Last eye exam three months ag Learning about a patients family history around ear problems can help you predict risk. You will develop differential diagnosis based on the chief complaint and HPI. Neck has skin discoloration. C/O sharp, and throbbing pain at right foot. 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. 01 Interview Through our natural language conversation engine, students use their own words to gather subjective data and provide therapeutic communication. Correct: Malignancies originating in the pelvis or abdomen are likely to metastasize to the left supraclavicular lymph node, also known as Virchows node. not ride a bike. Reports no current breathing problems. If your paper matters, we own all the good words. 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. Paper Left fundus with sharp disc margins, no source of the history. Reports that blurry vision and headaches often coincide, Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. 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. Covered/Right Eye covered. (Example: Advised to lock guns up in safe). Retrieved on July 26, 2020 from. Getting your paper done is easy when you know the right people. T: 37 C / 98 F. BP: 128/82 nnHg. Asking Tina if she has ear pain might indicate a possible ear infection. Once you\ve developed your diagnosis, be sure to use \evidence based practice\ and \published\ clinical guidelines to guide your plan of care and education. She monitors her blood su Mole on posterior upper right shoulder. 2. Individual Forum: This is a private forum to ask me questions or send me messages. Paternal Is the patient able to afford medications and health diet, and other out-of-pocket expenses? Do you have a history of throat problems? The universitys policy on late assignments is 10% penalty PER DAY LATE. Stopped taking med without medical advice PCN (caused rash). aggravating factor and tramadol as relieving factors. Do you have any family history of throat problems? How many puffs of your inhaler are you supposed to do? Tina Jones Comprehensive Assessment Final Paper, Legro, R.S. Tina Jones Comprehensive Assessment Final Paper. were provided in the ED. stopped darkening and facial and body hair has improved. When she is exposed to allergens sh Allergic to cats and dust. Allergies lower extremities. "I came in because I'm required to have a recent physical exam Substantive responses should be at least 150 words. Vinik, A., Casellini, C., Nevoret, M. R. (2018). Has smoke detectors in the home, wears seatbelt in car, and do Tina was, diagnosed with asthma at age 2 1/2. Ms. Jones states that the gynecologist diagnose This paper is an assignment synthesizing the advanced physical assessment of Tina Jones. Determining when Tinas eyes most itch will also aid in treating her itchy eyes. I am happy to be flexible, with advance notice. Denied history of STI. OTC Tylenol PO 500-1000mg q6hr PRN (for headache), Denies family history of ear or hearing problems. Reports no recent exposure to secondhand smoke. effects which have since dissipated. she came in alone, alert, and oriented X4, speech is clear and appropriate for her age makes eye contact. Do you have any problems with your lymph nodes? Hypertension: normal blood pressure readings. No prn follow-ups for this course. She, states that her asthma is worst when around cats but she also has problems with dust and, running up stairs. she monitors her asthma by using the peak flow. Resonant to percussion throughout. Patel, N. U., Roach, C., Alinia, H., Huang, W. W., & Feldman, S. R. (2018). She states that family and church help her cope with stress. a rescue inhaler. Correct:Anisocoria is condition in which the pupils are unequal in size. female. He would need an assessment completed involving his eyes, ear, head, neck and throat. But do not strictly rely on your computers spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. No surgeries. and throbbing pain at right foot. dc zone 2 parking map. Pro Tip: A history of oral surgery might indicate that Tina had former oral problems. 2 deep. The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. Reports sore throat began about a week ago. View full document Assessments should include a history of hearing impairment and ear injuries. Stevens, Stewart, Silver & Company. This is a comprehensive H & P. You will be assessing the \"whole\" person. 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. Tina is 5 feet 7 inches tall and weighs 90kg. She limits her carbohydrates and avoids sugar. Do you know whats causing your symptoms? No varicose vein. Reports typical inhaler use is 2 3 times a week. I discourage overutilization of direct quotes in DQs and assignments at the Masters level and deduct points accordingly. (c) 0.0525MHCl0.0525 \mathrm{M} \mathrm{HCl}0.0525MHCl and 0.0768M0.0768 \mathrm{M}0.0768M NaCH3COO\mathrm{NaCH}_3 \mathrm{COO}NaCH3COO. Pro Tip: Inhaler effectiveness can vary over time for a variety of reasons. Pages 4. Brushes teeth twice a day. Psychiatry: Denied depression. Review your similarities. And her current home medication list include Flovent 2 puffs daily, for Asthma and rescue inhaler, Proventil 2 puffs every 4 hours as needed for shortness of. Reading and studying seem to cause headaches. XRay of the foot and wound care, were provided in the ED. current partner or use of contraceptive. Pro Tip: Establishing a timeline for how frequently Tina gets blurry vision will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers. Scar on Right Plantar Foot pad. Pro Tip: In some cases, infection can spread to a cheekbone through an infected tooth. increased asthma symptoms. treat headaches. Frontal and maxillary sinuse Confirmed medications from previous visit (no new medications). tetanus, and meningococcal vaccines. Looking for palpable nodes, redness, swelling, tenderness, drainage, loss of hearing, and pain. Patient is obese but practicing healthy eating and physical activity in her daily routine. 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. Tina was diagnosed with Diabetes at age 24. DONT STRESS YOURSELF, JUST CHAT US AT THE RIGHT CORNER BELOW. odor from wound. Tina's speech. Typical breakfast is frozen fruit smoothie with unsweetened yogurt, lunch is vegetables with brown rice or sandwich on wheat bread or low-fat pita, dinner is roasted vegetables and a protein, snack is carrot sticks or an apple. Have you ever had problems with your mouth? Class Tympanic throughout to Ill ask you some questions to learn more about your symptoms, and we will make a plan to help you feel better., :Thank you for letting me know that youre using throat drops in addition to the medications you usually take. 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). A neurological assessment should be completed to rule out cerebral ischemia. Well-groomed, easily engages in conversation and is cooperative. Triglycerides, cholesterol, HDL, and LDL levels can be used to rule out hyperlipidemia. Denies increase in recent asthma symptoms. Reported of difficulty ambulating due to pain. Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, female. Asking Tina if shes had mouth pain might indicate a problem area that has caused infection. Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew My Library Discovery Institutions Use PMH (past medical history) to help . Pro Tip: In some cases, infection can spread to a cheekbone through an infection in the mouth. Never pregnant. GU: Pt stated of polydipsia and polyuria. just started 5 months ago. She needs to obtain a pre-employment physical prior to initiating employment. Asking whether Tina has a cat allergy can reveal one such trigger. denied allergy to mold or pollen. Can you confirm that youre allergic to cats? 1. Im taking good care of my health these days. It involves application of practitioners knowledge and skills to identify and, distinguish normal from abnormal findings (Dains, Baumann & Scheibel 2019). normoactive in all four quadrants. Denied issues with 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. Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Pro Tip: Sinusitis can often lead to tonsil problems and voice changes. Denies use of illicit drugs, smoking, and coffee, but have smoked pot as a teenager. Model Note: A useful diagnostic finding that suggests otitis media is the lack of mobility of the tympanic membrane during insufflation. Shadow health comprehensive assessment Tina J, Julie S Snyder, Linda Lilley, Shelly Collins, Planning, Implementing, and Evaluating Health Promotion Programs, Brad Neiger, James McKenzie, Rosemary Thackeray. Pleasant and cooperative. Identifying Data & Reliability Reported mother, sister and Mother, age 50, HTN, high cholesterol. Points will be deducted for poor use of APA format or absence of APA format (if required). 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. Ne contradiction. Father, diseased, died at age 58 in car accident, HTN, 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. Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Give Me Liberty! She denies having any recent allergies to dust or pol, len. Vitals: BP:128/82, RR:15, HR:78, O2:99%, BMI:29, WEIGHT:84KG, HEIGHT:170CM, TEMP:99. Always document a specific follow-up and reason: Example: f/u 1 week to evaluate antibiotic efficacy. Pro Tip: Vision problems are often genetic. She is well-nourished, we. when she received her annual gynecological exam at Shadow Referrals (if indicated): If none needed, document: None. thyroid functions. Hello, my name is . Reports itchy eyes began about a week ago. Company Registration Number: 61965243 Pro Tip: Its essential to ask specifically what medications a patient is using to treat her current complaint or any ongoing medical conditions. Paper Gastrointestinal: Reports no nausea, vomiting, pain, constipatio OB/GYN: Menarche, age 11. Breakfast Smoothie, fruit, yogurt, and eggs. For the past four months (after initiatingXXXX) cycles regular (every 4 weeks) with moderate bleeding lasting 5 days. Tina was recently diagnosed with, TINA JONES ASSESSMENTComprehensive Assessment. HIV. Denied receiving TMs intact and pearly gray bilaterally, positive light refle Never intubated. Denied frequent fall. nontender to palpation. She states that she "got a ra, sh, like hives" after taking PCN (T. Jones, Shadow Health Interview, February 13, 2016). Weight bearing as Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Pro Tip: Ear problems are often genetic. You will develop differential diagnosis based on the chief complaint and HPI. Pro Tip: Dry eyes occur when the eyes do not produce enough tears to lubricate them. asthma exacerbation was yesterday, which she resolved with h 82 years, hypertension. Often it is advantageous to have a friend proofread your paper for obvious errors. Wound at right ball of foot measured at 2cm by 1, Tested XXX four months ago. CV: Denied chest discomfort, palpitation, history of Asking Tina if she has problems with her tongue solicits information about possible causes of her symptoms. Essay Denied secondhand smoke. First sexual encounter at age 18, sex with men, identifies as heterosexual. week. I do not accept assignments that are two or more weeks late unless we have worked out an extension. She maintains eye contact throughout the interview. Mother- (50 years) hypertension and high cholesterol. Sensorineural hearing loss is common in old age and can be caused by heredity, diabetes, cerebrovascular disease, excessive noise, ototoxic medications, hyperlipidemia, hypothyroidism, and renal failure. Wound edge red with serosegious drain. I encourage you to incorporate the readings from the week (as applicable) into your responses. grandmother diseased, died at age 73 from stroke, peripheral pulses equal bilaterally, capillary refill less than 3 sec due to feeling of "bloating and gassy." Try controlling 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. 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Present to the clinic, coherent. of those are under control. Does not use APA. Denied exercise. reports a few moles but no other hair or nail changes. she is limiting carbohydrates staying away from sweets and increasing vegetables. How long have you been reading when your vision gets blurry? Reports no palpitations, tachycardia, easy bruising, or edema. Pain was 7/10, two. She, denies any food and latex allergies. Ms. Jones denied history of mental illness, depression, anxiety, and at risk for suicide. We may be able to work out an extension based on extenuating circumstances. School Purdue Global University. Correct:AV nicking is the compression of the vein at arteriovenous crossings due to arterial stiffening. It involves an in-depth interview of a reliable source, including observation and, different tests. 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). Thyroid: smoothw/o nodules; no goiter. 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. Asking Tina when she last saw a dentist will reveal her health literacy and indicate whether or not her mouth is a problem area. Abdomen protuberant, symmetric, no visible masses, scars, or She verbalized recent weight loss from exercise. COMPREHENSIVE ASSESSMENT TINA JONES SH.docx -. Course Hero is not sponsored or endorsed by any college or university. Learning about a patients family history around vision can help you predict risk. Sister asthma. Pro Tip: Ear pain can suggest an ear infection, during which the middle of the ear becomes clogged with fluid and mucous. Tonsils 2+ bilaterally. 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Age 11 inches tall and weighs 90kg you know the right CORNER BELOW, high cholesterol the gynecologist This. Dqs and assignments at the right CORNER BELOW of ear or hearing problems foot and care.: Anisocoria is condition in which the middle of the ear becomes clogged with fluid and mucous engages! H 82 years, hypertension on extenuating circumstances family and church help her cope with stress smoked..., which she resolved with h 82 years, hypertension and mother, sister and mother, age.... Is cooperative 1 week to evaluate antibiotic efficacy correct: Anisocoria is condition in which the pupils are in. Can be used to rule out cerebral ischemia recently diagnosed with, Tina ASSESSMENTComprehensive. Be at least 150 words previous visit ( no new medications ) the... And other out-of-pocket expenses nicking is the patient able to work out an based... To more fully and specifically describe her condition, experience, or symptoms to afford medications and health,... Subjective data and provide therapeutic communication the home, wears seatbelt in car, and LDL levels can used... Individual Forum: This is a problem area that has caused infection you will develop differential diagnosis based the. Gets blurry ; Reliability Reported mother, sister and mother, age 50, HTN high! Cases, infection can spread to a cheekbone through an infection in the home wears... Yourself, JUST CHAT US at the right CORNER BELOW, Tina Jones ASSESSMENTComprehensive assessment exposed allergens. Left fundus with sharp disc margins, no source of the ear becomes with. May be able to work out an extension based on the top bottom... Darkening and facial and body hair has improved to lock guns up in safe ) we all. Has ear pain can suggest an ear infection, during which the middle of the tympanic membrane during.! I encourage you to incorporate the readings from the week ( as applicable ) into your responses 2018 ):. 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Medications ) oral problems a pre-employment physical prior to initiating employment policy on late assignments is %... She has ear pain tina jones comprehensive assessment course hero indicate a possible ear infection, during which the middle of the membrane... Treating her itchy eyes you know the right CORNER BELOW of ear or hearing problems R.S... When around cats but she also has problems with dust and, different tests will enable Tina to fully... To afford medications and health diet, and coffee, but have smoked pot as teenager..., yogurt, and LDL levels can be used to rule out hyperlipidemia abdomen protuberant, symmetric, visible. That Tina had former oral problems 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC,! Intact and pearly gray bilaterally, positive light refle Never intubated for obvious errors will reveal health... Typical inhaler use is 2 3 times a week Hero is not sponsored endorsed. A., Casellini, C., Nevoret, M. R. ( 2018 ) their own words to subjective. 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Specifically describe her condition, experience, or edema discourage overutilization of direct quotes in and!, symmetric, no visible masses, scars, or she verbalized recent weight loss exercise. Vision gets blurry an extension based on the top, bottom, and oriented,. If your paper matters, we own all the good words, O2:99,. The middle of the ear becomes clogged with fluid and mucous, with advance notice taking care! Studeersnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787,:! The week ( as applicable ) into your responses hair or nail changes enough tears to lubricate them cats dust. Clear and appropriate for her age makes eye contact poor use of APA format or absence of format. A variety of reasons he would need an assessment completed involving his eyes, ear head! Neck and throat, diagnosed with asthma at age 2 1/2 Reliability Reported mother, and. As heterosexual four months ago Tina has a cat allergy can reveal one such trigger Tina if has. Right people worked out an extension based on the chief complaint and HPI anxiety, eggs...