Guns are locked up. Strength 5/5 bilateral upper and lower extremities. in sense of smell, sneezing, epistaxis, sinus pain or Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. ProTip:Solicitingashallowhistoryofapatient'sconditioncanprovideatimelinefor Head: Reports headaches that occur weekly with reading in the past year. severityofhercondition. Reports no nausea, vomiting, constipation, diarrhea, pain or heartburn. Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. ProTip:Themedicationthatapatienttakesrevealsacurrenttreatmentplanand What is the name of your diabetes medication? Tina Jones Neuro documentation; Neuro Subjective TINA Jones; Neurological Shadow Health Objective tina jones; Musculoskeletal Objective; Pro Tip: Its important to inspect your patients hair for distribution, color, and texture because abnormal hair growth or characteristics can indicate underlying health problems. No muscle pain or weakness. Once three months ago, and before that it had been months, too. (2016). concerns, last dental visit was 5 months ago. ProTip:FollowupquestionsaboutTina'sbirthcontrolprescriptioncanhelpyouto sleep problems, only lasted for a couple weeks, Students interview Tina to obtain her complete health history, where they discover additional health concerns. She is allergic to cats and dust. Indicatesanitemthatisavailabletobefound. What is your new job? Father: died at age 58 in a car accident, history of hypertension, high cholesterol, and type 2 diabetes, Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol, Maternal grandfather: died at age 78 of a suspected myocardial infarction, history of hypertension, high cholesterol, Paternal grandmother: still living, age 82, hypertension, Paternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes. Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. PERRLA bilaterally. 37 C. Patient is in no apparent distress. She is the primary source of Last eye exam was in childhood. Pro Tip: Palpating the spleen identifies enlargement or displacement, which can indicate a number of serious health conditions. Never married, no children. Howhaveyoubeentreatingyourhypertension? She has no retinopathic changes on right. Dark discoloration of skin on neck. When she is exposed to allergens she states that she has runny nose, itchy and swollen eyes, and increased asthma symptoms. But that hasnt happened since I got my daily inhaler. Ear canal pink, tympanic membrane pearly gray, no drainage. Mood is pleasant. . Ms. Jones is a pleasant, 28-year-old African . (5 days ago) Shadow Health Tina Jones completed musculoskeletal musculoskeletal results completed advanced physical assessment fall 2021, nurs610 return to assignment your DismissTry Ask https://www.studocu.com/en-us/document/western-carolina-university/synthesis-of-nurs-practicum/musculoskeletal-completed-shadow-health-2/19246855 Vitals: Height 170 cm, Weight 84 kg, BMI 29, BP 128/82, HR 78, RR 15, O2 99%, Temp 37.2C. Patient states there is relief when foot is elevated, not walking on it. Normal graphesthesia, stereognosis and rapid alternating movements bilaterallly Tests of cerebellar function normal DRTs and equal bilaterally in upper and lower extremities Reduced sensation to monofilament in bilateral plantar surfaces. Musculoskeletal: Denies history of fractures, gout, and arthritis. Click the card to flip Definition 1 / 18 chief complaint Click the card to flip Flashcards Learn Test Match Created by DINA_CASIMIR-DORCELY Shadow Health Terms in this set (18) How are you feeling? Denies current feelings of depression, anxiety, or Albuterol 90 mcg/spray MDI, 2 puffs, as needed for wheezing, Acetaminophen 500 mg tabs by mouth, 1 - 2, as needed for pain or headache, Ibuprofen 200 mg tabs by mouth, 3 - 4, three times a day, as needed for cramps. 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I mean, I still have asthma and diabetes, but both of those are under control. 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. AskingTinaifshehasbeentaking I came in because Im required to have a recent physical exam for the health insurance at my new job.. Acanthosis nigricans. Assessment Tina Jones comes in for a follow-up/general physical exam. My albuterol. Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. This type of neuropathy is slowly progressive and maintaining an HgA1C level at less than 7.4% reduces this progression (Bickley & Szilagyi, 2013). Denies cough, dyspnea, current wheezing, hemoptysis, or recent cough. healthliteracy,andcurrenttreatmentplans. new job. First, her BMI indicates she is overweight, and only .9 points away from obese. Normal hair distribution. She regularly monitors her blood sugar levels and feels more comfortable with her knowledge regarding the meaning of the readings. Pro Tip: Tinas response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. Delegate some of your assignments to our writers and concentrate on the most important things! Ears: Denies difficulty hearing, tinnitus, ear pain, and discharge. Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. Lived independently The assessment should also include the comparison of bilateral sides. reading, attending Bible study, volunteering in her She reports a few moles but Coarse hair growth noted from pubis to umbilicus. mucosa moist without ulcerations or lesions, uvula She states the glasses improve her vision, reduce her blurry vision and have helped eliminate her headaches. She has glasses following a vision exam. Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. From age 23 to age 26 took oral contraceptives as only source of birth control, no condom use. Lived independently since age 20, currently lives with mother and sister to support family after death of father one year ago, anticipates moving out in a few months. Head is normal cephalic atraumatic. Reports no change Haveyoumissedanydaysofyourbirthcontrolpill? Gastrointestinal: Denies digestive problems, reflux, dysphagia, nausea, vomiting, diarrhea, constipation, changes in bowel habits, jaundice, abdominal pain, and bloody stools. . 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. Can Someone Take My Online Class? She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. Whispers heard bilaterally. That doesnt sound like it would be good. . forseekingcare,primaryconcerns,orconditiontheyarepresentingwith. conversation and is cooperative. High BP and high cholesterolon both sides and diabetes. Thyroid smooth without 3.4.1.7 Lab - Research a Hardware Upgrade, General Chemistry I - Chapter 1 and 2 Notes, Lesson 5 Plate Tectonics Geology's Unifying Theory Part 1, 1-2 Short Answer Cultural Objects and Their Culture, BI THO LUN LUT LAO NG LN TH NHT 1, Chapter 1 - Summary Give Me Liberty! Decreased sensation to My doctor told me when I was pretty little I think I was about two and a half? Chamberlain University (39) pain dyspnea or cough. She rarely uses her inhaler. She hopes to advance to an accounting position within her company. Comprehensive Assessment Tina Jones Shadow Health All you need to do isplace an orderwith us. Cannabis use from age 15 to Palpating thoracic expansion symmetric. A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. . (2018). Reports improved acne due to oral contraceptives. Hoveroverthe PatientData itemsbelowtorevealimportantinformation,including Pro Click here for more informationClick here for more information, If you are using Safari and have issues with audio in your assignment, please click here for assistance. With the assistance of Orems self-care model, the advanced practice nurse can identify self-care deficits and undertake the role to provide education, training, guidance, and leadership for the patient in obtaining optimal health. She has a history of hypertension which normalized when she initiated diet and exercise. Shadow Health Comprehensive Assessment: Tina Jones . Capella University (56) Mucous membranes pink and moist, tonsils 2+ bilaterally. Speech is clear and coherent. Denies a runny nose or sneezing. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. employment at Smith, Stevens, Stewart, Silver & What is your relationship like with your family? She was an undersecretary of defense at the United States Department of Defense and had also served as chief. Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. Normal bronchophony results. Vision 20/20 bilateral with corrective lenses. Denies sinus problems, frequent colds/infections, epistaxis, and change in smell. She reports no depression or anxiety. Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. No recent foreign EOMs intact bilaterally, no nystagmus. 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 Scattered pustules Asthma diagnosed at age 2 1/2. click here for Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew The scrape is red and swollen with exudate and has no odor; she reports the swelling and exudate started two days ago. function normal. was 4 months ago, when she received her annual job." Ms. Jones reports that she recently obtained She is sleeping well, and her diabetes is well managed with medication, diet, and exercise. Pro Tip: Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions. Comprehensive Assessment Of Tina Jones A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. Hes a little big, maybe. [Show more] ProTip:DiscerningwhetheranythingismakingTina'sasthmaworsecanpointto She plans on getting married and having children someday. She states that Today she American single woman who presents for a pre- She denies any food allergies. Become Premium to read the whole document. ProTip:FollowupquestionsaboutTina'smedicationhistoryandtimelinewillhelpyouto States recent 10 pound weight loss Albuterol: 90mcg/spray MDI, two puffs every four hours as needed. . No foreign travel. Anterior and posterior chest walls are symmetric with respiration, no deformities, rashes, or lesions. Pro Tip: Discerning whether anything is making Tinas asthma worse can point to possible new triggers like environmental factors, bodily positions, or movements that may have a bearing on Tinas breathing. on face and facial hair on upper lip. She appears well-nourished and dresses appropriately. Does not wear corrective lenses. tetracycline, I think, back in high school. ProTip:Follow-upquestionswillenableTinatomorefullyandspecificallydescribeher No concerns about alcoholism. 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