Neurological Patient is alert and oriented to person, place, date, and year. Heart rate is regular, S1, S2, no murmurs, gallops or rubs. Do you have swelling? Denies current sleep issues Firstly, it seems that Ms. Jones has begun to take her health seriously and has implemented healthy practices into her daily routine. Abdomen tympanic on percussion. Personal and Social History: ago, twisting her right ankle, and scraping the ball off her foot. Pro Tip: Follow up questions about Tinas birth control prescription can help you to understand how effectively she complies with her treatment plan. 850 mg twice daily. Finding: Tina reports she has improved her diet by limiting carbohydrates, staying away from sweets and increasing vegetable consumption. Reports a typical snack is carrot sticks or an apple type 2 diabetes (DM 2) Finding: (Found) COMPREHENSIVE HISTORY (Subjective Data), Date & Time: 1/20/2023 at 8pm Finding: She doesnt monitor her blood sugar regularly at home. Comprehensive Health History for Shadow Health History & Final Comprehensive Health Reports swimming for exercise Reports menstrual cycle is normal She drinks socially when out with friends about 2-3 times per month, and her caffeine intake has decreased to 1-2 diet sodas per day. Position sense on toes and fingers intact. chest pain, and irregular heartbeat. Chest resonant on percussion. In: StatPearls [Internet]. Not only are these objectives in line with Healthy People 2020 (#4 of the 24 objectives) but they will aid in the control her diabetes and PCOS. Ms. Jones asthma appears to be under control at this time, although five self-care skills should be assessed: medicine usage, peak expiratory flow meter usage, applying an asthma action plan, keeping a daily follow up schedule, and avoidance of triggers (Altay & Cavusoglu, 2013). Denies current breathing problems She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. Use Coupon CODE: SAVE15, 2013 - 2023 Online Nursing Essays. Brother (Michael, 25): Overweight. A dietician referral may be beneficial to educate on specifics and offer support. Pro Tip: Dust is a common allergen, and discovering its effect on asthmatic patients is particularly important. She is a good historian. What reason did you decide to start taking birth control? Do you perform breast self-exams? Asking Tina what she typically has for dinner will illustrate her recent dietary patterns. Position sense in fingers and toes are normal. Reports starting birth control 4 months ago Another abnormal finding was the discoloration on her neck. Reports taking prescription birth control pills Denies genitourinary issues Self-care instruction should include reiterating the importance of taking her pill the same time every day to prevent pregnancy, the fact that the pill does not protect against sexually transmitted disease (STD) and that a form of protection needs to be used to protect against STDs when the time comes. Adult Illnesses: Negative for mental illness, other cancers, sudden death, kidney disease, sickle cell anemia, and Reports last optometrist visit was 3 months ago A comprehensive health history and physical examination revealed current health status, health behaviors and health issues of Ms. Tina Jones. Office of Disease Prevention and Health Promotion. Finding: All of the papers you get at MyCoursebay are meant for research purposes only. Firstly, it seems that Ms. Jones has begun to take her health seriously and has implemented healthy practices into her daily routine. Communication is so very important. ages of 15 and 21. When was the last time you took ibuprofen? room, where she underwent negative x-rays and received tramadol for pain management. Asking Tina what she typically has for a snack will illustrate her recent dietary patterns. Screening tests Last Pap smear was four years ago. Pro Tip: When doing a review of the musculoskeletal system, you will want to ask about general symptoms that will allow Tina to describe, in her own words, any specific bone or muscle problems that she is experiencing. The papers are not supposed to be submitted for academic credit. Denies cardiovascular issues (Found) Ms. Jones reports no shortness of breath or trouble breathing. Musculoskeletal. The object is in equilibrium if the forces are equal in magnitude and opposite in direction. medicationforherdiabeteswillindicatehertreatmentplanandthedegreetowhichshe Pro Tip: Determining if Tina has experienced any side effects of her diabetes medication will help you determine the efficacy and appropriateness of her medication. Asking Tina what exercise she does can help you to assess her current levels of health and nutrition. How many drinks do you have in a sitting? Assessment Tina Jones comes in for a follow-up/general physical exam. support her in managing stress. She is now on metformin, Proventil, and Flovent. Found: Reports occasional wheezing (2018). Reports that a typical walk is thirty or forty minutes Finding: (Found) (2014). Uses alcohol one to The estimated average time to complete this assignment each time is 3 hours. Finding: Denies history of breast cancer He had hypertension, high cholesterol, and type 2 diabetes. hertreatmentplanandthedegreetowhichshecomplieswithit. Asked about blood glucose monitoring. Finding: Example Question: January 30, 2023. A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. You may also need to provide further support and resources to the patient. Monofilament test shows decreased sensation in both right and left great toes and forefoot. thyroid problems. Example Question: Pro Tip: Discovering the reason a patient has been taking pain medication is a crucial part of the history of her condition or injury. A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. Oriented to person, place, and time. Finding: Finding: Finding: Finding: (Found) States skin on neck has stopped darkening. (Found) She regularly monitors her blood glucose levels, checking once a day in the morning. Reports a typical dinner is vegetables with a protein and brown rice or quinoa Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. i got the paper a bit late but it is good quality will for sure come back and use this website. Her snacks consist of pretzels or French fries. Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Example Question: Health Maintenance: No exercise but states her work keeps her very active. History Expertsselectedthesetopicsasessentialcomponentsofastrong,thoroughinterviewwiththis Bickley, L. S., & Szilagyi, P. G. (2013). Drospirenone and ethinyl estradiol: one pill every day. And lastly, the pustules on Ms. Jones face are consistent with a diagnosis of acne vulgaris (Dains, Baumann, & Scheibel, 2012). Normal hair distribution. Pro Tip: Asking if Tina is currently sexually active will help you determine is she is practicing safe sex and has any potential health risks. establishesatimelineofhercurrenttreatmentplan. Full ROM and 5/5 strength in extremities, spine, and hips. Pro Tip: Asking Tina about how many puffs of her inhaler she typically takes can help you determine if the treatment is effective and appropriate for her health needs. Research Request a Demo For Shadow Health billing/invoicing questions, email our billing team or call 800-222-9570. Do not use Nose/sinuses: Rhinitis and congestion related to cat allergy. She is the primary source of information and is reliable. What is your typical breakfast? Although Ms. Jones is not sexually active, she states she probably will be soon. CanIconfirmthatyouarehereforaphysical? Please communicate with me if you anticipate having to submit an assignment late. severityofhersymptoms,herhealthliteracy,andthewayshe'scompliedwithprevious She reports her type 2 diabetes is being well managed with metformin, diet and exercise. This type of neuropathy is slowly progressive and maintaining an HgA1C level at less than 7.4% reduces this progression (Bickley & Szilagyi, 2013). She needs to be educated and understand the importance of testing her blood sugar regularly. Reports recently beginning dieting to manage diabetes She maintains Example Question: Ms. Jones is sitting comfortably on the examination table, in no acute distress. Finding: andaccesstohealthcare. lunch, meatloaf, or chicken for dinner. Retrieved fromhttps://lc.gcumedia.com/nrs429vn/health-promotion-health-and-wellness-across-the-continuum/v1.1/, Muslim Community Services of San DIego. She appears well-nourished and dresses appropriately. Reports recent weight loss. Medical: Type 2 diabetes, diagnosed at age 24. Pro Tip: Tinas response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. Followed up about birth control prescription. Are you experiencing adverse effects from your diabetes medication? Diabetes requires self-management behaviors for life. These allergens aggravate her asthma symptoms, so she tries to avoid them. Pro Tip: Asking Tina about the recommended dose of her inhaler can help you determine if the treatment is effective and appropriate for her health needs. Review the report by clicking on each tab to the left titled; Transcript, Subjective Data Collection, Objective Data Collection, Documentation, and SBAR to compare your work. Do you have a history of breast cancer? (Found) She regularly monitors her blood sugar levels and feels more comfortable with her knowledge regarding the meaning of the readings. (Found) A "pass" on the SHCA means that the student has answered all ten questions correctly. (Found) Tina jones comprehensive. Paternal grandmother: still living, age 82, hypertension. She states she can cope well with upcoming life changes. Example Question: Example Question: Have you been exercising? Reports last visit to a healthcare provider was 4 months ago Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Acanthosis nigricans is a common condition characterized by velvety, hyperpigmented plaques on the skin (Sander, 2018, para. Fill out the Template, add an APA Cover Page, and an APA Reference list. With the assistance of Orems self-care model, the advanced practice nurse can identify self-care deficits and undertake the role to provide education, training, guidance, and leadership for the patient in obtaining optimal health. 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