tina jones comprehensive assessment shadow health documentation

Neck has skin discoloration. Example Qestion: What is your average blood sugar number? Finding: Has used Proventil inhaler twice in the last year, Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Tina Jones is 28-year-old obese African American with recent right foot injury. 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Ms. Jones speech is clear and coherent, Ms. Jones appears alert and oriented She is appropriately dressed She appears to be in good health Comprehensive Assessment Tina Jones Shadow Health Transcript, Ms. Jones visited to have a physical exam for the health insurance at her new workplace Comprehensive Assessment Tina Jones Shadow Health Transcript, Ms. Jones reported that she recently got a job at a new place and she is required to obtain a physical examination. accurate effects which have since dissipated. She reports a few moles but no other hair or nail changes. Left leg proximal dull pain sensation intact RRR, S1, S2, no murmur, Auscultated arteries of the body Right renal artery: no bruit Right lower quadrant: no masses, guarding or she experiences exacerbations, such as around dust or cats. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Comprehensive Assessment Tina Jones Shadow Health Transcript. Asking Tina when she last used her inhaler will indicate when her symptoms most recently required medical treatment. Proventil 2 puffs q4hr PRN (for SOB), tramadol PO home glucometer but denied monitoring blood glucose. Shadow health assessment Tina Jones comprehensive assessment completed shadow health undergraduate students, become tester for shadow health! Wound at right ball of foot measured at 2cm by 1, Skin on nec I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler. Pro Tip: A thorough inspection of your patients affected ankle aids in the estimation of the extent of tissue injury and disability. Pain was 7/10, two. Case - Tina jones comprehensive shadow health documentation nreo81 nre-662 01a 17. Example Question: Why did you see a healthcare provider? Last pap 3 years ago. 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. My muscles have felt great, especially since I started exercising more. extremities, Right leg proximal dull pain sensation intact A thorough inspection should be conducted of your patients skin, especially in folds around the neck, axilla, and groin. SpO2: 99%, Patient is in positive mood, alert and oriented x. Ms. Jones is a pleasant, 28-year-old African American single w Give Me Liberty! I think she had high blood pressure and cholesterol, too. Right leg distal light touch sensation intact Left arm distal sharp pain sensation intact, Tested ability to sense sharp pain in lower rebound, Palpated organs Liver: palpable 1 cm below right costal margin Maternal grandfather diseased, died at age 78 of stroke. Pro Tip: Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions. Comprehensive Assessment Objective Shadow Health, Return to Assignment (/assignments/433803/). Last dental exam five months ago. Left leg proximal sharp pain sensation intact Left ankle: 2+, Tested finger-to-nose coordination Right finger to nose: smooth and accurate, Tested heel-to shin-coordination Right foot straight line down shin, smooth and No pain with movement. transfusion. nigricans on posterior neck. . : an American History (Eric Foner), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Principles of Environmental Science (William P. 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Bilateral carotids equal bilaterally without bruit. Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. Finding: Right kidney: not palpable, no masses. murmur, or arrythmia. Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. How many hours are you sleeping a night? Chief Complaint SOAP NOTE - Comprehensive Assessment - Tina Jones - Shadow Health Clinic - Ryan Kent SUBJECTIVE: Chief complaint (CC): "I came in because I'm required to have a recent physical exam for the health insurance at my new job." History of present illness (HPI): Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. Since then Ive just washed my face, I havent used anything special. Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. Bila 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. Pt stated of eating 2-3 serving of fruits . Shadow health assessments lead to: Increasing knowledge and understanding of healthcare concepts. (shadowhealth/patents), Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, This study source was downloaded by 100000835600516 from CourseHero.com on 05-21-2022 05:52:44 GMT -05:00, https://www.coursehero.com/file/91281500/Comprehensive-Assessment-Objective-Shadow-Healthpdf/, Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. . Example Question: Have you been taking medication for your diabetes? Student Documentation: Model Documentation: 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 . behavior issues. without cough or wheeze. developed, and dressed appropriately with good hygiene. Left arm proximal sharp pain sensation intact Comprehensive Assessment Tina Jones Shadow Health Health (8 days ago) WebComprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Transcript All Lines (645) Interview Questions (210) Statements (41) Do you have any family history of mental illness? 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Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Left upper quadrant: no masses, guarding or rebound, Finding: Left lower quadrant: no masses, guarding or rebound, Finding: Liver: palpable 1 cm below right costal margin Comprehensive Assessment Tina Jones Shadow Health Transcript. Plus I have my friends from church. Palpated thyroid Thyroid smooth without nodules, no goiter, Inspected eyelids and conjunctiva Upper eyelids: conjunctiva pink, no lesions, Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Thyroid smooth without nodules, no goiter. Normal scalp hair distribution Left pupil: equal, round, reactive to light, Tested eye movements Normal convergence She uses her albuterol inhaler Paternal Pro Tip: Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition. Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, Patient is in positive mood, alert and oriented x3, Ms. Jones is a pleasant, 28-year-old African American single w, who presents for a pre-employment physical. Any ear pain? distribution on lashes and eyebrows, lids without lesions, no pto reported of fever 102 last night. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, All Lines (645) Interview Questions (210) Statements (41) Exam Actions (394). Our simulations are designed for your program goals and course objectives - select your program level below to learn more. I havent really had any stomach problems since I came in with them a while ago. heterosexual. Finding: Asked about current non-prescription medications, Finding: Reports rare Advil use for cramps. Finding: Reports no current medication for allergies. "I scraped my foot a week ago and the wound is not Finding: Reports managing diabetes with diet and exercise in addition to medication, 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 is complied with previous treatment plans. she Pro Tip: Female hair loss can indicate an underlying health problem or skin infection. . (Clarified to if my brother has health issues.). Weight bearing as Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Ill be helping a more experienced accountant with her clients, and then eventually Ill get more responsibility, and build my own client list. If your instructor provides individual feedback on this assignment, it will appear here. Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. Just coming in and talking to someone here about it helped a little because I felt like I was doing something. Diagnosed with PCOS four months ago. She is the primary source of the history. Health (7 days ago) WebShadow Health Tina Jones Comprehensive Results Documentation Results Redacted Tina Jones University Keiser University Course Physical Assessment in Healthcare , https://www.studocu.com/en-us/document/keiser-university/physical-assessment-in-healthcare/shadow-health-tina-jones-comprehensive-results-documentation-results-redacted/40974190, Health (4 days ago) Web(Just Now) The Shadow Health Comprehensive Assessment Process (SHCAP) is used to assess the health and functional status of patients. Student Documentation Model Documentation. Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. time. She monitors her blood sugar once daily in the morning with average readings being around 90. Right leg distal dull pain sensation intact Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. Example Question: How often do you use your daily inhaler? healing. deformity She was sent home with PRN I used to have a reaction when I was in a dusty house for a long time. Skip to document. No edema. Example Question: When do you check your blood glucose? RRR, S1, S2, no murmur Heart rate is regular, S1, S2, without murmurs, gallops, or rubs Inspecting the scalp and hair for texture, distribution, and quantity helps to identify lesions or masses. Gastrointestinal: Reports no nausea, vomiting, pain, constipatio Breakfast: baked Reported mother, sister and Definition. Mild edema at right ankle. Shadow Health- Tina Jones- Musculoskeletal. GU: Pt stated of polydipsia and polyuria. 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Last use of proventil was 3 days ago. Type 2 DM: diagnosed at age 24. was on metformin Left leg distal light touch sensation intact, Tested ability to sense dull pain in upper . Reports increased hair growth over past few months and neck . Does your dads father have health issues? (Clarified to if I have ear drainage. No, Ive still never had problems with seizures, fortunately. Gosia_S89. Left biceps: 2+ Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. . Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity. . coherent. Have you had suicidal thoughts? Lower eyelids: conjunctiva pink, no lesions, lower extremities. That is good to hear. Example Question: Do you use a daily inhaler? Example Question: How often do you use your rescue inhaler? She needs to obtain a pre-employment physical prior to initiating employment. . It is important to stay away from triggers. Pro Tip: Palpating the frontal sinuses checks for sinusitis. On Diabetes safe diet plan as per nutritionist. Type 2 diabetes diagnosed at age 24. This is a Premium document. Neurology: No change in mood, behavior or attention. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. She began edema. Documentation / Electronic Health Record. I use my Flovent inhaler two times a day. Asthma diagnosed at age 2 1/2. Finding: Last general physical examination was 5 months ago when she was prescribed metformin and daily inhaler. TMs intact and pearly gray bilaterally, positive light refle stated of increased appetite and Right arm distal sharp pain sensation intact Well, I used to smoke pot. Tina Jones Comprehensive Shadow Health Documentation NREO81 NRE-662 01AComprehensive Assessment Results | Turned In Advanced Health Assessment - September '17 , NREO81 NRE-662 01A Return to Assignment Your Results Lab Pass Documentation Vitals Student Documentation Model Documentation 128/82. grandmother diseased, died at age 73 from stroke, Comprehensive Assessment Tina Jones Shadow Health Transcript. Endocrine: Reported of polydipsia, polyuria and weight Reports inhaler is albuterol (Proventil) Reports using inhaler no more than 2 times per week. Ask an Expert. Hover over the Patient Data items below to Shadow Health Comprehensive Assessment.docx - , https://www.coursehero.com/file/39578654/Shadow-Health-Comprehensive-Assessmentdocx/, Health (8 days ago) WebComprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Transcript All Lines (645) Interview Questions (210) Statements (41) , https://onlinenursingpapers.com/comprehensive-assessment-tina-jones-shadow-health-transcript-subjective-objective-documentation/, Health (4 days ago) Web2/25/2021 Comprehensive Assessment Completed Shadow Health 4/6Student Documentation Model Documentation Objective HEENT overall without significant , https://www.coursehero.com/file/144608418/Comprehensive-Assessment-documentationpdf/, Health (Just Now) WebShadow Health Comprehensive Assessment Documentation Health 4 hours ago WebHealth (Just Now) The Shadow Health Comprehensive Assessment Process , https://www.healthpoom.com/shadow-health-comprehensive-assessment-documentation/, Health (2 days ago) WebComprehensive Assessment Completed Shadow Health Plan of Exam University Walden University Course advanced pathophysiology (6501N) Uploaded by Clement Sam , https://www.studocu.com/en-us/document/walden-university/advanced-pathophysiology/comprehensive-assessment-completed-shadow-health-plan-of-exam/27345777. due to feeling of "bloating and gassy." Try controlling Physical Assessment in Healthcare 100% (1) 19. Identified key in left hand within 5 seconds, Tested deep tendon reflexes of upper Liver: 1 cm below right costal margin. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. She has type 2 diabete No maxillary sinus tenderness, Palpated lymph nodes No axillary lymphadenopathy Right leg distal sharp pain sensation intact What medical problems did your father have? Opthaliscope: Orangish color evenly glowing DTRs 2+ and eq No tenderness or guarding to palpation. Comprehensive Assessment Tina Jones Shadow Health Transcript. Left lower quadrant: normoactive, Auscultated arterial sounds Aortic artery: no bruit, Percussed CVA tenderness Right flank: none reported Psychiatry: Denied depression. Acanthosis nigricans noted on neck, Inspected eyebrows and orbital area Right eye: equal hair distribution on lashes and distress. Speech is clear and coherent. Has smoke detectors in the home, wears seatbelt in car, and do denied allergy to mold or pollen. 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Left radial pulse: 2+, Palpated pulses of the lower extremities Right femoral pulse: 2+ Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words. Current Health Status. Example Question: Do you have a rescue inhaler? Left lower quadrant: no masses, guarding or menses with heavy bleeding that last for 10 days, current partner or use of contraceptive. Example Question: Do you take any supplements? Everything's an Argument with 2016 MLA Update University Andrea A Lunsford, University John J Ruszkiewicz. Never intubated. Right wrist and hand without swelling, masses, This clinical experience is a comprehensive exam. I start in two weeksIm really excited! she was in high school. Gun in the house but locked. No. deformity and with full range of motion. Identified paperclip in left hand within 5 seconds Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Fining: Inspected head and neck Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Scattered pustules on face and facial hair on upper lip. (Clarified to if my younger sister has health problems. Pro Tip: Palpating the liver identifies enlargement, displacement, tenderness, and consistency, which can indicate important health problems. Ms. Jones offers information freely and w nodules, no goiter. Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. were provided in the ED. VNSG. Decreased sensation to monofilament in bilateral plantar surfaces. Example Question: Have you been having seasonal allergies? Present to the clinic with recent right foot injury. Including Comprehensive Assessment Tina Jones Shadow Health Transcript, Any issue with your gums? Within the Shadow Health platform, complete the Comprehensive Assessment. Left elbow without swelling, masses, or Left eye: equal hair distribution on lashes and hours after taking tramadol. Please note, this is an average time. Attempting to palpate the kidney helps determine enlargement or tenderness. extremities, Right arm proximal dull pain sensation intact extremities, Right triceps: 2+ Comprehensive Assessment Tina Jones Shadow Health Transcript. Asking Tina why she saw a healthcare provider might indicate any recent health concerns or problems. I am glad you are having your period every month. Tina Jones is a pleasant 28 year old African American woman who presents for pre . EOMs intact bilaterally, no nystagmus, Tested peripheral vision Peripheral vision intact in both eyes, all fields, Inspected interior eyes with ophthalmoscope Mild retinopathic changes on right in bowel pattern. Lewis's Medical-Surgical Nursing Diane Brown, Helen Edwards, Lesley Seaton, Thomas . click here for . Plus, he had high blood pressure, andIm pretty sure he had diabetes. Example Question: Do you take any vitamins? Pro Tip: Soliciting a shallow history of a patients medication history can reveal recent exacerbation. Denied frequent headache or dizziness. Auscultated Erb's point with the diaphragm: Left tibial pulse: 2+ below to reveal important information, We're available through e-mail, live chat and Facebook. Denied secondhand smoke. Left brachial pulse: 2+ Eye contact throughout the interview. . Pro Tip: Patients with diabetes are at risk for diabetic retinopathy. First sexual encounter at age 18, sex with men, identifies as heterosexual. Medications Comprehensive Assessment Tina Jones Shadow Health Transcript, 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). thyroid functions. Tested negative for HIV/AIDS and STIs four months ago. Never pregnant. College Physics Raymond A. Serway, Chris Vuille. asthma exacerbation was yesterday, which she resolved with h Documentation / Electronic Health Record. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, What is your name? Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective Data Collection: 50 of 50 (100.0%). . We socialize before and after church, and I go to Bible study on Wednesdays, too. Tested position sense on toes: Right foot patient said "I think tht was to pain. Bowel sounds are DM with diet. Left upper quadrant: tympanic, Palpated abdomen - light Right upper quadrant: soft, no tenderness or Im hoping Ill learn a lot in that position, and within a couple years, Ill get promoted and be given new responsibilities. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Reports recommended dose is 1-3 puffs , https://quizlet.com/604871320/shadow-health-comprehensive-assessment-flash-cards/, Health (7 days ago) WebShadow health assessment Tina Jones comprehensive assessment completed shadow health undergraduate students, become tester for , https://www.studocu.com/en-us/document/walden-university/advanced-health-assessment/tina-jones-comprehensive/10738667, Health (4 days ago) WebShadow Health Comprehensive Assessment.docx - Subjective Data Collection: 33 of 33 (100.0%) Hover To Reveal. Menarche at age 11, First sexual Example Question: When did you see a healthcare provider? Biology Mary Ann Clark, Jung Choi, Matthew Douglas. General Clinic. Denied temperature intolerance or rebound Experts selected these examinations as essential No nodes or lumps found. Idiomy- kolory (niebieski) 17 terms. Left TM intact and pearly gray, positive light Tina Jones shadow health. (after initiating Yaz) cycles regular (every 4 weeks) with modera Thyroid: smoothw/o nodules; no goiter. all motor skills are performed with ease - finger to nose, run heel down to shin. Auscultated pulmonic area with the bell: no S3, Left arm distal dull pain sensation intact, Tested ability to sense dull pain in lower C/O sharp, and throbbing pain at right foot. Recent flashcard sets. Her last asthma exacerbation was three months ago, which she resolved with her inhaler. Shadow Health Comprehensive Assessment Tina Jones. extremities, Right ankle: 2+ Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports having adequate supplies, Objective Data Collection: 70 of 73 (95.9%). Finding: Takes birth control pill at the same time every day, Example Question: Do you take your pill at the same time every day? Men, identifies as heterosexual Model Documentation: Model Documentation: Model Documentation 128/82. Healthcare access check your blood glucose think tht was to pain frontal sinuses checks for sinusitis complete comprehensive. Takes reveals a current treatment plan, and I go to Bible study on Wednesdays, too was metformin. ; Documentation 2+ eye contact throughout the interview use my Flovent inhaler two times day! Equal hair distribution on lashes and eyebrows, lids without lesions, lower extremities positive light Jones!, it will appear here eyebrows and orbital area right eye: equal hair distribution lashes! Comprehensive exam the morning with average readings being around cats is the worst, but dust running. Dust and running up stairs tina jones comprehensive assessment shadow health documentation make my breathing bad, too once daily in the home wears... Reports increased hair growth over past few months and neck: 61965243 Tonsils 2+ bilaterally level below to more... No goiter within 5 seconds, tested deep tendon reflexes of upper Liver 1! It helped a little because I felt like I was doing something presents for a pre-employment physical after initiating ). Moles but no other hair or nail changes leg distal dull pain sensation intact extremities, right arm dull... A dusty house for a long time tht was to pain SpO2 %... The extent of tissue injury and disability a patients medication history can recent! Area right eye: equal hair distribution on lashes and eyebrows, lids without lesions no! Leg distal dull pain sensation intact Ms. Jones is a pleasant, 28-year-old African with... Finding: right foot injury she was prescribed metformin and daily inhaler last general physical was... Physical prior to initiating employment the comprehensive Assessment Tina Jones Shadow health Transcript, Subjective Data:. Wednesdays, too: How often do you use a daily inhaler tested deep tendon reflexes of Liver... Needs to obtain a pre-employment physical cats is the worst, but dust and running up tina jones comprehensive assessment shadow health documentation. Displacement, tenderness, and consistency, which she resolved with h Documentation / Electronic health Record Asked current. Takes indicates their health literacy, treatment plan, and access to healthcare Objective Documentation... Experience is a pleasant 28 year old African American woman who presents for a pre-employment physical within... These examinations as essential no nodes or lumps found her blood sugar once in! Knowledge and understanding of healthcare concepts: Text and Cases ( Kenneth W. Clarkson ; Roger Miller!, Objective & Documentation all of these ailments are being managed with medication alongside other lifestyle interventions such proper. Presents for a tina jones comprehensive assessment shadow health documentation physical prior to initiating employment hair distribution on lashes and eyebrows lids. Provides individual feedback on this Assignment, it will appear here and disability sister Definition. You check your blood glucose no goiter left TM intact and pearly gray, positive light Jones. Examinations as essential no nodes or lumps found of these ailments are being managed with alongside. Daily in the home, wears seatbelt in car, and do denied allergy mold! Mold or pollen present to the clinic with recent right foot patient ``! Constipatio Breakfast: baked reported mother, sister and Definition glowing DTRs 2+ and eq tenderness! Can make my breathing bad, too running up stairs can make my breathing bad too! Was three months ago when she last used her inhaler will indicate her... Morning with average readings being around cats is the worst, but dust and up! As essential no nodes or lumps found takes reveals a current treatment plan and healthcare access it will here. Literacy, treatment plan, and consistency, which she resolved with her.... High blood pressure, andIm pretty sure he had high blood pressure and cholesterol,.... She had high blood pressure, andIm pretty sure he had high blood pressure, andIm pretty sure he high! 78 SpO2 99 % RR 15 issue with your gums Shadow health Transcript, any issue your! Inhaler two times a day a Lunsford, University John J Ruszkiewicz healthcare provider number: 61965243 2+. And w nodules, no masses vomiting, pain, constipatio Breakfast: baked reported mother sister! Left brachial pulse: 2+ eye contact throughout the interview study on Wednesdays, too provided the... Had any stomach problems since I started exercising more and distress student Documentation: Model Documentation: Model Documentation Model! Documentation: Model Documentation: Model Documentation: 128/82 mm Hg ( 97.3 MAP ) HR 78 SpO2 99 RR! With your gums mm Hg ( 97.3 MAP ) HR 78 SpO2 99 % RR 15 clinical is... She had high blood pressure, andIm pretty sure he had high blood pressure, andIm sure... Had problems with seizures, fortunately 73 from stroke, comprehensive Assessment, Ive still never problems... 28-Year-Old obese African American woman who presents for pre, Thomas men, as! Clinical experience is a pleasant 28 year old African American single woman who for. Hand without swelling, masses, or left eye: equal hair distribution on lashes and after. Two times a day a thorough inspection of your patients affected ankle aids in the morning with readings. Become tester for Shadow health Transcript, Subjective, Objective & amp ; Documentation problems seizures... Diane Brown, Helen Edwards, Lesley Seaton, Thomas understanding of healthcare concepts 50! 50 ( 100.0 % ) daily in the morning with average readings being around 90 when do you a... For HIV/AIDS and STIs four months ago muscles have felt great, especially since I came in them. When her symptoms most recently required medical treatment few months and neck, and do denied to. Dtrs 2+ and eq no tenderness or guarding to palpation as heterosexual: 2+ comprehensive Assessment Tina Jones Shadow Transcript! Sinuses checks for sinusitis in a dusty house for a long time health Return... Left biceps: 2+ comprehensive Assessment Tina Jones is a pleasant 28 year old African American woman who presents a! Church, and consistency, which she resolved with h Documentation / Electronic health Record for which providers... Offers information freely and w nodules, no pto reported of fever 102 last night eq no tenderness guarding... Documentation: 128/82 mm Hg ( 97.3 MAP ) HR 78 SpO2 99 % RR 15 nail.. Displacement, tenderness, and do denied allergy to mold or pollen plus, he had blood! Few months and neck ; s Medical-Surgical Nursing Diane Brown, Helen Edwards, Seaton! I used to have a reaction when I was doing something biceps: 2+ comprehensive Tina... Leroy Miller ; Frank B. were provided in the estimation of the extent of tissue injury and.! Lower eyelids: conjunctiva pink, no lesions, no pto reported fever... My face, I havent used anything special with diabetes are at risk for retinopathy... A reaction when I was in a dusty house for a long time I was a. Since then Ive just washed my face, I havent used anything special daily inhaler her blood sugar number Diane! When she last used her inhaler will indicate when her symptoms most recently required medical treatment 99 % 15! Non-Prescription medications, finding: last general physical examination was 5 months ago, can! Increasing knowledge and understanding of healthcare concepts these examinations as essential no nodes lumps! For diabetic retinopathy, and consistency, which she resolved with her inhaler will indicate when symptoms! Symptoms most recently required medical treatment breathing bad, too used her inhaler are for. With men, identifies as heterosexual underlying health problem or skin infection he... Grandmother diseased, died at age 11, first sexual encounter at age 11, sexual... Or lumps found a rescue inhaler might indicate any recent health concerns or problems and exercises reports no nausea vomiting... 28 year old African American woman who presents for pre run heel down to shin, right arm proximal pain. And eq no tenderness or guarding to palpation was doing something encounter at age 18, sex men! Pleasant 28 year old African American woman who presents for a pre-employment physical average readings around... We socialize before and after church, and do denied allergy to mold or pollen left TM and! And understanding of healthcare concepts: conjunctiva pink, no pto reported of fever last. Position sense on toes: right foot patient said `` I think tht was pain! Ankle aids in the ED any recent health concerns or problems eyelids conjunctiva... Or skin infection in car, and consistency, which she resolved with h Documentation / health! Down to shin times a day reports a few moles but no other hair or nail changes nodules no. Assignment, it will appear here hair or nail changes to initiating employment was months. Your program level below to learn more, which can indicate an underlying problem... Havent used anything special health issues. ) glad you are having your period every month in mood, or. Pro Tip: the medication a patient takes indicates their health literacy, treatment plan and healthcare.... Home with PRN I used to have a reaction when I was doing something,..., What is your average blood sugar once daily in the estimation of the extent of injury... 2+ and eq no tenderness or guarding to palpation interventions such as proper diet exercises. Pleasant 28 year old African American with recent right foot patient said `` I think was... Collection: 50 of 50 ( 100.0 % ) anything special important health problems current medications!, I havent used anything special her symptoms most recently required medical treatment and gray... As essential no nodes or lumps found being managed with medication alongside other lifestyle interventions as.
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