Her caffeine intake is reduced to 1-2 sodas per day. female. No peripheral edema. percussion. Liver: 1 cm below right costal margin. Establishing a timeline for how long Tinas eyes have been itching will also aid in treating her itchy eyes. Student Documentation Model Documentation. Shadow health comprehensive assessment Tina J, Julie S Snyder, Linda Lilley, Shelly Collins, Planning, Implementing, and Evaluating Health Promotion Programs, Brad Neiger, James McKenzie, Rosemary Thackeray. Patient verbalized sleeping well at night with no pain or discomfort. She has a documented medical history of, Asthma and Diabetes. Takes tylenol to The patient is here, for physical assessment for work insurance for a new job. She is treating her asthma with a daily inhaler as well as. Tina Jones shadow health. Maternal grandfather diseased, died at age 78 of stroke. Tina Jones Comprehensive Assessment Final Paper, Legro, R.S. 02 Physical Exam Students gather and interpret objective data to assess the patient's condition. bilaterally in upper and lower extremities. She came into the clinic for, She is starting a new job as an accounting clerk at Smith, Stewart, Silver & Company. heterosexual. Liver Span: 7cm MCL on percussion Have you had any changes in your hearing? How many puffs of your inhaler do you use? Ms. Jones states that the gynecologist diagnose Pro Tip: Asking about how Tina is recently breathing can provide a comparative baseline for assessing Tinas current condition and previous breathing concerns or conditions. 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. individualized health plan. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation - OnlineNursingPapers | OnlineNursingPapers Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Fluticasone propionate, XXX(last use: this morning) Drospirenone and XXXX (last use: this morning) XXXX (last use: three months ago) XXX) IXXXX (menstrual cramps: last taken 6 weeks ago). denied Identified health concerns based on screening assessments and demographic information, What is the patients activity level, is the environment where the patient lives safe for activity, Nutrition recommendations based on age, race gender and pre-existing medical conditions, Support systems, family members, community resources, Recommended health screening based on age, race, gender and pre-existing medical conditions. She states that she has had problems in the past but they have not h, appened in "a while" (T. Jones, Shadow Health Interview, February 13, 2016). No edema. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. Proventil 2 puffs q4hr PRN (for SOB), tramadol PO This is a comprehensive H & P. You will be assessing the \whole\ person. (2017). Thyroid smooth withou three years ago. Mother, age 50, HTN, high cholesterol. Type 2 diabetes Maternal Grandparents: both deceased in age 70s-stroke, hypertension, high cholesterol. Hypertension: normal blood pressure readings. You will develop differential diagnosis based on the chief complaint and HPI. Patel, N. U., Roach, C., Alinia, H., Huang, W. W., & Feldman, S. R. (2018). Have you done anything for your runny nose? Maternal grandfather- deceased at 65 years- colon cancer and diabetes type 2. she is limiting carbohydrates staying away from sweets and increasing vegetables. Pro Tip: Tinas response to a question about managing her headaches will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. Never pregnant. she was in high school. Air flows steadily between two cross sections in a long, straight section of 0.1-m-inside-diameter pipe. Chest is symmetric with respiration, clear to auscultation bilater Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Model Note: Differential diagnosis includes viral pharyngitis, strep throat, influenza, cold, and sinusitis. White pus pockets and petechiae on the palate are classic signs of strep throat. in bowel pattern. C word/document.xml}RH{}[=[GLYc aggravating factor and tramadol as relieving factors. is clear and coherent. How often did you see the dentist when you were a child? No prn follow-ups for this course. 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. Skin on nec She is well-developed and dress appropriately with good hygiene. Use PMH (past medical history) to help . grandmother diseased, died at age 73 from stroke, Near sighted and blurry vision- wears glasses to help with vision. fao.b*lIrj),l0%b Looking at the template, it asks for rationales. Pro Tip: Sinusitis can create pressure behind the eyes, causing eye pain. General Clinic. For assignments that need to be submitted to LopesWrite, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a final submit to me. Erythema alone may indicate viral infection or postnasal drip. goods, lunch: sandwich, dinner: meatloaf or chicken. Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words. There are multiple ways to communicate with me: encounter at age 18, Sex with men only. If your paper matters, we own all the good words. Advil 2 tabs. Denied issues with Cross), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Civilization and its Discontents (Sigmund Freud), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), The Methodology of the Social Sciences (Max Weber), 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), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler). Case - Tina jones mental health shadow health assessment transcript 4. Familiarize yourself with APA format and practice using it correctly. Tina also takes Advil 500mg as needed for menstrual cramps and for headache. Her last asthma related hospitalization was when she was 16. Pharmacologic Therapeutics Pro Tip: Assessing how a patient feels in the current moment can allow you to juxtapose their chief complaint alongside symptoms they experience. she experiences exacerbations, such as around dust or cats. Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Last menstrual period 2 weeks ago. Retrieved on July 26, 2020 from. Never pregnant. U++ # word/_rels/document.xml.rels ( Vr03?d|+.R'(3=pak[j$Iuk;N)V{w An analysis of Tinas great aunts medications and past medications can be used to rule out ototoxicity. for menstrual pain and headaches. Pro Tip: Because problems like mouth or throat cancer can be genetic, its important to understand family history to determine risk factors. Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. By asking Tina if she regularly changes her bedding, youre soliciting information about environmental factors that might exacerbate her condition. Read over your paper in silence and then aloud before handing it in and make corrections as necessary. Asking Tina about her nasal symptoms solicits information about her sinuses and possible sinus problems. Reports occasional sho discoloration over last few years. Menarche at age 11, First sexual Participates in mild to moderate exercise four to five times per week consisting of walking, yoga, or swimming. Stopped taking med without medical advice Tina Jones Comprehensive Assessment Final Paper, Assessment Tina Jones Comprehensive Assessment Final Paper, Differential Diagnosis Tina Jones Comprehensive Assessment Final Paper, This diagnosis is because of patients history of dysmenorrhea and longer periods, and severe cramps, as a birth control was prescribed. Mild retinopat Essay Scattered pustules on face and facial hair on upper lip, acantho XXXdiagnosed at age 2 1/2. Conjunctiva pink, no lesions, white sclera. Denied Education/Health Promotion: deformity and with full range of motion. Reports that the symptoms dont seem like a common cold. Self-care needs/ Activities of daily living. For the past four mont PERRLA Do you think you are having an allergic reaction? As per policy, no assignments are accepted after the last day of class. Left fundus with sharp disc margins, no any acute concerns. It, includes interview of patient or a caregiver as is the case with adults with dementia and, for children. Speech is clear and coherent. Today she Heart rate is regular, S1, S2, without murmurs, gallops, or rubs lesions, coarse hair from pubis to umbilicus. Paper A. business establishments B. educational institutions C. municipal buildings D. churches. click here for Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew Pro Tip: Soliciting a shallow medical history relevant to Tinas chief complaint will allow you to assess her condition relative to past concerns. Tina has been diagnosed with diabetes, asthma and polycystic ovarian syndrome (PCOS). Right foot become red and swollen. Pro Tip: Broad, open questions will allow Tina to describe, in her own words, the specific pain and discomfort that she is experiencing. Resonant to percussion throughout. Pro Tip: A patient is an expert on her body. She enjoys spending time with friends, reading, attending Bible study, volunteering in her church, and dancing. She was sent home with PRN Once you\ve developed your diagnosis, be sure to use \evidence based practice\ and \published\ clinical guidelines to guide your plan of care and education. literature. She needs to obtain a pre-employment physical prior to initiating employment. Missing some information regarding health concerns, by excluding information from screening assessments and demographics, Health concerns are not identified due to information missing from screening assessments and demographics, Completely asses patients nutrition and activity levels and makes recommendations based on age, race, gender and pre-existing medical conditions, Missing some information regarding the patients nutrition and activity levels, make recommendations based on age, race, gender and pre-existing medical conditions, Most of the information regarding the patients nutrition and activity levels are missing, recommendations are missing or not based on the patients age, race, gender and pre-existing medical conditions, Identifies support systems such as family members and community resources, Missing some information regarding support systems such as family members and/or community resources, Little to no information regarding social support Tina Jones shadow health, Overall health maintenance recommendations made based on age, race, gender and pre-existing medical conditions, Missing some recommendations, mostly based on age, race, gender and pre-existing medical conditions, Missing many recommendations, loosely related to age, race, gender and pre-existing medical conditions, Identified knowledge deficit areas/patient education needs including self-care needs and activities of daily living, Missing one or more areas of knowledge deficit/patient education needs including self-care and activities of daily living. Tina Jones is a 28 year old African America women. Reading and studying seem to cause headaches. Asking Tina how often she saw the dentist as a child will suggest her health and dental history. intubated. lenses. Blurry vision occurs when reading for long periods. She has no medication side effects at this time. Gastrointestinal: Reports no nausea, vomiting, pain, constipatio Type 2 diabetes, diagnosed at age 24. How would you rate your headache pain on a scale of 0 to 10? Learning about a patients family history around vision can help you predict risk. deceased in car crash, hypertension, high cholesterol. influenza is not current, and human papillomavirus has been Many puffs of your inhaler do you think you are having an allergic reaction is well-developed and dress appropriately good. To assess the patient is an expert on her body many puffs of your inhaler do you think you having. 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