PK ! she experiences exacerbations, such as around dust or cats. Denies history of general throat problems. GU: Pt stated of polydipsia and polyuria. required change of tampon every 2-3 hours. H or sensation, seizures, or sense of disequilibrium. L/R Otoscopic: No inflammation with pearly/gray color contact throughout the interview. She is the primar Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. Terms of Use The paper is focused on designing evidence-based, culturally competent nursing interventions through the development of an individualized health plan.Assessment is based on a Comprehensive Patient Interview, Physical . Sister asthma. Pro Tip: People whove experienced head injuries are at increased risk for sinusitis. and vegetables a week. * The paper should be written and referenced in APA format and be no longer than 4 pages (excluding cover page and references). EOMs intact bilaterally, no nystagmus. Pro Tip: Swollen lymph nodes may appear in the neck when an infection is present. No lymphadenopathy. She is well-nourished, well-developed, and dressed appropriately with good hygiene. Health Maintenance Tina Jones Comprehensive Assessment Final Paper. healing. stated of increased appetite and Tes Pro Tip: Low energy or fatigue can be an important symptoms or contributing factor to discover, and can help you rule out certain conditions. Self-care needs/ Activities of daily living. Mother- (50 years) hypertension and high cholesterol. Ms. Jones twisted her ankle walking down the stairs a T: 37 C / 98 F. BP: 128/82 nnHg. (2017). Paternal grandmother, She is well-developed and dress appropriately with good hygiene. Identified health concerns based on screening assessments and demographic information, What is the patients activity level, is the environment where the patient lives safe for activity, Nutrition recommendations based on age, race gender and pre-existing medical conditions, Support systems, family members, community resources, Recommended health screening based on age, race, gender and pre-existing medical conditions. Pro Tip: Sinus problems are often genetic. Asking Tina if she has dust in her house might indicate a possible trigger that she has been exposed to. For the past four mont This paper is an assignment synthesizing the advanced physical assessment of Tina Jones. Visits her dentist, gynecologist- 4 months ago, and ophthalmologist 3 months ago. C/O sharp Pro Tip: Ear pain can suggest an ear infection, during which the middle of the ear becomes clogged with fluid and mucous, which can affect hearing. Hematology or Lymphatic: Denied history of anemia or School Purdue Global University. Asking Tina if she has ear pain might indicate a possible ear infection. of those are under control. inhaler. Do you have any family history of throat problems? She is the primary source of the history. She is allergic to PCN. Fill out the Template, add an APA Cover Page, and an APA Reference list. Have you noticed any changes to your voice? GI: Denied nausea, vomiting, abdominal pain, or change Speech is clear and Brushes teeth twice a day. Asking Tina if she has problems with her jaw solicits information about possible causes of her symptoms. If purulent discharge is noted in the posterior pharynx assess for nasal discharge and palpate the appropriate sinuses for the patients age. Reports increased hair growth over past few months and neck I came in because Im required to have a recent physical exam for the health insurance at my new job.. Please reference the APA 7 manual for assistance in the cover page, reference sheet, and running heads on your paperwork. Mood is pleasant. Those are gotten from EBP and clinical guidelines. When, interviewing the patient the practitioner is able to get a health history and the history of, the patients chief complaint. Endocrine: Reported of polydipsia, polyuria and weight Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. MS. Eye contact throughout the interview. Last pap 3 years ago. table, and is in no apparent distress. Exam a. Missing information regarding the patients insurance status, ability to pay of medications and other out-of-pocket expenses. Gastrointestinal: Reports no nausea, vomiting, pain, constipatio One or two sentence responses, simple statements of agreement or good post, and responses that are off-topic will not count as substantive. Have you had any changes in your breathing? SpO2: 99%, Patient is in positive mood, alert and oriented x. Ms. Jones is a pleasant, 28-year-old African American single w Last Pap smear 4 months ago. We're available through e-mail, live chat and Facebook. Education level (health literacy). Asked about aggravating factors for throat symptoms, Reports throat pain is worse in the morning. Has new male relationship, sexual contact not initiated. Scar on Right Plantar Foot pad. Preipheral Vision: Reports no longer visible 45 degrees. Familiarize yourself with APA format and practice using it correctly. Cross), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Psychology (David G. Myers; C. Nathan DeWall), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. 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Cheever), The Methodology of the Social Sciences (Max Weber), Shadow Health Tina Jones Comprehensive Results Subjective Results Redacted, Tina Jones Comprehensive Assessment Transcript, Subjective, Objective, Documentation Data, Shadow Health Tina Jones Comprehensive Results Objective Results Redacted, Test Bank Chapter 01- Evidence-Based Assessment, Test Bank Chapter 04- The Complete Health History, Shadow Health Digital Clinical Experiences from Elsevier 1, Shadow Health Digital Clinical Experiences from Elsevier 3, Shadow Health Digital Clinical Experiences from Elsevier 99, Student - Head to toe Health Assessment Check off list, Critical Business Skills For Success (bus225), Seidel's Guide to Physical examination (043), Organizational Systems and Quality Leadership (NURS 4210), Introduction to Computer Technology (BIT-200), Healthcare Strategic Management and Policy (HCM415), Foundations of Addiction and Substance Use Disorders (PCN-100), Child and Adolescent Psychology (PSY-355), Leadership and Management in Nursing (NUR 4773), Professional Application in Service Learning I (LDR-461), Advanced Anatomy & Physiology for Health Professions (NUR 4904), Principles Of Environmental Science (ENV 100), Operating Systems 2 (proctored course) (CS 3307), Comparative Programming Languages (CS 4402), Business Core Capstone: An Integrated Application (D083), Student-HTN-Atherosclerosis Unfolding Reasoning, Bates Test questions Children: Infancy Through Adolescence, UWorld Nclex General Critical Thinking and Rationales, Furosemide ATI Medication Active learning Template, Sawyer Delong - Sawyer Delong - Copy of Triple Beam SE, Test Bank Varcarolis Essentials of Psychiatric Mental Health Nursing 3e 2017, Calculus Early Transcendentals 9th Edition by James Stewart, Daniel Clegg, Saleem Watson (z-lib.org), Ati-rn-comprehensive-predictor-retake-2019-100-correct-ati-rn-comprehensive-predictor-retake-1 ATI RN COMPREHENSIVE PREDICTOR RETAKE 2019_100% Correct | ATI RN COMPREHENSIVE PREDICTOR RETAKE, Historia de la literatura (linea del tiempo), SCS 200 Applied Social Sciences Module 1 Short Answers, Applying the Scientific Method - Pillbug Experiment, Myers AP Psychology Notes Unit 1 Psychologys History and Its Approaches, Leadership class , week 3 executive summary, I am doing my essay on the Ted Talk titaled How One Photo Captured a Humanitie Crisis https, School-Plan - School Plan of San Juan Integrated School, SEC-502-RS-Dispositions Self-Assessment Survey T3 (1), Techniques DE Separation ET Analyse EN Biochimi 1, Metformin, 850 mg PO BID (last use: this morning), Drospirenone and ethinyl estradiol PO QD (last use: this morn, Albuterol 90 mcg/spray MDI 1-3 puffs Q4H prn (last use: yeste, Acetaminophen 500-1000 mg PO prn (headaches), Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6 Skin on nec Asking Tina how often she saw the dentist as a child will suggest her health and dental history. Irregular Diabetic Neuropathy as evidence to decreased sensation on both right and left great toes and right heels. Complete Blood Count (CBC) is a blood test that is done for evaluation of overall health of a patient and to detect disorders; red blood cells, white blood cells, platelets, hemoglobin, hematocrit, mean corpuscular volume, reticulocyte count. Review your similarities. PPD (negative) ~2 years ag Model Note: A useful diagnostic finding that suggests otitis media is the lack of mobility of the tympanic membrane during insufflation. Pro Tip: Environmental factors can often be primary allergy triggers. Asking Tina if she has any mouth sores might indicate a problem area that has caused infection. Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Denied receiving Stated of inability to bear weight on right foot due with polycystic ovarian syndrome and prescribed oral contracep She is the primary source of health history. Conjunctiva pink, no lesions, white sclera. she was in high school. received. These announcements are made to ensure you understand everything that is due during the week. Learning about a patients family history around vision can help you predict risk. Pleasant and cooperative. Pro Tip: Pain severity might change for a variety of reasons. Asking whether shes noticed ear discharge could indicate whether she has a ruptured eardrum. Pro Tip: Chills could be an indication of fever, which could be an indication of infection. denied Use PMH (past medical history) to help . PERRLA, EOMS are intact. Asked about review of systems for neck, throat and glands. She maintains eye contact throughout the interview. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Para 0. 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. OTC Advil PO 600mg TID PRN (for menstrual cramps), Pro Tip: In some cases, infection can spread to a cheekbone through an infected tooth. Patient appears stated age and in good health. due to feeling of "bloating and gassy." Try controlling Pro Tip: Determining what, if any, medications a patient is taking is a crucial element of a thorough health history and will help you avoid unwanted drug interactions. Pro Tip: Sinusitis can result in decreased smell or taste. This is the most common complication of diabetic mellitus. When submitting hard copy, be sure to use white paper and print out using dark ink. Case - Week 4 shadow health tina jones 3. Asking Tina whether she has had any problems with her lymph nodes will solicit a history of her condition. Well-groomed, easily engages in conversation and is cooperative. 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. xxx2 years ago. I discourage overutilization of direct quotes in DQs and assignments at the Masters level and deduct points accordingly. stopped darkening and facial and body hair has improved. She Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. distribution on lashes and eyebrows, lids without lesions, no pto Pro Tip: Because problems like mouth or throat cancer can be genetic, its important to understand family history to determine risk factors. R: 15. L/R Pupillary Reflex: Consenual & Symmetrical midline on phonation. Pro Tip: Some people who experience chronic asthma may be accustomed to wheezing and thus might not volunteer this information. Have you been recently exposed to any allergens? Asking Tina to rate the severity of her pain on a scale of 1-10 will provide a quantified and relative measurement of her condition. Maternal grandfather diseased, died at age 78 of stroke. You will develop differential diagnosis based on the chief complaint and HPI. Pro Tip: Its essential to ask specifically what medications a patient is using to treat her current complaint or any ongoing medical conditions. 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