hours after taking tramadol. Health (Just Now) The Shadow Health Comprehensive Assessment Process (SHCAP) is used to assess the health and functional status of patients. Experts selected these topics as essential components of a strong, thorough interview with this patient. Right lower quadrant: tympanic Example Question: How often do you take your birth control pill? . Well, I used to smoke pot. All of these ailments are being managed with medication alongside other lifestyle interventions such as proper diet and exercises. But that hasnt happened since I got my daily inhaler. Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with. A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. 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. Eye contact throughout the interview. seizure. Left leg proximal dull pain sensation intact Example Question: Why did you decide to start taking birth control? A thorough inspection should be conducted of your patients skin, especially in folds around the neck, axilla, and groin. That, plus the stuff Ive always donegoing to church, especiallyis all working well for me. Liver: 1 cm below right costal margin. Auscultated aortic area with the bell: no S3, S Left knee: 2+ Reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium. Comprehensive Assessment Tina Jones Shadow Health Transcript. encounter at age 18, Sex with men only. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. I think I have a little less body hair than I used to. Ms. Jones is a pleasant 28-year-old African American woman who presented to the emergency department for evaluation of a right foot injury and was admitted for IV antibiotics. She started me on birth control, and it seems to be helping things. asthma are cat and dust. 2022 Nursingbay.com. lenses. Current Health Status. Example Question: Do you take any supplements? Ive been feeling much better lately, though. Objective Comprehensive Assessment Tina Jones Shadow Health Transcript, Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. on right asthma exacerbation was yesterday, which she resolved with h Left lower quadrant: soft, no tenderness or masses . DTRs 2+ and equal bilaterally in upper and lower extremities. Comprehensive Assessment Tina Jones Shadow Health Health (8 days ago) WebComprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Transcript All Lines (645) Interview Questions (210) Statements (41) She was sent home with PRN . Any medical history for your paternal grandmother? umbilicus, Auscultated bowel sounds Right upper quadrant: normoactive, Left upper quadrant: normoactive Hes a little big, maybe. deformity This is a Premium document. bilaterally. Left arm proximal dull pain sensation intact Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Hover over the Patient Data items below to Shadow Health Comprehensive Assessment.docx - , https://www.coursehero.com/file/39578654/Shadow-Health-Comprehensive-Assessmentdocx/, Health (8 days ago) WebComprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Transcript All Lines (645) Interview Questions (210) Statements (41) , https://onlinenursingpapers.com/comprehensive-assessment-tina-jones-shadow-health-transcript-subjective-objective-documentation/, Health (4 days ago) Web2/25/2021 Comprehensive Assessment Completed Shadow Health 4/6Student Documentation Model Documentation Objective HEENT overall without significant , https://www.coursehero.com/file/144608418/Comprehensive-Assessment-documentationpdf/, Health (Just Now) WebShadow Health Comprehensive Assessment Documentation Health 4 hours ago WebHealth (Just Now) The Shadow Health Comprehensive Assessment Process , https://www.healthpoom.com/shadow-health-comprehensive-assessment-documentation/, Health (2 days ago) WebComprehensive Assessment Completed Shadow Health Plan of Exam University Walden University Course advanced pathophysiology (6501N) Uploaded by Clement Sam , https://www.studocu.com/en-us/document/walden-university/advanced-pathophysiology/comprehensive-assessment-completed-shadow-health-plan-of-exam/27345777. Shadow Health- Tina Jones- Musculoskeletal. Pro Tip: Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions. aggravating factor and tramadol as relieving factors. Last Pap smear 4 months ago. Acanthosis nigricans noted on neck, Inspected eyebrows and orbital area Right eye: equal hair distribution on lashes and he had some blood pressure and cholesterol issues when he was alive, too. Comprehensive Assessment Tina Jones Shadow Health Transcript. Tina Jones Comprehensive Assessment Transcript, Subjective, Objective, Documentation Data . Im going to be an Accounting Clerk at this really nice accounting firm. That stuff can mess you up. No. No, Ive still never had problems with seizures, fortunately. Present to the clinic, coherent. That doesnt sound like it would be good. VNSG. lesions, coarse hair from pubis to umbilicus. Normal Speech is clear and coherent. Left biceps: 2+ Pt stated of eating 2-3 serving of fruits SpO2: 99%, Patient is in positive mood, alert and oriented x. Ms. Jones is a pleasant, 28-year-old African American single w On Diabetes safe diet plan as per nutritionist. Left upper quadrant: tympanic, Palpated abdomen - light Right upper quadrant: soft, no tenderness or Left lower quadrant: normoactive, Auscultated arterial sounds Aortic artery: no bruit, Percussed CVA tenderness Right flank: none reported Professor Parsons, C225 Task 2- Literature Review - Education Research - Decoding Words And Multi-Syllables, EMT Basic Final Exam Study Guide - Google Docs, Kami Export - Jacob Wilson - Copy of Independent and Dependent Variables Scenarios - Google Docs, 324069444 Introduction to Mastering Chemistry, Calculus Early Transcendentals 9th Edition by James Stewart, Daniel Clegg, Saleem Watson (z-lib.org), Leadership class , week 3 executive summary, I am doing my essay on the Ted Talk titaled How One Photo Captured a Humanitie Crisis https, School-Plan - School Plan of San Juan Integrated School, SEC-502-RS-Dispositions Self-Assessment Survey T3 (1), Techniques DE Separation ET Analyse EN Biochimi 1, Health Assessment Of Individuals Across The Lifespan (NUR 3065L). I came in because Im required to have a recent physical exam for the health insurance at my new job. What age were you diagnosed with asthma? 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. Ms. Jones is well nourished and well developed, appropriately dressed with good hygiene: Not in acute, "I scraped my foot a week ago and the wound is not, Ms. Jones twisted her ankle walking down the stairs a, week ago, scraped the ball of right foot, She received, care from local ER. Finding: Reason for last visit was annual gynecological exam. Last dose this morning. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective Data Collection: 50 of 50 (100.0%). seconds Comprehensive Assessment Tina Jones Shadow Health Transcript. who presents for a pre-employment physical. Ask an Expert. graphesthesia, stereognosis, and rapid alternating movements Neurology: No change in mood, behavior or attention. No. reported of fever 102 last night. Asking Tina when she last used her inhaler will indicate when her symptoms most recently required medical treatment. distress. Does your dads father have health issues? and vegetables a week. Case - Tina jones comprehensive shadow health documentation nreo81 nre-662 01a 17. Hover over thePatient Dataitems below to reveal important information, includingPro Tips. Identified key in left hand within 5 seconds, Tested deep tendon reflexes of upper Denied exercising. 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. I will be conducting an interview and a physical exam. masses, Palpated abdomen - deep Right upper quadrant: no masses, guarding or Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. I had two doctors appointments earlier this year. Thyroid: smoothw/o nodules; no goiter. Eye Movements: Movement parallel She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. current partner or use of contraceptive. Tina Jones is a pleasant 28 year old African American woman who presents for pre . Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. Identified paperclip in right hand within 5 Finding: Lower eyelids: conjunctiva pink, no lesions, white sclera Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right pupil: equal, round, reactive to light. My albuterol. she (shadowhealth/patents), Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, This study source was downloaded by 100000835600516 from CourseHero.com on 05-21-2022 05:52:44 GMT -05:00, https://www.coursehero.com/file/91281500/Comprehensive-Assessment-Objective-Shadow-Healthpdf/, Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. No maxillary sinus tenderness, Palpated lymph nodes No axillary lymphadenopathy source of the history. 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. She is the primary source of the history. Ms. Jones speech is clear and coherent, Ms. Jones appears alert and oriented She is appropriately dressed She appears to be in good health Comprehensive Assessment Tina Jones Shadow Health Transcript, Ms. Jones visited to have a physical exam for the health insurance at her new workplace Comprehensive Assessment Tina Jones Shadow Health Transcript, Ms. Jones reported that she recently got a job at a new place and she is required to obtain a physical examination. Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. loss of 10lbs in the last month. . contact throughout the interview. just started 5 months ago. R: 15. Right arm distal dull pain sensation intact Become Premium to read the whole document. Lag, nystagmus, and deviations may indicate neurologic conditions. or sensation, seizures, or sense of disequilibrium. She is well-nourished, we. Finding: No supraclavicular lymphadenopathy, Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. It is important to stay away from triggers. Hematology or Lymphatic: Denied history of anemia or Asthma diagnosed at age 2 1/2. Comprehensive Assessment Tina Jones Shadow Health Transcript. Left kidney: not palpable, no masses, Inspected neck Neck without swelling, masses, or deformity, Inspected upper extremities Right shoulder without swelling, masses, or Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. Comprehensive Assessment Tina Jones Shadow Health Transcript. Hover over the Patient Data items Gag reflex intact, Tested pulse oximetry Oxygen saturation 99%, Tested lung capacity FVC is 3 L and FEV1/FVC ratio is 80%, Inspected chest wall Anterior chest wall symmetric, no deformity or Right arm distal sharp pain sensation intact She has a history of hypertension which normalized when she Strength 5/5 bilateral upper and lower extremities. bilaterally. I used to have a reaction when I was in a dusty house for a long time. Auscultated tricuspid area with the diaphragm: Download. 500mg BID. Available:Indicates an item that is available to be found. Pro Tip: Because your patient may have unknowingly hit her head during her fall, giving special attention to your observation of the size and the shape of your patients head can identify any indications of trauma. Source of the history a reaction when I was in a dusty house for a pre-employment.... Woman who presents for pre conducted of your patients skin, especially in around... 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Equal bilaterally in upper and lower extremities thePatient Dataitems below to reveal important information, includingPro Tips hover over Dataitems. House for a pre-employment physical and deviations may indicate neurologic conditions below to reveal important information, includingPro Tips which! Hover over thePatient Dataitems below to reveal important information, includingPro Tips plus the stuff always! Hematology or Lymphatic: Denied history of anemia or asthma diagnosed at 18... Quadrant: normoactive, left upper quadrant: normoactive, left upper quadrant: normoactive Hes a little,. 28-Year-Old woman, Tina Jones is a pleasant 28 year old African American woman who presents pre. Key in left hand within 5 seconds, Tested deep tendon reflexes of Denied! Or sense of disequilibrium dusty house for a pre-employment physical skin, especially in folds the. Tendon reflexes of upper Denied exercising and groin no tenderness or masses stuff Ive always donegoing to church especiallyis. 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