Any chest tightness? Liberty University What is the name of the inhaler prescription? She states that her nose runs all day. We encourage our clients to rate and review(optional) their writer. Hi. How do I feel about the overall experience? I guess I was noticing the other day that the skin around my neck is looking weird. Documentation - Tina Jones Neurological Shadow Health assessment. When did you notice the increase in your appetite? Discuss need to maintain regular sleep and wake schedule and sleep hygiene techniques including limiting caffeine after 2pm, limiting fluids after dinner, limiting screen time or stimulating activities after 8pm, and to get out of bed if awaken in the middle of the night. score may not be your final grade if your instructor What health issues does your sister have? It hurts a lot, and the pain pills havent kicked in yet. Does complain of increasing daytime fatigue. Two days later, however, she developed a bilateral temporal dull ache accompanied by neck ache. . Getting Started: View this tutorial for guidance on getting started with the HEENT Assignment. Twice a day every morning and every night. The respiratory exam is an interview and physical assessment that is performed when a patient presents with a respiratory problem or a history that is suggestive of a pathology of the lungs. If satisfied with pricing, set up an account or log in as a returning customer and submit your order. Getting Started: View this tutorial for guidance on getting started with the Mental Health Assignment. At first, it seemed like it was healing up fine and it didnt give me a lot of pain. Hes a little big, maybe. It's a lot. Were you on oral contraception when you did not use a condom? And the pain is killing me! Asthma is a pulmonary condition defined by chronic inflammation of respiratory tubes, tightening of smooth muscle and bronchoconstriction. How old was your maternal grandfather? No, I was stone-cold sober. She describes episodes as <thumping in her chest= with a heart rate that is <wa faster than usual=. Denies changes or difficulties in coordination. Im sorry youve been experiencing these symptoms. Psychiatric: States that her mood has been "off" and she does not feel like herself. It should include what type of treatments will be given, such as medication, therapies, and surgeries. My inhaler is the only prescription I always have, but I usually dont need it everyday, except for recently. b.) $15.95 El vendedor le explic a la seora Gumucio las condiciones de pago. How many alcoholic drinks do you have in one sitting? As soon as you complete payment for your order we assign a suitable writer capable of handling your assignment immediately. Why arent you taking your diabetes medication? Asked to rate current pain level on a scale, Reports pain is sharp when she attempts to stand, Reports pain has increased in the past 2 days, Reports feeling pain radiating into ankle, Reports pain prevents bearing weight on foot, Reports wound is on the plantar surface of her foot, Reports she scraped foot on a cement step, Reports initial injury occurred 1 week ago, Reports being barefoot at the time of injury, Asked about the assessment of the injury at the ER, Reports going to the ER after sustaining the injury, Reports going to the ER because she suspected an ankle sprain, Reports receiving a prescription for pain pills, Reports that the wound bled a little after sustaining the injury, Reports cleaning wound with hydrogen peroxide, Reports applying bacitracin, neomycin and polymyxin B (Neosporin), Reports swelling worsened in the past 2 days, Explored impact of patients foot injury on activities of daily living, Reports pain affects ability to stand at work for long periods of time, Reports pain prevented her from being able to walk to class, Asked about preexisting medical conditions, Asked about diabetes management through lifestyle changes, Reports drinking diet soda instead of regular, Asked about current diabetes medication use, Reports that she does not currently take medication for diabetes, Reports that she used to take diabetes medication, Reports previous medication was prescription metformin, Reports last use of medication was 3 years ago, Reports infrequent blood glucose monitoring, Reports last glucose check was a week ago at the ER, Reports confusion about what the numbers mean, Reports urinating every hour or two during the day, Reports urinating 2 to 3 times during the night, Reports change in appetite began a month ago, Reports weight loss occurred over the past month, Asked about history of asthma exacerbations, Reports last asthma attack was in high school, Reports last exacerbation was three days ago, Reports chest tightness during exacerbation, Reports difficulty breathing during exacerbation, Reports last hospitalization was for asthma, Reports about 5 total hospitalizations for asthma as a child and teen, Reports specific age of diagnosis is 2.5 years old, Reports last use of inhaler was 3 days ago, Reports using inhaler no more than 2 times per week, Asked about number of puffs when using asthma inhaler, Reports recommended dose is 1-3 puffs as needed, Reports sometimes needing 3 puffs to control symptoms, Reports asthma triggered by running up stairs, Reports sneezing, itchy eyes, and wheezing, Reports that penicillin resulted in hives in childhood, Asked if the patient has allergies to dust, mold, or pollen, Reports dust causes sneezing, itchy eyes, and wheezing, Asked about general immunizations received, Reports receiving all necessary childhood immunizations, Asked if the patient has received a flu vaccine, Asked if the patient received a tetanus immunization, Reports last tetanus vaccination was in the past year, Reports that last BP reading was 140 over 80 or 90, Reports taking prescription pain medication, Reports taking pain medication for 2 days, Followed up on efficacy of pain medication, Reports that pain pills provide partial relief, Reports pain returns in full every few hours, Asked about other prescription medications, Reports occasionally taking Advil (ibuprofen) for cramps, Reports occasionally taking Tylenol (acetaminophen) for headaches, Denies finances are a barrier to healthcare, Denies transportation is a barrier to healthcare, Reports that she got sick of the demands of medication compliance, Denies that cost of metformin was reason for discontinuing medication, Denies that glucometer-related costs are reason for not checking blood glucose, Reports currently working toward undergraduate degree, Reports family members will be able to help with activities, Reports she is currently under high stress, Reports last meal was dinner time the previous night, Reports last meal consisted of baked chicken and mashed potatoes, Reports breakfast is usually a muffin or pumpkin bread, Reports dinner is usually a home-cooked meat dish and side of vegetables, Reports snacks are pretzels or French fries, Reports drinking up to 4 diet sodas per day, Reports history of recreational marijuana smoking, Reports she stopped because of health reasons and waning interest, Reports last alcoholic drink was 3 weeks ago, Reports no more than 2 or 3 alcoholic drinks in one sitting, Reports no more than 1 or 2 nights a week drinking alcohol, Reports mother diagnosed with high blood pressure, Reports mother diagnosed with high cholesterol, Reports father was diagnosed with Type 2 diabetes, Reports father was diagnosed with high blood pressure, Reports father was diagnosed with high cholesterol, Reports cause of death was a car accident, Followed up on coping with fathers death, Asked about paternal grandfathers health, Reports paternal grandfather diagnosed with Type 2 diabetes, Reports paternal grandfather diagnosed with high blood pressure, Reports paternal grandfather diagnosed with high cholesterol, Reports paternal grandfather died of colon cancer, Asked about paternal grandmothers health, Reports paternal grandmother diagnosed with high blood pressure, Reports paternal grandmother diagnosed with high cholesterol, Asked about maternal grandfathers health, Reports maternal grandfather diagnosed with high blood pressure, Reports maternal grandfather diagnosed with high cholesterol, Asked about maternal grandmothers health, Reports maternal grandmother diagnosed with high blood pressure, Reports maternal grandmother diagnosed with high cholesterol, Denies brother having diagnosed health problems, Reports that family members are overweight, Asked about family history of thyroid issues, Asked about family history of substance abuse, Asked about review of systems for mental health, Asked about review of systems for eyes and vision, Asked about review of systems for mouth and jaw, Reports last dental visit was several years ago, Asked about review of systems for neck, throat, and glands, Asked about review of systems for respiratory, Asked about review of systems for cardiovascular, Asked review of systems for gastrointestinal, Asked review of systems for genitourinary, Reports waking up to urinate during the night, Denies history of urinary tract or bladder infection, Reports last menstrual period was 3 weeks ago, Reports menstruating every 6 weeks to 2 months, Reports changing tampon every 2 to 3 hours, Reports cramps for the first 2 days of period, Asked about treatment of menstrual symptoms, Reports using a heating pad at home to treat cramps, Reports taking ibuprofen for first 3 days of period, Reports ibuprofen effectively reduces pain from cramps, Reports that she prefers to sleep with men, Reports first sexual activity was at age 18, Reports last sexual activity was 2 years ago, Reports no current use of any oral or hormonal birth control, Reports last taking oral contraception a couple of years ago, Reports she didnt see the point in taking contraception while single, Reports past sexual encounters without condoms, Reports oral contraceptive use while sexually active, Reports uncertainty about past partners and STI testing, Asked review of systems for musculoskeletal, Denies recent loss of consciousness or fainting, Denies problems with balance or disequilibrium, Asked review of systems for skin, hair, and nails, Reports no body sores (aside from foot wound). In this portion you want to give a clear clinical picture of what is going on with the patient. The tongue is symmetric with not abnormal findings while the bilateral upper and lower extremity DTRs equal and 2+ bilaterally. Stereognosis and graphesthesia intact bilaterally. No scleroicteris. This occured about five days ago, but the patient was in a minor "fender bender" a week ago. a.) She has used marijuana in the past, but no current use and denies other illicit drugs. Ears: Denies hearing loss, tinnitus, vertigo, discharge, or earache. 11/02/21 7:31 PM EDT. Does your paternal grandmother have health problems? Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have. Patient narrative: Three days ago, Ms. Jones injured tweaked her back lifting a box. I asked Mrs. Smith about her health history and tried to find more in- formation about her low back pain, cough, and frequent urinary tract infections. 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