. Have you taken any prescription pain medications? Can you rate the pain on a scale of 0 to 10? She complains of difficulty falling asleep at least 4 or 5 nights per week, but states that she is able to stay asleep without difficulty. I usually get the headaches at night from reading squinting I guess and so I take one or two and go to bed. How do I begin? Asking about a patients social history can also unveil the influence of their present illnesses in their social lives. She has used marijuana in the past, but no current use and denies other illicit drugs. Empathize If any changes are needed, request a revision to be done. Diana Shadow: Your patient is Tina Jones:, a 28-year-old African American woman who has just been admitted to Shadow General Hospital for a painful foot wound. Question Assessment: In the a, or assessment portion, you are going to synthesize the subjective and objective data into a list of prioritized differential diagnosis. 01:44 PM EST. Mucous membranes. Hello.My name is Gisselle. This is an incomplete reflection. Overall, my health is pretty good. it doesnt feel totally under control, though. How often have you been cleaning your scrape? Educate on when to seek further or emergent care including feelings of self-harm or hopelessness. How are you coping with your fathers death? While the student identified areas that should improve, he or she does not make a specific and measurable improvement plan or challenge any of his or her assumptions or practices. Extraocular movements intact bilaterally. She had no rebound tenderness or guarding. Cross), Psychology (David G. Myers; C. Nathan DeWall), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Give Me Liberty! Question Educate on when to seek emergent care including the worst headache of her life, acute changes in vision, hearing, or consciousness, episodes of nausea or vomiting associated with headache, or numbness, tingling, or paralysis of new onset. The facial sensatins are intact and the facial features are symmetric. 01:35 PM EST. My asthma used to be really scary. Tina was the passenger and she was wearing a seatbelt. 01:44 PM EST, ####### 3 Medications Followed UpFollowed Up, Does the breathing problem affect your ability to work? Im Preceptor Diana. Question You should prepare prior to seeing Ms. Jones. Things were only hard like that for a few months. What are my objectives in this assessment? . WellI guess I was noticing the other day that the skin around my neck is looking weird. A little while ago, I had some seasonal allergies, but it didnt really bother my asthma, and its better now. Respiratory Shadowhealth Tina Jones Documentation Focused Exam-Abdominal Pain Esther Parks Shadowhealth Subjective Focused Exam-Cough Danny Rivera Shadowhealth Objective Heent Shadowhealth Tina Jones Subjective Focused Exam-Chest Pain Brian Foster Shadowhealth Objective Heent Shadowhealth Tina Jones Objective Data Other related documents Do you take any over-the-counter medications? Tongue symmetric with no abnormal findings. The patient is a 70 year old female complaining of abdominal pain and indigestion. Hello. We have assisted many students who passed the assessment. It demonstrates analysis of missed items. questioned about adaptability - Identifies a history of walking difficulties - Tina claims to have had a wound that caused her walking difficulties. Liver and spleen are not enlarged. I guess I was noticing the other day that the skin around my neck is looking weird. My asthma doesnt usually wake me up, but it has the past couple nights. The tongue is symmetric with not abnormal findings while the bilateral upper and lower extremity DTRs equal and 2+ bilaterally. I used OLDCARTS to interview her, and it worked well. No past suicide attempts. No. attack during my shift. thats not whats been happening recently, though. Eating worsens the pain, making her feel excess gas and bloating. There are multiple essential questions for each of these topics: The mental health exam is an interview and that will give you an idea of how your patient is doing emotionally and cognitively. Recognizing a patients SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face. Getting Started: View this tutorial for guidance on getting started with the Comprehensive Assessment Assignment. You will be evaluated on your ability to use the patients context to construct a health interview that is thorough and relevant for Ms. Jones. Mrs. Smith was a very easy patient to interview. Question So I guess at first I just focused on getting things donegroceries, laundry, insurance papers and stuff. What have I learned about my practice? Head: Denies history of trauma before this incident. . Were you on oral contraception when you did not use a condom? Getting Started: View this tutorial for guidance on getting started with the Health History Assignment. Let me learn more about what you're experiencing, and I will try to help.". Encourage Ms. Jones to continue to monitor symptoms and log her episodes of insomnia and anxiety with associated factors and bring log to next visit. Right fundoscopic exam reveals mild retinopathic changes. How many times a day do you take pain medication? What health issues does your sister have? Id say it takes about a minute to work at most after that. Students spend, on average, two and a half hours on this assignment. Review of Systems: General: Denies changes in weight, weakness, fever, chills, and night sweats. We suggest taking out your textbook to remind yourself of what doing a mental health assessment entails. Psychiatric: States that her mood has been "off" and she does not feel like herself. She does not take any prescription or over the counter sleep aids. Do you have a family history of headaches? Patient narrative: Tina had an asthma episode 2 days ago. ), Well . Getting Started: View this tutorial for guidance on getting started with the Cardiovascular Assignment. I havent had a mammogram. . What prescription medications do you take? One week ago she states that she was a restrained passenger in an accident in a parking lot and estimates the speed to be approximately 5-10 mph. Its not bleeding anymore. When did you last have issues with asthma? There are essential sections of patient information that your interview will need to uncover. Endorses changes in concentration and sleep. Empathize We suggest taking out your textbook to remind yourself of what doing a musculoskeletal assessment entails. 11/02/21 7:31 PM EDT. Bilateral upper and lower extremity DTRs equal and 2+ bilaterally. Well, I had to come back to get my foot checked out even though I used the ointment. Category: Hospital Detail Drugs I caught the railing, but I guess I kind of turned my ankle a little bit. Self-reflection is proven1 to improve our skills as providers, which leads to better patient outcomes. improve your breathing.". Have you noticed any lumps in your breasts? Well, I got the scrape a week ago, but the scrape and the pain got a lot worse in the last few days. Documentation - Tina Jones Neurological Shadow Health assessment. Mike T, 2023 Shadow Health - Tina Jones, Health History With Complete Solution updated. Pro Tip: A patients family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Have you ever taken medication for your diabetes? We accept a variety of payment methods such as VISA, PayPal, MasterCard, American Express, Amex, Discover, Maestro among others. My name is xxxx and I will be interviewing you today and later do a physical exam. comprehensive Assessment Tina Jones Shadow Health Transcript Transcript This study source was downloaded by 100000824189183 from CourseHero on 09-07-2021 07:53:41 GMT -05: coursehero/file/37208372/Tina-Jones-Respiratory-Completed-Shadow-Health-4pdf/, ####### 2 Asthma Triggers Followed UpFollowed Up, How often do you notice the wheezing? She states that she has a strong support system made up of friends and family and she is active in her church. Mother died of alzheimers, father of heart attack. She has cats, and I'm allergic, so my There are multiple essential questions for each of these topics: The neurologic exam is an interview and physical assessment that assesses the nervous system, which includes the brain and spinal cord. Empathize I asked Mrs. Smith about her health history and tried to find more in- formation about her low back pain, cough, and frequent urinary tract infections. There are essential sections of patient information that your interview will need to uncover. She occasionally takes 650 mg of over the counter Tylenol with relief of the pain. Email us: It seems you are having an asthma exacerbation We suggest taking out your textbook to remind yourself of what doing a respiratory assessment entails. Email us: Resonant to percussion. Do you notice being more clumsy than usual? Maybe some soreness before my period, but that seems pretty typical. Tina Jones, a 28-year-old African-American woman, came to our clinic complaining of breathing difficulties and windedness following asthma attacks. Vital Signs BP 125/85, P 70 bpm, R 16 breaths, T 99.1 F. and keeping the wound clean. I havent taken medicine for it or anything. As soon as you complete payment for your order we assign a suitable writer capable of handling your assignment immediately. Family History: Denies any history of known sleep disorders or psychiatric disorders. I find Docmerit to be authentic, easy to use and a community with quality notes and study tips. Question Its important for me to know how youre using all of your Point-to-point movements smooth and accurate for finger-to-nose and heel-to-shin. 01:46 PM EST, Have you used your inhaler today? c.) What did I do that was unsuccessful that I will discontinue? At first, it seemed like it was healing up fine and it didnt give me a lot of pain. I mean, sometimes, I freeze up during a test, but thats everybody, right? Providing high quality help on your way to academic excellence! Self-reflection enables us to look at our performance be it on the job, in the classroom, or out on the field and critique our practice in a systematic and rigorous way. Does your paternal grandfather have health conditions? Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation As you continue StudyCorp.com has the top and most qualified writers to help with any of your assignments. Submit All your files, such as rubrics, instructions, and essential sources given to you by your instructor. Im sorry youve been experiencing these symptoms. Do you have a history of throat problems? The lessens the pain, but did not improve her pain in the last incident. After editing, you can check your paper in the preview mode. b.) What did I do that was successful that I will continue to do? If it meets your requirements, download it. Patient narrative: Three days ago, Ms. Jones injured tweaked her back lifting a box. We suggest taking out your textbook to remind yourself of what doing a focused, complaint oriented cardiovascular exam assessment entails. She denies known associated symptoms. I went about an hour after I fell, I think. Pro Tip: A patients chief complaint establishes any illnesses or concerns they are presenting. She takes some blood pressure pills, and I think she has high cholesterol, but Grannys doing great for 82. No, I dont think so. When did you start having breathing problems? She endorses decreased feelings of sleepiness over the past month. Ive had asthma a long time. point-to-point movements were smooth ad accurate for finger-to-nose and heal-to-shin. She drinks approximately 10-12 alcoholic beverages per month, but never more than 3 per sitting and does not note any impact on her sleep. Do you have problems affording the glucometer? Students rated as proficient demonstrate an entry-level expertise in advanced practice competencies and clinical reasoning skills. Do you take any over the counter medications? (Clarified to How much Tylenol do you take?. Instructor Test Bank, Burn Sheet Music Hamilton (Sheet Music Free, Analysis of meaning and relevance of History from the millennial point of view, Fundamentals-of-nursing-lecture-Notes-PDF, Myers AP Psychology Notes Unit 1 Psychologys History and Its Approaches, Week 1 short reply - question 6 If you had to write a paper on Title IX, what would you like to know more about? Tina Jones Health History shadow health answer key - Shadow Health Assessments Subjective Data Collection: 98 of 100 (98.0%) Hover To Reveal Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions. Have you noticed any changes in your vision? -Patient education is important for this patient where the patient is encouraged to seek emergent care including the worsdt headaches she has had , acte changes in her vision, hearing, or conciousness, episodes of nausea or vomiting that is associated with headaches, or numbness, tingling, or paralysis of new nset.
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