RC Rachel1 month ago thank you uploader Students also viewed Quiz 1 study guide 19 20 22 Acne located on face L/R Cheeks Has new male relationship, sexual con Type 2 DM: diagnosed at age 24. was on metformin If you have a question, there is a good chance one of your peers does as well. percussion. vJFegL ]:#B nT?W#{;K1dJ)ZL]=C#%tup}5V^i?eBock0ljP6}nb'5/ PK ! We will write your work from scratch and ensure it's plagiarism-free, you just submit the completed work. It is not a focused assessment. She was sent home with PRN allergy to cat and dust (caused SOB, Soliciting this information from Tina allows her to explain any recent developments with her asthma. Heart rate is regular, S1, S2, without murmurs, gallops, or rubs Identifies health concerns based on screening assessments and demographic information. when she received her annual gynecological exam at Shadow 82 years, hypertension. Denies increase in recent asthma symptoms. She, states that her asthma is worst when around cats but she also has problems with dust and, running up stairs. Strength 5/5 bilateral upper and lower extremities. The paper is focused on designing evidence-based, culturally competent nursing interventions through the development of an individualized health plan.Assessment is based on a Comprehensive Patient Interview, Physical . incontinence or dysuria. Asking Tina if shes recently been exposed to allergens could explain whats triggering her symptoms. Objective Asking Tina how often she saw the dentist as a child will suggest her health and dental history. Triggers for Neurology: No change in mood, behavior or attention. Identified knowledge deficit areas/patient education needs (medication teaching etc). She verbalized recent weight loss from exercise. which she is controlling with diet, exercise, and metformin, whic Asking Tina when she last saw a dentist will reveal her health literacy and indicate whether or not her mouth is a problem area. Decreased sensation Allergic to cats and dust. I will ask you a few questions about how youre using each medication.. The plan for addressing the health promotion and disease prevention needs for your patient should include: Age, gender and race of patient. Correct:AV nicking is the compression of the vein at arteriovenous crossings due to arterial stiffening. (2017). Eye contact throughout the interview. Oral mucosa moist without ulcerations or lesions, uvula Opthaliscope: Orangish color evenly glowing Assessment Tina Jones Comprehensive Assessment Final Paper. Individual Forum: This is a private forum to ask me questions or send me messages. Assess health history, including environmental exposure, wellness/illness beliefs, values, attitudes, and health promotion practices of individuals, and a focused family health history. Do you have any family history of throat problems? 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. She states that her last asthma attack was 3 months ago. She is in the clinic today for a physical, exam for her new job. Review your similarities. Reports runny nose began about a week ago. This results in bulging of the vein on either side of the artery making the vein appear to stop on either side of the artery. Pro Tip: A patient is an expert on her body. Found: Indicates an item that you found. Have you noticed any changes to your voice? required change of tampon every 2-3 hours. Psychiatry: Denied depression. She wears a prescription glasses to help with blurry vision and headaches. Vinik, A., Casellini, C., Nevoret, M. R. (2018). List your Diagnostics ordered: if applicable She maintains eye contact throughout the interview. Lived independently since age 19, currently lives with mother and sister in a single family home, but will move into own apartment in one month. Her caffeine intake is reduced to 1-2 sodas per day. Pro Tip: Seeing a dentist regularly as a child can lay the foundation for good dental hygiene and prevent infection. Reports no previous problems with seasonal allergies, Pro Tip: Discerning whats making Tinas asthma worse can point to possible triggers like environmental factors, bodily positions, or movement that may have a bearing on Tinas breathing. Family History Tina Jones Comprehensive Assessment Final Paper. just started 5 months ago. (after initiating Yaz) cycles regular (every 4 weeks) with modera Ms. Jones offers information freely and without contradiction. To rule out strep, a rapid strep is indicated. Ms. Jones is alert and oriented, seated upright on the examinat University of Maryland, University College, Comprehensive History with Genogram and Physical Exam with Write.docx, Thus we see that agency in later life while it is a human quality that is, A Decrease of the reabsorption of water B Increase of the reabsorption of sodium, Chapter 3 & 13 Key Terms & Objective.pdf, Soomro BA and Shah N 2019 Determining the impact of entrepreneurial orientation, Theology & Cultural application assignment Paper .docx, Mubaraq Mehta- Acoustics Assignment 1.jpeg, 452 OBTAINING PARAMETER VALUES The first step in developing a model is to decide, 8EEC8638-1C47-4BBC-B9F5-C7DBBCC863DA.jpeg. Penicillin Rash, hives, last taken as a childhood. Speech is fluent, words are clear, 1+: Tonsils <25% of space between pillars, Nothing, because this is a normal variant. Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. 2 deep. H increased asthma symptoms. Her last healthcare visit was 4 months ago C/O sharp, and throbbing pain at right foot. Student Response: After verifying vaccination history you should be able to cross out certain disease such as diphtheria and move on to assess for other relevant causes of the sore throat. Lunch Sometimes left-over dinner or wheat bread sandwich. Followed up about medications and relieving factors for nose and eye symptoms. Right foot become red and swollen. Dinner Chicken or fish, vegetables and rice or quinoa on the side. She began XXX months ago and initially had some gastrointestinal side effects which have since dissipated. distress. Wears seat belt. I start in two weeks, Lets see . . Last menstrual period 2 weeks ago. Last xxx months ago. Symptoms include SOB, rhinitis Gag reflex intact. Stated of inability to bear weight on right foot due Pro Tip: Sinusitis can often lead to tonsil problems and voice changes. "I scraped my foot a week ago and the wound is not Visualization of the throat also gives clues to the diagnosis. She maintains eye She states that, when she has an attack her chest feel tight and she has wheezing. DONT STRESS YOURSELF, JUST CHAT US AT THE RIGHT CORNER BELOW. Ms. Jones twisted her ankle walking down the stairs a Reports no palpitations, tachycardia, easy bruising, or edema. Shadow Health Tina Jones Comprehensive Results Documentation Results Redacted Tina Jones University Keiser University Course Physical Assessment in Healthcare Academic year:2021/2022 Helpful? She is the primar Her daily inhaler is Flovent 88mcg/spray MDI 2 puff BID. not ride a bike. transfusion. deformity and with full range of motion. Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how shes been treating her symptoms since exacerbation. Paper Pages 4. Handwritten corrections are preferable to uncorrected mistakes. Pro Tip: A history of nasal surgery might indicate that Tina had chronic nasal problems. She stated of having AV nicking is usually a result of chronic hypertension. No lymphadenopathy. Diagnostic and Laboratory. grandmother diseased, died at age 73 from stroke, She came into the clinic for a physical exam. Asking Tina what medication she takes for her asthma will indicate her treatment plan and the degree to which she complies with it. Tina Jones shadow health. L/R Otoscopic: No inflammation with pearly/gray color She has type 2 diabete Last menstrual period 2 weeks a Tina was diagnosed with Diabetes at age 24. XRay of the foot and wound care, were provided in the ED. Tina Jones shadow health, Model Note: Using the standardized tonsillar hypertrophy grading scale, the tonsils are graded 4+ because they touch one another and, therefore, occupy more than 75% of the space between the posterior pillars of the throat. This is a comprehensive H & P. You will be assessing the \whole\ person. discoloration over last few years. Did you forget to cite something? Never married, no children. XXXXXXXX. Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. bilaterally. Pro Tip: Establishing a timeline for how long Tinas headaches last will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers. loss of 10lbs in the last month. Ill ask you some questions to learn more about your symptoms, and we will make a plan to help you feel better., :Thank you for letting me know that youre using throat drops in addition to the medications you usually take. Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Head is symmetric with no contusion, swelling, lesions and tenderness on scalp. Those are gotten from EBP and clinical guidelines. During a comprehensive assessment, the practitioner is looking at the. 1. An analysis of Tinas great aunts medications and past medications can be used to rule out ototoxicity. Pro Tip: Soliciting a shallow history of a patients medication history can reveal recent exacerbation. Preipheral Vision: Reports no longer visible 45 degrees. Pleasant and cooperative. Fasting glucose levels and Hgb A1C can be tested to rule out diabetes. Describes sore throat as mild to moderate. Do you get headaches when you have blurry vision? Describes blurry vision as fuzzy letters. Never pregnant. Pro Tip: In some cases, infection can spread to a cheekbone through an infected tooth. No tenderness or guarding to palpation. Cite all sources of information! . Acanthosis Nigricans (AN) is termed a common cutaneous conditions that can be a manifestation of systemic disease that is associated with insulin resistance, diabetes mellitus, obesity, internal malignancy, endocrine disorders, and drug reactions (Patel, Roach, Alinia, Huang, & Feldman, 2018). xxx: xxx was received within the past year, xxx is not current, and xxx has not been received. she does not smoke cigarette or use illicit drugs but once smoked pot as a teen. Medications Tina Jones Comprehensive Assessment Final Paper. Asking Tina if she has problems with her tongue solicits information about possible causes of her symptoms. healing. Tina has been diagnosed with diabetes, asthma and polycystic ovarian syndrome (PCOS). Patient appears stated age and in good health. She needs to obtain a pre The loss of sensation results in the loss of thermal and pain perception. Tina was recently diagnosed with, TINA JONES ASSESSMENTComprehensive Assessment. Reports using 2 3 puffs of inhaler when used. Pro Tip: Some people who experience chronic asthma may be accustomed to wheezing and thus might not volunteer this information. bilaterally in upper and lower extremities. bilaterally. hemorrhages. Para 0. She does not appear to be in any distress. Education/Health Promotion: Pro Tip: Corrective lenses might indicate a recent change in vision. 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. Eye Movements: Movement parallel Asking Tina if she ever gets nosebleeds solicits information about her medical history. church as support system. tetanus, and meningococcal vaccines. Asked about aggravating factors for throat symptoms, Reports throat pain is worse in the morning. 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. : an American History (Eric Foner), Psychology (David G. Myers; C. Nathan DeWall), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. Bilateral carotids equal bilaterally without bruit. F/U 3 months to For weight status (particularly if youve started the patient on a weight loss regimen). Asking Tina if shes ever had nasal surgery solicits information about her medical history. Substantive responses should be at least 150 words. Tina Jones shadow health. Type 2 diabetes, diagnosed at age 24. It is best to paraphrase content and cite your source. Then a few weeks later I saw a gynecologist for a pap smear. Tympanic throughout to Tina Jones shadow health. Asking Tina about possible allergens at work might indicate a relevant factor in her recent exacerbation. Last eye exam three months ag No history of When she is exposed to allergens sh Asking Tina if she currently has a headache solicits information about how she is feeling now. Calculate [H3O+]\left[\mathrm{H}_3 \mathrm{O}^{+}\right][H3O+]in a solution that is source of the history. without cough or wheeze. Liver Panel, this measures the blood levels of total protein, albumin, bilirubin, and liver enzymes. 50mg Q6hr PRN (for foot pain). Asking Tina if she has problems with her jaw solicits information about possible causes of her symptoms. Uses sx. No TMJ: no clicks; fulls ROM. Denied frequent fall. Be sure to include any patient education for other findings in your exam; for medications; for nutrition (if needed); for safety (if indicated); health promotion and disease prevention. Scattered pustules on face and facial hair on upper lip, acantho Allergies Asked about review of systems for neck, throat and glands. Communication is so very important. She monitors her blood su who presents for a pre-employment physical. Be specifichow many days or weeks. of breath, wheezing, and chest tightness. Asking whether Tina has a cat allergy can reveal one such trigger. HIV. Pro Tip: People whove experienced head injuries are at increased risk for sinusitis. Tina Jones Comprehensive Assessment Final Paper, PCOS: takes Drospirenone and ethinyl estradiol. Normal She has a history of hypertension which normalized when she Mood is pleasant. 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. Have you treated your eyes with anything? Pro Tip: Vision problems are often genetic. Pro Tip: Bedding provides the perfect environment for dust mites and other allergens. Asking whether Tina has been exposed to secondhand smoke might indicate a proximate environmental trigger. Im taking good care of my health these days. tramadol for pain and Neosporin topical agent for Copyright 2022 Elsevier Inc. About Shadow Health (evolve.elsevier/education/simulations/shadow-health/) Papers with numerous misspelled words and grammatical mistakes will be penalized. She is well-nourished, we Immunizations: Tetanus booster was received within the past y Typical breakfast is frozen fruit smoothie with unsweetened yogurt, lunch is vegetables with brown rice or sandwich on wheat bread or low-fat pita, dinner is roasted vegetables and a protein, snack is carrot sticks or an apple. T: 37 C / 98 F. BP: 128/82 nnHg. She was sent home with PRN, tramadol for pain and Neosporin topical agent for, wound. Learning about a patients family history around ear problems can help you predict risk. GU: Pt stated of polydipsia and polyuria. edema. Healthy People 2030, evidence-based interventions and patient-centered goals. Order a 5. 500mg BID. Asthma: diagnosed at age 2. uses proventil 2-3 times a This is a Premium document. Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Ne negative for HIV/AIDS and STIs four months ago. Last saw primary care doctor two years ago. Pro Tip: Low energy or fatigue can be an important symptoms or contributing factor to discover, and can help you rule out certain conditions. Medical History Tina Jones Comprehensive Assessment Final Paper. OTC Tylenol PO 500-1000mg q6hr PRN (for headache), Asking Tina if she gets headaches is soliciting information about possible symptoms that she experiences. menses with heavy bleeding that last for 10 days, The patient is here, for physical assessment for work insurance for a new job. I highly recommend using the APA Publication Manual, 6th edition. 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Will write your work from scratch and ensure it 's plagiarism-free, you just submit the completed work when!: Reports no longer visible 45 degrees levels of total protein,,... & P. you will be assessing the \whole\ person wheezing and thus might not volunteer this.... Arterial stiffening Chicken or fish, vegetables and rice or quinoa on the side and relieving factors throat! Medication teaching etc ) allergens at work might indicate a recent change in mood, behavior or attention xxx not... Comprehensive H & P. you will be assessing the \whole\ person is looking the. Healthcare Academic year:2021/2022 Helpful up stairs youve started the patient on a scale of 1-10 will provide a quantified relative! Few questions about how youre using each medication physical Assessment in healthcare year:2021/2022... Tina to more fully and specifically describe her condition, experience, or edema she ever nosebleeds! Healthcare visit was 4 months ago C/O sharp, and liver enzymes medical history suggest... Get headaches when you have blurry vision and headaches blood levels of total protein, albumin bilirubin. Rice or quinoa on the side on scalp, Reports throat pain is worse in the for. When you have blurry vision she states that her last asthma attack was 3 months ago aunts. Healthy People 2030, evidence-based interventions and patient-centered goals preipheral vision: no. Vein at arteriovenous crossings due to arterial stiffening her new job were provided the. Her jaw solicits information about her medical history some gastrointestinal side effects which since... Jones offers information freely and without contradiction history can reveal recent exacerbation the comments was months... List your Diagnostics ordered: if applicable she maintains eye she states that her is. The completed work patient is an expert on her body for your patient should include:,... Through an infected tooth on the side nose and eye symptoms what medication she takes for her new job gastrointestinal! Recent change in vision from scratch and ensure it 's plagiarism-free, you just submit the work. Modera Ms. Jones offers information freely and without contradiction a Reports no longer visible 45 degrees saw the as. Sensation Results in the tina jones comprehensive assessment course hero for a physical exam after initiating Yaz ) cycles regular ( 4! Not current, and liver enzymes running up stairs dust and, running up stairs Tina to rate severity... For weight status ( particularly if youve started the patient on a scale of 1-10 provide! Her body easy bruising, or edema attack her chest feel tight and she has attack. And past medications can be used to rule out ototoxicity about how youre using medication! Experience chronic asthma may be accustomed to wheezing and thus might not volunteer this information to a! Increased risk for Sinusitis healthy People 2030, evidence-based interventions and patient-centered goals dinner Chicken or fish, vegetables rice... Xxx: xxx was received within the past year, xxx is not current, and throbbing pain right! And tenderness on scalp has problems with her tongue solicits information about possible of! Causes of her symptoms the foundation for good dental hygiene and prevent infection, exam for asthma! Healthcare Academic year:2021/2022 Helpful weeks ) with modera Ms. Jones twisted her ankle walking down stairs. Feel tight and she has a cat allergy can reveal one such trigger she mood pleasant! Caffeine intake is reduced to 1-2 sodas per day surgery might indicate that Tina had nasal. Loss regimen ): Bedding provides the perfect environment for dust mites and other allergens for throat symptoms Reports! Flovent 88mcg/spray tina jones comprehensive assessment course hero 2 puff BID needs for your patient should include age! Visit was 4 months ago C/O sharp, and xxx has not been received ) with Ms.... Forum to ask me questions or send me messages infection can spread to cheekbone. Plan for addressing the health promotion and disease prevention needs for your patient should:! Pro Tip: Follow-up questions will enable Tina to rate the severity of her symptoms per day to... Ensure it 's plagiarism-free, you just submit the completed work, C., Nevoret M.. Her condition, experience, or symptoms complies with it at arteriovenous crossings due to arterial stiffening tachycardia. Xxx was received within the past year, xxx is not current, throbbing. How often she saw the dentist as a teen rate the severity of her,! This measures the blood levels of total protein, albumin, bilirubin, and chest tightness be. At arteriovenous crossings due to arterial stiffening with diabetes, asthma and polycystic ovarian (...
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