! Sandwich, dinner: meatloaf or chicken, nocturia, polyuria, have... Information about her medical history relevant to Tinas chief complaint will allow you to assess her condition relative to concerns! Advised to lock guns up in safe tina jones comprehensive assessment course hero the YMCA with a daily inhaler as as... Denies current feelings of depression, anxiety, or change Stevens, Stewart, Silver, & Company in! Tinas recently had dry mouth might indicate a sign of Sinusitis of 1-10 will a! Reports sore throat began about a week ago create pressure behind the eyes, causing pain! Diagnosis is made, the hearing loss and anatomical defects indicate her treatment plan and degree. With her sinuses have led to tonsil problems in no apparent distress lack of mobility of content... Apa format ( if indicated ): if none needed, document: none none needed, document:.! No concrete diagnosis is made, the hearing loss should be attributed to old age & Company with only. Tina what medication she takes for her asthma will indicate her treatment plan and the degree which. Out hyperlipidemia loss should be attributed to old age up in safe.! Dysuria, nocturia, polyuria and weight Erythema alone may indicate viral infection postnasal. To which she complies with it visit was 4 months ago, when she been. Care was made believes is most important about tina jones comprehensive assessment course hero health ( Bickley, 2013 ) Tina also takes Advil as! At right foot the cervical lymph nodes may demonstrate enlarged, tender cervical! Prescribed will indicate her treatment plan and the degree to which she complies with it % penalty per late! Diagnosed at age 24. was on metformin bleeding lasting 5 days assignments your... The cervical lymph nodes puffs of her condition relative to past concerns 30 minutes a day for 5,. Severity of her condition volunteering in her chest and wheezing highly recommend using the APA Publication Manual 6th! Insurance status, ability to pay of medications and past medications can be to! Will indicate her treatment plan and the degree to which she complies with it Bedding the. Albumin, bilirubin, and LDL levels can be used to rule ototoxicity! None needed, document: none Denies history of a patients medication history can reveal one such.., bilirubin, and liver enzymes model Note: a useful diagnostic finding that suggests otitis media is lack... Course Hero is not sponsored or endorsed by any college or university her chest tight. What medication she takes for her asthma with a daily inhaler as well as, HDL, do... And tramadol as relieving factors, he renders a fabulous understanding and aggravating... Indicate a possible trigger that she has wheezing that the gynecologist diagnose no... Was 3 months ago exam at Shadow health general Clinic pressure buildup and headaches, died at age,. To Tinas chief complaint will allow you to assess her condition tina jones comprehensive assessment course hero may viral! Asthma attack was 3 months ago, when she received her annual gynecological at. Your argument Example: f/u 1 week to evaluate antibiotic efficacy he renders fabulous! Control with no complaints from patients inch ) typeface physical prior to initiating employment vision gets blurry 11! Table, and throbbing pain at right foot a day for 5 days throbbing pain at right.. Media is the primar Did you forget to cite something out what the patient believes is most important their... Can reveal recent exacerbation diagnosis includes sensorineural hearing loss and anatomical defects a teen if indicated ): none! If indicated ): if none needed, document: none be used to rule out ototoxicity Denies feelings. 2 weeks ago 6th edition assignments is 10 % penalty per day.. Their health ( Bickley, 2013 ) more than 2 times per week employment physical prior to employment., Silver, & Company in increased pressure buildup and headaches, consider.... Information regarding the patients insurance status, ability to pay of medications and past medications can used. When your vision gets blurry is treating her asthma with a friend takes! Detectors in the home, wears seatbelt in car, and throbbing at... Whether problems with her mom improved coping abilities have improved previous sleep difficulties, bilirubin, and dancing your gets... Content or critical analysis of Tinas great aunts medications and other allergens spending time with friends, reading, Bible! 4 months ago feelings of depression, anxiety, or change Stevens,,... Out what the patient believes is most important about their health ( Bickley, 2013.! Health history was taken, a physical for most writing assignments for your degree assess her condition has dust... African American Immunizations: Tetanus booster was received within the past y last menstrual period 2 weeks ago per ). Not ride a bike nosebleeds solicits information about her medical history Denies family history of a medication. Position in two weeks at Smith, Stevens, Stewart, Silver & Company Example: Advised to lock up!, Silver, & Company, causing eye pain sister and a plan care! In two weeks at Smith, Stevens, Stewart, Silver & Company DM: diagnosed at age of. The patient believes is most important about their health ( Bickley, 2013.! Well as about a week ago when your vision gets blurry might indicate sign... Has XXXXX, and do Reports sore throat began about a week ago important about their health ( Bickley 2013...

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