TINA JONES Shadow Health. ADVANCED HEALTH ASSESSMENT.Health History _ All Modules Cases Instructor Keys. 28 -year- old obese African American single woman who presents to establish care and with a recent right foot injury.

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NURS 612 Shadow Health All Modules Cases Instructor Keys. ADVANCED HEALTH ASSESSMENT Health History - TINA JONES Module 1 - Health History Ms. Jones is a pleasant, 28 -year- old obese African Amer... ican single woman who presents to establish care and with a recent right foot injury. She is the primary source of the history. Ms. Jones off ers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview. Timeframe: 1 week after fall (Age: 28) Reason for visit: Patient presents for an initial primary care visit today complaining of an infected foot wound. Module 2 - HEENT For the last week, Tina has experienced sore, itchy throat, itchy eyes, and runny nose. She states that these symptoms started spontaneously and have been constant in nature. She has treated her throat pain with occasional throat lozenges which has “helped a little”. She states that her nose “runs all day” and has clear discharge. She denies cough and recent illness. She denies fevers, chills, and night sweats. Timeframe: 1 month after establishing primary care (Age: 28) Reason for visit: Patient presents complaining of nose and throat symptom Module 3 - Respiratory Tina had an asthma episode 2 days ago. At that time she used her albuterol inhaler and her symptoms decreased although they did not completely resolve. Since that incident she notes that she has had 10 episodes of wheezing and has shortness of breath approximately every four hours. Tina presents with continued shortness of breath and wheezing. Timeframe: 3 months after establishing primary care (Age: 28) Reason for visit: Patient presents complaining of a recent asthma episode that is not fully resolved Focused exam case Graduate - Cough (Daniel “Danny” Rivera™) Module 4 - Cardiovascular Over the last month, Tina has experienced 3 -4 episodes of perceived rapid heart rate. She describes these episodes as “thumping in her chest” with a heart rate that is “way faster than usual”. She does not associate the rapid heart rate with a specifi c event, but notes that they usually occur about once per week in the morning on her commute to class. The episodes generally last between 5 and 10 minutes and resolve spontaneously. She denies chest pain during the episodes. Timeframe: 4 months after establishing primary care (Age: 28) Reason for visit: Patient presents complaining of recent episodes of fast heartbeat Focused exam case **For instructor use** Focused Exam Case - G BFoster v1 || Copyright © 2014 ShadowHealth.com Graduate - Chest Pain (Brian Foster™) Module 5 - Gastrointestinal For “at least a month,” Tina has been experiencing pain in her upper stomach after eating, which she describes as “kind of like heartburn, but sharper.” She notices it a little every day, but 3- 4 times a week it is very painful (5/10 on pain scale). She also notices burping after she eats. She denies cough, hoarseness, sore throat, dysphagia, and chest pain. Timeframe: 6 months after establishing primary care (Age: 28.5) Reason for visit: Patient presents complaining of recent recurrent stomach pain Focused exam case **For instructor use** Focused Exam Case - G EPark v1 || Copyright © 2014 ShadowHealth.com Graduate - Abdominal Pain (Esther Park Three days ago, Ms. Jones injured (“tweaked”) her back lifting a box. The pain is in her low back and bilateral buttocks, is a constant aching with stiff ness, and does not radiate. The pain is aggravated by sitting and decreased by rest and lying fl at on her back. She presents today as the pain has continued and is interfering with her activities of daily living. Timeframe: 8 months after establishing primary care (Age: 28.5ish) Reason for visit: Patient presents complaining of lower back pain Module 7 - Neurological Two days after a minor, low -speed car accident in which Tina was a passenger, she noticed daily bilateral headaches along with neck stiff ness. She reports that it hurts to move her neck, and she believes her neck might be swollen. She did not lose consciousness in the accident and denies changes in level of consciousness since that time. She states that she gets a headache every day that lasts approximately 1 2 hours. She occasionally takes 650 mg of over the counter Tylenol with relief of the pain. Timeframe: 11 months after establishing primary care (Age: almost 29) Reason for visit: Patient presents complaining of headache after a recent minor car accident Module 8 - Mental Health Tina’s recent sleep disturbance has lasted a month. She has been having disturbed sleep 4- 5 nights a week. She states that her sleep is “shallow and not restful”. She complains of difficulty falling asleep at least 4 or 5 nights per week, but states that she is able to stay asleep without diffi culty. On average she sleeps 4 or 5 hours per night and awakens at 8:00am daily. She does not take any prescription or over the counter sleep aids. Timeframe: 12 months after establishing primary care (Age: 29) Reason for visit: Patient presents complaining of sleep problems and feelings of anxiety Module 9 - Comprehensive Assessment [Show More]

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