Finding: Bilateral carotids 2+, no thrill, no bruits. The following details are facts of the patients case. I. (Found) ProTip:AskingTinawhenshelastsawaneyedoctorwillindicatethedegreetowhich dental exam was a few years ago. The Tuberculosis (TB) test was negative two years ago. She reports her type 2 diabetes is being well managed with metformin, diet and exercise. Anterior and posterior chest walls are symmetric with respiration, no deformities, rashes, or lesions. Ms. Jones has a penicillin allergy with a reaction of rash. Finding: Finding: Paper was great and accomplished everything I needed. How many times a day do you take metformin? Pro Tip: A patients use of birth control can impact the care plan, such as which medications are prescribed. (Found) Example Question: Example Question: What is the name of your diabetes medication? Finding: Advanced Health Assessment 95% (444) Finding: hercurrenttreatmentplan. Able to perform repetitive alternating movements, finger to nose smooth, able to run heel down shin with no deviation. What is your typical breakfast? Finding: Review the report by clicking on each tab to the left titled; Transcript, Subjective Data Collection, Objective Data Collection, Documentation, and SBAR to compare your work. comparinganattack,exacerbation,andmoreregularbreathing. Ms. Jones states her acne has improved due to oral contraceptive use. Finding: She visited a nearby emergency Denies OTC herbals Example Question: Reports that glasses improve overall vision Her speech is clear and eye contact is appropriate. This clinical experience is a comprehensive exam. Asking Tina if she takes herbal products will indicate her current treatment plan. Example Question: Example Question: It is important to continually monitor proper inhaler use and educate on the importance of monitoring the use of her rescue inhaler. Pro Tip: Determining if Tina experiences wheezing is important for assessing her respiratory health and providing quality patient care. She should be encouraged to continue taking her metformin as prescribed and be instructed on the importance of regular follow up visits to monitor glucose control through HgA1C levels. Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. She is sleeping well, and her diabetes is well managed with medication, diet, and exercise. Finding: Tina Jones comes into the clinic for a general physical exam. Her snacks consist of pretzels or French fries. Askedaboutlastvisittoahealthcareprovider, Askedaboutcurrentprescriptionmedications. Pro Tip: When doing a review of the neurological system, you will want to ask about general symptoms that will allow Tina to describe, in her own words, any specific neurological problems that she is experiencing. COMPREHENSIVE HISTORY (Subjective Data), Date & Time: 1/20/2023 at 8pm (Found) Example Question: Pro Tip: Determining any outcomes from Tinas last optometrist visit is important, as it may reveal treatments that you should follow-up on. (Found) You'll also be able to download it from your account and request a revision or rate the work as appropriate. Example Question: forseekingcare,primaryconcerns,orconditiontheyarepresentingwith. Mucous membranes pink and moist, tonsils 2+ bilaterally. Denies current sleep issues She complained of darkened skin on Finding: lunch, meatloaf, or chicken for dinner. Do you drink coffee? Your initial responses to the mandatory DQ do not count toward participation and are graded separately. Do you use any herbal products? ProTip:Asthmaexacerbationcanresultinincreasedwheezing,shortnessofbreath, There is no family history of other cancers, mental illness. She has glasses following a vision exam. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score. Finding: The rescue inhaler was last used three months ago with a total of two uses in the past year. She states she goes for a 30-40-minute walk 4-5 times per week and swims one time per week. Reports recent weight loss. Musculoskeletal. How do you exercise? NRS 434 Shadow Health: Comprehensive Assessment Ms. Jones has already begun treating her diabetes, but early treatment has not been established to improve cardiovascular outcomes (Bickley & Szilagyi, 2013). Reportsnocurrentmedicationforallergies. Her Patient able to identify dull, sharp, and soft touch on all extremities. Reports taking birth control pill daily An individualized plan of care taking into consideration Ms. Jones age, physical examination results, nursing theory, and Healthy People 2020 objectives will be discussed. Example Question: Example Question: (Found) Upon completion, submit the lab pass through the assignment dropbox. As Masters level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Example Question: Not Scored, A combination of open and closed questions will yield better patient data. Health Maintenance: No exercise but states her work keeps her very active. Example Question: She is the primary source to her own health history. Neurological. Once you have received your report, please review it. Hoveroverthe PatientData itemsbelowtorevealimportantinformation,including Pro Full ROM and 5/5 strength in extremities, spine, and hips. 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. Example Question: Employed 32 hours per week as a supervisor at Mid- Upon inspection, abdomen protuberant and symmetric. Denies sinus problems, frequent Has your asthma medication changed? Example Question: Skin, hair, and nails. click here for Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew ProTip:Themedicationsthatapatienttakesindicatetheirhealthconcernsorproblems, Gag reflex present, swallows without difficulty. Ms. Jones should be encouraged by the additions and progress she has made. Finding: No current complaints or recent illness. Last dental visit was five months ago with no concerns. No peripheral edema. Using Orems self-care model for asthmatic adolescents. She is a good historian. Finding: She is starting a new job as an accounting clerk at Smith, Stewart, Silver & Company. Pro Tip: Determining any recent or past history of drug use is essential to revealing any substance abuse issues, and if the patient is likely to seek drugs while admitted. andchesttightness. Do you perform breast self-exams? Active problems: Acute foot pain and local infection of the tissue and subcutaneous tissue of It is not a focused assessment. How long have you been taking metformin? Points will be deducted for poor use of APA format or absence of APA format (if required). ProTip:AskingTinaifshehasbeentoaneyedoctorwillindicatethedegreetowhich Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Transcript All Lines (645) Interview Questions (210) Statements (41) Exam Actions (394) I have a few friends I've known since middle or high school, and we're all pretty close. Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. Her 24-hour diet healthliteracy,andcurrenttreatmentplans. AskingTinawhenshelastusedherinhalerwillindicatewhenher Greet 07/22/20 5:37 PM ED. Get 15% OFF your order now! Asked review of systems for gastrointestinal. (Found) Skin, hair, and nails. (Found) Example Question: Breath sounds present and equal bilaterally, no adventitious sounds noted. Reports recently prescribed eyeglasses Available from:https://www.ncbi.nlm.nih.gov/books/NBK499933/, Grand Canyon University (Ed). Her maternal grandparents both died in their 70s from stroke and had a history of hypertension and high cholesterol. Example Question: Substantive responses should be at least 150 words. She needs to be educated and understand the importance of testing her blood sugar regularly. Ms. Jones reports no muscle pain or weakness. (7 days ago) WebAlthough Ms. Jones can answer over 100,000 questions, you should only need to ask a fraction of these to obtain a complete health history. It may also reveal problems not covered elsewhere in the exam. Finding: Another abnormal finding was the discoloration on her neck. (Found) Example Question: Denies current acute health problems She reports she has a strong friend and family support system and is very active in her church. And lastly, the pustules on Ms. Jones face are consistent with a diagnosis of acne vulgaris (Dains, Baumann, & Scheibel, 2012). Pro Tip: Establishing a timeline for Tinas gynecological exams will allow you to develop a comprehensive health history. Pro Tip: Asking if a patient perform breast self-examinations is important because it reveals a patients level of health literacy. Finding: Capillary refill <3 seconds.Comprehensive Assessment of Tina Jones. sexually active; first sexual experience at age 18 never pregnant; and no miscarriage. Tina reports she has improved her diet by limiting carbohydrates, staying away from sweets and increasing vegetable consumption. Nasal cavities pink, no discharge. Example Question: A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. Retrieved from http://www.uptodate.comComprehensive Assessment of Tina Jones, If your paper matters, we own all the good words. Example Question: Reports last optometrist visit was 3 months ago Pro Tip: Follow up questions about Tinas diabetes medication history and timeline will help you to understand her treatment plan and recent health history. (Found) Fluticasone propionate: 88 mcg/spray, two puffs twice daily. For example, when caring for a 19 year old female with Muslim faith, it is important to know the specifics of the culture to provide the appropriate care. If she has not had any screenings, it provides an opportunity for patient education. No use of Does ibuprofen help your cramps? The SHCA consists of ten multiple-choice questions that test a student's comprehension of key health concepts. Do you have a history of breast cancer? Example Question: ProTip:Conditions,likepalpitations,mightchangeovertime. Ms. Jones reports no headaches, vision changes, eye pain or itchy eyes. Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. (Found) There are no pets. Denies changes in hearing or ear pain. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Reports history of smoking recreational marijuana Musculoskeletal. Denies sexual activity (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 Firstly, it seems that Ms. Jones has begun to take her health seriously and has implemented healthy practices into her daily routine. 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