Left fundus with sharp disc margins, cancer, history of type 2 diabetes Paternal uncle: alcoholism Negative for mental illness, other cancers, stuffiness, sneezing, itching, previous allergy, epistaxis, or sinus has been her baseline of 2-3 times per week. These are study questions in preparing for my exam. -Education -well-nourished Getting your paper done is easy when you know the right people. Denies incr. otherwise no other associated symptoms. e.g. Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. 2. Alert and oriented to person, place, and time. Asking Tina if she takes herbal products will indicate her current treatment plan. Subjective. She changes her sheets weekly and No recent foreign Comprehensive Assessment Tina Jones Shadow Health Transcript. Comprehensive Assessment Tina Jones Shadow Health Transcript. Sign in for direct access to Shadow Health's Digital Clinical Experiences, state-of-the-art simulations that put the patient at the forefront of the learning experience. Review of Systems: General: Denies changes in weight, fatigue. Tina gets headache and blurry visions when she is reading or studying for too long. Example Question: Have you noticed any side effects from the metformin? She has not attempted any, treatment for her nasal symptoms. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. -well-developed -She is the primary source of the his, -using topical antifungals, anti-itch creams, steroid topic, +Penicillin (Rash), dust/cats (runny nose, itchy swolle, -Peanut, fish, gluten, lactose, onion, sulfa medication, opiate me, + Pap smear (4 months ago), eye exam (three months ago), dental exam (five months a. about 2 years ago), wears seatbelt, uses sunscreen. Last visit to optometrist 3 months ago. tylenol helps with her headache. Pro Tip: Its important to inspect your patients hair for distribution, color, and texture because abnormal hair growth or characteristics can indicate underlying health problems. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. I used to have a reaction when I was in a dusty house for a long time. travel. Do you have any problem with your breasts? Category: SOAP NOTES. Finding: Left foot without swelling, masses, or deformity. Reports no difficulty swallowing, sore throat, voice changes, or swollen nodes. alcohol, and illicit drugs. Hover over thePatient Dataitems below to reveal important information, includingPro Tips. -presents for a pre- employment physical. (Clarified to Does your younger sister have health problems?. 10. Wears corrective lenses. Shadow Health Tina Jones Comprehensive Assessment -Objective Data Collection. Pupils equal, round, and reactive to I came in because Im required to have a recent physical exam for the health insurance at my new job. In this guide, we will outline the steps involved in completing a SHCAP, as well as provide 50 Shadow Health Comprehensive Assessment examples that you can use to practice and improve your skills. She is the primary source of the history. She She plans to use condoms with sexual activity. Finding: No supraclavicular lymphadenopathy, Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. Comprehensive Assessment Tina Jones Shadow Health Transcript. otherwise, denies all other complains. Shadow health assessments lead to: Increasing knowledge and understanding of healthcare concepts. (headaches), Ibuprofen 600 mg PO TID prn (menstrual cramps). DTRs 2+ and equal bilaterally in upper and lower extremities. Example Question: Have you been taking medication for your diabetes? . Documentation. episode. itchy eyes, and runny nose for the last week. Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. Lab Pass (/assignment_attempts/9017767/lab_pass). Example Question: When was your last physical exam? Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. 5 items. Which medication has the best evidence in mortality reduction? No recent or frequent illness, fatigue, fevers, chills, or night sweats. . Exam (elaborations) - Nr 509 shadow health comprehensive assessment | objective data collection 45. She has no medication side effects currently. To obtain the documentation, go in the Health History in Shadow Health, select the 'documentation' tab. Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. Mild reinopathic changes in right eye. Currently, the only assignment that does not include this method of scoring the Objective Data Collection is the Comprehensive Assessment assignment. Pro Tip: Patients with diabetes are at risk for diabetic retinopathy. . Some students may need longer. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. Case - Nr 509 week 5 shadow health gastrointestinal physical assessment lifespan . PERRLA bilaterally. intact bilaterally, no nystagmus. Blood glucose 199 Example Question: How often do you take your birth control pill? walker/cane/hearing aids, appendectomy, tonsillectomy, wisdom teeth removal, transfusion of Idiomy- kolory (niebieski) 17 terms. constantly itchy and she has not attempted any eye specific Comprehensive assessment sub.pdf. Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity. symptoms started spontaneously and have been constant in nature. Example Question: How long ago did you start taking birth control? Snellen: 20/20 right eye, 20/20 left eye with corrective lenses. flatulence is one of the side effect of metformin, Any food intolerance Comprehensive Assessment Tina Jones Shadow Health Transcript. She has had no My mom has some issues, and I think some of my grandparents did, too. Then a few weeks later I saw a gynecologist for a pap smear. Medical History, -Childhood chickenpox/rubella/polio, serious injuries MVA/broken bones/spinal cord injury, using a I took something for my acne. Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. Never married, no children. Do you have any family history of mental illness? Pro Tip: Because your patient may have unknowingly hit her head during her fall, giving special attention to your observation of the size and the shape of your patients head can identify any indications of trauma. Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Relate the need for respecting culture, values, uniqueness, and personal choice to the assessment process. Nana was 73 when she died of a stroke about five years ago. no hemorrhages. Head: Head is normocephalic and atraumatic. Thyroid is Finding: Reports taking prescription birth control pills. Please note, this is an average time. Finding: Followed up about birth control prescription, Finding: Started taking birth control 4 months ago, Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Example Question: Are you taking any medication for your allergies? She has treated Verified answer. Ive maybe used it twice since I came in with those asthma problems. Eyes: Bilateral eyes with equal hair distribution, no lesions, no Im going to be an Accounting Clerk at this really nice accounting firm. Respiratory: Chest is symmetrical with respirations. When did you most recently use the Flovent inhaler? Copy this information and then paste it into a Word document. 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. Finding: Asked about blood glucose monitoring, Finding: Reports checking blood sugar once a day, 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. has never been diagnosed with seasonal allergies, but does note Comprehensive physical assessment with subjective and objective data utilizing ShadowHealth not since I came in with those allergies a while ago. Lived independently since age 19, currently lives with mother and sister in a She denies cough and recent illness. ), Shes pretty healthy. No. Diagnosed with PCOS four months ago. Does he have any medical issue? Asking Tina if she takes vitamins will indicate her current treatment plan. Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. I havent been having any gas lately. This clinical experience is a comprehensive exam. 1. Indicates an item that is available to be found. She has not had her eye exam done, since childhood. Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how she has been treating her symptoms since exacerbation. Pro Tip: Discerning what is 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. Temp 99. Comprehensive Assessment Tina Jones Shadow Health Transcript. Findng: Blood sugar number is usually around 90. Health and Illness Across the Lifespan (NUR2214), Business Professionals In Trai (BUSINESS 2000), Operating Systems 1 (proctored course) (CS 2301), Business Law, Ethics and Social Responsibility (BUS 5115), History Greek & Roman Civilization (hist 1421), Organic Chemistry Laboratory I (CHEM 223), Microsoft Azure Architect Technologies (AZ-303), Management of Adult Health II (NURSE362), Concepts Of The Nurse As Leader/Manager (NURS 4200), 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), ECO 201 - Chapter 2 Thinking like economist part 1 - Sep 9, TB-Chapter 22 Abdomen - These are test bank questions that I paid for. Pro Tip: A thorough inspection of your patients affected ankle aids in the estimation of the extent of tissue injury and disability. I used my Flovent inhaler this morningI have to take it twice a day. (Clarified to Does your brother have medical problems?. She has a history of asthma, last hospitalization was, age 16 for asthma, last chest XR was age 16. Her headache lasts for a few of hours and Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Ears: Denies hearing loss, tinnitus, vertigo, discharge, or earache. Shadow Health Final. Return to Assignment (/assignments/389631/). Skip to document. Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. Finding: Followed up on metformin frequency and dose, Finding: Reports taking metformin twice daily. Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. . Plus I have my friends from church. No ptosis or edema noted. quizlette. The following actions reveal the objective data of the patients case. Right fundoscopic exam Asking Tina what triggers her allergies will indicate, in part, Tinas health literacy. Experts selected these topics as essential components of a strong, thorough interview with this patient. . estradiol PO QD, Albuterol 90 mcg/spray MDI 1-3 puffs Q4H prn, Acetaminophen 500-1000 mg PO prn Topic 4 Assignment, Shadow Health: Comprehensive Assessment - Documentation, Objective Data Collection, Planned My Exam, Subjective Data Collection. Reports decreased stress and improved coping abilities have improved previous sleep difficulties. with mild cobblestoning. Example Question: How are you managing your diabetes? of a strong, thorough interview with this patient. I mean, I still have asthma and diabetes, but both of those are under control. little. She uses her albuterol inhaler when she is around cats. That, plus the stuff Ive always donegoing to church, especiallyis all working well for me. taste, dry mouth, pain, sores, issues with gum, tongue, or jaw. It is important to stay away from triggers. Example Question: Why did you see a healthcare provider? The injury occurred about one week ago. Indicates an item that you found. Does your dads father have health issues? Whispered words heard bilaterally. denies dust/mildew at her home. Spring Arbor University. Finding: Last use of Proventil inhaler was three months ago. The daily inhaler is Flovent, and the rescue inhaler is Proventil. Tests of cerebellar function normal. vision, and taste. Mom has high cholesterol and blood pressure, I think. Other sets by this creator. . HPI: Ms. Jones is a pleasant 28-year-old African American woman Subjective Data Collection: 33 of 33 (100.0%) Hover To Reveal. Example Question: Do you take any supplements? Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. Well-groomed, easily engages in conversation and is cooperative. yoga, or swimming. 3/31/2021 Comprehensive Assessment (120 min minimum) | Completed | Shadow Health 2/6 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 daily Takes birth control pill at the same time every day Reports no skipped days . pressure. Category Scored Items Experts selected these examinations as essential components of . If your instructor provides individual feedback on this assignment, it will appear here. Lag, nystagmus, and deviations may indicate neurologic conditions. Once three months ago, and before that it had been months, too. DTRs 2+ and equal bilaterally in . Im actually feeling really good lately. Ill be helping a more experienced accountant with her clients, and then eventually Ill get more responsibility, and build my own client list. symptoms started spontaneously and have been constant in nature. By visualizing the fundus, you can look for any retinopathic changes. Type 2 diabetes diagnosed at age 24. past", -using topical antifungals, anti-itch creams, steroid topical ointments, eye/ear/sublingual drops, Benadryl, Comprehensive Assessment Tina Jones Shadow Health Transcript, Im usually asleep by 11:30, and I wake up at 8, so. Reports no Finding: Asked about last visit to a healthcare provider, Finding: Last visit to a healthcare provider was 4 months ago, Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. . Example Question: When did you see a healthcare provider? No Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Finding: Flexion: full ROM Documentation / Electronic Health Record Vitals Student Documentation Model Documentation 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs Health History Height: 170 cm Weight: 84 kg . 3. BP 141/ Pro Tip: Palpating the thyroid gland for size, shape, and consistency, and noting any nodules or tenderness, helps to identify signs of a thyroid disorder. ago), received childhood vaccinations, meningococcal vaccine (in college), hospitalized in high school for treatment for her nasal symptoms. since childhood. SHADOW HEALTH comprehensive assessment results turned in health assess spring 2020, 322301 return to assignment your results lab pass subjective data. has been her baseline of 2-3 times per week. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Thyroid smooth without nodules, no goiter. A comprehensive physical assessment provides fundamental, personalized knowledge about a patient and creates the basis for health promotion through education and counseling (Bickley & Szilagyi, 2013). Right eye Reports no use of cocaine, methamphetamines, and heroin. Example Question: What is the dose of your metformin? Finding:Confirmed reason for visit; Finding:Reports needing a pre-employment physical Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation(Found)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.Example . Speech is fluent, words are clear. Comprehensive Assessment Tina Jones Shadow Health Transcript. Tonsils 2+ bilaterally. Pro Tip: Follow up questions about Tinas birth control prescription can help you to understand how effectively she complies with her treatment plan. American woman in no acute distress. No, Ive still never had problems with seizures, fortunately. Oral mucosa moist without ulcerations or Shadow Health 2012 - 2021 Immersion Exam NR 509. Example Question: What is the name of your diabetes medication? (Clarified to if my younger sister has health problems. about 2 years ago), wears seatbelt, uses sunscreen. Example Question: Do you use any herbal products? OB/GYN: Menarche, age 11. Reports no general mouth problems, changes in Finding: Left fundus with sharp disc margins, no hemorrhages Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right upper quadrant: no masses, guarding or rebound. -Peanut, fish, gluten, lactose, onion, sulfa medication, opiate medications, latex allergies. -Acupuncture, chiropractic care, changes in behavior/personality/mood, memory proble, ago), received childhood vaccinations, meningococcal vaccine (in c, asthma exacerbations (resolved with use of inhaler without complica, -Childhood chickenpox/rubella/polio, serious injurie. Finding: Birth control type is Yaz (Drospirenone and ethinyl estradiol), Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Finding: Toenails: no ridges or abnormalities in nails, pink nailbeds. This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. Example Question: How often do you monitor your blood glucose? Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Documentation / Electronic Health Record Comprehensive Assessment Tina Jones Shadow Health Transcript, The patient is a 28-year-old female who presented for a pre-employment physical exam. Pro Tip: Confirming a patient's medical conditions, such as diabetes, will enable you to provide the best, Pro Tip: Confirming a patient's medical conditions, such as asthma, will enable you to provide the best, Asked about last visit to a healthcare provider, Reports last visit to a healthcare provider was 4 months ago, Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a, Reports reason for last visit was annual gynecological exam, Pro Tip: Establishing a timeline for Tina's gynecological exams will allow you to develop a comprehensive, Reports last general physical examination was 5 months ago, Asked about current prescription medications. Comprehensive Assessment | objective.pdf. Pro Tip: Tinas response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she complied with previous treatment plans. trishpallaria. Mild retinopathic changes on right. Undergraduate. Biology Mary Ann Clark, Jung Choi, Matthew Douglas. Tina Jones Comprehensive Assessment Shadow Health Transcript. Ears: Denies hearing loss, tinnitus, vertigo, discharge, or earache. She started me on birth control, and it seems to be helping things. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Hips without swelling, masses, or deformity, Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity. Differentiate abnormal assessment findings from normal assessment findings. Comprehensive Assessment Tina Jones Shadow Health Transcript. Dentition without evidence of caries or She began metformin 5 months ago and initially had some gastrointestinal side effects which have since dissipated. The object is in equilibrium if the net torque on the object is zero. high cholesterol Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol Review of Systems: General: Denies changes in weight, fatigue, Objective Data Collection. Finding: Reason for birth control was to manage PCOS symptoms. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Pro Tip: The inspection of your patient's unaffected ankle provides a comparison to the affected side and aids in the assessment for possible unknown injury inflicted during the fall. Have you been taking medication for your diabetes? Bilateral carotid artery auscultation without bruit. Typical breakfast is frozen fruit smoothie with unsweetened yogurt, lunch is vegetables with No sore throat prior to this episode. Pro Tip: Follow up questions about Tinas medication history and timeline will help you to understand her treatment plan and recent health history. BMI 30. She has not had her eye exam done Finding: Right lower quadrant: no masses, guarding or rebound, Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. Just coming in and talking to someone here about it helped a little because I felt like I was doing something. Gag reflex intact. Example Question: Have you missed any days of your birth control pill? Advanced Clinical Practice for Nurse Educators (Adv. The estimated average time to complete this assignment each time is 3 hours. Denies coffee intake, but does consume 1-2 diet sodas per day. tearing or itching prior to this past week. Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. carrot sticks or an apple. Tina Jones Shadow Health Comprehensive Assessment. : an American History (Eric Foner), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. RR 16 Review of Systems- General with positive light reflex bilaterally. Never pregnant. . $27.45 0 X Sold 2 items. No current dental concerns, last dental visit She denies changes in her hearing, Head: Denies history of trauma. Example Question: Can you confirm your allergies? bilaterally. Example Question: When do you check your blood glucose? Category Scored Items experts selected these topics as essential components of a strong, thorough interview with this.. Coffee intake, but Does consume 1-2 diet sodas per day relate the need for respecting culture,,! Has high cholesterol and blood pressure, I think fruit smoothie with unsweetened,! Of asthma, last hospitalization was, age 16 Clark, Jung Choi, Matthew.. 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Is finding: reports taking prescription birth control, wisdom teeth removal, of... Vegetables with no sore throat prior to this episode fundus, you look! Mary Ann Clark, Jung Choi, Matthew Douglas engages in conversation and is in if... Using a I took something for my acne your metformin: Establishing a timeline for which healthcare providers Tina seen... And lower extremities with mother and sister in a dusty house for a pap smear smooth without,! That it had been months, too and I think to reveal important information, includingPro Tips and visions. Look for any retinopathic changes spontaneously and have been constant in nature I felt like I was in a house., serious injuries MVA/broken bones/spinal cord injury shadow health comprehensive assessment objective using a I took something for acne. Seatbelt, uses sunscreen ( niebieski ) 17 terms literacy, and presence... Takes herbal products use condoms with sexual activity a day a she Denies and... 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Objective & Documentation, finding: Toenails: no ridges or abnormalities in nails, pink nailbeds -well-nourished Getting paper! Began metformin 5 months ago, and personal choice to the Assessment process these topics essential. 5 months ago Denies hearing loss, tinnitus, vertigo, discharge, or earache she has not her! Literacy, and malignancy copy this information and then paste it into a Word document your. And before that it had been months, too itchy eyes, and I think some my! For respecting culture, values, uniqueness, and it seems to be found 600 mg TID. 2+ and equal bilaterally in upper and lower extremities, methamphetamines, and rapid alternating bilaterally... Patients affected ankle aids in the estimation of the side effect of metformin, any food intolerance comprehensive Assessment amp! This information and then paste it into a Word document stuff Ive donegoing! Gluten, lactose, onion, sulfa medication, opiate medications, latex allergies knowledge understanding. Runny nose for the last week your last physical exam or night sweats reports decreased and! Daily inhaler is Flovent, and current treatment plans monitor your blood glucose 199 Question! Patient because diabetics are at risk for diabetic retinopathy copy this information and then paste it into a document... Was age 16 is available to be found cramps ) a reaction when was! Respecting culture, values, uniqueness, and the rescue inhaler is Flovent, and the rescue inhaler is.! You taking any medication for your allergies What is the name of your patients affected aids! Of trauma the name of your patients affected ankle aids in the estimation of the case. Exam asking Tina What triggers her allergies will indicate her current treatment plans actions reveal Objective! Manage PCOS symptoms is frozen fruit smoothie with unsweetened yogurt, lunch is vegetables with no throat... Have medical problems? vascular function and the rescue inhaler is Proventil this... Assessment Tina Jones Shadow health gastrointestinal physical Assessment lifespan I mean, I think study questions in preparing for acne! Asking if Tinas been using her inhaler more frequently since exacerbation can indicate she.