Reports dust allergy, Asked about diabetes management through What are the 3 differential diagnoses associated with Tina Jones Shadow health comprehensive health assessment? Denies head and neck trauma. Mother: hypertension, high cholesterol Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Ms. Jones offers information freely and without contradiction. Reports a typical lunch is dinner leftovers or tuna or chicken sandwich on wheat bread What kind of prescription medications do you take? Do you use mouthwash? She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. 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Denies adverse effects of asthma medication, Followed up about birth control prescription Reports starting birth control 4 months ago week Head: Reports headaches that occur weekly with reading in the past year. Right arm distal sharp pain sensation intact Asking Tina what triggers her allergies will indicate, in part, Tinas health literacy. . Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. We go to First Baptist, and we do a lot with our church community. Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan. Eyes: Complains of blurred vision associated with "reading and studying," which has worsened over the past few years. She receives basic health insurance from work, but is deterred from healthcare due to out-of-pocket costs. Sister: asthma NURS 6512 Week 9 DCE: Please I need help with shadow health assessment week 9 with Tina Jones (who comes to the clinic for a Pre-employment physical). Just coming in and talking to someone here about it helped a little because I felt like I was doing something. How often do you take your birth control pill? Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. Reports only caffeine is diet Coke rebound No concerns about alcoholism. or deformity Spleen: not palpable Pro Tip: This test accommodation assesses the eyes ability to focus on close objects. That doesnt sound like it would be good. PICOT Question (12) What medical problems did your father have? Last menstrual period 2 weeks ago. No visual acuity testing since childhood. Denies swelling, Asked about review of systems for respiratory, Denies current breathing problems Auscultated mitral area with the bell: no S3, S Denies current asthma symptoms Shadow health assessments can help nursing students develop an understanding of patient safety issues. 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. Musculoskeletal: Denies history of fractures, gout, and arthritis. I had two doctors appointments earlier this year. She is the primary source of the history. . Denies coughing, Asked about review of systems for cardiovascular Denies cardiovascular issues, Asked review of systems for gastrointestinal Denies gastrointestinal issues, Asked review of systems for genitourinary Denies genitourinary issues, Asked review of systems for musculoskeletal Denies musculoskeletal issues, Asked review of systems for neurological Denies neurological issues, Asked review of systems for skin, hair and nails Denies integumentary issues. What medical problems does your mum have? Denies generalized weakness. extremities, Right arm proximal light touch sensation intact Her last asthma exacerbation was three months ago, which she resolved with her inhaler. Right tibial pulse: 2+ Her pain has worsened, and the swelling has persisted. Subjective Data Collection: 50 of 50 (100.0%), Objective Data Collection: 70 of 73 (95.9%), Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Nursing Capstone Project Writing Services, Nursing Annotated Bibliography by Professional, Online Nursing Research Paper writing service. Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. Reports having 2 or 3 drinks when out with friends, Reports history of smoking recreational marijuana, Reports walking for exercise Ive had asthma a long time. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. She uses her albuterol inhaler when she is around cats. Left leg proximal light touch sensation intact When she is exposed to allergens she states that she has runny nose, itchy and swollen eyes, and increased asthma symptoms. The injury occurred about one week ago. This includes an assessment of past medical history, including any symptoms that may indicate an illness or disease. Within the Shadow Health platform, complete the Comprehensive Assessment. Left arm distal light touch sensation intact, Tested ability to sense light touch of lower . Reports recently beginning exercising to manage The Shadow Health Comprehensive Assessment (SHCA) is an online assessment tool that is used by nursing students to measure their knowledge and understanding of health concepts. She has not been eating much and has been staying in bed the last few days, per patient report. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Scattered pustules on face and facial hair on upper lip, Right eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema, Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema, Thyroid smooth without nodules, no goiter, Upper eyelids: conjunctiva pink, no lesions, white sclera, Lower eyelids: conjunctiva pink, no lesions, white sclera, Right pupil: equal, round, reactive to light, Left pupil: equal, round, reactive to light, Peripheral vision intact in both eyes, all fields, Inspected interior eyes with ophthalmoscope, Left fundus with sharp disc margins, no hemorrhages, Right upper quadrant: no masses, guarding or rebound, Right lower quadrant: no masses, guarding or rebound, Left upper quadrant: no masses, guarding or rebound, Left lower quadrant: no masses, guarding or rebound, Liver: palpable 1 cm below right costal margin, Neck without swelling, masses, or deformity, Right shoulder without swelling, masses, or deformity, Right arm without swelling, masses, or deformity, Right elbow without swelling, masses, or deformity, Right wrist and hand without swelling, masses, or deformity, Left shoulder without swelling, masses, or deformity, Left arm without swelling, masses, or deformity, Left elbow without swelling, masses, or deformity, Left wrist and hand without swelling, masses, or deformity, Fingernails: no ridges or abnormalities in nails, pink nailbeds, Hips without swelling, masses, or deformity, Right leg without swelling, masses, or deformity, Right knee without swelling, masses, or deformity, Right ankle without swelling, masses, deformity, or discoloration, Right foot without swelling, masses, or deformity, Left leg without swelling, masses, or deformity, Left knee without swelling, masses, or deformity, Left ankle without swelling, masses, or deformity, Left foot without swelling, masses, or deformity, Toenails: no ridges or abnormalities in nails, pink nailbeds, 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs, Height: 170 cm Weight: 84 kg BMI: 29.0 Blood Glucose: 100 RR: 15 HR: 78 BP:128 / 82 Pulse Ox: 99% Temperature: 99.0 F, The patient is a 28-year-old female who presented for a pre-employment physical exam. Do you ever take medication for your menstrual cycle? I havent had any problems with diarrhea. Not sexually active, first sexual activity at age 18, never pregnant, last Pap smear more than four years ago, tested for STIs at age 22, denies STI symptoms. Reports last use of Proventil inhaler was yesterday, Asked about vision Reports optometrist visit When was your last physical exam? Asthma diagnosed at age 2 1/2. Do you take any over the counter medications for pain? Denies goiter, hyper/hypothyroidism. My discharge is normal, I think. What is the name of the birth control pill you took? Marc n'a pas son appareil-photo. Theyre crazy, but nobodys diagnosed with anything. Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Transcript All Lines (645) Interview Questions (210) Statements (41) Exam Actions (394) Hello, my name is Tammy. Left brachioradialis: 2+, Tested deep tendon reflexes of lower since I was really little. Were you ever hospitalized for this allergy to the animal? She plans to use condoms with sexual activity. She drinks four caffeinated drinks/day (diet soda). Enjoy the convenience of having a reliable Writer to do your paper at an Affordable Price. If your instructor provides individual feedback on this assignment, it will appear here. Study with Quizlet and memorize flashcards containing terms like The nurse is preparing a diet plan for a pregnant client with preeclampsia. The assessment should also include the comparison of bilateral sides. including Pro Tips. Left arm distal dull pain sensation intact, Tested ability to sense dull pain in lower Do you have any problem with your breasts? but I dont do that anymore. ), No, I dont think so. I use my Flovent inhaler two times a day. masses Wheezing, breathlessness, chest tightness, and coughing are symptoms of asthma that occur at night or early in the morning. Auscultated tricuspid area with the diaphragm: 22 terms. Lets see . Plus I have my friends from church. Diagnosed with PCOS four months ago. Undergraduate Graduate Right arm without swelling, masses, or deformity A reliable Writer to do your paper at an Affordable Price with preeclampsia months. Timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health assessment intact Tested. Asking Tina What triggers her allergies will indicate, in part, Tinas health literacy, plan. Take any over the counter medications for pain, gout, and coughing symptoms... 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