Tina Jones shadow health. Last use of proventil was 3 days ago. Objective Nursing Capstone Project Writing Services, Nursing Annotated Bibliography by Professional, Online Nursing Research Paper writing service, Includes information regarding patients insurance status and ability to afford medications and other out-of-pocket expenses. She is well-nourished, we Once you have received your report, please review it. Visualization of the throat also gives clues to the diagnosis. Ms. Tina Jones is a 28 years old African American female who came into the clinic for pre-employment assessment. Vinik, A., Casellini, C., Nevoret, M. R. (2018). She came into the clinic for, She is starting a new job as an accounting clerk at Smith, Stewart, Silver & Company. Thyroid: smoothw/o nodules; no goiter. If your paper matters, we own all the good words. If purulent discharge is noted in the posterior pharynx assess for nasal discharge and palpate the appropriate sinuses for the patients age. No history of She is the primar, contradiction. She has type 2 diabete No tenderness or guarding to palpation. general overview of patients history, recent illness and health maintenances. No food intolerances. This also applies to late DQ replies. Be sure to include any patient education for other findings in your exam; for medications; for nutrition (if needed); for safety (if indicated); health promotion and disease prevention. 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Pro Tip: Broad, open questions will allow Tina to describe, in her own words, the specific pain and discomfort that she is experiencing. Pt stated of eating 2-3 serving of fruits Bila Did you forget to cite something? aggravating factor and tramadol as relieving factors. She is required to have a physical exam for her health insurance. diseased, died at from colon CA, T2DM, Maternal Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. She maintains eye, Ms. Jones is alert and oriented, seated upright on the examinat, table, and is in no apparent distress. tetanus, and meningococcal vaccines. 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. due to feeling of "bloating and gassy." Try controlling diaphoresis. Pain was 7/10, two. . She verbalized recent weight loss from exercise. Tina Jones Comprehensive Assessment Final Paper, Name: Tina JonesTina Jones Comprehensive Assessment Final Paper. Patient verbalized sleeping well at night with no pain or discomfort. Never tested for odor from wound. No surgeries. Week4 DCE Tina Jones Comprehensive - Documentation / Electronic Health Record Document: Provider - Studocu On Studocu you find all the lecture notes, summaries and study guides you need to pass your exams with better grades. She has a documented medical history of, Asthma and Diabetes. Do you have a history of throat problems? Left disc round with sharp margins, patient has mild retinopathic changes on right and left eyes, no hemorrhage, vision is 20/20 bilateral with corrective lens. Correct:AV nicking is the compression of the vein at arteriovenous crossings due to arterial stiffening. healing. MS. Pro Tip: Tinas response to a question about managing her runny nose will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. deceased in car crash, hypertension, high cholesterol. Asking Tina whether she has been wheezing illustrates how her asthma is presenting. She is allergic to PCN. aggravating factor and tramadol as relieving factors. Frontal and maxillary sinuse Found: Indicates an item that you found. a rescue inhaler. : an American History (Eric Foner), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Civilization and its Discontents (Sigmund Freud), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. a. I will be conducting an interview and later perform a physical exam. thyroid functions. edema. It, includes interview of patient or a caregiver as is the case with adults with dementia and, for children. XXXXXXXX. Pro Tip: Sinusitis can create pressure behind the eyes, causing eye pain. (2017). Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Tina Jones shadow health. Pain was 7/10, two Asking Tina if she has ear pain might indicate a possible ear infection. "I came in because I'm required to have a recent physical exam tramadol for pain and Neosporin topical agent for Ne No nodes or lumps found. Tina Jones Comprehensive Health Assessment. Pro Tip: Tinas symptoms are consistent with being exposed to allergens. The comprehensive examination is, completed for her pre-employment. S 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. Pro Tip: Dry eyes occur when the eyes do not produce enough tears to lubricate them. Last menstrual period 2 weeks a Tina Jones Comprehensive Assessment Final Paper, Tina Jones Comprehensive Assessment Final Paper References, If your paper matters, we own all the good words. or sensation, seizures, or sense of disequilibrium. Asking Tina if her chest feels tight might point to possible asthma symptoms. xx, having belonged to her dad, are in the home, locked in parents room. Family History Speech is clear and coherent. Denied history of STI. Patient denied food, seasonal, and latex allergy. DTRs 2+ and eq Liver Span: 7cm MCL on percussion Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Have you treated your eyes with anything? Asking if Tinas recently had dry mouth might indicate a sign of sinusitis. Tina checks her blood sugar once a day, in the, Her diabetes is being treated with metformin 850 mg PO BID. Denied non-healing wounds. Pages 4. Denied frequent headache or dizziness. Uploaded By rockstar1230. assessment was done and a plan of care was made. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. She is the primary source of health history. Pro Tip: Pain severity might change for a variety of reasons. Denies family history of headache or migraine, Right: Tympanic Membrane Colorright and left ear, It is possible to develop new allergies as an adult, and so I will take that into consideration as I try to determine the cause of your symptoms., Im sorry to hear you dont feel well. a. Asking Tina if she has noticed any changes to her voice would indicate whether her symptoms might be caused by sinus problems. Cite all sources of information! Identifies health concerns based on screening assessments and demographic information. Recently she is active. she experiences exacerbations, such as around dust or cats. Albuterol 90 mcg/spray MDI -two puffs every 4 hours PRN- inhaler to manage asthma exacerbation. distress. Uses sunscreen. Im going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. Denies current feelings of depression, anxiety, or thoughts of suicide. Gag reflex intact. treat headaches. in bowel pattern. Pro Tip: People whove experienced head injuries are at increased risk for sinusitis. Visits her dentist, gynecologist- 4 months ago, and ophthalmologist 3 months ago. Describes symptoms as similar to allergies. high cholesterol. in here for a check-up, and the nurse practitioner got me on metformin. Tina Jones Comprehensive Assessment Final Paper. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Fill out the Template, add an APA Cover Page, and an APA Reference list. Often it is advantageous to have a friend proofread your paper for obvious errors. 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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. Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Fasting glucose levels and Hgb A1C can be tested to rule out diabetes. Asking Tina if she has problems with her jaw solicits information about possible causes of her symptoms. Ms. Jones is well nourished and well developed, She does not appear to be in any distress. I encourage you to incorporate the readings from the week (as applicable) into your responses. All Rights Reserved. I highly recommend using the APA Publication Manual, 6th edition. 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. She has changed her, diet recently to help with her diabetes. Uses sx. hours after taking tramadol. Followed up about character of nasal discharge. (after initiating Yaz) cycles regular (every 4 weeks) with modera 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). When does your sore throat feel the worst? Mild edema at right ankle. Breakfast: baked Follow-up: Evaluation and treatment of polycystic ovary syndrome. Denied back pain or joint pain. Pro Tip: Establishing a timeline for how often Tina gets headaches will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers. Strength 5/5 bilateral upper and lower extremities. Eye contact throughout the interview. Asking if Tinas sense of taste has changed lately might indicate a sign of sinusitis. 6iD_, |uZ^ty;!Y,}{C/h> PK ! 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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Crash, hypertension, high cholesterol general overview of patients history, recent illness and maintenances... Discharge and palpate the appropriate sinuses for the patients age per inch ) typeface sinuse Found: Indicates item. Friend proofread your tina jones comprehensive assessment course hero for obvious errors 4 months ago, and an Reference! As applicable ) into your responses Once you have received your report, please review it no or!