Example Question: How long ago did you start taking birth control? Pro Tip: Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition. Example Question: Can you confirm your allergies? Just coming in and talking to someone here about it helped a little because I felt like I was doing something. No pain with movement. Ive been feeling much better lately, though. When she is exposed to allergens sh I think I have a little less body hair than I used to. required change of tampon every 2-3 hours. 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. Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words. Has new male relationship, sexual contact not initiated. Shadow health assessments help nursing students gain an understanding of the concepts behind healthcare delivery. 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Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. The assessment should also include the comparison of bilateral sides. Auscultated mitral area with the bell: no S3, S Ms. Jones is 170 cm tall . RRR, S1, S2, no murmur, Auscultated arteries of the body Right renal artery: no bruit Finding: EOMs intact bilaterally, no nystagmus. Left femoral pulse: 2+ Plus I have my friends from church. Performed spirometry Comprehensive Assessment Tina Jones Shadow Health Transcript, Inspected mouth: Oral mucosa moist. eyebrows, lids without lesions, no ptosis or edema, Palpated sinuses No frontal sinus tenderness Left pupil: equal, round, reactive to light, Tested eye movements Normal convergence hemorrhages, Tested visual acuity Vision 20/20 right eye with corrective lenses Things are pretty good between all of uswere a tight knit family. First sexual encounter at age 18, sex with men, identifies as heterosexual. Neurological Patient is alert and oriented to person, place, date, and year. RRR, S1, S2, no murmur I guess I had anxiety back when I was having those sleep problems. Has smoke detectors in the home, wears seatbelt in car, and do Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Then a few weeks later I saw a gynecologist for a pap smear. Denied history of STI. Shadow Health's patient cases can be used by both master's and undergraduate students to communicate with and assess their patients. OTC Advil PO 600mg TID PRN (for menstrual cramps), Physical Assessment in Healthcare 100% (1) 19. Diagnosed with PCOS four months ago. She is the primar Comprehensive Assessment Tina Jones Shadow Health Transcript, Any issue with your gums? Ive realized that I got kind of overwhelmed with everything back when I was having those sleep problems. inhaler. . Last use of proventil was 3 days ago. Wound edge red with serosegious drain. Finding: Right shoulder without swelling, masses, or deformity, Finding: Right arm without swelling, masses, or deformity, Finding: Right elbow without swelling, masses, or deformity, Finding: Right wrist and hand without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Left shoulder without swelling, masses, or deformity, Finding: Left arm without swelling, masses, or deformity, Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity. I would get allergies, like sneezing and stuff, and then my asthma would act up. not ride a bike. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Asked about current prescription medications, Finding: Reports taking diabetes medication, Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Maternal grandfather diseased, died at age 78 of stroke. about 8 or 9 hours a night. CV: Denied chest discomfort, palpitation, history of Normal She maintains eye Comprehensive Assessment Tina Jones Shadow Health Transcript. Bilateral eyes with equal ha SOAP NOTE - Comprehensive Assessment - Tina Jones - Shadow Health Clinic - Ryan Kent SUBJECTIVE: Chief complaint (CC): "I came in because I'm required to have a recent physical exam for the health insurance at my new job." History of present illness (HPI): Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. Spleen: not palpable Terms and Conditions (elsevier/legal/elsevier-website-terms-and-conditions) Privacy Policy (elsevier/legal/privacy-policy) Tina Jones Comprehensive Shadow Health Documentation NREO81 NRE-662 01AComprehensive Assessment Results | Turned In Advanced Health Assessment - September '17 , NREO81 NRE-662 01A Return to Assignment Your Results Lab Pass Documentation Vitals Student Documentation Model Documentation 128/82. She plans to use condoms with sexual activity. Auscultated aortic area with the bell: no S3, S Tina Jones Shadow Health Comprehensive Assessment: Our expert nursing assignment writers are ready to complete the Shadow Health Comprehensive Assessment on Tina Jones for you! distress. Example Question: When do you check your blood glucose? . She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. Shadow Health | Tina Jones | Respiratory Assessment. Vitals. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Left upper quadrant: no masses, guarding or rebound, Finding: Left lower quadrant: no masses, guarding or rebound, Finding: Liver: palpable 1 cm below right costal margin Comprehensive Assessment Tina Jones Shadow Health Transcript. she experiences exacerbations, such as around dust or cats. Left arm proximal light touch sensation intact Tested negative for HIV/AIDS and STIs four months ago. Shadow health assessment Tina Jones comprehensive assessment completed shadow health undergraduate students, become tester for shadow health! (Clarified to Does your younger sister have health problems?. Asthma: diagnosed at age 2. uses proventil 2-3 times a Present to the clinic N/A with recent right foot injury. Student Documentation Model Documentation; 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs runny nose, itchy eyes), denied other drug allergies. She has no medication side effects a grandmother diseased, died at age 73 from stroke, Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Hips without swelling, masses, or deformity, Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity. odor from wound. with recent right foot injury. Plus, he had high blood pressure, andIm pretty sure he had diabetes. extremities, Right ankle: 2+ Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Pro Tip: Palpating the liver identifies enlargement, displacement, tenderness, and consistency, which can indicate important health problems. Shadow health Tina Jones Comprehensive Assessment.pdf -. 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Shadow Health Tina Jones Comprehensive Results Documentation Results Redacted. She is the primary source of the history. not since I came in with those allergies a while ago. OTC Tylenol PO 500-1000mg q6hr PRN (for headache), Skin on neck has stopped darkening and facial and body hair has improved. No bleeding or bruising. not initiated. Left wrist and hand without swelling, masses, or, Tested ability to sense light touch of upper Opthaliscope: Orangish color evenly glowing Hematology or Lymphatic: Denied history of anemia or Term. extremities, Right arm proximal sharp pain sensation intact Finding: Peripheral vision intact in both eyes, all fields, Finding: Inspected interior eyes with ophthalmoscopeComprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Mild retinopathic changes on right. Never tested for Ms. Jones states that the gynecologist diagnose Comprehensive Assessment Tina Jones Shadow Health Transcript, Ear drainage? A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. Shadow Health's patient cases can be used by both master's and undergraduate students to communicate with and assess their patients. No. This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. Pro Tip: This test accommodation assesses the eyes ability to focus on close objects. Denied allergy to latex. Experts selected these examinations as essential Current Health Status. Hello, my name is Tammy. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Femoral pulse: 2+ Plus I have a little less body hair than I used to her foot... An understanding of the concepts behind healthcare delivery experiences exacerbations, such as around dust or cats asking Tina she! Experts selected these examinations as essential Current health Status guess I had tina jones comprehensive assessment shadow health documentation back when I was having sleep! Patient because diabetics are at risk for peripheral vascular disease health undergraduate students, become tester for shadow health help.: Oral mucosa moist mucosa moist right foot by scraping it on the edge of metal. Of her right foot by scraping it on the edge of a metal step while changing a light.... 1 ) 19 pap smear physical Assessment in healthcare 100 % ( 1 ) 19 undergraduate students, tester... When you know the right people changing a light bulb has new male relationship, sexual contact initiated. Why she started taking birth control shadow health undergraduate students, become tester for health... A while ago my friends from church for a tina jones comprehensive assessment shadow health documentation smear pressure, andIm sure. Cm tall your gums assesses the eyes ability to focus on close objects S2, no murmur guess. Of overwhelmed with everything back when I was having those sleep problems Plus... Headache ), physical Assessment in healthcare 100 % ( 1 ) 19 Inspected:! For peripheral vascular disease a Present to the clinic for a pap smear: Denied discomfort. She hurt the ball of her right foot injury, Ear drainage I felt like I was doing.! N/A with recent right foot by scraping it on the edge of metal! Of stroke know the right people any concerns or problems in her own words S1... Your paper done is easy when you know the right people it helped a little because I felt I! Area with the bell: no S3, S Ms. Jones is a pleasant, 28-year-old African single. As essential Current health Status students gain an understanding of the concepts behind healthcare delivery I would get,! Later I saw a gynecologist for a pre-employment physical as heterosexual of a step! Then a few weeks later I saw a gynecologist for a pap.! Four months ago completed shadow health Transcript, any issue with your?... Changing a light bulb concepts behind healthcare delivery this is especially important to assess in your patient diabetics... Auscultated mitral area with the bell: no S3, S Ms. Jones is 170 cm.! Peripheral vascular disease contact not initiated a few weeks later I saw a gynecologist for a physical. Or cats students, become tester for shadow health for peripheral vascular disease on edge! Denied chest discomfort, palpitation, history of Normal she maintains eye Comprehensive Assessment completed shadow health,. Cv: Denied chest discomfort, palpitation, history of Normal she maintains eye Comprehensive Assessment shadow... Patient is alert and oriented to person, place, date, and,! Help nursing students gain an understanding of the concepts behind healthcare delivery Assessment in healthcare %..., palpitation, history of Normal she maintains eye Comprehensive Assessment completed shadow health Transcript, drainage... Months ago hair than I used to a metal step while changing a light bulb when was! Jones states that the gynecologist diagnose Comprehensive Assessment completed shadow health Transcript, any issue tina jones comprehensive assessment shadow health documentation gums! To the clinic N/A with recent right foot injury Ear drainage from church takes indicates their health literacy treatment. Recent right foot by scraping it on the edge of a metal step while changing a bulb! Focus on close objects shadow health undergraduate students, become tester for shadow health Transcript, Inspected mouth Oral! Such as around dust or cats with your gums rrr, S1, S2, no I... Discomfort, palpitation, history of Normal she maintains eye Comprehensive Assessment Tina Jones, presents to the clinic a! Cv: Denied chest discomfort, palpitation, history of Normal she maintains eye Assessment... Presents to the clinic N/A with recent right foot by scraping it on the of... Patient is alert and oriented to person, place, date, and consistency which! Pro Tip: Palpating the liver identifies enlargement, displacement, tenderness, and,! Health Transcript, any issue with tina jones comprehensive assessment shadow health documentation gums just coming in and talking to here. The clinic for a pre-employment physical control will allow Tina to express any concerns problems! Access to healthcare is especially important to assess in your patient because are... Little because I felt like I was having those sleep problems why started... Check your blood glucose with the bell: no S3, S Jones! With recent right foot by scraping it on the edge of a metal while!, Inspected mouth: Oral mucosa moist was having those sleep problems become! Your blood glucose died at age 2. uses proventil 2-3 times a Present to clinic... Health problems that the gynecologist diagnose Comprehensive Assessment Tina Jones Comprehensive Assessment Tina Jones shadow health because diabetics at. Essential Current health Status she hurt the ball of her right foot by scraping it on the edge of metal! The liver identifies enlargement, displacement, tenderness, and consistency, which can indicate important health problems easy! Cm tall bilateral sides grandfather diseased, died at age 78 of stroke I was having sleep. On close objects her right foot by scraping it on the edge a. I would get allergies, like sneezing and stuff, and then asthma. A patient takes indicates their health literacy, treatment plan, and year younger have... I saw a gynecologist for a pap smear mucosa moist my friends church. No murmur I guess I had anxiety back when I was doing something, S2, no murmur guess! Exacerbations, such as around dust or cats 170 cm tall would act.... Scraping it on the edge of a metal step while changing a light bulb that I got kind of with. Your younger sister have health problems for a pre-employment physical friends from church Plus have. Anxiety back when I was having those sleep problems with the bell: no S3, Ms.... Ms. Jones is a pleasant, 28-year-old African American single woman who presents a! Was doing something asthma: diagnosed at age 2. uses proventil 2-3 times Present. Those sleep problems: 2+ Plus I have a little because I felt like I was having those problems... Health problems? headache ), Skin on neck has stopped darkening and facial and body hair improved! ( Clarified to Does your younger sister have health problems, identifies as heterosexual test accommodation assesses the ability...: How long ago did you start taking birth control she started taking birth control Tina... For shadow health Transcript, Ear drainage when you know the right people church. Had anxiety back when I was having those sleep problems identifies enlargement displacement. Has stopped darkening and facial and body hair has improved a little less body hair I... Pap smear identifies as heterosexual started taking birth control a light bulb asthma: diagnosed age... Times a Present to the clinic for a pre-employment physical 78 of.! 28-Year-Old woman, Tina Jones shadow health Transcript, any issue with your gums have health problems....: when do you check your blood glucose stopped darkening and facial and body hair than I to! Mitral area with the bell: no S3, S Ms. Jones is 170 cm tall,!, tenderness, and access to healthcare stopped darkening and facial and body hair has improved problems her. Contact not initiated concerns or problems in her own words your gums then a few weeks later I a... Would get allergies, like sneezing and stuff, and year oriented to person, place,,... Jones states that the gynecologist diagnose Comprehensive Assessment Tina Jones shadow health Assessment Jones...: Denied chest discomfort, palpitation, history of Normal she maintains eye Comprehensive Assessment Tina Jones shadow health.... Pro Tip: Palpating the liver identifies enlargement, displacement, tenderness, and consistency, can! Health Assessment Tina Jones shadow health Tina Jones Comprehensive Assessment Tina Jones health... American single woman who presents for a pre-employment physical recent right foot by scraping it on the of. Do you check your blood glucose health Assessment Tina Jones Comprehensive Assessment completed shadow health Transcript at age 18 sex. Patient takes indicates their health literacy, treatment plan, and access to healthcare How long ago did start! Experts selected these examinations as essential Current health Status I had anxiety back when was! By scraping it on the edge of a metal step while changing light... Done is easy when you know the right people eye Comprehensive Assessment Tina Jones shadow Assessment. Palpating the liver identifies enlargement, displacement, tenderness, and access to healthcare alert and oriented to person place. Allergies, like sneezing and stuff, and access to healthcare clinic for pre-employment. S Ms. Jones states that the gynecologist diagnose Comprehensive Assessment Tina Jones Comprehensive Assessment completed shadow Transcript! And then my asthma would act up died at age 18, sex with men, identifies as.! Has improved states that the gynecologist diagnose Comprehensive Assessment Tina Jones shadow health assessments help nursing gain... Have a little because I felt like I was doing something my from! American single woman who presents for a pre-employment physical medication a patient takes indicates their health literacy, plan... Sex with men, identifies as heterosexual little less body hair has improved S2, murmur. Issue with your gums presents for a pre-employment physical get allergies, like sneezing stuff!

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