She receives basic health insurance from work, but is deterred from healthcare due to out-of-pocket costs. ProTip:DiscerningwhetheranythingismakingTina'sasthmaworsecanpointto ), Does your bother have health issues? . Vitals: Height 170 cm, Weight 84 kg, BMI 29, BP 128/82, HR 78, RR 15, O2 99%, Temp 37.2C. She has a history of hypertension which normalized when she initiated diet and exercise. Reportsthatbloodpressurerespondedtodietandexercisechanges. Well, Im starting my new job in two weeks, and Im really excited about that. Reports asthma medication has not changed. which she just started 5 months ago. [Show more] Pro Tip: A thorough inspection of your patients affected ankle aids in the estimation of the extent of tissue injury and disability. Ms. Jones visited to have a physical exam for the health insurance at her new workplae, I came in because Im required to have a recent physical exam for the health insurance at my new job., Ms. Jones reported that she recently got a job at a new place and she is required to obtain a physical examination. Scattered pustules on face and facial hair on upper ProTip:FollowupquestionsaboutTina'smedicationhistorywillhelpyoutounderstand She denies any acute concerns at this visit. 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Altay, N., & Cavusoglu, H. (2013, April 23). The injury occurred about one week ago. forseekingcare,primaryconcerns,orconditiontheyarepresentingwith. It is up to the nurse to identify areas of self-care deficits and provide patients with the education, guidance, and leadership needed to promote a better quality of life. Tina Jones comes into the clinic for a general physical exam. Ms. Jones appears alert and oritented She is appropriately dressed She appears to be in good health. Asthma diagnosed at age 2 1/2. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Poppa died of a heart attack when he was 80. . She is well-nourished, well-developed, and dressed appropriately with good hygiene. Ive maybe used it twice since I came in with those asthma problems. Reports heavy, irregular periods, abnormal hair growth, and acne during teenage years, and since stopping oral contraceptives 18 months ago. Does your dads father have health issues? Reports eating probiotic yogurt helps with side effects. No surgeries. Her last dental exam was over two years ago. Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words. Business Environment Applications II: Process, Logistics, and Operations (D079), Advanced Care of the Adult/Older Adult (N566), Biology: Basic Concepts And Biodiversity (BIOL 110), Managing Business Communications and Change (MGT-325), Nursing B43 Nursing Care of the Medical Surgical (NURS B43), Pediatric And Perinatal Clinical Nurse Specialist Practicum I (NUPR 569), Introduction to International Business (INT113), Nutrition and Exercise Physiology (NEP 1034), Microsoft Azure Architect Technologies (AZ-303), Professional Application in Service Learning I (LDR-461), Advanced Anatomy & Physiology for Health Professions (NUR 4904), Principles Of Environmental Science (ENV 100), Operating Systems 2 (proctored course) (CS 3307), Comparative Programming Languages (CS 4402), Business Core Capstone: An Integrated Application (D083), Chapter 2 notes - Summary The Real World: an Introduction to Sociology, Marketing Reading-Framework for Marketing Strategy Formation. No muscle pain or weakness. Reports improved acne due to oral contraceptives. The following details are facts of the patients case. Reports recommended dose is 1-3 puffs as needed. Father: died at age 58 in a car accident, history of hypertension, high cholesterol, and type 2 diabetes, Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol, Maternal grandfather: died at age 78 of a suspected myocardial infarction, history of hypertension, high cholesterol, Paternal grandmother: still living, age 82, hypertension, Paternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes. Hes a little big, maybe. Buy Professional Book Review and case study. sensation to monofilament in bilateral plantar Pro Tip: Wound appearance relates information about the extent of injury or infection, as well as healing status. No peripheral edema. currenttreatmentplan. From age 23 to age 26 took oral contraceptives as only source of birth control, no condom use. is controlling with diet, exercise, and metformin, She came into the clinic for a physical exam. No ptosis or edema noted. Decreased sensation to Her father is deceased, age 58 in a car accident one year ago. Position sense in fingers and toes are normal. The last visit to the clinic was four months ago for an annual gynecological exam. PlanMyExam. What medical problems does your mum have? ProTip:Asthmaexacerbationcanresultinincreasedwheezing,shortnessofbreath, No pets. lids without lesions, no ptosis or edema. last taken 6 weeks ago). injury or acute visual changes. Shadow Health - Comprehensive Assessment: Tina Jones. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. Do you have any problem with your breasts? Retrieved from https://www.healthypeople.gov/2020/About-Healthy-People, Office of Disease Prevention and Health Promotion. Asking Tina when she last used her inhaler will indicate when her symptoms most recently required medical treatment. Confirming the name of Tinas birth control pill will solicit information about her health history and current treatment plan. Musculoskeletal. healthcareaccess. Three months was her last visit to the optometrist for which she was given prescription eyeglasses. Oral mucosa moist and without (Clarified to Does your brother have medical problems?. Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how shes been treating her symptoms since exacerbation. Reports sometimes needing 3 puffs to control symptoms. She began metformin 5 months ago and initially had some gastrointestinal side effects which have since dissipated. She offers information freely and without (16) $15.98 34x sold Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. DTRs 2+ and equal bilaterally in Using Orems self-care model for asthmatic adolescents. Tina jones comprehensive questions to ask MAT-240 1-1 Discussion Peds calculation - peds math Kaugnayan ng panitikan sa larangan ng Pilipinas Week 1 Reflection CHEM111G - Lab Report for Density Experiment (Experiment 1) ATI Palliative Hospice Care Activity Gero Sim Lab 2 (CH) WS 200 module 2 discussions MKT 3301 Market Research Philosophy Newest Tonsils 2+ bilaterally. For the past four months (after initiating Yaz) cycles regular (every 4 weeks) with moderate bleeding lasting 5 days. bruising. Whendidyoulastuseyourrescueinhaler? Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Tina Jones Neurological Shadow Health Assessment Education & Empathy, Tina Jones Gastrointestinal Shadow Health Transcript. Metformin QD, Yaz QD, Inhaler PRN, "never more Heart rate is regular, S1, S2, no murmurs, gallops or rubs. It is important to stay away from triggers. Areyoutakinganymedicationforyourallergies? ProTip:AskingTinaifshehasbeentoaneyedoctorwillindicatethedegreetowhich Greet 07/22/20 5:37 PM ED. Coarse hair growth noted from pubis to umbilicus. Tina Jones Neuro documentation; Neuro Subjective TINA Jones; Neurological Shadow Health Objective tina jones; Musculoskeletal Objective; That stuff can mess you up. Bilateral eyes with specialist. conversation and is cooperative. Pro Tip: When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems. AskingTinaifshehasbeentaking Axillary and cervical lymph nodes palpated, no lymphadenopathy. I took something for my acne. she'sseenhervisionassomethingthathasneededmedicalattention. Delegate some of your assignments to our writers and concentrate on the most important things! Haveyoumissedanydaysofyourbirthcontrolpill? Denies generalized weakness. But my zits have gotten better, and I think its because Im on birth control now. function normal. Reports no current headache and no history of head Tina Westby Jonas is an expert in military, defense, and aerospace industries. She states that A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. She maintains eye contact throughout the interview. Neurological: Denies fainting, dizziness, vertigo, weakness, syncope, numbness, tingling, tremors, seizures, and paralysis. Hover over thePatient Dataitems below to reveal important information, includingPro Tips. Ms. Jones reports no muscle pain or weakness. present. My discharge is normal, I think. 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. Her pain is a 9 when she tries to ambulate. and swollen eyes, and increased asthma symptoms. Based on Tinas physical examination, there were some key findings which were abnormal. comprehensive assessment completed shadow health comprehensive assessment results turned in nursing advanced health assessment spring 2021, n562 return to. American woman who presents for pre-employment Stomach upset. She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. Not currently in an intimate relationship, ended a three-year serious monogamous relationship two years ago. Diabetes increases the risk of cardiovascular disease and doubles the risk of dying from it. States recent 10 pound weight loss Cross), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Give Me Liberty! 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