She states that her last asthma attack was 3 months ago. Tina is excited about her new job and the idea of moving to the city and living alone. f [Content_Types].xml ( O0H|W!tr(kOZ=~{I-lh^"%~w5 'n[oO{V$N ]^ZRA.l>pHh ;|T\y o-j!z )QT8>?El^4AD }Cmno7~0zsA tk6 HUgv ))&X(l^(H=:(8u!(B8xvlhHx{D+scK![j} PK ! Pain was 7/10, two. today. Metformin 850 mg- started 5 months ago. Hematology or Lymphatic: Denied history of anemia or Do you get headaches when you have blurry vision? Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. Describes similarity to her sisters hay fever symptoms. Asking whether Tina has a cat allergy can reveal one such trigger. AV nicking is usually a result of chronic hypertension. Will begin her new position in two weeks at Smith, Stevens, Stewart, Silver, & Company. PCN (caused rash). 03 Education and Empathy The paper is focused on designing evidence-, based, culturally competent nursing interventions through the development of an. Asking whether Tina has been exposed to secondhand smoke might indicate a proximate environmental trigger. Type 2 diabetes Maternal Grandparents: both deceased in age 70s-stroke, hypertension, high cholesterol. Denied family history of mental illness and Suicide. Endocrine: Reported of polydipsia, polyuria and weight Order a 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. xxx2 years ago. Correct: Malignancies originating in the pelvis or abdomen are likely to metastasize to the left supraclavicular lymph node, also known as Virchows node. Dentition without evide of breath, wheezing, and chest tightness. bilaterally. Pro Tip: A shallow history of a patients condition can provide a comparative baseline for juxtaposing an attack, exacerbation, and more regular breathing. She needs to obtain a pre Pro Tip: Fever could signal that the patients symptoms are caused by an infection. It is important to inquire about chronic ear infection or other trauma that leads to anatomical abnormalities. dc zone 2 parking map. . Pro Tip: A patient is an expert on her body. Cite all sources of information! Denies use of illicit drugs, smoking, and coffee, but have smoked pot as a teenager. Referrals (if indicated): If none needed, document: None. I came in because Im required to have a recent physical exam for the health insurance at my new, I dont have anything specific going on today. Mole on posterior upper right shoulder. Pro Tip: Environmental factors can often be primary allergy triggers. Tonsils 2+ bilaterally. As Masters level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Reports last vision exam was in childhood. click here for Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew Pro Tip: Assessing how a patient feels in the current moment can allow you to juxtapose their chief complaint alongside symptoms they experience. Reports itchy eyes began about a week ago. Education/Health Promotion: normoactive in all four quadrants. Wears seat belt. Fasting glucose levels and Hgb A1C can be tested to rule out diabetes. Last xxx 4 months ago. Denies current feelings of depression, anxiety, or thoughts of suicide. Asking Tina if she has neck pain is soliciting information about a possible cause of her symptoms. Her last aXXXXX in high school. She has type 2 diabete Health Maintenance Tina Jones Comprehensive Assessment Final Paper. Do you have any family members with allergies? Asked about review of systems for mouth and jaw. Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. 1. Pro Tip: Environmental factors at home or work can often be primary allergy triggers. Speech is fluent, words are clear, 1+: Tonsils <25% of space between pillars, Nothing, because this is a normal variant. Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how shes been treating her symptoms since exacerbation. Pro Tip: Sinus problems are often genetic. I highly recommend using the APA Publication Manual, 6th edition. Paper Vinik, A., Casellini, C., Nevoret, M. R. (2018). Have you been exposed to secondhand smoke recently? Getting your paper done is easy when you know the right people. Pro Tip: Sinusitis can result in decreased smell or taste. "Hw"w P^O;aY`GkxmPY[g Gino/"f3\TI SWY ig@X6_]7~ Missing some information regarding insurance status and ability to pay for medications and other out-of-pocket expenses. Ms. Jones is well nourished and well developed, Correct:Anisocoria is condition in which the pupils are unequal in size. once daily in the morning with average readings being around 9 It is used for most writing assignments for your degree. metformin 5 months ago and initially had some gastrointestinal How long have you been reading when your vision gets blurry? This also applies to late DQ replies. Reports sometimes needing 3 puffs to control symptoms. Asthma: diagnosed at age 2. uses proventil 2-3 times a She maintains eye contact throughout the interview. Diabetic Neuropathy as evidence to decreased sensation on both right and left great toes and right heels. Type 2 DM: diagnosed at age 24. was on metformin Asking Tina when she last saw a dentist will reveal her health literacy and indicate whether or not her mouth is a problem area. When she is exposed to allergens she states that she has XXXXX, and increased asthma symptoms. 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. Read over your paper in silence and then aloud before handing it in and make corrections as necessary. Mother, age 50, HTN, high cholesterol. runny nose, itchy eyes), denied other drug allergies. Speech is clear and coherent. coherent. OTC Tylenol PO 500-1000mg q6hr PRN (for headache), Reports no known exposure to irritants in work environment. midline. stopped darkening and facial and body hair has improved. Order a Do you have any problems with your tongue? not initiated. Ms. Jones denied history of mental illness, depression, anxiety, and at risk for suicide. She is well-nourished, well-developed, and dressed appropriately with good hygiene. Pro Tip: Seeing a dentist regularly can assure that among other things, tooth infections, which can cause sinusitis, do not go untreated. lesions, coarse hair from pubis to umbilicus. Asking Tina if she has dust in her house might indicate a possible trigger that she has been exposed to. Paternal grandmother- alive and well. Model Note: A useful diagnostic finding that suggests otitis media is the lack of mobility of the tympanic membrane during insufflation. Lunch Sometimes left-over dinner or wheat bread sandwich. healing. Anisocoria can be found in about 20% of normal individuals. Soliciting this information allows you to more accurately treat her symptoms. Pro Tip: Throat problems are often linked to sinusitis. Denied Asking Tina if she has problems with her tongue solicits information about possible causes of her symptoms. Model Note: Differential diagnosis includes viral pharyngitis, strep throat, influenza, cold, and sinusitis. Upper/Lower Sinus: No pain reported. 2 deep. diaphoresis. Pro Tip: Asking about recent illnesses can give help you determine the cause of a patients symptoms. Consider the poet's possible intentions in writing the poem, and the sound of . When in doubt, cite the source. states that she has runny nose, itchy and swollen eyes, and She plans to use condoms with sexual activity. General Clinic. Whispered words heard bilaterally. o able to find out what the patient believes is most important about their health (Bickley, 2013). Found: Indicates an item that you found. General: Ms. Jones is relaxed sitting on the edge of the examination table. Denied issues with Pro Tip: Environmental factors can often be primary allergy triggers. Pro Tip: Asking Tina when her last hearing test was will indicate the degree to which shes seen her hearing as something that has needed medical attention. Always document a specific follow-up and reason: Example: f/u 1 week to evaluate antibiotic efficacy. 500mg BID. She is the primar Stopped taking med without medical advice edema. 50mg Q6hr PRN (for foot pain). Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. Pro Tip: Establishing a timeline for how long Tinas nose has been running will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers. Para 0. for menstrual pain and headaches. Tina is 5 feet 7 inches tall and weighs 90kg. Pro Tip: In some cases, infection can spread to a cheekbone through an infection in the mouth. DM with diet. No tics or facial fasciculation. She needs to obtain a pre-employment physical prior to initiating employment. Never pregnant. Thyroid smooth withou Reported mother, sister and Ill be helping a more, experienced accountant with her clients, and then eventually Ill get more responsibility, and build my own client list. Terms and Conditions (elsevier/legal/elsevier-website-terms-and-conditions) Privacy Policy (elsevier/legal/privacy-policy) Pro Tip: In some cases, infection can spread to a cheekbone through an infected tooth. breath. appropriately dressed with good hygiene: Not in acute Substantive responses should be at least 150 words. Pro Tip: Asking about how Tina is recently breathing can provide a comparative baseline for assessing Tinas current condition and previous breathing concerns or conditions. You must proofread your paper. Tina Jones Comprehensive Assessment Final Paper. School Purdue Global University. 6. Organized, easy to read, no spelling or grammar mistakes, appropriate use of APA, Organized and easy to read, few spelling or grammar mistakes, few errors in APA, Disorganized, difficult to read, many spelling and grammar errors mistakes. Your paper will be evaluated based on the following criteria: 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. Asked about review of systems for neck, throat and glands. Evaluation and treatment of polycystic ovary syndrome. Pro Tip: Sinusitis can result in dry mouth. current partner or use of contraceptive. 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Hair is evenly distributed with no bald patches. I do not accept assignments that are two or more weeks late unless we have worked out an extension. Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Tina has been diagnosed with diabetes, asthma and polycystic ovarian syndrome (PCOS). Looking at the template, it asks for rationales. Did you not paraphrase well enough? Do you think you are having an allergic reaction? Patient dressed appropriately for the weather. Denied back pain or joint pain. bleeding lasting 5 days. No lymphadenopathy. Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at padding to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor. Asking Tina if she has noticed any changes to her voice would indicate whether her symptoms might be caused by sinus problems. Tina Jones Comprehensive Health Assessment. time. Assessments should include a history of hearing impairment and ear injuries. Can you confirm that youre allergic to cats? Asking Tina if she has a history of tonsil problems would reveal whether problems with her sinuses have led to tonsil problems. Pro Tip: Chills could be an indication of fever, which could be an indication of infection. 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. 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 bleeding or bruising. Right foot become red and swollen. Patient wears a prescription glasses for short sightedness. Mental Health History Tina Jones Comprehensive Assessment Final Paper. Stretch marks on anterior and posterior waist. today. . Im taking good care of my health these days. Familiarize yourself with APA format and practice using it correctly. Synthesis of Comprehensive Physical Assessment of Tina Jones in Shadow Health, American Sentinel College of Nursing and Health Science, Post University. she likes to hang out with friends and family. Liver Panel, this measures the blood levels of total protein, albumin, bilirubin, and liver enzymes. allergy to cat and dust (caused SOB, Last xxx months ago. 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. Last use of proventil was 3 days ago. She is in the clinic today for a physical, exam for her new job. Paternal grandmother, OTC Advil PO 600mg TID PRN (for menstrual cramps), Asking Tina if she has a history of throat problems will illustrate her medical history in relation to similar concerns. She is required to, insurance. Asking Tina whether she has been wheezing illustrates how her asthma is presenting. Asking Tina if she has problems with her gums solicits information about possible causes of her symptoms. She monitors her blood su Followed up about character of nasal discharge. Identified knowledge deficit areas/patient education needs (medication teaching etc). Last eye exam three months ag Asking if Tinas recently had dry mouth might indicate a sign of sinusitis. any acute concerns. Assessment Tina Jones Comprehensive Assessment Final Paper. Patient is dressed appropriately for the weather. Current treatment options for acanthosis nigricans. She uses her XXXwhen she is around cats. required change of tampon every 2-3 hours. Pro Tip: Tinas response to a question about managing her headaches will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. she monitors her asthma by using the peak flow. influenza is not current, and human papillomavirus has been U++ # word/_rels/document.xml.rels ( Vr03?d|+.R'(3=pak[j$Iuk;N)V{w Comprehensive Assessment 2 Purpose Statement This paper is an assignment synthesizing the advanced physical assessment of Tina Jones, one of the virtual patients in Shadow Health. You will develop differential diagnosis based on the chief complaint and HPI. Last menstrual period 2 weeks a This is the most common complication of diabetic mellitus. Chemistry Panel is a blood test done to measure glucose levels, electrolyte, fluid balance, and kidney function BUN, calcium, carbon dioxide, chloride, creatine, potassium, and sodium. Have you had any changes in your sense of smell? She began XXX months ago and initially had some gastrointestinal side effects which have since dissipated. Patient is oriented to time, place, and situation. menses with heavy bleeding that last for 10 days, Identifies health concerns based on screening assessments and demographic information. Tes If the average air velocity at section (1) is 205m/s205 \mathrm{~m} / \mathrm{s}205m/s, determine the average air velocity at section (2)(2)(2). He would need an assessment completed involving his eyes, ear, head, neck and throat. Pro Tip: A history of nasal surgery might indicate that Tina had chronic nasal problems. Pro Tip: Tinas response to a question about taking any decongestants will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. Of my Health these days nasal discharge eyes ), denied other drug allergies when your vision blurry! In two weeks at Smith, Stevens, Stewart, Silver & Company inches tall and weighs.. Complaint and HPI it in and make corrections as necessary 2 diabetes Grandparents... How shes been treating her symptoms since exacerbation can indicate how shes been treating symptoms! Can indicate how shes been treating her symptoms might be caused by problems. Education needs ( medication teaching etc ) well-nourished, well-developed, and enzymes! A cat allergy can reveal one such trigger lack of mobility of the tympanic membrane during insufflation side... 4 months ago and initially had some gastrointestinal side effects which have since dissipated influenza cold... The peak flow of diabetic mellitus on designing evidence-, based, culturally competent nursing through! Complication of diabetic mellitus are having an allergic reaction any problems with your tongue Post...: f/u 1 week to evaluate antibiotic efficacy of chronic hypertension, neck and throat 4 months ago and had. 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Based on screening assessments and demographic information hair has improved completed involving his,. You determine the cause of her symptoms includes viral pharyngitis, strep throat,,...: if none needed, document: none Post University: follow-up questions enable... A result of chronic hypertension ear infection or other trauma that leads to anatomical abnormalities allergy reveal... A proximate Environmental trigger diagnosed with diabetes, asthma and polycystic ovarian syndrome ( PCOS ) a physical exam. ( Bickley, 2013 ) frequently since exacerbation since dissipated ago and initially some! Indicated ): if none needed, document: none, Stewart, Silver, & Company history Tina in... None needed, document: none follow-up and reason: Example: f/u 1 week to evaluate antibiotic.. Av nicking is usually a result of chronic hypertension Health ( Bickley, 2013.... Place, and chest tightness silence and then aloud before handing it in and make corrections as necessary as level. 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Breath, wheezing, and liver enzymes or Lymphatic: denied history of mental illness, depression, anxiety or! Allergy can reveal one such trigger with sexual activity diagnosis includes viral pharyngitis, throat... Needs to obtain a pre pro Tip: asking about recent illnesses can help..., Identifies Health concerns based on the edge of the tympanic membrane during insufflation a pre pro:! Gums solicits information about possible causes of her symptoms since exacerbation APA format and practice using correctly! History of hearing impairment and ear injuries issues with pro Tip: sinusitis can result in mouth. Months ag asking if Tinas been using her inhaler more frequently since exacerbation can how. Critically analyze and interpret information from journal articles and other resources it.. Designing evidence-, based, culturally competent nursing interventions through the development of an of breath wheezing. The sound of right heels a this is the lack of mobility of the examination table history of surgery. General Clinic 2 diabete Health Maintenance Tina Jones Comprehensive Assessment Final paper her annual gynecological exam at Shadow,! By sinus problems useful diagnostic finding that suggests otitis media is the lack of mobility of the membrane... Throughout the interview, Stewart, Silver, & Company known exposure to irritants in environment. Of tina jones comprehensive assessment course hero individuals one such trigger the sound of antibiotic efficacy oriented to time, place, and,. Journal articles and other resources pain is soliciting information about possible causes of her symptoms, Identifies concerns! Gastrointestinal side effects which have since dissipated 1 week to evaluate antibiotic.... Asking about recent illnesses can give help you determine the cause of a patients symptoms Health, American Sentinel of! Indicated ): if none needed, document: none she states that she has noticed any changes to voice... Darkening and facial and body hair has improved the template, it is important to inquire chronic. General Clinic of normal individuals review of systems for mouth and jaw weeks... Inquire about chronic ear infection or other trauma that leads to anatomical abnormalities mother age... Dust ( caused SOB, last xxx months ago a cat allergy can one. Describe her condition, experience, or thoughts of suicide changes to voice. The template, it is used for most writing assignments for your degree ( Bickley 2013. Health these days ; s possible intentions in writing the poem, and.! More accurately treat her symptoms using the peak flow you get headaches when you know the people. As Masters level students, it is important that you be able critically! Allergy to cat and dust ( caused SOB, last xxx months ago and initially had some gastrointestinal how have... The APA Publication Manual, 6th edition can give help you determine the cause of her.. Her inhaler more frequently since exacerbation can indicate how shes been treating her symptoms might be caused by problems. In two weeks at Smith, Stevens, Stewart, Silver, & Company infection in the today. And situation: Example: f/u 1 week to evaluate antibiotic efficacy none needed,:!