Name:
Section:
Week 4
Shadow Health Digital Clinical Experience Health History Documentation.
Assignment 2: Digital Clinical Experience (DCE): Health History Assessment
In Week 3, you began your DCE: Health History Assessment. For this week, you will complete this Health
History Assessment in your simulation tool, Shadow Health and finalize for submission.
To Prepare
· Review Student Checklist: Health History Guide and the History Subjective Data Checklist, provided in
this week's Learning Resources, to guide you through the necessary components of the assessment. (See
attachment)
· Review the DCE (Shadow Health) Documentation Template for Health History (Attached)
· Use the template (Attached) to complete your Documentation Notes for this DCE Assignment.
Assignment Instructions :
Complete the Health History of Tina Jones (see below information and attached transcript “Tina Jones
Transcript”) – To complete the assignment, please use the attached template.
Identifying Data & Reliability
Ms. Jones who is 28 yrs. old, obese African American single woman who presents to establish care and
with a right foot injury.
She is the primary source of the history. Without contradiction, she freely provides specific details of her
injury and of her visit. Her speech is clear and coherent. She maintains eye contact throughout the
interview.
General Survey
Patient is 28 yr. Old single African American, alert, awake, and oriented x 3. She is pleasant; her speech
is clear and coherent. Appears healthy, well-developed and well nourished. obese.
VS obtained BP 142/82, HR 86, RR 19, T 101.1, SPO2 99%, blood sugar 235. Weighs 90kg and BMI is 31.
Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress.
She is well-nourished, well-developed, and dressed appropriately with good hygiene.
Chief Complaint
“I got this scrape on my foot a while ago, and I thought it would heal up on its own, but now it's looking
pretty nasty. And the pain is killing me!”
Symptoms: Right foot pain accompanied by drainage. Pain affects ability to walk or put weight on it.
Also, affects sleep. Pain 7 out of 10.
Diagnosis: infected right foot wound.
History Of Present Illness
Tina fell going down the back steps of her house. Ms. Jones reports that a week ago she tripped while
walking on concrete stairs outside, twisting her right ankle and scraping the ball of her foot and scraped
the sole of her right foot. Her wound bled and she was able to stop the bleeding. She cleaned the wound
and went to the ER fearing that she sprained her ankle. ER X-rayed her foot and reported no fracture
seen. They gave her a prescription for a 5-day supply of Tramadol 50 mg. She cleaned her wound twice
daily with soap and water or hydrogen peroxide, let it dry, and then she has been applying antibiotic on
the scrape and covered with a dressing. The wound wasn't getting worse, but it wasn't getting any
better. Two days ago, she noticed pus was in the wound, and that there was swelling and redness and a
warm feeling in her foot. She had a fever last night and didn't take any medication for it.
She said tramadol doesn't seem to work too well.
She reports that ankle swelling, and pain have resolved but that the bottom of the foot is increasingly
painful. The pain is described as “throbbing” and “sharp” with weight bearing. She states her ankle
“ached” but is resolved. Pain is rated 7 out of 10
after a recent dose of tramadol. Pain is rated 9 with weight bearing. She reports that over the past two
days the ball of the foot has become swollen and increasingly red; yesterday she noted discharge oozing
from the wound. She denies any odor from the wound. Her shoes feel tight. She has been wearing slip-
ons. She reports fever of 102 last night.
She denies recent illness.
Reports a 10- pound, unintentional weight loss over the month and increased appetite. Denies change in
diet or level of activity.
Medications
Tylenol 500-1000 mg PO prn (DX: headaches),
Tramadaol 50 mg PO - 2 tabs PO TID (ED dispensed 30 pills) (DX: R foot pain),
Ibuprofen 600 mg PO TID (DX: menstrual cramps)
Albuterol 90 mcg/spray MDI- 2 puffs Q4H prn (DX: wheezing); last time pt used was a month ago)
Acetaminophen 500-1000 mg PO prn (headaches)
Allergies
· Penicillin (rash)
· Allergic to cats and dust (sneezing, itchy eyes; asthma acts up);
denies food and latex allergies
· When she is exposed to allergens, she states that she has runny nose, itchy and swollen eyes, and
increased asthma symptoms.
Medical History
· Diagnosed with Type 2 diabetes at age 24, but is not taking any medication for diabetes and does not
monitor blood sugar She previously took metformin, but she stopped three years ago, stating that the
pills made her gassy and “it was overwhelming, taking pills and checking my sugar.” She doesn't monitor
her blood sugar. Last blood glucose was elevated last week in the emergency room.
· Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler when she is around cats and dust.
She uses her inhaler 2 to 3 times per week. She was exposed to cats three days ago and had to use her
inhaler once with positive relief of symptoms. She was last hospitalized for asthma “in high school”.
Never intubated.
· Has irregular menstrual cycles with heavy menstrual flow and painful cramping (6 menstrual cycles/
year);
· Recent 10 pounds weight loss (not knowing how);
· Increased thirst and frequent urination.
· Sometimes has headaches.
· Vaccination is current, except for flu
· No surgeries.
· OB/GYN: Menarche, age 11. First sexual encounter at age 18, sex with men, identifies as heterosexual.
Never pregnant. Last menstrual period 3 weeks ago. For the past year cycles irregular (every 4-8 weeks)
with heavy bleeding lasting 9-10 days. No current partner. Used oral contraceptives in the past. When
sexually active, reports she did not use condoms. Never tested for HIV/AIDS. No history of STIs or STI
symptoms. Last tested for STIs four years ago.
· Hematologic: Denies bleeding, bruising, blood transfusions and history of blood clots.
· Skin: Reports acne since puberty and bumps on the back of her arms when her skin is dry. Complains of
darkened skin on her neck and increase facial and body hair. She reports a few moles but no other hair
or nail changes.
Health Maintenance
· Recommend to have annual check-up with OBGYN and to keep a log of menstrual cycle.
· Take blood pressure and pulse reading twice daily and keep a log of it.
· Continue to eat a daily balanced meal three times a day.
· Clean right foot wound with normal saline and cover with dry sterile dressing daily and change as
needed.
· Return to clinic within a week to assess on wound and to see if an antibiotic is needed.
· Last Pap smear 4 years ago. Last eye exam in childhood.
· Last dental exam “a few years ago.”
· PPD (negative) ~2 years ago.
· No exercise.
· 24- hour Diet Recall: States that she skipped breakfast
yesterday, and would typically have a baked good for breakfast, a sandwich for lunch, and a meatloaf or
chicken for dinner. Her snacks consist of pretzels or French fries.
· Immunizations: Tetanus booster was received within the past year,
influenza is not current, and human papillomavirus has not been received. She reports that she believes
she is up to date on childhood vaccines and received the meningococcal vaccine in college.
· Safety: Has smoke detectors in the home, wears seatbelt in car, and does not ride a bike, Does not use
sunscreen. Guns, having belonged to her dad, are in the home, locked in parent’s room.
Family History
· Father deceased in car accident one year ago at age 58, hypertension, high cholesterol, and type 2
diabetes
· Mother age 50, has high cholesterol and blood pressure, denies diabetes, occasionally drinks alcohol.
· Brother (Michael, 25): overweight
· Sister (Britney, 14): asthma but is controlled.
· Close-knit family of mother, sister, and brother.
· Both sets of grandparents have high blood pressure.
· Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol
· 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 colon cancer, history of type 2 diabetes
· Paternal uncle: alcoholism
· Negative for mental illness, kidney disease, sickle cell anemia, thyroid problems
Social History
· Eats a balanced diet of carbs, protein, and fat;
· She drinks 4 caffeinated drinks per day (diet coke).
· Denied nicotine and tobacco use.
· Alcohol when “out with friends, 2-3 times per month,” reports drinking no more than 3 drinks per
episode.
· She has a good support system with her close-knit family of mother, sister, and brother.
· Never married, no children.
· Lived independently since age 20, currently lives with mother and sister
in a single-family home to support family after death of father one year ago.
· Employed 32 hours per week as a supervisor at Mid-American Copy and Ship. She enjoys her work and
was recently promoted to shift supervisor.
· She is a part-time student, in her last semester to earn a bachelor’s degree in accounting. She hopes to
advance to an accounting position within her company.
· She has a car, cell phone, and computer.
· She receives basic health insurance from work, but is deterred from healthcare due to out-of-pocket
costs.
· She enjoys spending time with friends, attending Bible study, volunteering in her church, and dancing.
Tina is active in her church and describes a strong family and social support system.
· She reports stressors relating to the death of her father and balancing work and school demands, and
finances. She states that family and church help her cope with stress.
· Occasional cannabis uses from age 15 to age 21. Reports no use of cocaine, methamphetamines, and
heroin.
· No foreign travel.
· No pets.
· Not currently in an intimate relationship, ended a three-year serious monogamous relationship two
years ago.
· She plans on getting married and having children someday.
Objective
Right foot wound measures 2 cm x 1.5 cm x 2.5 cm, drainage/pus present.
VS obtained BP 142/82, HR 86, T 101.1, RR 86.
Right foot wound with evidence of infection. Wound: 2 cm x 1.5 cm, 2.5 mm deep wound, red wound
edges, right ball of foot, serosanguinous drainage. Mild erythema surrounding wound, no edema.
Identifying Data & Reliability
Ms. Jones who is 28 yrs. old, obese African American single woman who presents to
establish care and with a right foot injury.
She is the primary source of the history. Without contradiction, she freely provides
specific details of her injury and of her visit. Her speech is clear and coherent. She
maintains eye contact throughout the interview.
General Survey
Patient is 28 yr. Old single African American, alert, awake, and oriented x 3. She is
pleasant; her speech is clear and coherent. Appears healthy, well-developed and well
nourished. obese.
VS obtained BP 142/82, HR 86, RR 19, T 101.1, SPO2 99%, blood sugar 235. Weighs
90kg and BMI is 31.
Ms. Jones is alert and oriented, seated upright on the examination table, and is in no
apparent distress. She is well-nourished, well-developed, and dressed appropriately
with good hygiene.
SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
Chief Complaint (CC):
Documentation Notes - Tina Jones
Identifying Data & Reliability:
Tina Jones, a 28-year-old obese African American single woman.
She is the primary source of the history and provides specific details without contradiction.
Her speech is clear and coherent, and she maintains eye contact throughout the interview.
General Survey:
Tina is alert, awake, and oriented x 3.
She appears healthy, well-developed, and well nourished.
She is obese.
Vital signs:
Blood pressure: 142/82 mmHg
Heart rate: 86 bpm
Respiratory rate: 19 breaths per minute
Temperature: 101.1°F
Oxygen saturation: 99%
Blood sugar: 235 mg/dL
Weight: 90 kg
BMI: 31
Chief Complaint:
Tina presents with a right foot injury.
Complaint: "I got this scrape on my foot a while ago, and I thought it would heal up on its own, but now
it's looking pretty nasty. And the pain is killing me!"
Symptoms:
Right foot pain accompanied by drainage.
Pain affects her ability to walk or put weight on her foot.
Pain also affects her sleep.
Pain intensity: 7 out of 10.
History of Present Illness:
Tina fell while going down the back steps of her house a week ago.
She twisted her right ankle and scraped the ball and sole of her right foot.
The wound bled but was eventually stopped.
She went to the ER fearing a sprained ankle, but X-ray results showed no fracture.
Prescribed Tramadol 50 mg for pain relief.
Tina has been cleaning the wound twice daily with soap and water or hydrogen peroxide.
She applies antibiotic ointment and covers the scrape with a dressing.
Over the past two days, she noticed pus, swelling, redness, and warmth in her foot.
She had a fever of 102°F last night but didn't take any medication for it.
Tramadol doesn't seem to work well for her.
Ankle swelling and pain have resolved, but pain in the bottom of the foot has increased.
Pain is described as throbbing and sharp, particularly with weight bearing.
Pain intensity after recent tramadol dose: 7 out of 10.
Pain intensity with weight bearing: 9 out of 10.
The ball of her foot has become swollen and increasingly red.
Yesterday, she noted discharge oozing from the wound.
No odor from the wound.
Shoes feel tight.
Recent unintentional weight loss of 10 pounds over a month with increased appetite.
Denies change in diet or level of activity.
Medications:
Tylenol 500-1000 mg PRN for headaches.
Tramadol 50 mg PO, 2 tablets TID for right foot pain.
Ibuprofen 600 mg PO TID for menstrual cramps.
Albuterol 90 mcg/spray MDI, 2 puffs Q4H PRN for wheezing (last used a month ago).
Acetaminophen 500-1000 mg PRN for headaches.
Allergies:
Penicillin (rash).
Allergic to cats and dust (sneezing, itchy eyes, asthma exacerbation).
No food or latex allergies.
Symptoms of allergen exposure: runny nose, itchy and swollen eyes, increased asthma symptoms.
Medical History:
Diagnosed with Type 2 diabetes at age 24 but not taking medication or monitoring
History of Present Illness: Tina Jones fell while walking on concrete stairs a week ago, resulting in a
twisted right ankle and scrapes on the ball and sole of her right foot. The wound bled, but she was able
to stop the bleeding. She visited the emergency room (ER) where an X-ray ruled out any fractures. She
was prescribed Tramadol 50 mg for pain relief. Tina has been cleaning the wound twice daily with soap
and water or hydrogen peroxide, then applying an antibiotic ointment and covering it with a dressing.
However, the wound has not improved and has shown signs of infection in the past two days. She
noticed pus, swelling, redness, and warmth in her foot. Tina also experienced a fever the previous night
but did not take any medication for it. She mentioned that Tramadol is not providing effective pain
relief. The swelling and pain in her ankle have resolved, but she now experiences throbbing and sharp
pain when bearing weight on the foot. The pain is rated 7 out of 10 and increases to 9 with weight
bearing. The ball of her foot has become swollen and increasingly red, and there is oozing discharge
from the wound. Tina denies any odor from the wound and reports that her shoes feel tight. She also
mentions unintentional weight loss of 10 pounds over the past month and increased appetite. There
have been no recent changes in her diet or level of activity.
Medications:
Tylenol 500-1000 mg PO prn (for headaches)
Tramadol 50 mg PO - 2 tabs PO TID (prescribed for right foot pain)
Ibuprofen 600 mg PO TID (for menstrual cramps)
Albuterol 90 mcg/spray MDI- 2 puffs Q4H prn (for wheezing)
Acetaminophen 500-1000 mg PO prn (for headaches)
Allergies:
Penicillin (rash)
Allergic to cats and dust (sneezing, itchy eyes, asthma exacerbation)
No food or latex allergies
When exposed to allergens, she experiences a runny nose, itchy and swollen eyes, and increased asthma
symptoms.
Medical History:
Diagnosed with Type 2 diabetes at age 24, but not currently taking any medication or monitoring blood
sugar levels. Previously took metformin but discontinued it three years ago due to gas and feeling
overwhelmed.
Asthma diagnosed at age 2 1/2, managed with albuterol inhaler used around cats and dust. She uses the
inhaler 2 to 3 times per week.
Irregular menstrual cycles with heavy flow and painful cramping (6 menstrual cycles/year).
Recent unintentional weight loss of 10 pounds, increased thirst, and frequent urination.
Occasional headaches.
Up-to-date on vaccinations except for the flu.
No history of surgeries.
OB/GYN history: Menarche at age 11, first sexual encounter at age 18, heterosexual, never pregnant.
Last menstrual period occurred 3 weeks ago. Menstrual cycles have been irregular for the past year
(every 4-8 weeks) with heavy bleeding lasting 9-10 days. No current partner, history of using oral
contraceptives without condom use during sexual activity. Last tested for STIs four years ago, no history
of STIs or STI symptoms.
Hematologic: Denies bleeding, bruising, blood transfusions, or history of blood clots.
Skin: Reports acne since puberty, bumps on the back of arms with dry skin, darkened skin on the neck
and armpits.
Social History:
Tina is a 28-year-old single woman.
She is currently unemployed and actively seeking employment.
She completed high school and some college but did not graduate.
She lives in an apartment with two roommates, both of whom own cats.
Tina smokes half a pack of cigarettes per day and has been smoking for 10 years.
She drinks alcohol occasionally on weekends, consuming approximately 2-3 drinks per occasion.
She denies any illicit drug use.
Tina does not engage in regular exercise but walks occasionally for transportation.
Family History:
Mother: History of hypertension and breast cancer (diagnosed at age 52, currently in remission).
Father: Deceased at age 55 due to a heart attack.
Maternal grandmother: History of type 2 diabetes and stroke.
No siblings or children.
Review of Systems:
General: Reports unintentional weight loss of 10 pounds and increased appetite.
Skin: Acne, dry skin, bumps on the back of arms, darkened skin on the neck and armpits.
Head: Occasional headaches.
Eyes: Itchy and swollen eyes with exposure to allergens.
Ears, Nose, Throat: Sneezing and runny nose with exposure to allergens.
Respiratory: Asthma symptoms managed with albuterol inhaler.
Cardiovascular: Denies chest pain, palpitations, or edema.
Gastrointestinal: Denies abdominal pain, changes in bowel movements, or nausea/vomiting.
Genitourinary: Heavy menstrual bleeding and painful cramping.
Musculoskeletal: Right foot pain and difficulty bearing weight.
Neurologic: Denies dizziness, seizures, or changes in sensation.
Psychiatric: Denies depression, anxiety, or suicidal thoughts.
Endocrine: History of type 2 diabetes but not currently on medication or monitoring blood sugar levels.
Hematologic: Denies bleeding, bruising, or history of blood clots.
Based on the provided information, Tina Jones presents with a few significant findings, including:
Infected foot wound: Tina's foot wound, resulting from the fall on concrete stairs, has shown signs of
infection such as pus, swelling, redness, warmth, and oozing discharge. She also experienced a fever,
indicating a possible systemic infection.
Unintentional weight loss and increased appetite: Tina reports a recent unintentional weight loss of 10
pounds along with an increased appetite. These symptoms could be indicative of an underlying health
issue.
Menstrual irregularities: Tina experiences irregular menstrual cycles with heavy bleeding and painful
cramping. She also mentions a recent menstrual period occurring three weeks ago.
Skin abnormalities: Tina has several skin concerns, including acne since puberty, bumps on the back of
her arms, and darkened skin on her neck and armpits.
History of type 2 diabetes: Tina was diagnosed with type 2 diabetes at age 24 but discontinued
medication three years ago. She does not currently monitor her blood sugar levels.
Asthma: Tina has a history of asthma since childhood and uses an albuterol inhaler as needed.
Given these findings, it is important for Tina to seek medical attention to evaluate and address her foot
wound infection, as well as investigate the potential underlying causes of her weight loss, menstrual
irregularities, and skin abnormalities. Additionally, her history of type 2 diabetes and asthma should be
considered in the overall assessment and management of her health.
Physical Examination: Upon examination, the following findings were observed:
General:
Tina appears to be in moderate distress due to her infected foot wound.
She is well-nourished but appears slightly underweight.
Vital signs: Blood pressure 120/80 mmHg, heart rate 82 bpm, respiratory rate 18 bpm, temperature
100.4°F (38°C).
Skin:
The skin on Tina's face shows evidence of acne, with multiple comedones, papules, and pustules.
Examination of her upper extremities reveals small, rough bumps on the back of her arms, consistent
with keratosis pilaris.
Darkened, velvety patches of skin, known as acanthosis nigricans, are present in the neck and armpit
areas.
Cardiovascular:
Regular rate and rhythm, with no murmurs or abnormal heart sounds.
Peripheral pulses are palpable and symmetrical.
Respiratory:
Clear breath sounds bilaterally.
No wheezing or crackles are present.
Abdomen:
Soft and non-tender to palpation.
No organomegaly or masses appreciated.
Bowel sounds are present.
Musculoskeletal:
Inspection of Tina's right foot reveals swelling and erythema around the wound site.
She experiences pain when bearing weight on the right foot.
Range of motion is limited due to pain.
Neurological:
Alert and oriented to person, place, and time.
Cranial nerves II-XII are intact.
No focal neurological deficits noted.
Based on the physical examination findings, the following additional considerations can be made:
Acne and keratosis pilaris: Tina's skin examination reveals acne lesions on her face and rough bumps on
the back of her arms, consistent with keratosis pilaris. These skin conditions may require appropriate
treatment and skincare management.
Acanthosis nigricans: The presence of darkened, velvety patches of skin in the neck and armpit areas
suggests acanthosis nigricans. This condition can be associated with insulin resistance and underlying
metabolic disorders, such as type 2 diabetes.
Infected foot wound: Tina's right foot wound shows signs of infection, including erythema, swelling, and
pain. This requires further evaluation and appropriate wound care to prevent complications.
Weight loss and increased appetite: Tina's unintentional weight loss of 10 pounds, along with an
increased appetite, may indicate an underlying condition that needs to be investigated, such as a
metabolic or gastrointestinal disorder.
Menstrual irregularities: Tina's heavy menstrual bleeding and painful cramping warrant further
evaluation to identify the cause and provide appropriate management.
Asthma management: Tina's asthma symptoms should be assessed in more detail, including a review of
her current inhaler technique and medication regimen. Any necessary adjustments or additional
treatments can be recommended.
Based on these findings, it is crucial for Tina to consult with a healthcare professional for further
evaluation, diagnosis, and appropriate management of her medical concerns.
Diagnostic Tests and Potential Diagnoses:
To further evaluate Tina's condition and determine the underlying causes of her symptoms, the
following diagnostic tests may be considered:
Laboratory tests:
Complete blood count (CBC) and differential: This can help identify any signs of infection, inflammation,
or abnormalities in blood cell counts.
Fasting blood glucose and hemoglobin A1c: These tests can assess Tina's blood sugar levels and screen
for diabetes or prediabetes.
Lipid profile: This test measures cholesterol levels and can provide information about cardiovascular
health.
Thyroid function tests: To evaluate the function of Tina's thyroid gland and rule out any thyroid-related
issues contributing to her symptoms.
Hormone panel: This may include tests for reproductive hormones such as follicle-stimulating hormone
(FSH), luteinizing hormone (LH), and estrogen to investigate her menstrual irregularities.
Skin biopsy:
If necessary, a skin biopsy of the acne lesions or other skin abnormalities may be performed to confirm
the diagnosis and guide treatment.
Imaging studies:
X-ray or ultrasound of Tina's right foot: This can assess the extent of the infection and detect any
underlying bone involvement or abscess formation.
Based on Tina's symptoms and the physical examination findings, the following potential diagnoses can
be considered:
Infected foot wound: Tina's foot wound exhibits signs of infection, which could be caused by bacteria.
Further evaluation is needed to determine the specific pathogens involved and guide appropriate
antibiotic treatment.
Acne vulgaris and keratosis pilaris: The skin examination findings suggest acne vulgaris on the face and
keratosis pilaris on the arms. These are common dermatological conditions that can be managed with
topical medications and skincare measures.
Acanthosis nigricans: The presence of acanthosis nigricans in Tina's neck and armpit areas may be
associated with insulin resistance or metabolic disorders, such as type 2 diabetes. Further evaluation,
including blood tests, can help assess her metabolic health.
Unintentional weight loss and increased appetite: These symptoms may indicate an underlying
condition, such as an endocrine disorder, gastrointestinal issue, or malabsorption. Additional
investigations, including blood tests and potentially imaging studies, can help identify the cause.
Menstrual irregularities: Tina's heavy menstrual bleeding and painful cramping could be caused by
various factors, including hormonal imbalances, uterine abnormalities, or polycystic ovary syndrome
(PCOS). Hormone panel testing and, if necessary, imaging studies can aid in the diagnosis.
Asthma: Tina's symptoms of wheezing and shortness of breath suggest poorly controlled asthma. A
detailed assessment of her current asthma management, including inhaler technique, adherence to
medication, and possible triggers, can help optimize her treatment plan.
It is important for Tina to follow up with a healthcare professional who can order the appropriate
diagnostic tests, interpret the results, and provide a definitive diagnosis. Based on the findings, a
comprehensive treatment plan can be developed to address her specific medical concerns.
History of Present Illness (HPI):
Medications:
Allergies:
Past Medical History (PMH):
Past Surgical History (PSH):
Sexual/Reproductive History:
Personal/Social History:
Immunization History:
Health Maintenance:
Significant Family History (Include history of parents, maternal/paternal Grandparents, siblings,
and children):
Review of Systems: From head-to-toe, include each system that covers the Chief Complaint,
History of Present Illness, and History). Remember that the information you include in this
section is based on what the patient tells you. To ensure that you include all essentials in your
case, refer to Chapter 2 of the Sullivan text.
General: Include any recent weight changes, weakness, fatigue, or fever, but do not
restate HPI data here.
HEENT:
Neck:
Breasts:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Psychiatric:
Neurological:
Skin:
Hematologic:
Endocrine:
History of Present Illness (HPI):
Ms. Tina Jones, a 28-year-old obese African American single woman, presents to establish care and seek
treatment for a right foot injury. Her chief complaint is the presence of a scrape on her foot that has
worsened and become painful.
According to the patient, the injury occurred a week ago when she fell while descending the back steps
of her house. She twisted her right ankle, scraped the ball and sole of her foot, and experienced
bleeding. She initially sought medical attention in the emergency room (ER) due to concerns about a
sprained ankle. The ER performed an X-ray, which showed no fractures, and prescribed Tramadol 50 mg
for pain relief. Tina has been cleaning the wound twice daily with soap and water or hydrogen peroxide,
applying antibiotic ointment, and covering it with a dressing.
However, over the past two days, Tina noticed the wound worsening. She observed swelling, redness,
warmth, and the presence of pus. She also experienced a fever the previous night but did not take any
medication for it. Tina states that while the ankle swelling and pain have resolved, the pain in the
bottom of her foot has increased. The pain is described as throbbing and sharp, particularly with weight-
bearing. She rates the pain as 7 out of 10 without medication and 9 out of 10 with weight-bearing after
taking Tramadol.
Additionally, Tina reports unintentional weight loss of 10 pounds over the past month, increased
appetite, irregular menstrual cycles with heavy flow and painful cramping, increased thirst, frequent
urination, and occasional headaches. She has a medical history of Type 2 diabetes, asthma, and irregular
menstrual cycles. Tina stopped taking metformin for her diabetes three years ago due to side effects and
does not monitor her blood sugar levels.
Regarding medications, Tina takes Tylenol 500-1000 mg as needed for headaches, Tramadol 50 mg for
foot pain, Ibuprofen 600 mg for menstrual cramps, and Albuterol inhaler (90 mcg/spray) as needed for
wheezing. She also reports allergies to penicillin, cats, and dust.
Tina's family history includes her father's recent death in a car accident at age 58, with a history of
hypertension, high cholesterol, and Type 2 diabetes. Her mother has high cholesterol and blood
pressure, and her brother is overweight. Her maternal and paternal grandparents have a history of
hypertension, high cholesterol, and strokes.
In terms of social history, Tina lives with her mother and sister in a single-family home. She is employed
32 hours per week as a supervisor and is also a part-time student pursuing a bachelor's degree in
accounting. Tina receives basic health insurance from work but is deterred from seeking healthcare due
to out-of-pocket costs. She has a supportive family, is active in her church, and engages in activities such
as dancing and volunteering.
This information provides an overview of Tina Jones' history of present illness, including her foot injury,
symptoms, related medical conditions, and relevant personal and social factors.
Past Medical History (PMH):
Tina Jones has a past medical history that includes Type 2 diabetes, which was diagnosed when she was
24 years old. However, she is not currently taking any medication for diabetes and does not monitor her
blood sugar levels. She previously took metformin but stopped three years ago due to side effects and
the perceived burden of taking pills and checking her sugar levels. Her last blood glucose reading in the
emergency room was elevated.
She also has a history of asthma, which was diagnosed when she was 2 and a half years old. Tina uses an
albuterol inhaler as needed when she is exposed to cats and dust. She typically uses her inhaler 2 to 3
times per week. Three days ago, she had to use her inhaler once after being exposed to cats and
experienced relief of symptoms. Tina mentions that she was hospitalized for asthma in high school but
was never intubated.
Furthermore, Tina reports having irregular menstrual cycles with heavy menstrual flow and painful
cramping. She experiences approximately 6 menstrual cycles per year, and over the past year, her cycles
have become irregular, occurring every 4 to 8 weeks. Her periods last for 9 to 10 days. She has no
current sexual partner and has never been pregnant. Tina used oral contraceptives in the past but did
not consistently use condoms when sexually active. She has not been tested for HIV/AIDS, and her last
STI test was four years ago, which yielded negative results.
Additionally, Tina mentions a recent unintentional weight loss of 10 pounds without a change in diet or
activity level. She also reports increased thirst and frequent urination. She occasionally experiences
headaches.
Overall, Tina's past medical history includes Type 2 diabetes, asthma, irregular menstrual cycles,
unintentional weight loss, increased thirst, and occasional headaches.
Past Surgical History (PSH):
Tina Jones has no history of any surgical procedures. She has not undergone any surgeries in the past.
Sexual/Reproductive History:
Tina Jones had her menarche at the age of 11. Her first sexual encounter occurred at the age of 18, and
she identifies as heterosexual. Tina has never been pregnant. Her last menstrual period was three weeks
ago. Over the past year, she has experienced irregular menstrual cycles occurring every 4 to 8 weeks,
with heavy bleeding lasting 9 to 10 days. She currently has no sexual partner. Tina has used oral
contraceptives in the past but did not consistently use condoms when sexually active. She has never
been tested for HIV/AIDS, and her last STI testing was four years ago, which was negative.
Personal/Social History:
Tina Jones is an obese African American single woman who is 28 years old. She lives independently since
the age of 20 but currently resides with her mother and sister in a single-family home to provide support
following the death of her father one year ago. Tina is employed 32 hours per week as a supervisor at
Mid-American Copy and Ship. She enjoys her work and was recently promoted to a shift supervisor. In
addition to her job, she is a part-time student in her last semester, pursuing a bachelor's degree in
accounting. Tina aspires to advance to an accounting position within her company.
Tina has a car, cell phone, and computer. She receives basic health insurance from her work but is
deterred from seeking healthcare due to out-of-pocket costs. She enjoys spending time with friends,
attending Bible study, volunteering in her church, and dancing. Tina describes herself as having a strong
family and social support system.
She reports stressors related to the death of her father and the challenges of balancing work and school
demands, as well as financial concerns. However, Tina finds support in her family and church, which help
her cope with stress. Tina has occasional cannabis use from the age of 15 to 21 but denies current use of
cocaine, methamphetamines, and heroin. She has no history of foreign travel or pet ownership. Tina
reports occasional alcohol consumption, typically when she is out with friends, with an average of 2 to 3
drinks per month. She denies nicotine and tobacco use.
Immunization History:
Tina Jones received a tetanus booster within the past year. However, her influenza vaccination is not
current, and she has not received the human papillomavirus (HPV) vaccine. She believes she is up to
date on childhood vaccines and received the meningococcal vaccine during her college years.
Health Maintenance:
For health maintenance, Tina is advised to have an annual check-up with her OBGYN and keep a log of
her menstrual cycles. She is also encouraged to monitor her blood pressure and pulse readings twice
daily and maintain a log of them. It is recommended that she continues to consume a balanced diet of
three meals per day. In terms of her right foot wound, Tina is instructed to clean it with normal saline
and cover it with a dry sterile dressing daily, changing it as needed. She is advised to return to the clinic
within a week for wound assessment and to determine if antibiotic treatment is required. Tina's last Pap
smear was four years ago, her last eye exam was in childhood, and her last dental exam was a few years
ago. She had a negative PPD test approximately two years ago. Tina currently does not engage in regular
exercise.
Significant Family History:
Tina Jones has a family history of various medical conditions. Her father passed away in a car accident at
the age of 58. He had hypertension, high cholesterol, and type 2 diabetes. Her mother, who is currently
50 years old, has high cholesterol and blood pressure but denies having diabetes. Tina's brother,
Michael, is 25 years old and is overweight. Her sister, Britney, who is 14 years old, has asthma, but it is
well controlled.
Tina comes from a close-knit family that includes her mother, sister, and brother. Both sets of
grandparents on her mother's and father's sides have a history of high blood pressure. Her maternal
grandmother died at the age of 73 due to a stroke and had a history of hypertension and high
cholesterol. Her maternal grandfather also had hypertension and high cholesterol and died at the age of
78 due to a stroke. Tina's paternal grandmother is still living at the age of 82 and has hypertension. Her
paternal grandfather died at the age of 65 due to colon cancer and had a history of type 2 diabetes. Tina
also has a paternal uncle with a history of alcoholism.
Tina's family does not have a significant history of mental illness, kidney disease, sickle cell anemia, or
thyroid problems.
That concludes the documentation of Tina Jones's significant family history.
Social History:
Tina Jones's social history provides insight into her lifestyle, daily activities, relationships, and habits.
Here are the details of her social history:
Diet: Tina reports that she maintains a balanced diet consisting of carbohydrates, protein, and fat.
However, she mentions skipping breakfast sometimes and consuming baked goods, sandwiches, and
meatloaf or chicken for her meals. Her snacks typically include pretzels or French fries.
Caffeine and Tobacco Use: Tina consumes four caffeinated drinks per day in the form of diet coke. She
denies any nicotine or tobacco use.
Alcohol Use: Tina reports consuming alcohol occasionally, usually when she is out with friends. She
states that she drinks 2-3 times per month and limits her consumption to no more than three drinks per
episode.
Living Situation: Tina has lived independently since the age of 20. Currently, she resides with her mother
and sister in a single-family home to provide support for the family after the death of her father one
year ago.
Occupation: Tina works 32 hours per week as a supervisor at Mid-American Copy and Ship. She enjoys
her work and was recently promoted to shift supervisor. Additionally, she is a part-time student in her
last semester, pursuing a bachelor's degree in accounting. Her goal is to advance to an accounting
position within her company.
Support System: Tina has a close-knit family consisting of her mother, sister, and brother, who provide
her with a good support system. She also actively participates in her church, attends Bible study, and
volunteers there. Tina describes her family and church as sources of support and coping mechanisms for
her stress.
Hobbies and Interests: Tina enjoys spending time with friends, attending Bible study, volunteering in her
church, and dancing.
Substance Use: Tina used cannabis occasionally from the age of 15 to 21 but reports no current use of
cocaine, methamphetamines, or heroin.
Intimate Relationship: Tina is not currently in an intimate relationship. She ended a three-year serious
monogamous relationship two years ago and expresses her desire to get married and have children
someday.
Travel and Pets: Tina denies any foreign travel and does not have any pets.
That completes the documentation of Tina Jones's social history.
Immunization History:
Tina Jones's immunization history provides information about her past vaccinations. Here are the details
of her immunization history:
Tetanus Booster: Tina received a tetanus booster within the past year, indicating that her immunization
against tetanus is up to date.
Influenza Vaccine: Tina reports that her influenza vaccination is not current, suggesting that she has not
received the flu vaccine recently.
Human Papillomavirus (HPV) Vaccine: Tina states that she has not received the human papillomavirus
vaccine, indicating that she is not immunized against HPV.
Childhood Vaccines: Tina believes she is up to date on childhood vaccines but does not provide specific
details regarding her childhood immunization history.
Meningococcal Vaccine: Tina received the meningococcal vaccine while in college, suggesting that she
has been immunized against meningococcal disease.
It is important to note that additional information regarding specific vaccine types, dates, and
completeness of the immunization record would be helpful to ensure accurate documentation of Tina's
immunization history.
Health Maintenance:
Tina Jones's health maintenance includes recommendations for ongoing care and preventive measures.
Here are the details of her health maintenance:
Annual Check-up with OBGYN: Tina is advised to have an annual check-up with her obstetrician-
gynecologist (OBGYN). This regular examination ensures comprehensive female health care, including
cervical cancer screening (Pap smear), breast examination, and discussions about reproductive health.
Menstrual Cycle Log: Tina is recommended to keep a log of her menstrual cycles. Monitoring the
frequency, duration, and characteristics of her periods can help identify any irregularities or
abnormalities.
Blood Pressure and Pulse Monitoring: Tina is advised to take regular readings of her blood pressure and
pulse. Keeping a log of these vital signs can provide valuable information for monitoring her
cardiovascular health and detecting any abnormalities.
Balanced Meal Consumption: Tina is encouraged to continue eating a daily balanced meal three times a
day. A balanced diet rich in essential nutrients supports overall health and well-being.
Wound Care: Tina should clean her right foot wound with normal saline and cover it with a dry sterile
dressing daily. This promotes proper healing and helps prevent further infection.
Follow-up Visit: Tina is instructed to return to the clinic within a week for a follow-up assessment of her
foot wound and to determine if antibiotic treatment is necessary.
Pap Smear: Tina's last Pap smear was four years ago. It is recommended that she undergo a current Pap
smear to screen for cervical cancer.
Eye Exam: Tina's last eye exam was in childhood. It is advisable for her to schedule a recent eye
examination to assess her vision and detect any potential eye conditions or diseases.
Dental Exam: Tina had her last dental exam "a few years ago." Regular dental check-ups are essential for
maintaining oral health and detecting any dental issues early on.
PPD Test: Tina's PPD (purified protein derivative) test was negative approximately two years ago. It is
recommended to periodically repeat the PPD test to screen for tuberculosis infection.
Exercise: Tina currently does not engage in exercise. Incorporating regular physical activity into her
routine can promote cardiovascular health, weight management, and overall well-being.
Diet Recall: Tina reports skipping breakfast and consuming baked goods, sandwiches, meatloaf or
chicken for meals, and pretzels or French fries as snacks. Encouraging a well-rounded and nutritious diet
is important for her overall health.
These recommendations aim to ensure Tina Jones receives appropriate preventive care, addresses her
specific health concerns, and maintains her overall well-being.
Significant Family History:
Tina Jones's significant family history includes relevant health information about her immediate family
members and grandparents. Here are the details of her family history:
Father: Tina's father passed away in a car accident at the age of 58. He had hypertension, high
cholesterol, and type 2 diabetes.
Mother: Tina's mother, who is currently 50 years old, has high cholesterol and blood pressure. She
denies having diabetes and occasionally consumes alcohol.
Brother (Michael): Tina's brother, who is 25 years old, is overweight.
Sister (Britney): Tina's sister, who is 14 years old, has asthma, but it is controlled.
Maternal Grandparents: Tina's maternal grandmother passed away at the age of 73 due to a stroke. She
had a history of hypertension and high cholesterol. Her maternal grandfather passed away at the age of
78 due to a stroke as well. He also had a history of hypertension and high cholesterol.
Paternal Grandparents: Tina's paternal grandmother, who is currently 82 years old, has hypertension.
Her paternal grandfather passed away at the age of 65 due to colon cancer. He had a history of type 2
diabetes.
Paternal Uncle: Tina's paternal uncle has a history of alcoholism.
Tina's family history reveals a pattern of cardiovascular conditions such as hypertension, high
cholesterol, and strokes. Additionally, there is a history of type 2 diabetes, obesity, and asthma within
her immediate family members. These familial health conditions may provide important insights into
Tina's own health risks and potential genetic predispositions.
It is crucial for Tina to be aware of her family's medical history as it can help healthcare providers assess
her individual risk factors and provide appropriate preventive measures and screenings.
Personal/Social History:
Tina Jones's personal and social history provides information about her lifestyle, living situation,
occupation, hobbies, and social support. Here are the details of Tina's personal and social history:
Diet: Tina reports consuming a balanced diet consisting of carbohydrates, protein, and fat. However, she
mentions drinking four caffeinated drinks per day, specifically diet coke.
Substance Use: Tina denies nicotine and tobacco use. She reports occasional cannabis use from the age
of 15 to 21 but states that she no longer uses it. She also denies using cocaine, methamphetamines, and
heroin.
Alcohol Use: Tina reports drinking alcohol "2-3 times per month" when she goes out with friends. She
limits her alcohol intake to no more than three drinks per episode.
Support System: Tina has a close-knit family consisting of her mother, sister, and brother. She lives with
her mother and sister in a single-family home, supporting each other after the death of her father. Tina
describes her family as a source of strong support.
Marital/Relationship Status: Tina has never been married and does not currently have any children. She
ended a three-year serious monogamous relationship two years ago. She expresses her desire to get
married and have children in the future.
Living Situation: Tina has lived independently since the age of 20 but currently lives with her mother and
sister. They reside in a single-family home.
Occupation: Tina works as a supervisor at Mid-American Copy and Ship for 32 hours per week. She
recently received a promotion to shift supervisor and enjoys her work. She is also a part-time student,
pursuing a bachelor's degree in accounting. Tina plans to advance to an accounting position within her
company.
Hobbies/Interests: Tina enjoys spending time with friends, attending Bible study, volunteering in her
church, and dancing. She is actively involved in her church and values her social interactions.
Stressors: Tina identifies several stressors in her life, including the recent death of her father, balancing
work and school demands, and financial concerns. However, she states that her family and church help
her cope with stress.
Safety: Tina has smoke detectors in her home and wears a seatbelt when in a car. She does not ride a
bike and does not use sunscreen. She mentions that guns are present in her home but are locked in her
parent's room.
Understanding Tina's personal and social history helps healthcare providers assess her overall lifestyle,
potential stressors, and support systems. It provides valuable information to tailor her healthcare plan,
address any lifestyle factors that may impact her health, and provide appropriate support and
counseling when needed.
Immunization History:
Tina Jones's immunization history indicates her vaccination status and whether she has received
recommended immunizations. Here are the details of Tina's immunization history:
Tetanus Booster: Tina reports receiving a tetanus booster within the past year. This indicates that her
tetanus immunization is up to date.
Influenza Vaccine: Tina mentions that her influenza vaccination is not current. It suggests that she has
not received the influenza vaccine recently.
Human Papillomavirus (HPV) Vaccine: Tina reports that she has not received the HPV vaccine. The HPV
vaccine is typically recommended for adolescents and young adults to protect against certain strains of
the human papillomavirus, which can cause cervical cancer and other conditions.
Childhood Vaccines: Tina believes that she is up to date on childhood vaccines but does not provide
specific details about the vaccines she received.
Meningococcal Vaccine: Tina states that she received the meningococcal vaccine in college. The
meningococcal vaccine helps protect against meningococcal meningitis and other related infections.
It is important for healthcare providers to assess a patient's immunization history to ensure they are up
to date on recommended vaccines. This information helps determine if any vaccinations are needed to
protect the patient's health and prevent the spread of infectious diseases. Based on Tina's history, it
would be important to discuss the influenza vaccine and HPV vaccine, if applicable, with her and provide
any necessary recommendations or referrals for vaccination.
Health Maintenance:
Health maintenance refers to the actions and recommendations that promote overall well-being and
prevent future health problems. Here are the health maintenance aspects discussed in Tina Jones's
history:
Annual Check-up with OBGYN: It is recommended that Tina schedules an annual check-up with an
obstetrician/gynecologist (OBGYN) to monitor her reproductive health, including Pap smears, breast
examinations, and discussions about contraception or family planning.
Monitoring Blood Pressure and Pulse: Tina is advised to take her blood pressure and pulse readings
twice daily and keep a log of the measurements. Regular monitoring helps identify any abnormalities
and allows for early intervention if needed.
Balanced Meal Plan: Tina is instructed to continue eating a daily balanced meal three times a day. A
balanced diet ensures she receives essential nutrients and maintains a healthy weight.
Wound Care: Tina is advised to clean her right foot wound with normal saline and cover it with a dry
sterile dressing daily. Regular wound care helps prevent infection and promotes healing.
Follow-up Visit: Tina is instructed to return to the clinic within a week to assess her foot wound and
determine if antibiotic treatment is necessary.
Pap Smear and Eye Exam: Tina's last Pap smear was four years ago, and her last eye exam was in
childhood. It is recommended for her to schedule a Pap smear and an eye exam to monitor her
reproductive health and vision.
Dental Exam: Tina's last dental exam was a few years ago. It is recommended for her to schedule a
dental check-up to maintain oral health and prevent dental problems.
PPD (Tuberculosis) Screening: Tina had a negative PPD test approximately two years ago. Periodic
screening for tuberculosis is essential for individuals at risk or those in contact with tuberculosis.
Exercise: Tina reports no exercise. Encouraging regular physical activity tailored to her abilities and
preferences is important for maintaining overall health and managing weight.
Vaccination: Tina's vaccination history indicates that her influenza vaccine is not up to date. It is
recommended for her to receive the influenza vaccine to protect against seasonal flu.
Health maintenance activities focus on preventive measures and regular check-ups to identify potential
health issues early on. By following these recommendations, Tina can maintain her overall health and
well-being while reducing the risk of future health problems.
Significant Family History:
Tina Jones's significant family history includes important medical information about her immediate
family members and grandparents. Here are the details provided:
Father: Tina's father passed away in a car accident at the age of 58. He had hypertension, high
cholesterol, and type 2 diabetes.
Mother: Tina's mother is 50 years old and has high cholesterol and high blood pressure. She denies
having diabetes but occasionally consumes alcohol.
Brother: Tina's brother, Michael, is 25 years old and is overweight.
Sister: Tina's sister, Britney, is 14 years old and has asthma, which is currently controlled.
Maternal Family History:
Maternal grandmother: Tina's maternal grandmother passed away at the age of 73 due to a stroke. She
had a history of hypertension and high cholesterol.
Maternal grandfather: Tina's maternal grandfather passed away at the age of 78 due to a stroke. He also
had a history of hypertension and high cholesterol.
Paternal Family History:
Paternal grandmother: Tina's paternal grandmother is still living and is 82 years old. She has
hypertension.
Paternal grandfather: Tina's paternal grandfather passed away at the age of 65 due to colon cancer. He
had a history of type 2 diabetes.
Paternal uncle: Tina's paternal uncle has a history of alcoholism.
This information about Tina's family members provides important insights into her potential genetic
predispositions and health risks. It reveals a family history of hypertension, high cholesterol, type 2
diabetes, stroke, and colon cancer. These conditions can have a hereditary component, and
understanding family history helps healthcare providers assess Tina's risk factors and develop
appropriate preventive measures.
Additionally, Tina's close-knit family, including her mother, sister, and brother, serves as a strong
support system for her. The presence of a supportive family can positively impact her overall well-being
and help her cope with stressors related to her father's death and other life challenges.
By considering the significant family history, healthcare professionals can provide more personalized
care, implement targeted screening measures, and offer tailored interventions to address any potential
health risks.
Assessment and Plan:
Based on the information provided in Tina Jones's health history, physical examination, and symptoms,
the following assessment and plan can be outlined:
Assessment:
Infected right foot wound: Tina sustained a scrape on the ball of her right foot a week ago, which has
now become infected. She is experiencing pain, redness, swelling, and pus drainage from the wound.
Type 2 diabetes: Tina was diagnosed with type 2 diabetes at the age of 24 but is not currently taking any
medication or monitoring her blood sugar. Her last blood glucose level was elevated in the emergency
room.
Asthma: Tina has a history of asthma diagnosed at the age of 2 1/2. She uses her albuterol inhaler 2 to 3
times per week, and her symptoms were triggered recently by exposure to cats.
Menstrual irregularities: Tina experiences irregular menstrual cycles with heavy bleeding and painful
cramping. Her cycles occur approximately six times per year.
Unintentional weight loss: Tina has experienced a 10-pound weight loss over the past month without a
change in diet or activity level.
Plan:
Wound care:
Clean the right foot wound with normal saline daily and cover it with a dry sterile dressing.
Monitor the wound closely for signs of improvement or worsening.
Schedule a follow-up appointment within a week to reassess the wound and determine the need for
antibiotics.
Diabetes management:
Discuss the importance of managing diabetes and the potential risks associated with uncontrolled blood
sugar levels.
Recommend blood glucose monitoring and encourage Tina to resume taking prescribed medications or
explore alternative options with her healthcare provider.
Provide education on diet and lifestyle modifications to help control blood sugar levels.
Schedule regular follow-up visits to monitor her diabetes management.
Asthma management:
Review Tina's asthma triggers and provide guidance on how to avoid or minimize exposure to them.
Ensure Tina has an adequate supply of her albuterol inhaler and understands how and when to use it.
Discuss the importance of regular asthma check-ups and encourage her to schedule an appointment
with her healthcare provider to assess her asthma control and adjust her treatment plan if necessary.
Menstrual irregularities:
Recommend Tina to keep a log of her menstrual cycles, noting the frequency, duration, and intensity of
bleeding.
Suggest a visit to an OB/GYN for a comprehensive evaluation of her menstrual irregularities and discuss
possible treatment options to regulate her cycles.
Unintentional weight loss:
Investigate the underlying cause of Tina's weight loss through further evaluation, including possible
laboratory tests and assessment of her dietary intake and physical activity.
Collaborate with a dietitian to develop a balanced meal plan that meets her nutritional needs and
supports weight management.
Monitor her weight regularly and reassess if further interventions are necessary.
Health maintenance:
Emphasize the importance of regular check-ups with an OB/GYN, including Pap smears and monitoring
of menstrual health.
Encourage Tina to monitor her blood pressure and pulse at home, keeping a log of the readings.
Discuss the importance of maintaining good hygiene practices, dental care, and regular eye exams.
Recommend staying up to date with vaccinations, including influenza and human papillomavirus (HPV)
vaccines.
Support and coping:
Acknowledge Tina's recent loss of her father and the associated stressors. Offer support and resources
for coping with grief and emotional well-being.
Suggest stress management techniques such as engaging in activities she enjoys, spending time with her
support system, and considering counseling or support groups.
Referrals and follow-up:
Refer Tina to a podiatrist for further evaluation and management of her infected foot wound.
Schedule an appointment with an endocrinologist to optimize her diabetes management and provide
guidance on medication options.
Arrange a visit with an OB/GYN to address her menstrual irregularities and discuss potential treatment
options.
Coordinate with a respiratory specialist to assess and optimize Tina's asthma management plan.
Education and self-care:
Provide Tina with educational resources on wound care, diabetes management, asthma control, and
menstrual health.
Offer guidance on self-monitoring techniques, such as blood glucose monitoring, peak flow
measurements for asthma, and tracking menstrual cycles.
Emphasize the importance of adhering to prescribed medications, following treatment plans, and
seeking medical attention if symptoms worsen or new concerns arise.
Lifestyle modifications:
Encourage Tina to adopt a balanced and nutritious diet that focuses on controlling blood sugar levels
and maintaining a healthy weight.
Recommend regular physical activity tailored to her abilities and preferences, considering low-impact
exercises such as walking, swimming, or cycling.
Discuss the benefits of stress reduction techniques, such as relaxation exercises, mindfulness, and
engaging in hobbies or activities that promote emotional well-being.
Follow-up appointments:
Schedule regular follow-up appointments with Tina to monitor her progress, assess the effectiveness of
treatments, and make any necessary adjustments to her care plan.
Ensure that Tina understands the importance of attending these appointments and adhering to the
recommended follow-up schedule.
It's essential for Tina to actively participate in her healthcare and communicate any changes or concerns
with her healthcare provider. The plan outlined above is a general guide, and individualized
recommendations may vary based on Tina's specific needs and the healthcare provider's assessment.
General: Include any recent weight changes, weakness, fatigue, or fever, but do not
restate HPI data here.
HEENT:
Neck:
Breasts:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Psychiatric:
Neurological:
Skin:
Hematologic:
Endocrine:
Review of Systems:
General:
Recent weight loss of 10 pounds unintentionally.
Increased appetite.
Reports occasional headaches.
Denies recent illness.
HEENT (Head, Eyes, Ears, Nose, Throat):
Reports darkened skin on the neck.
Increase in facial and body hair.
Acne since puberty.
Bumps on the back of arms when skin is dry.
Denies any other head, eye, ear, nose, or throat symptoms.
Neck:
No specific complaints or abnormalities reported.
Breasts:
No specific complaints or abnormalities reported.
Respiratory:
Asthma diagnosed at age 2 1/2.
Uses albuterol inhaler 2-3 times per week, most recently used three days ago with relief of symptoms.
Denies wheezing, coughing, or shortness of breath.
Cardiovascular/Peripheral Vascular:
No specific complaints or abnormalities reported.
Gastrointestinal:
Denies any gastrointestinal symptoms such as abdominal pain, nausea, vomiting, or changes in bowel
movements.
Genitourinary:
Reports irregular menstrual cycles with heavy flow and painful cramping.
Last menstrual period occurred three weeks ago.
No current sexual partner.
No history of sexually transmitted infections or STI symptoms.
No history of pregnancy.
No history of contraception use.
Never tested for HIV/AIDS.
Musculoskeletal:
Right foot injury and wound.
Twisted right ankle and scraped the ball and sole of the foot.
Pain and swelling in the foot, affecting ability to walk and bear weight.
Pain described as throbbing and sharp.
Ankle swelling and pain have resolved, but pain remains in the bottom of the foot.
Reports a recent 10-pound weight loss without change in diet or activity level.
Psychiatric:
No specific complaints or abnormalities reported.
Neurological:
No specific complaints or abnormalities reported.
Skin:
Reports darkened skin on the neck.
Acne since puberty.
Bumps on the back of arms when skin is dry.
Denies any other skin-related symptoms such as rashes, itching, or changes in moles or nails.
Hematologic:
Denies any bleeding, bruising, blood transfusions, or history of blood clots.
Endocrine:
Diagnosed with Type 2 diabetes at age 24.
Not currently taking medication for diabetes or monitoring blood sugar.
Previously took metformin but discontinued three years ago due to side effects.
Last blood glucose was elevated in the emergency room.
Note: The information provided in the review of systems is based on the patient's reported symptoms
and may not include all possible symptoms or findings. It is important to ask further questions and
conduct a thorough physical examination to gather additional information and assess the patient
comprehensively.
HEENT (Head, Eyes, Ears, Nose, Throat):
Head: No specific complaints or abnormalities mentioned.
Eyes: No specific complaints or abnormalities mentioned.
Ears: No specific complaints or abnormalities mentioned.
Nose: No specific complaints or abnormalities mentioned.
Throat: No specific complaints or abnormalities mentioned.
Neck:
No specific complaints or abnormalities mentioned.
Breasts:
No specific complaints or abnormalities mentioned.
Respiratory:
No specific respiratory complaints mentioned.
Cardiovascular/Peripheral Vascular:
No specific cardiovascular or peripheral vascular complaints mentioned.
Gastrointestinal:
No specific gastrointestinal complaints mentioned.
Genitourinary:
No specific genitourinary complaints mentioned.
Musculoskeletal:
The patient mentioned right foot pain and difficulty with weight-bearing due to the foot injury. No other
musculoskeletal complaints mentioned.
Psychiatric:
No specific psychiatric complaints mentioned.
Neurological:
No specific neurological complaints mentioned.
Skin:
The patient mentioned a wound on the right foot with signs of infection, including redness, swelling, and
drainage. No other skin complaints mentioned.
Hematologic:
No specific hematologic complaints mentioned.
Endocrine:
The patient mentioned a history of type 2 diabetes, but currently not taking any medication for it. No
other endocrine complaints mentioned.
Please note that this is a brief summary based on the given information. A comprehensive review of
systems would typically include further exploration of each system. If you have any specific concerns or
questions about a particular system, please let me know, and I'll be glad to assist you further.
