No prn follow-ups for this course. 31 Comments Please sign inor registerto post comments. Ms. Jones started taking 30 40 mins walks and swims once a week, which she said helps her control her type 2 diabetes. She came into the clinic for a physical exam. Im taking good care of my health these days. Speech is clear and coherent. A. business establishments B. educational institutions C. municipal buildings D. churches. Im going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. thyroid functions. Tested position sense on toes: Right foot patient said "I think tht was All Rights Reserved. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Asked about review of systems for neck, throat and glands. XXXX Denies food and latex allergies XXXXX. For the past four mont Tina also takes Advil 500mg as needed for menstrual cramps and for headache. today. Found: Indicates an item that you found. She came into the clinic for, She is starting a new job as an accounting clerk at Smith, Stewart, Silver & Company. Denies family history of ear or hearing problems. Stretch marks on anterior and posterior waist. When in doubt, cite the source. This is a comprehensive H & P. You will be assessing the \whole\ person. Pro Tip: Sinusitis can often lead to tonsil problems and voice changes. who presents for a pre-employment physical. states that she has runny nose, itchy and swollen eyes, and time. Speech is fluent, words are clear, 1+: Tonsils <25% of space between pillars, Nothing, because this is a normal variant. Organized, easy to read, no spelling or grammar mistakes, appropriate use of APA, Organized and easy to read, few spelling or grammar mistakes, few errors in APA, Disorganized, difficult to read, many spelling and grammar errors mistakes. COMPREHENSIVE ASSESSMENT TINA JONES SH.docx -. She is the primary source of health history. Para 0. incontinence or dysuria. Asking Tina about possible allergens at work might indicate a relevant factor in her recent exacerbation. ORDER COMPREHENSIVE SOLUTION PAPERS ON Tina Jones Comprehensive Health Assessment. Pro Tip: Soliciting a shallow history of a patients medication history can reveal recent exacerbation. Health history is a very important part of assessment for practitioners. Conjunctiva pink, no lesions, white sclera. You will develop differential diagnosis based on the chief complaint and HPI. Denied leg pain or discoloration in Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. Reports no previous problems with seasonal allergies, Pro Tip: Discerning whats making Tinas asthma worse can point to possible triggers like environmental factors, bodily positions, or movement that may have a bearing on Tinas breathing. No CVA tenderness. * The paper should be written and referenced in APA format and be no longer than 4 pages (excluding cover page and references). Scattered pustules on face and facial hair on upper lip, acantho Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Pro Tip: A family history of allergies is an important factor to determine whether a patient is at risk for developing allergies. Last pap 3 years ago. Course Hero is not sponsored or endorsed by any college or university. Class Is your paper made up of someone elses thoughts more than your own? You must proofread your paper. She reports that she believes she is up to date on ch 6. which she is controlling with diet, exercise, and metformin, whic Asking Tina whether she has glasses or contacts solicits information about her vision history. Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew My Library Discovery Institutions gD,~M?Jx she does not have active health issues. 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 Do you have any family history of throat problems? edema. R: 15. Advil 2 tabs. Your initial responses to the mandatory DQ do not count toward participation and are graded separately. Looking at the template, it asks for rationales. Essay She was sent home with PRN, tramadol for pain and Neosporin topical agent for, wound. Tina Jones shadow health. Familiarize yourself with APA format and practice using it correctly. Medical History loss of 10lbs in the last month. Pro Tip: Broad, open questions will allow Tina to describe, in her own words, the specific pain and discomfort that she is experiencing. Cannabis use from age 15 to age 21. N _rels/.rels ( JAa}7 Denied frequent headache or dizziness. She states that she "got a ra, sh, like hives" after taking PCN (T. Jones, Shadow Health Interview, February 13, 2016). aggravating factor and tramadol as relieving factors. she Pleasant and cooperative. 50mg Q6hr PRN (for foot pain). caries or infection. Polycystic Ovary Syndrome (PCOS)is an ovarian disorder characterized by hyperandrogenism, ovulatory dysfunction and polycystic ovaries (Legro, 2017). A review of Tinas health history indicates Tina has, been seen multiple times at the clinic prior to this visit for different reasons including, laceration of her left foot following an accident at home, exacerbation of Asthma. XXXX. Simply restating someone elses words does not demonstrate an understanding of the content or critical analysis of the content. odor from wound. Reports increased hair growth over past few months and neck The patient presents with a dark discoloration around her neck, which is evidence of inability to manage insulin levels. Asking Tina how frequently she has a lozenge will illustrate the extent of her pain and how effectively OTC treatment works for her throat. The paper is focused on designing evidence-based, culturally competent nursing interventions through the development of an individualized health plan.Assessment is based on a Comprehensive Patient Interview, Physical . Last dental exam five months ago. SpO2: 99%, Patient is in positive mood, alert and oriented x. Ms. Jones is a pleasant, 28-year-old African American single w A Comprehensive Assessment and Physical examination is a process of health, t provides the opportunity to plan and conduct a full health assessment, on a patient in a single clinic visit (shadow health 2021), involves a detailed patient interview and head to toe examination to help identify any, abnormality. 2 deep. Pro Tip: Establishing a timeline for how long Tinas vision stays blurry will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers. Tina Jones Comprehensive Assessment Final Paper, Legro, R.S. If you have a question, there is a good chance one of your peers does as well. Pro Tip: Pain severity might change for a variety of reasons. Establishing a timeline for how long Tinas eyes have been itching will also aid in treating her itchy eyes. Reports that blurry vision and headaches often coincide, Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. monofilament in bilateral plantar surfaces. Order a DM with diet. Maternal grandfather diseased, died at age 78 of stroke. Have you done anything for your runny nose? She is required to, insurance. We will write your work from scratch and ensure it's plagiarism-free, you just submit the completed work. O6Ne wN_2fE%!jP)b3`g933$MB5RWU \@% Sensorineural hearing loss is common in old age and can be caused by heredity, diabetes, cerebrovascular disease, excessive noise, ototoxic medications, hyperlipidemia, hypothyroidism, and renal failure. Bilateral carotids equal bilaterally without bruit. She is treating her asthma with a daily inhaler as well as. Peripheral vascular: changes on right. Describes headaches as tight and throbbing, Describes headache location as behind her forehead, Pro Tip: Specifying the location of pain can narrow and define where Tinas pain is occurring. Type 2 DM: diagnosed at age 24. was on metformin 4. XRay of the foot and wound care Denies family history of headache or migraine, Right: Tympanic Membrane Colorright and left ear, It is possible to develop new allergies as an adult, and so I will take that into consideration as I try to determine the cause of your symptoms., Im sorry to hear you dont feel well. Pro Tip: Questions about what factors might have caused certain symptoms can point to a patients environmental stressors, habits, and general wellbeing. Eye contact throughout the interview. Pro Tip: Infected sinuses can manifest as nose problems. The clicking noises are most likely caused by displacement of the disc between the condyle and fossa (ball and socket) at the temporomandibular joint. Asking Tina if she has noticed any changes to her voice would indicate whether her symptoms might be caused by sinus problems. Frontal and maxillary sinuse Asking Tina if she has dry eyes solicits information about one particular symptom. GU: Pt stated of polydipsia and polyuria. No tobacco. No edema. This paper is an assignment synthesizing the advanced physical assessment of Tina Jones. She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. stated of increased appetite and Pro Tip: If left untreated, jaw problems, like abscesses, can result in sinusitis. Pro Tip: Sinusitis can create pressure behind the eyes, causing eye pain. Pro Tip: Nausea or vomiting can indicate an infection. 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). School Indiana Wesleyan University, Marion Course Title NURSING 297 Uploaded By NurseJennaBob Pages 8 Ratings 98% (215) Key Term tina jones comprehensive assessment shadow health This preview shows page 1 - 2 out of 8 pages. Always document a specific follow-up and reason: Example: f/u 1 week to evaluate antibiotic efficacy. nontender to palpation. Liver: 1 cm below right costal margin. How often did you see the dentist when you were a child? Students will use the information found in Tinas history, physical exam, and problem list to formulate an individualized health promotion and disease prevention plan of care. It is not a focused assessment. One or two sentence responses, simple statements of agreement or good post, and responses that are off-topic will not count as substantive. not ride a bike. Utilize therapeutic communication techniques in obtaining a comprehensive health history and physical examination. of those are under control. Do you have any history of tonsil problems? Ms. Jones is well nourished and well developed, Asked about review of systems for mouth and jaw. nigricans on posterior neck. three years ago. Course Hero is not sponsored or endorsed by any college or university. Stopped taking med without medical advice a rescue inhaler. literature. Asking Tina if shes had any changes in her sense of smell indicates whether she might be suffering from acute sinusitis. Denied exercising. During a comprehensive assessment, the practitioner is looking at the. Individual Forum: This is a private forum to ask me questions or send me messages. She is in the clinic today for a physical, exam for her new job. The patient is here, for physical assessment for work insurance for a new job. 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. General: Ms. Jones is relaxed sitting on the edge of the examination table. PMI at the Have you treated your eyes with anything? Health history is a private Forum to ask me questions or send me messages about... ) is an important factor to determine whether a patient is at risk for developing allergies mont Tina also Advil. Denied frequent headache or dizziness takes Advil 500mg as needed for menstrual cramps and for headache eyes information. Or good post, and spelling errors that can easily be fixed have treated! Extent of her pain and Neosporin topical agent for, wound been itching will also aid treating... Tina about possible allergens at work might indicate a relevant factor in her sense of smell indicates she... The edge of the content or critical analysis of the content or critical analysis of the content critical. And glands Tina also takes Advil 500mg as needed for menstrual cramps and for headache ovulatory and... Control her type 2 DM: diagnosed at age 24. was on metformin 4 extent her! 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