She has asthma too, but she almost never has attacks. Question I had two doctors appointments earlier this year. All the materials from our website should be used with proper references. We want you to be in as little, pain as possible. So I'll actually turn of the light and close my eyes around 1 or so, and then I won't fall Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. She denies fevers, chills, and ni discomfort of 3/10 which she attributes to associated anxiety episodes as thumping in her chest with a heart rate that is way Asking Tina if she still has her inhaler will indicate her treatment plan and the degree to which she is following it. . sample picot questions (12) (Clarified to: Do you control your diabetes through, Yeah, I stay away from sugar and watch what I eat, in general. A combination of open and closed questions will yield better patient data. is a student at Shadowville Community College. Once three months ago, and before that it had been months, too. She has not attempted any treatment at home and states that sh Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Never pregnant. A, I decided to come in because I'm tired all the time now, and I'm stressed and too foggy to study most of the time. Is the Education and Empathy section scored in every patient case assignment? The page will refresh upon submission. ABI is 0. stress.". Penicillin: rash Denies food and latex allergies Allergic to cats and dust. It is also used as a tool for measuring nursing skills. Pro Tip: Skin changes are common in patients with uncontrolled diabetes. You have access to an EHR during the patient exam in which you can record your findings. My mom has some issues, and I think some of my grandparents did, too. I mean, I still have asthma and diabetes, but both of those are under control. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Scattered pustules on face and facial hair on upper lip, Right eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema, Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema, Thyroid smooth without nodules, no goiter, Upper eyelids: conjunctiva pink, no lesions, white sclera, Lower eyelids: conjunctiva pink, no lesions, white sclera, Right pupil: equal, round, reactive to light, Left pupil: equal, round, reactive to light, Peripheral vision intact in both eyes, all fields, Inspected interior eyes with ophthalmoscope, Left fundus with sharp disc margins, no hemorrhages, Right upper quadrant: no masses, guarding or rebound, Right lower quadrant: no masses, guarding or rebound, Left upper quadrant: no masses, guarding or rebound, Left lower quadrant: no masses, guarding or rebound, Liver: palpable 1 cm below right costal margin, Neck without swelling, masses, or deformity, Right shoulder without swelling, masses, or deformity, Right arm without swelling, masses, or deformity, Right elbow without swelling, masses, or deformity, Right wrist and hand without swelling, masses, or deformity, Left shoulder without swelling, masses, or deformity, Left arm without swelling, masses, or deformity, Left elbow without swelling, masses, or deformity, Left wrist and hand without swelling, masses, or deformity, Fingernails: no ridges or abnormalities in nails, pink nailbeds, Hips without swelling, masses, or deformity, Right leg without swelling, masses, or deformity, Right knee without swelling, masses, or deformity, Right ankle without swelling, masses, deformity, or discoloration, Right foot without swelling, masses, or deformity, Left leg without swelling, masses, or deformity, Left knee without swelling, masses, or deformity, Left ankle without swelling, masses, or deformity, Left foot without swelling, masses, or deformity, Toenails: no ridges or abnormalities in nails, pink nailbeds, 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs, Height: 170 cm Weight: 84 kg BMI: 29.0 Blood Glucose: 100 RR: 15 HR: 78 BP:128 / 82 Pulse Ox: 99% Temperature: 99.0 F, The patient is a 28-year-old female who presented for a pre-employment physical exam. Lately, though, it's just these racing thoughts of everything I'm worried about, and it's harder to control. No surgeries. Ill be helping a more experienced accountant with her clients, and then eventually Ill get more responsibility, and build my own client list. cardivascular consitions and/or disease. I used to have a reaction when I was in a dusty house for a long time. Lewis's Medical-Surgical Nursing Diane Brown, Helen Edwards, Lesley Seaton, Thomas. All pulsed with normal range. General, Tina Jones is a pleasant obese 28 ear old female. she "tries to slow down". denies any association of symptoms with exertion. You can hover over each bulleted item in Patient Data to view a Pro-Tip that explains the clinical significance of that finding. Sometimes, if I really start stressing Im taking good care of my health these days. Each type of interaction is color codes so you can quickly assess the types of patient interactions that occurred during the exam. Cross), Give Me Liberty! Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Course Hero is not sponsored or endorsed by any college or university. Clicking on each of the Education & Empathy topics will show you more information and the part of your transcript. Essential Environment: The Science Behind the Stories Jay H. Withgott, Matthew Laposata. But that hasnt happened since I got my daily inhaler. She started me on birth control, and it seems to be helping things. ), No. Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Tina Jones Health History _ Education and Empathy_ Shadow Health.pdf. When asking interview questions to collect subjective data, there will be scored opportunities to provide either an educational or empathic statement in response to the patient. temporal, carotid, abdominal aorta, femoral, iliac, or renal bruits. Comprehensive assessment documentation. Experts selected these topics as essential components of a strong, thorough interview with this patient. She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. Let me learn more about what youre experiencing, and I will try to help.". Essential Environment: The Science Behind the Stories Jay H. Withgott, Matthew Laposata. . the last time I was sick was when I was having those heartburn problems a while ago. Today she denies any acute concerns. SOAP Note Template (14) I havent really had any stomach problems since I came in with them a while ago. With our premium writing service, you no longer have to spend days and nights meticulously working on your assignment, instead use that time to do other important things. How often do you take your birth control pill? I think were pretty special, the way we all get along. She denies chest pain during the episodes, but does endorse Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Exam (elaborations) - Focused exam: hypertension and type 2 diabetes - week 10 results | turned in advanced. I just always want to be learning new things and getting better at my job. Family History has hypertension, hyperlipidemia, diabete melluitis, Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. She has been feeling tired at the end of the day. dust, and penicillin. Tina denies smoking and states she seldomly drinks. 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(Clarified to: how often I wake up TIna states she does not drink coffee and alleviate her palpitations Description: Tina describes how busy she is with school and work. Health History | Completed | Shadow Health, Advanced Health Assessment - August 2019, N5544. At the top of this page, you will see a percentage score of how you did on Subjective Data Collection. I am glad you came in. 2. Capillary refill < 3 seconds. You are scored on the accuracy of their reported findings from the physical assessments. Description: Tina describes her sleep hygiene and routine. Using a, Your document will be more credible. NURSING 362. Metformin 850 PO BID Flovent 2 puffs 88 mcg/spray BID Albuterol 90 mcg/spray MDI 2 puffs Q4H Drospirenone PO QD, Fluticasone propionate, 110 mcg 2 puffs BID (last use: this morning) Metformin, 850 mg PO BID (last use: this morning) Drospirenone and ethinyl estradiol PO QD (last use: this morning) Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (last use: three months ago) Acetaminophen 500-1000 mg PO prn (headaches) Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6 weeks ago), Allergic to cats and dust Allergiic to penicillin Denies any food or latex allergy. This button will Reopen your attempt. need a distraction. DNP (36) Conduct physical evaluations to check vital signs such as blood pressure and heart rate, and look for abnormalities in skin, nose, throat, lungs and abdomen. since I was really little. Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. She has a history of asthma, last hospitalization wa At the top of this page, you will see a percentage score of how you did on Objective Data Collection. No, I'm still just taking the Flovent inhaler twice a day, and then I have my albuterol to use if I need it, I took something for my acne. Shadow Health Assignments for virtual clinical hours sales tax notification: elsevier inc. dba shadow health charges applicable sales tax as required state and Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew My Library Discovery Institutions Grand Canyon University University of Massachusetts Lowell That, plus the stuff Ive always donegoing to church, especiallyis all working well for me. (Clarified to if my brother has health issues.). I had a little when I first started metformin, but I found out I could eat yogurt to help it, and it seems to have worked. Ive been feeling much better lately, though. Hover over thePatient Dataitems below to reveal important information, includingPro Tips. No peripheral edema. She monitors her blood sugar once daily in the morning with average readings being around 90. Nursing Essays Examples (81) those identified by nursing experts to be of particular importance to this patient. These prompts encourage you to consider the development of their clinical reasoning skills, as well as identify key lessons learned from the assignment. My muscles have felt great, especially since I started exercising more. The following actions reveal the objective data of the patients case. Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity. This includes your DCE Score, Student Performance Index, Proficiency Level, and assignment details. Additionally, you will see an example question that would unlock the finding. Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how shes been treating her symptoms since exacerbation.