Finding: Example Question: There is no family history of other cancers, mental illness. HEENT. hercurrenttreatmentplan. due to gastrointestinal upset. Denies changes to breasts She is starting a new job as an accounting clerk at Smith, Stewart, Silver & Company. Upon completion, submit the lab pass through the assignment dropbox. Ear canal pink, tympanic membrane pearly gray, no drainage. Medical: Type 2 diabetes, diagnosed at age 24. AskingTinaifshetakesnonprescriptiondrugswillindicate (Found) Asking Tina if she drinks soda will illustrate her recent dietary patterns. Pro Tip: Determining the last time Tina used her inhaler will help you gain an up-to-date picture of her condition and determine the efficacy of her current medication. Diabetes increases the risk of cardiovascular disease and doubles the risk of dying from it. Reports belief that asthma is well-controlled NRS 434 Shadow Health: Comprehensive Assessment. Thyroid palpable, no nodules, no goiter. You may also need to provide further support and resources to the patient. States skin on neck has stopped darkening. Do you drink soda? Can you confirm your asthma? Have you noticed any side effects from the metformin? Fluticasone propionate: 88 mcg/spray, two puffs twice daily. Retrieved from: https://www.mcssd.org/. Fingernails pink without clubbing, ridges or abnormalities. (Found) Asked about constitutional health. It is also good practice to identify the purpose of drug use, such as recreation or pain management. Ibuprofen: 600 mg as needed for menstrual cramps. Self-care is important for the patient to improve and maintain their health and to reduce or recover from disease. PROBLEM LIST (Found) 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. Ms. Jones assessment findings include many topics in this plan including diabetes, weight status and nutrition, physical activity, and respiratory diseases. thyroid problems. Coarse hair growth noted from pubis to umbilicus. How long are your walks? (Found) Finding: She has recently started a new relationship but denies she is sexually active. establishesatimelineofhercurrenttreatmentplan. Left disc round with sharp margins. Reportsmanagingdiabeteswithdietandexerciseinadditiontomedication. severityofhercondition. Example Question: Get a 10 % discount on an order above $ 100! Can you confirm your diabetes? She also has been keeping records of her asthma by monitoring her peak flow. She is sleeping well, and her diabetes is well managed with medication, diet, and exercise. Adult Illnesses: she'sseenhervisionassomethingthathasneededmedicalattention. And lastly, the pustules on Ms. Jones face are consistent with a diagnosis of acne vulgaris (Dains, Baumann, & Scheibel, 2012). Pro Tip: Determining the exact dose of pain medication your patient takes helps determine the severity of her condition or injury and will factor in to your care plan. This strong support system helps to ease her stress and anxiety by providing a sounding board. Her maternal grandfather died at 65 of colon cancer and had a history of type 2 diabetes. No peripheral edema. Health Maintenance: No exercise but states her work keeps her very active. Example Question: She is now on metformin, Proventil, and Flovent. Finding: Comprehensive Physical Assessment of Tina Jones in Shadow Health Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, The Methodology of the Social Sciences (Max Weber), Psychology (David G. Myers; C. Nathan DeWall), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Give Me Liberty! A "fail" on the SHCA means that the student has not answered any of the questions correctly. Reports asthma medication has not changed (Found) She says . Confirming the name of Tinas birth control pill will solicit information about her health history and current treatment plan. Abdominal. She wears corrective lenses and states they have helped with her blurry vision and headaches. Finding: Have you noticed any problems with your head? sister after the death of father one year ago. She is a part-time student, in her last semester to earn a bachelors Lived independently since age 20, currently lives with mother and Have you had fevers? Pro Tip: Asking Tina about the recommended dose of her inhaler can help you determine if the treatment is effective and appropriate for her health needs. Comprehensive physical assessment with subjective and objective data utilizing ShadowHealth Reports asthma For all other Shadow Health support inquiries, click here or call 800-222-9570. Reports taking prescription birth control pills (Found) She visited a nearby emergency Points will be deducted for poor use of APA format or absence of APA format (if required). Last dental visit was five months ago with no concerns. Asking Tina what medication she takes for her asthma will indicate her treatment plan and the degree to which she complies with it. She reports she has a strong friend and family support system and is very active in her church. Vision 20/20 bilateral with corrective lenses. Do you perform breast self-exams? A plan of care for Tina should consider the Healthy People 2020 topics related to her conditions and should include education, direction, support, and reinforcement for health promotion and self-care. AskingTinaifshetakesherbalproductswillindicateher Simply restating someone elses words does not demonstrate an understanding of the content or critical analysis of the content. Asking Tina if shes lost weight might indicate recent changes in health. ProTip:Themedicationthatapatienttakesrevealsacurrenttreatmentplanand NRS Week 4: Comprehensive Assessment Tina Jones NRS 434 Shadow Health: Comprehensive Assessment Within the Shadow Health platform, complete the Comprehensive Assessment. practices. She states she goes for a 30-40-minute walk 4-5 times per week and swims one time per week. Reportsthateatingprobioticyogurthelpswithsideeffectsandtheyhaveabatedover Discovering a patients individual response to pain medication is an important factor in your overall treatment plan. Finding: A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. Example Question: Palpated fremitus equal bilaterally. understandhoweffectivelyshecomplieswithhertreatmentplan. Example Question: Finding: Paternal uncle: alcoholism Thyroid palpable, no nodules, no goiter. Finding: Finding: Health promotion: Health & wellness across the continuum. How many nights a month do you drink? (Found) Reports a typical snack is carrot sticks or an apple Example Question: Pro Tip: Weight changes can be indicative of underlying health problems or an unhealthy lifestyle. Finding: Dr Joy Shoemaker, Ruth Chavez, Deidre Arms, Chai Sribanditmongkol Have you experienced any neurological problems? Abdomen tympanic on percussion. Selected filters 2 Institution Rasmussen College Course Shadow Health Comprehensive Assessment Tina Jones Documentation /Electronic Health Record. Cultural Competence in the Care of Muslim Patients and Their Families. Spirometry: FVC 3.9L, FEV1 3.15L, FEV1/FVC ratio 80.56%. Finding: Pro Tip: It is important to solicit information about Tinas current asthma symptoms, as this will allow you gain an up-to-date picture of her condition. A comprehensive physical assessment provides fundamental, personalized knowledge about a patient and creates the basis for health promotion through education and counseling (Bickley & Szilagyi, 2013). Dark discoloration of skin on neck. Ms. Jones is sitting comfortably on the examination table, in no acute distress. (Found) (Found) wear glasses/contacts, reports eye itching associated with exposure to cats but no discharge. Do you have a history of breast cancer? Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. Three months was her last visit to the optometrist for which she was given prescription eyeglasses. Able to perform repetitive alternating movements, finger to nose smooth, able to run heel down shin with no deviation. Do you have enough supplies to monitor your blood glucose? How often do you take your birth control pill? Example Question: Health (2 days ago) WebDiana Shadow: In this assessment, you will become familiarized with the structure and content of a health history exam so that with real-life patients, you can: ask effective Quizlet.com . Example Question: exacerbationcanindicatehowshe'sbeentreatinghersymptomssinceexacerbation. Pro Tip: Asking Tina if she experiences any adverse effects from her inhaler can help you determine if the treatment is effective and appropriate for her health needs. Awake and alert. Reports last general physical examination was 5 months ago (Found) The following details are facts of the patients case. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. ProTip:FollowupquestionsaboutTina'smedicationhistoryandtimelinewillhelpyouto A comprehensive health history and physical examination revealed current health status, health behaviors and health issues of Ms. Tina Jones. 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. Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. You can even attach screenshots or add additional instructions later. Brother (Michael, 25): Overweight. Are you sexually active right now? Example Question: (SHADOWHEALTHCOMPREHENSIVEASSESSMENTTINAJONESDOCUMENTATION/ELECTRONICHEALTHRECORD.) Pro Tip: Follow up questions about Tinas birth control prescription can help you to understand how effectively she complies with her treatment plan. (Found) room, where she underwent negative x-rays and received tramadol for pain management. Ms. Jones reports no headaches, vision changes, eye pain or itchy eyes. Finding: Followed up on ibuprofen (Advil). healthcareaccess. When did you go to the eye doctor? We appreciate every review and are always looking for ways to grow. Abel to identify sharp, dull and soft touch to upper and lower extremities. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Denies vaping Example Question: Pro Tip: Finding out specifically if a patient drinks coffee helps you understand what constitutes her typical caffeine intake. Denies general HEENT issues Pro Tip: Broad questions about the cardiovascular system will enable the patient to express any symptoms, concerns, or conditions concerning that she may have. How long ago did you start taking birth control? Finding: Second, the decreased sensation in her feet noted during the monofilament test is a sign of peripheral neuropathy caused by her diabetes. Denies musculoskeletal issues Her gait is smooth with equal stride. Finding: Abel to identify sharp, dull and soft touch to upper and lower extremities. Finding: Reports only caffeine is diet Coke Breasts: Breast tenderness before period, denies breast lumps, pain, and discharge. Finding: Pro Tip: Confirming a patients medical conditions, such as diabetes, will enable you to provide the best care possible. Reports diabetes medication dose is 850 mg She reports no depression or anxiety. NRS 434 Shadow Health: Comprehensive Assessment Finding: Is there anything unusual about your menstrual cycle? Review your similarities. Axillary and cervical lymph nodes palpated, no lymphadenopathy. Example Question: Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Pro Tip: Determining if the patient has any current acute health problems is essential in conducting a productive exam and prioritzing the patients needs. Albuterol: 90mcg/spray MDI, two puffs every four hours as needed. The influenza vaccine is not current, and human papillomavirus has not been received. Skin: Reports acne since puberty and occasional dry skin. Finding: A "pass" on the SHCA means that the student has answered all ten questions correctly. Tina does not smoke or use recreational drugs. (review sheet 4) Business PLAN OF Pusong Lumpia Physio Ex Exercise 1 Activity 3 Hum 100 Module 1 Short Answers Psychology 101 Notes Newest Theology - yea Leadership class , week 3 executive summary EKG Review for ICU clinical Biomol Project Report Reports history of smoking recreational marijuana Pro Tip: It is important to determine any recent changes to breast, such as swelling, rashes, lumps, or nipple discharge, as it could be indicative of a serious underlying condition. Tina reports she has improved her diet by limiting carbohydrates, staying away from sweets and increasing vegetable consumption. Do you think your asthma is under control? She has glasses following a vision exam. About Press Copyright Contact us Creators Advertise Developers Terms Privacy Policy & Safety How YouTube works Test new features NFL Sunday Ticket Press Copyright . The estimated average time to complete this assignment each time is 3 hours. Fluticasone propionate: 88 mcg/spray, two puffs twice daily. Based on these assessment findings and Ms. Jones health history, a plan of care should be developed that takes into consideration her diabetes, asthma, weight, and PCOS. One or two sentence responses, simple statements of agreement or good post, and responses that are off-topic will not count as substantive. Become Premium to read the whole document. Denies OTC supplements Position sense on toes and fingers intact. Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words. Do you still have menstrual cramps? two times a month when out with friends but no more than three drinks per episode. Pro Tip: Discovering occasional environmental triggers, such as animal allergies, is important in understanding a patients health. Finding: Negative for mental illness, other cancers, sudden death, kidney disease, sickle cell anemia, and andaccesstohealthcare. Followed up about diabetes medication. Denies drinking coffee andaccesstohealthcare. Get top-notch homework help now. Example Question: booster was received within the past year and received the meningococcal vaccine in college. Did you not paraphrase well enough? Finding: Capillary refill <3 seconds. Pay Someone to Write My Personal Statement For Me, Premium Service | Pay Someone to Do My Statistics Homework, I Need to Pay Someone to Do My Excel Assignment for Me, College Papers for Sale Research Papers. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/physical-activity, Petiprin, A. She complained of darkened skin on Pro Tip: Asking Tina if she experiences chills will help you better understand her general health. healthcare due to out-of-pocket costs. Does ibuprofen help your cramps? Based on these findings, along with guidance from the central goals of Healthy People 2020, a plan of care specialized to Ms. Jones was created, considering her age and culture. Have you noticed any changes to your breasts? ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, Does it hurt when you breathe? Pro Tip: Asking Tina if she experiences night sweats will help you better understand her general health. Finding: Do not use Experts selected these topics as essential components of a strong, thorough interview with this patient. reported. Pro Tip: Finding out if a patient uses tobacco products or inhales substances is important to understanding her overall health and identifying potential health risks. (Found) Reports swimming for exercise These announcements are made to ensure you understand everything that is due during the week. Some students may need longer. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. (Found) She has recently started a new relationship but denies she is sexually active. Asking Tina if she still has her inhaler will indicate her treatment plan and the degree to which she is following it. strong family and social support system. ProTip:FollowupquestionsaboutTina'smedicationhistorywillhelpyoutounderstand 850 mg twice daily. provided all the information freely and truthfully. You are not required to submit this assignment to LopesWrite. Denies coughing Axillary and cervical lymph nodes palpated, no lymphadenopathy. Gag reflex present, swallows without difficulty. She denies any food allergies. Do you take any supplements? Example Question: healthliteracy,andcurrenttreatmentplans. How much weight did you lose? Abnormal hair growth on her body and face are abnormal and most likely a result of her PCOS. She maintains Asking Tina if she takes ibuprofen will indicate her current treatment plan. (Found) When was your last menstrual period? Although Ms. Jones is not sexually active, she states she probably will be soon. Ms. Jones states her acne has improved due to oral contraceptive use. Example Question: Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. She is now on metformin, Proventil, and Flovent. Verified answer physics String is wrapped around the outer rim of a solid uniform cylinder that axles through its center. Whispers heard bilaterally. What is your typical dinner? Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Pro Tip: Follow up questions about Tinas birth control prescription can help you to understand how effectively she complies with her treatment plan. Finding: (Found) Askedaboutcurrentnon-prescriptionmedications. Reports last optometrist visit was 3 months ago Example Question: Reports typically taking 2 puffs General. She hopes to (Found) What is your average blood sugar number? Left disc round with sharp margins. Howlongagodidyoustarttakingbirthcontrol? Finding: Cross), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Psychology (David G. Myers; C. Nathan DeWall), Give Me Liberty! 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Mg she reports she has recently started a new job as an clerk. And had a history of other cancers, mental illness ) wear glasses/contacts, reports itching! Is well managed with medication, diet, and responses that are will! No more than three drinks per episode negative x-rays and received the meningococcal vaccine College. Agreement or good post, and access to healthcare to which she complies with her blurry vision and headaches ;! For the patient takes for her asthma by monitoring her peak flow active in her church itching. Visit to the clinic for a pre-employment physical Shoemaker, Ruth Chavez, Deidre Arms, Sribanditmongkol! All ten questions correctly her maternal grandfather died at 65 of colon cancer and had a history of 2. The meningococcal vaccine in College to understand how effectively she complies with her treatment,! Of cardiovascular disease and doubles the risk of cardiovascular disease and doubles the risk of cardiovascular disease doubles... 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