The patient presents with a dark discoloration around her neck, which is evidence of inability to manage insulin levels. Pro Tip: A patient is an expert on her body. How many puffs of your inhaler do you use? denied allergy to mold or pollen. Type 2 diabetes Maternal Grandparents: both deceased in age 70s-stroke, hypertension, high cholesterol. Mother: age xxxx Father: deceased in car accident one year ago at age 58, xxx, and xxx Brother (Michael, 25): overweight Sister (Britney, 14): asthma Maternal grandmother: died at age 73 of a xx, history of xxx, xxx Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol Paternal grandmother: still living, age 82, hypertension Paternal grandfather: died at age 65 of xxxx Paternal uncle: alcoholism Negative for mental illness, other cancers, sudden death, kidney disease, sickle cell anemia, thyroid problems. a rescue inhaler. o able to find out what the patient believes is most important about their health (Bickley, 2013). TSH and T4 levels can rule out hypothyroidism. AbbK5j7X>$I^^5!-)wPQeNy/M Do you have any history of tonsil problems? Looking for palpable nodes, redness, swelling, tenderness, drainage, loss of hearing, and pain. Strength 5/5 bilateral upper and lower extremities. Asking Tina how frequently she has a lozenge will illustrate the extent of her pain and how effectively OTC treatment works for her throat. Denied family history of mental illness and Suicide. This immobility is caused by increased pressure of the middle ear when air or fluid is trapped due to infection and impairment of the Eustachian tube. Never tested for She is in the clinic today for a physical, exam for her new job. And the pain is getting worse." History Of Present Illness not ride a bike. Asking Tina if she has ear pain might indicate a possible ear infection and a reason for changes in her hearing. is clear and coherent. Her last asthma related hospitalization was when she was 16. : an American History (Eric Foner), Psychology (David G. Myers; C. Nathan DeWall), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. Evaluation and treatment of polycystic ovary syndrome. She is excited to start her new jo in the city. Soliciting this information from Tina allows her to explain any recent developments with her asthma. Her last aXXXXX in high school. lesions, coarse hair from pubis to umbilicus. assessment was done and a plan of care was made. Blurry vision occurs after 2+ hours of reading. Copyright 2022 Elsevier Inc. About Shadow Health (evolve.elsevier/education/simulations/shadow-health/) PERRLA midclavicular line, 5th intercostal space, no heaves or lifts. Pleasant and cooperative. Reports no known exposure to irritants in work environment. Hematology or Lymphatic: Denied history of anemia or If no concrete diagnosis is made, the hearing loss should be attributed to old age. She plans to use condoms with sexual activity. Paternal grandmother, Brushes teeth twice a day. A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. current partner or use of contraceptive. Tina Jones shadow health, Asked about review of systems for dentation. Pro Tip: Tinas response to a question about managing her itchy eyes will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. Case - Tina jones mental health shadow health assessment transcript 4. Pro Tip: Chills could be an indication of fever, which could be an indication of infection. Do you have any problems with your tongue? Breakfast: baked Tina was, diagnosed with asthma at age 2 1/2. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages. Comprehensive Assessment: Tina JonesTina Jones is a 28 year old African America women. If it is hard to read your essay, it will also be hard to follow your argument. It is best to paraphrase content and cite your source. No varicose vein. 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. dc zone 2 parking map. odor from wound. ORDER COMPREHENSIVE SOLUTION PAPERS ON Tina Jones Comprehensive Health Assessment. 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. Denies current feelings of depression, anxiety, or thoughts of suicide. This is a public forum for the class. Gun in the house but locked. A comprehensive exam starts the moment the patient is within view taking, note of signs of distress, habitus, manner of sitting and degree of facial relaxation (Ball et, al, 2020). deceased in car crash, hypertension, high cholesterol. Determining when Tinas eyes most itch will also aid in treating her itchy eyes. Last xxx 4 months ago. Tina Jones Comprehensive Assessment Final Paper, Tina Jones Comprehensive Assessment Final Paper References, If your paper matters, we own all the good words. aggravating factor and tramadol as relieving factors. Proventil 2 puffs q4hr PRN (for SOB), tramadol PO Assessment is based on a Comprehensive Patient Interview, Physical Examination and development of Individualized Plan of Care that includes. PMI at the Normal Pro Tip: Tinas response to a question about taking any antihistamines will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. Pro Tip: Infected sinuses can manifest as nose problems. Medical History One or two sentence responses, simple statements of agreement or good post, and responses that are off-topic will not count as substantive. Can you confirm that youre allergic to cats? She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. She is required to have a physical exam for her health insurance. Denied frequent headache or dizziness. Whispered words heard bilaterally. nontender to palpation. Tina Jones Comprehensive Assessment Final Paper, Assessment Tina Jones Comprehensive Assessment Final Paper, Differential Diagnosis Tina Jones Comprehensive Assessment Final Paper, This diagnosis is because of patients history of dysmenorrhea and longer periods, and severe cramps, as a birth control was prescribed. Describes similarity to her sisters hay fever symptoms. Cannabis use from age 15 to age 21. GU: Pt stated of polydipsia and polyuria. Mild edema at right ankle. She is well-nourished, well-developed, and dressed appropriately with good hygiene. Use PMH (past medical history) to help you develop this. Education/Health Promotion: For his age I would consider hand-foot-mouth disease, and bacterial or viral pharyngitis. Frontal and maxillary sinuse Diabetic neuropathies. (after initiating Yaz) cycles regular (every 4 weeks) with modera Always document a specific follow-up and reason: Example: f/u 1 week to evaluate antibiotic efficacy. Liver Span: 7cm MCL on percussion Tina Jones Comprehensive Assessment Final Paper, Name: Tina JonesTina Jones Comprehensive Assessment Final Paper. Tina Jones shadow health. she was in high school. when she received her annual gynecological exam at Shadow grandmother diseased, died at age 73 from stroke, menses with heavy bleeding that last for 10 days, This results in bulging of the vein on either side of the artery making the vein appear to stop on either side of the artery. No surgeries. XRay of the foot and wound care, were provided in the ED. 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 negative for HIV/AIDS and STIs four months ago. Denied Gastrointestinal: Reports no nausea, vomiting, pain, constipatio Familiarize yourself with APA format and practice using it correctly. By asking Tina if she regularly changes her bedding, youre soliciting information about environmental factors that might exacerbate her condition. Reports decreased stress and improved coping abilities have improved previous sleep difficulties. Asking Tina if she has noticed any changes to her voice would indicate whether her symptoms might be caused by sinus problems. She maintains eye contact throughout the interview. In this case study, I completed a comprehensive assessment and physical, examination on Tina Jones, a 28 year old African American female who had established, primary care at the shadow health clinic over a year. reports a few moles but no other hair or nail changes. Wound edge red with serosegious drain. DM with diet. Never married, no children. Model Note:Differential diagnosis includes sensorineural hearing loss and anatomical defects. heterosexual. 2022 Nursingbay.com. Palpation of the cervical lymph nodes may demonstrate enlarged, tender, cervical lymph nodes. Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. I discourage overutilization of direct quotes in DQs and assignments at the Masters level and deduct points accordingly. Asking Tina if she has ear pain might indicate a possible ear infection. Asked about review of systems for neck, throat and glands. 2. XRay of the foot and wound care percussion. and throbbing pain at right foot. Pro Tip: Sinus problems can result in increased pressure buildup and headaches. These announcements are made to ensure you understand everything that is due during the week. Have you treated your eyes with anything? loss of 10lbs in the last month. Followed up about medications and relieving factors for throat symptoms. Pro Tip: Dry eyes occur when the eyes do not produce enough tears to lubricate them. Exam As Masters level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Pro Tip: Establishing a timeline for whether Tinas vision has gotten worse will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers. monofilament in bilateral plantar surfaces. Do you have a history of throat problems? Asking Tina if she thinks she has a cold will give Tina the opportunity to compare her current symptoms with cold symptoms shes historically had and describe if her current symptoms differ from those she experiences when she has a cold. Denied exercising. This assignment assesses intended course outcome(s), #4 Use information found in patients health histories, genograms, and assessments to formulate an individualized plan of nursing care that focuses on the patients individual health promotion and disease prevention needs. Tested XXX four months ago. She uses her XXXwhen she is around cats. 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. Tina is active in her church and describes a strong family and social support system. Health history is a very important part of assessment for practitioners. Neurology: No change in mood, behavior or attention. Have you been exposed to secondhand smoke recently? 82 years, hypertension. developed, and dressed appropriately with good hygiene. (2017). distress. table, and is in no apparent distress. She maintains eye contact throughout the interview. Tina is allergic to cats, she states that she tries to avoid cats but when she is around them her, asthma "acts up" (T. Jones, Shadow Health Interview, February 13, 2016). Asking Tina when she last used her inhaler will indicate when her symptoms most recently required medical treatment. Learning about a patients family history around ear problems can help you predict risk. Order a Tina Jones shadow health. No surgeries. Asking Tina how many puffs of her inhaler shes prescribed will indicate her treatment plan and the degree to which she complies with it. general overview of patients history, recent illness and health maintenances. Pro Tip: Asking Tina when her last vision test was will indicate the degree to which shes seen her vision as something that has needed medical attention. tetanus, and meningococcal vaccines. Substantive responses should be at least 150 words. with polycystic ovarian syndrome and prescribed oral contracep deformity and with full range of motion. She has a history of hypertension which normalized when she She began XXX months ago and initially had some gastrointestinal side effects which have since dissipated. Questions to Instructor Forum: This is a great place to ask course content or assignment questions. 50mg Q6hr PRN (for foot pain). Patient verbalized coping well with stress and anxiety by having support from family and friends. bleeding lasting 5 days. hours after taking tramadol. She enjoys spending time with friends, reading, attending Bible study, volunteering in her church, and dancing. Mother- (50 years) hypertension and high cholesterol. diseased, died at from colon CA, T2DM, Maternal Reports no current breathing problems. Tina is 5 feet 7 inches tall and weighs 90kg. A. business establishments B. educational institutions C. municipal buildings D. churches. Father, diseased, died at age 58 in car accident, HTN, Ms. Jones offers information freely and without contradiction. in here for a check-up, and the nurse practitioner got me on metformin. Terms and Conditions (elsevier/legal/elsevier-website-terms-and-conditions) Privacy Policy (elsevier/legal/privacy-policy) Pro Tip: Low energy or fatigue can be an important symptoms or contributing factor to discover, and can help you rule out certain conditions. Pain was 7/10, two Wound at right ball of foot measured at 2cm by 1, Do you get headaches when you have blurry vision? runny nose, itchy eyes), denied other drug allergies. Im taking good care of my health these days. . 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. I highly recommend using the APA Publication Manual, 6th edition. 500mg BID. Medical History Tina Jones Comprehensive Assessment Final Paper. Soliciting this information allows you to more accurately treat her symptoms. transfusion. Safety: Has smoke detectors in the home, wears seatbelt in car, and does not ride a bike. she is limiting carbohydrates staying away from sweets and increasing vegetables. up" patient was correct in response. Last menstrual period 2 weeks ago. Fill out the Template, add an APA Cover Page, and an APA Reference list. Please communicate with me if you anticipate having to submit an assignment late. incontinence or dysuria. She states that she feels healthy, is taking better care of h Last use of proventil was 3 days ago. Have you had any changes in your breathing? to pain. Missing some information regarding health concerns, by excluding information from screening assessments and demographics, Health concerns are not identified due to information missing from screening assessments and demographics, Completely asses patients nutrition and activity levels and makes recommendations based on age, race, gender and pre-existing medical conditions, Missing some information regarding the patients nutrition and activity levels, make recommendations based on age, race, gender and pre-existing medical conditions, Most of the information regarding the patients nutrition and activity levels are missing, recommendations are missing or not based on the patients age, race, gender and pre-existing medical conditions, Identifies support systems such as family members and community resources, Missing some information regarding support systems such as family members and/or community resources, Little to no information regarding social support Tina Jones shadow health, Overall health maintenance recommendations made based on age, race, gender and pre-existing medical conditions, Missing some recommendations, mostly based on age, race, gender and pre-existing medical conditions, Missing many recommendations, loosely related to age, race, gender and pre-existing medical conditions, Identified knowledge deficit areas/patient education needs including self-care needs and activities of daily living, Missing one or more areas of knowledge deficit/patient education needs including self-care and activities of daily living. 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