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SOAP Note (14) Health History | Completed | Shadow Health, Advanced Health Assessment - August 2019, N5544. . The "fast heartbeat" is lo alized t the left For the past four months (after initiating Yaz) cycles regular (every 4 weeks) with moderate bleeding lasting 5 days. Reports improved acne due to oral contraceptives. Besides nursing care, assess the patients mental health, pain management, dietary habits as well as any social needs. Do you have any problem with your breasts? Any pending input will be lost. Pro Tip: Discerning whether anything is making Tinas asthma worse can point to possible triggers like environmental factors, bodily positions, or movements that may have a bearing on Tinas breathing. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. College Physics Raymond A. Serway, Chris Vuille. Do you take your pill at the same time every day? . I made sure to clean it and just keep it bandaged. s1 and s2 heard without murmurs or additional sounds. No, Ive still never had problems with seizures, fortunately. Pro Tip: Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition. Denies any dizinness, ligh-headedness, loss of sensation, tingling, numbness Denies any seizures or sense of disequilibrium. Medications include Flovent and rescue inhalers. Ear drainage? Over th At the top of this section, you will see a key indicating the status of each opportunity. Everything's an Argument with 2016 MLA Update University Andrea A Lunsford, University John J Ruszkiewicz. Ive been feeling much better lately, though. I am glad you are having your period every month. But my zits have gotten better, and I think its because Im on birth control now. about 8 or 9 hours a night. Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan. This is the raw score you achieved on your attempt. Some of these items may not appear depending on the assignment and the options set by your instructor. Additionally, you will see an example question that would unlock the finding. TIna states she does not drink coffee and alleviate her palpitations Company Registration Number: 61965243 they also make her jittery. Have you noticed any side effects from the metformin? auscultation without wheezes, crackles, or cough. : an American History, 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. Nursingstudy.orgs Shadow Health Comprehensive Assessment writing services can help you to create a thoughtful and well-organized document that meets all of the requirements of the SHCA. Privacy Statement, Stuvia is not sponsored or endorsed by any college or university, Also available in package deal from $24.99, Pennsylvania State University - All Campuses, Rutgers University - New Brunswick/Piscataway, University Of Illinois - Urbana-Champaign, Essential Environment: The Science Behind the Stories, Everything's an Argument with 2016 MLA Update, Managerial Economics and Business Strategy, Primates of the World: An Illustrated Guide, The State of Texas: Government, Politics, and Policy, IELTS - International English Language Testing System, TOEFL - Test of English as a Foreign Language, USMLE - United States Medical Licensing Examination, Shadow Health Focused Exam Abdominal Education Empathy, SHADOW HEALTH FOCUSED EXAMS ALL IN ONE BUNDLE, Education & Empathy : 6 of 7 (85.7%) During the patient interview, there are a number of opportunities to provide patient education and empathy. The opportunities listed below are those identifie. I am glad you came in. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Scattered pustules on face and facial hair on upper lip, Right eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema, Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema, Thyroid smooth without nodules, no goiter, Upper eyelids: conjunctiva pink, no lesions, white sclera, Lower eyelids: conjunctiva pink, no lesions, white sclera, Right pupil: equal, round, reactive to light, Left pupil: equal, round, reactive to light, Peripheral vision intact in both eyes, all fields, Inspected interior eyes with ophthalmoscope, Left fundus with sharp disc margins, no hemorrhages, Right upper quadrant: no masses, guarding or rebound, Right lower quadrant: no masses, guarding or rebound, Left upper quadrant: no masses, guarding or rebound, Left lower quadrant: no masses, guarding or rebound, Liver: palpable 1 cm below right costal margin, Neck without swelling, masses, or deformity, Right shoulder without swelling, masses, or deformity, Right arm without swelling, masses, or deformity, Right elbow without swelling, masses, or deformity, Right wrist and hand without swelling, masses, or deformity, Left shoulder without swelling, masses, or deformity, Left arm without swelling, masses, or deformity, Left elbow without swelling, masses, or deformity, Left wrist and hand without swelling, masses, or deformity, Fingernails: no ridges or abnormalities in nails, pink nailbeds, Hips without swelling, masses, or deformity, Right leg without swelling, masses, or deformity, Right knee without swelling, masses, or deformity, Right ankle without swelling, masses, deformity, or discoloration, Right foot without swelling, masses, or deformity, Left leg without swelling, masses, or deformity, Left knee without swelling, masses, or deformity, Left ankle without swelling, masses, or deformity, Left foot without swelling, masses, or deformity, Toenails: no ridges or abnormalities in nails, pink nailbeds, 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs, Height: 170 cm Weight: 84 kg BMI: 29.0 Blood Glucose: 100 RR: 15 HR: 78 BP:128 / 82 Pulse Ox: 99% Temperature: 99.0 F, The patient is a 28-year-old female who presented for a pre-employment physical exam. Let me learn more about what youre experiencing, and I will try to help.". location of pain. I had two doctors appointments earlier this year. Advanced Health Assessment for the APN - Fall 2021, 625, /site_notice_dismissals?from_flash=true&site_notice_id=499, Sales Tax Notification: Elsevier Inc. DBA Shadow Health charges applicable sales tax as required by state and local, /site_notice_dismissals?from_flash=true&site_notice_id=283. (Clarified to if I have ear drainage.). She denies use of tobacco, alcohol, a Last menstrual period 2 weeks ago. Essential Environment: The Science Behind the Stories Jay H. Withgott, Matthew Laposata. Review of Systems: General: Denies changes in weight, but The first number represents the amount of points you earned. Hematologic: She denies history of anemia, easy bruising or Pro Tip: Palpating the thyroid gland for size, shape, and consistency, and noting any nodules or tenderness, helps to identify signs of a thyroid disorder. Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. She describes t Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. Pro Tip: Discerning whats making Tinas asthma worse can point to possible triggers like environmental factors, bodily positions, allergies, or movement that may have a bearing on Tinas breathing. Things are pretty good between all of uswere a tight knit family. A, is provided as an example of an appropriate, are opportunities that were not elicited in the interview, are missed opportunities that were present in the interview, but where no statements were made, were followed up by students, and include the dialogue between student and patient. Question maintains eye contact throughout interview and examination. My discharge is normal, I think. Hover over thePatient Dataitems below to reveal important information, includingPro TipsandExample Questions. The following details are facts of the patients case. Heart rate is is regular and normal. During the patient interview, there are a number of opportunities to provide patient education and empathy. ABI is 0. The episodes generally Hes a little big, maybe. Thorough examinations will yield better patient data. The Shadow Health Comprehensive Assessment Process (SHCAP) is used to assess the health and functional status of patients. All you need to do isplace an orderwith us. -pain lasted 3 days. -does not radiate or migrate. Im hoping Ill learn a lot in that position, and within a couple years, Ill get promoted and be given new responsibilities. Everything's an Argument with 2016 MLA Update University Andrea A Lunsford, University John J Ruszkiewicz. Respiratory (75 mins) Respiratory education.pdf, Respiratory Assignment _ Completed _ Shadow Health 12.pdf, 1 Cardiac 2 Respiratory 3 Gastrointestinal 4 Genitourinary Answer 3 Explanation, 103 AZUMA HOEFFDING INEQUALTITY 331 new process e D e D n n 1 defined by e D n H, ling to check before trying to assign it to the temporary object Each of these, Biguanides MetforminGlucophage o Decrease glucose production by the liver o, Dividends are usually paid by mature companies that need further incentives for, C increases the NAIRU D decreases the official unemployment rate E decreases the, Always consider checking myUnisa for any communication from the lecturer or, 2021-09-27-180925Managerial_Communication.docx, Correct correlational non experimental quantitative descriptive non experimental, A14 Consider the K a values for the following acids Cyanic acid HOCN 35 10 4, 18 All of the following is true of the Critical Perspective except a It asserts, A 51 yo male has been diagnosed with chronic bronchitis after a long history of, ADN TEST 4 A-Notes for Metabolism & Nutrition (1).docx. Im glad you came in. Ive realized that I got kind of overwhelmed with everything back when I was having those sleep problems. The second number represents the total possible points in the assignment. Here you will see a verbatim record of every interaction you had with the patient. Diana Shadow : Your patient is Tina Jones:, a 28-year-old African American woman who has just been admitted to Shadow General Hospital for a painful foot wound. Clicking on each of the Education & Empathy topics will show you more information and the part of your transcript. The formula used to decide your DCE Score is NOT a flat curve, rather it is based on a standard deviation of results. Tina Jones is alert and oriented x3 and she is a credible source of her If the Reopening feature is enabled, you can make up the lost point in the education and empathy section by recreating the opportunity. Tina Jones endorses that she does not really watch her diet. My eyes havent been red lately. 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