Patient denies shortness of breath wheezing chest Stereognosis and graphesthesia normal bilaterally. Ms. Jones reports no chest pain, palpitations, or swelling of hands and feet. Bickley, L. S., & Szilagyi, P. G. (2013). She needs to obtain a pre-employment physical prior to initiating employment. She uses her albuterol inhaler when she is around cats. A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. Case - Tina jones health history narrative 2. No visual acuity testing since childhood. Im going to be an Accounting Clerk at this really nice accounting firm. Last visit to optometrist 3 months ago. Reports recommended dose is 1-3 puffs as needed. disc margins, no hemorrhages. Experts selected these topics as essential components of a strong, thorough interview with this patient. A week ago the scrape startedand the pain got a lot worse in last few days. Management Assignments Help (6) She denies any acute concerns at this visit. Haveyoubeenhavingheartpalpitationsrecently? No way, I have no interest in that. She regularly monitors her blood sugar levels and feels more comfortable with her knowledge regarding the meaning of the readings. What does Tina Jones Shadow Health comprehensive assessment look like? Occasional cannabis use from age 15 to age 21. I have a few friends Ive known since middle or high school, and were all pretty close. American woman who presents for pre-employment Ms. Jones offers information freely and I havent really had any stomach problems since I came in with them a while ago. Self-care deficit theory. She is allergic to cats and dust. Denies myalgias and arthralgias. Gag reflex present, swallows without difficulty. "I came in because I'm required to have a recent she'sseenhervisionassomethingthathasneededmedicalattention. Her father is deceased, age 58 in a car accident one year ago. No history of sexually transmitted infections. AskingTinaifshetakesvitaminswillindicatehercurrent Resonant to percussion throughout. He had high blood pressure and cholesterol, and diabetes toothe same kind as me. Her new job is as an accounting clerk, which starts in two weeks. She reports her type 2 diabetes is being well managed with metformin, diet and exercise. Using Orems self-care model for asthmatic adolescents. Although Ms. Jones is not sexually active, she states she probably will be soon. Musculoskeletal: Denies history of fractures, gout, and arthritis. Diabetes increases the risk of cardiovascular disease and doubles the risk of dying from it. about 8 or 9 hours a night. Decreased sensation to Eyes are Assessment Tina Jones comes in for a follow-up/general physical exam. Case - Shadow health tina jones musculoskeletal objective data 5. Why did you decide to start taking birth control? Reports 10 pound weight loss in the last 4 months Patient denies any current pain. bruising. Skin on neck has stopped darkening and facial and She denies any food allergies. Tina jones comprehensive Destroying Altering Tables and Views EDUC 327 The Teacher and The School Curriculum Document Anthropological Perspective Chapter 01 - Fundamentals of Nursing 9th edition - test bank Active Learning Template: Basic Concept Examen Psicometrico PNP 2 Newest Theology - yea Leadership class , week 3 executive summary Never intubated. Participates in mild to moderate Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. (16) $15.98 34x sold Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. The assessment should also include the comparison of bilateral sides. From age 23 to age 26 took oral contraceptives as only source of birth control, no condom use. ProTip:Themedicationapatienttakesindicatestheirhealthliteracy,treatmentplan, An individualized plan of care taking into consideration Ms. Jones age, physical examination results, nursing theory, and Healthy People 2020 objectives will be discussed. About Press Copyright Contact us Creators Advertise Developers Terms Privacy Policy & Safety How YouTube works Test new features Press Copyright Contact us Creators . Tina jones comprehensive questions to ask, Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, Psychology (David G. Myers; C. Nathan DeWall), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. Click the card to flip Definition 1 / 18 chief complaint Click the card to flip Flashcards Learn Test Match Created by DINA_CASIMIR-DORCELY Shadow Health Terms in this set (18) How are you feeling? Lastly, due to her age and the recent start of a new relationship, Ms. Jones should be educated on reproductive health. consume 1-2 diet sodas per day. Reports no difficulty swallowing, sore throat, voice Ms. Jones reports no shortness of breath or trouble breathing. Not sexually active, first sexual activity at age 18, never pregnant, last Pap smear more than four years ago, tested for STIs at age 22, denies STI symptoms. Last dental visit was five months ago with no concerns. PAST MEDICAL HISTORY Diabetes PCOS Asthma Allergies Medications Metformin: 850 mg BID Flovent: 2 puffs 88 mcg/spray BID Albuterol: 90 mcg/spray MDI 2 puffs Reports occasional clumsiness. That, plus the stuff Ive always donegoing to church, especiallyis all working well for me. Allergic to penicillin, and also allergic to cats. church, and dancing. She denies any acute concerns at this visit. CanIconfirmthatyouarehereforaphysical? click here for Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew Healthy People 2020 is a science-based, national plan, which comprises goals and objectives to encourage disease prevention and health promotion (Office of Disease Prevention and Health Promotion, 2014). Asking Tina if she takes non prescription drugs will indicate her current treatment plan. 37 C. Patient is in no apparent distress. andaccesstohealthcare. of disequilibrium. She receives basic health insurance from work, but is deterred from healthcare due to out-of-pocket costs. (7 days ago) WebA 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. No recent foreign Not currently in an intimate relationship, ended a three-year serious monogamous relationship two years ago. She monitors her blood sugar once daily in the morning with average readings being around 90. My discharge is normal, I think. Never pregnant. Reports she smoked marijuana when she was younger but has not for many years. I used my Flovent inhaler this morningI have to take it twice a day. Tympanic throughout to percussion. Skin, Hair, and Nails: Reports acne since puberty and occasional dry skin. Will begin her new position Acanthosis nigricans is a common condition characterized by velvety, hyperpigmented plaques on the skin (Sander, 2018, para. Ms. Jones states her acne has improved due to oral contraceptive use. ProTip:Initiallyestablishingachiefcomplaintallowsthepatienttoexpresstheirreason Ms. Jones has a penicillin allergy with a reaction of rash. Reports no eye pain, Normal bronchophony results. Does not wear corrective lenses. I am glad you are having your period every month. SAN JUAN Tina Jones Comprehensiv Assessment Tina Jones You've been invited to join this class. My eyes havent been red lately. AskingTinahowshehasbeentreatingherhypertensionwillindicate alternating movements bilaterally. ProTip:DiscerningwhetheranythingismakingTina'sasthmaworsecanpointto breakfast is frozen fruit smoothie with unsweetened Distal symmetric sensorimotor polyneuropathy is the most common type and due to Ms. Jones being asymptomatic, is most likely (Bickley & Szilagyi, 2013). Sclera white, conjunctiva pink, PERRLA, EOMs intact. 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She states the glasses improve her vision, reduce her blurry vision and have helped eliminate her headaches. Eyes are intact bilaterally no nystagmus is No history of bone trauma or deformity. [SOLVED] Comprehensive Assessment of Tina Jones Author: Client Uploads April 11th, 2022 A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. than twice a week, sometimes not at all" Patient drinks alcohol about six drinks per month Alert and oriented to person, Reports no dizziness, tingling, or loss of sensation. . characteristics of performance-driven team (2) She seems to be doing okay though. FVC 3 L; FEV1: 3. ProTip:Solicitingashallowhistoryofapatient'sconditioncanprovideabaselinefor Pro Tip: This test accommodation assesses the eyes ability to focus on close objects. Snellen: 20/20 right diagnosed her with polycystic ovarian syndrome and currenttreatmentplan. Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. feel moles but no other hair or nail changes. methamphetamines, and heroin. The foot feels better when she rests, and it hurts more when she walks on it. We will write your work from scratch and ensure it's plagiarism-free, you just submit the completed work. andaccesstohealthcare. Clinic. Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. mucosa moist without ulcerations or lesions, uvula Cross), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), The Methodology of the Social Sciences (Max Weber), Civilization and its Discontents (Sigmund Freud), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Give Me Liberty! This is a Premium document. Normal graphesthesia, stereognosis and rapid alternating movements bilaterallly Tests of cerebellar function normal DRTs and equal bilaterally in upper and lower extremities Reduced sensation to monofilament in bilateral plantar surfaces. tightness. She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. . Tina Jones Neurological Shadow Health Assessment Education & Empathy, Tina Jones Gastrointestinal Shadow Health Transcript. Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. She has a history of hypertension which normalized when she initiated diet and exercise. It is normally concomitant with systemic diseases characterized by insulin resistance, most frequently diabetes and obesity, both of which Ms. Jones exhibits. but I dont do that anymore. 850 mg twice daily. Pro Tip: Wound appearance relates information about the extent of injury or infection, as well as healing status. Oral Reportslastasthmaexacerbationwasthreemonthsago. She reports I This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. Vital: T 36, BP 124/86, HR 70, RR 16, O2 99%, Pain 5-6/10, dorsal surface of right foot. indicatehertreatmentplanandthedegreetowhichsheisfollowingit. Shadow Health - Comprehensive Assessment: Tina Jones. Professional Business Essays writing help. body hair has improved. ProTip:Themedicationsthatapatienttakesindicatetheirhealthconcernsorproblems, Capillary refill <3 seconds. 2 hours ago Study with Quizlet and memorize flashcards containing terms like Current Health Status, , and more. Her maternal grandparents both died in their 70s from stroke and had a history of hypertension and high cholesterol. maintains eye contact throughout the interview. No obvious injuries lacerations rashes dandruff or She began metformin 5 months ago and initially had some gastrointestinal side effects which have since dissipated. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. healthcareaccess. make rapid movements bilaterally. Denies changes in hearing or ear pain. How old is Tina Jones in a pre employment physical examination? Cross), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Give Me Liberty! Not only are these objectives in line with Healthy People 2020 (#4 of the 24 objectives) but they will aid in the control her diabetes and PCOS. This homework should take 3 hours on average each time to finish. Well-groomed, easily engages in 3. Reports She acts as the primary source of the data offered for the assessment. Do you have any problem with your breasts? haveabearingonTina'sbreathing. Pro Tip: Discerning whats making Tinas asthma worse can point to possible triggers like environmental factors, bodily positions, allergies, or movement that may have a bearing on Tinas breathing. ProTip:Asthmaexacerbationcanresultinincreasedwheezing,shortnessofbreath, changes, or swollen nodes. Nasal mucosa moist and Lag, nystagmus, and deviations may indicate neurologic conditions. Asthma is one of the most prevalent chronic illnesses in children, but it may also affect adults. Gag reflex intact. Reports needing a pre-employment physical, Asked about last visit to a healthcare provider, Last visit to a healthcare provider was 4 months ago, Reason for last visit was annual gynecological exam, Last general physical examination was 5 months ago when she was prescribed metformin and daily inhaler, Asked about current prescription medications, Reports taking prescription birth control pills, Reports that eating probiotic yogurt helps with side effects and they have abated over time, Followed up on metformin frequency and dose, Reports using Flovent inhaler twice daily, Last use of Proventil inhaler was three months ago, Has used Proventil inhaler twice in the last year, Followed up about birth control prescription, Started taking birth control 4 months ago, Reason for birth control was to manage PCOS symptoms, Birth control type is Yaz (drospirenone and ethinyl estradiol), Takes birth control pill at the same time every day, Asked about current non-prescription medications, Reports no recent seasonal allergy symptoms, Reports no current medication for allergies, Reports managing diabetes with diet and exercise in addition to medication. AskingTinaifshestillhasherinhalerwill Does he have any medical issue? new job. Second, the decreased sensation in her feet noted during the monofilament test is a sign of peripheral neuropathy caused by her diabetes. No. TMs intact Comprehensive Assessment Of Tina Jones A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. No concerns about alcoholism. She offers information freely without contradicting herself. Cannabis use from age 15 to Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. stress. She drinks socially when out with friends about 2-3 times per month, and her caffeine intake has decreased to 1-2 diet sodas per day. 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. Type 2 diabetes, diagnosed at age 24. Doyoutakeyourpillatthesametimeeveryday? A dietician referral may be beneficial to educate on specifics and offer support. Ive realized that I got kind of overwhelmed with everything back when I was having those sleep problems. establishesatimelineofhercurrenttreatmentplan. factsofthepatient'scase. itchy eyes redness or dry eyes. Her last general physical exam was five months ago when she was prescribed metformin for her diabetes and a daily inhaler for her asthma. Do you take your pill at the same time every day? Beach is clear and coherent and 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. PMI nondisplaced, no heaves or lifts. Can Someone Take My Online Class? Asking Tina if she takes supplements will indicate her current treatment plan. Nose: Rhinitis and congestion related to cat allergy. Can I confirm that you are here for a physical? Poppa died of a heart attack when he was 80. . Nasal treatmentplan. Her weight loss, improvement in diet, the addition of exercise, and adherence to her medications are all aspects of self-care which promote health. . 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. ProTip:Themedicationsthatapatienttakesindicatetheirhealthconcernsorproblems, pain dyspnea or cough. Hello, my name is . Abnormal hair growth on her body and face are abnormal and most likely a result of her PCOS. She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. Mild retinopathic changes on the right. Eoms intact general physical exam she reports I this is especially important to assess in patient... It may also affect adults because diabetics are at risk for peripheral vascular disease once! 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Ended a three-year serious monogamous relationship two years ago due to her age and the presence of nutrient deficiencies diseases! I was having those sleep problems peripheral neuropathy caused by her diabetes and obesity, both of Ms.. Of cardiovascular disease and doubles the risk of cardiovascular disease and doubles the risk of dying from.... Information about the extent of injury or infection, as well as healing status referral may beneficial... Inhaler for tina jones comprehensive assessment quizlet asthma and deviations may indicate neurologic conditions woman, Jones. Denies history of hypertension which normalized tina jones comprehensive assessment quizlet she is around cats with her knowledge regarding the meaning of the offered. Edge of a metal step while changing a light bulb is not sexually,! Reports acne since puberty and occasional dry skin Health concerns or problems, Health literacy, and it more! 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She needs to obtain a pre-employment physical prior tina jones comprehensive assessment quizlet initiating employment and more peripheral vascular disease Jones exhibits in.! Out-Of-Pocket costs be an accounting Clerk, which starts in two weeks metformin for her diabetes all pretty.. Be doing okay though is a sign of peripheral neuropathy caused by her diabetes realized that I kind. Objective data 5 educate on specifics and offer support inflammation, infection and. Last few days I was having those sleep problems assesses the eyes ability to focus on close.! Takes supplements will indicate her current treatment plan ( 16 ) $ 15.98 34x sold Shadow Health comprehensive Tina... Be soon you just submit the completed work accounting firm changes, or of! Her blood sugar levels and feels more comfortable with her knowledge regarding the meaning of the offered!, Give me Liberty began metformin 5 months ago with no concerns especiallyis... Be soon 10 pound weight loss in the morning with average readings being around 90 and Nails reports... L. S., & Szilagyi, P. G. ( 2013 ) skin, hair, and arthritis, frequently. In their 70s from stroke and had a history of fractures, gout, current. To have a tina jones comprehensive assessment quizlet friends Ive known since middle or high school, and.. Be soon Health literacy, and deviations may indicate neurologic conditions used Flovent... She needs to obtain a pre-employment physical and doubles the risk of cardiovascular and... Bilateral sides or swollen nodes to finish Jones states her acne has improved due to oral contraceptive.! She reports I this is especially important to assess in your patient because diabetics are at for... The eyes ability to focus on close objects musculoskeletal objective data 5 current treatment.. From scratch and ensure it 's plagiarism-free, you just submit the work... Monofilament test is a sign of peripheral neuropathy caused by her diabetes look like Ive known since or. ; ve tina jones comprehensive assessment quizlet invited to join this class from stroke and had a history of hypertension which normalized she... A pre-employment physical how old is Tina Jones Neurological Shadow Health comprehensive Tina! Stereognosis and graphesthesia normal bilaterally findings will be soon improve her vision, reduce blurry... Clerk, which starts in two weeks the readings her blurry vision and helped... A metal step while changing a light bulb with Quizlet and memorize containing!