TINA JONES HEALTH HISTORY SHADOW HEALTH INFORMATION PROCESSING

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tina jones health history shadow health Information Processing

tina jones health history shadow health Information Processing
Information Processing: 40 of 40 (100.0%)
Each relevant diagnosis is scored on a four-point scale:
Priority (1 point): the correct priority of the diagnosis was chosen
Evidence (up to 2 points): the strength of the patient cue(s) selected as evidence for the identified diagnosis
Required Evidence: selecting at least one cue that directly indicates the presence of a problem or risk is worth 2 points
Supporting Evidence: selecting at least one cue that is a contributing factor or cause of a problem or risk, without the presence of Required Evidence, is worth 1 point
Planning (1 point): the plan proposed to address the diagnosis includes at least one correct component
Relevant Diagnoses
1. Acute pain of the foot
4 of 4 points
Priority 1 / 1
Student Response: High
Correct Priority:High
Priority Pro Tip: Managing acute pain is an immediate high priority, because other health concerns cannot be effectively addressed while a patient experiences severe pain.
Evidence 2 / 2
Relevant
“I’d say a 7. It hurts a lot, and the pain pills haven’t kicked in yet.” Required Evidence
Irrelevant
(None provided)
Evidence Pro Tip: Tina reports intense pain and rates her pain on a numerical scale. She also reports characteristics of the pain, including its duration of one week; this timespan defines her pain as acute.
Planning 1 / 1
Relevant
Intervene – Prescribe:Prescribe medications to treat pain.
Educate – Medication:Educate the patient on medications used for pain relief.
Educate – Medication:Educate the patient on non-pharmaceutical methods to reduce pain intensity.
Irrelevant
(None provided)
Planning Pro Tip: Intervene to reduce the pain by prescribing an appropriate analgesic and educating the patient on its effective use and potential side effects. Provide the patient with options for non-pharmacological pain relief, such as RICE (rest, ice, compression, elevation).
2.
4 of 4 points
3.
4 of 4 points
4.
4 of 4 points
5.
4 of 4 points
6.
4 of 4 points
Priority 1 / 1
Student Response: Low
Correct Priority:Low
Priority Pro Tip: Tina’s hypertension should be addressed in this visit, as reducing her blood pressure may reduce her risks relating to cardiovascular sequelae. However it is lower priority than her acute complaints as her hypertension will not be significantly improved in a single visit.
Evidence 2 / 2
Relevant
“Blood pressure: 142/82” Required Evidence
“Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though.” Supporting Evidence
“She takes some blood pressure pills, and I think she has high cholesterol, but Granny’s doing great for 82.” Supporting Evidence
“It’s . . . oh, I don’t remember exactly because I never write it down. Let me try to remember . . . I feel like it’s usually around 140. And the bottom number is 80 or 90. I do know the last time in the ER it was something like 141/92. They said it was on the high side. [AUDIO COMING SOON]” Required Evidence
Irrelevant
“Well, he passed away. But he had a couple things . . . Type 2 diabetes, like me, and high cholesterol and blood pressure.”
“Grandpa Jones had colon cancer, and that caused all kinds of problems for him. Plus, he had high blood pressure, and . . . I’m pretty sure he had diabetes.”
“Poppa died of a heart attack when he was 80. . . he had some blood pressure and cholesterol issues when he was alive, too.”
“Nana was 73 when she died of a stroke about five years ago. I think she had high blood pressure and cholesterol, too.”
Evidence Pro Tip: Hypertension is established via measurement of elevated blood pressure (systolic > 140 or diastolic > 90) on two separate occasions. Tina’s records reveal an elevated BP at the time of her ER visit, so the elevated BP at today’s visit establishes Tina’s diagnosis of hypertension. Tina’s risk factors include: race, family history of hypertension, diet, and diabetes.
Planning 1 / 1
Relevant
Assess – Cardiovascular:Assess renal arteries for bruits, with auscultation.
Educate – Disease Process:Educate the patient on associated risks of hypertension with diabetes.
Educate – Disease Process:Educate the patient on relation of genetic and lifestyle factors, including diet, with hypertension.
Irrelevant
Educate – Health Maintenance:Educate the patient on the role of lifestyle changes, including diet and exercise, in improving health outcomes.
Educate – Disease Process:Educate the patient on the risks of morbidity and mortality due to obesity and comorbidities.
Planning Pro Tip: Tina should be educated regarding hypertension (pathophysiology, associated risks relating to morbidity and mortality, and lifestyle interventions). It is important to consider Tina’s risk for secondary hypertension. Auscultate for renal artery bruits as they may be present in renal artery stenosis. Other causes of secondary hypertension should also be considered including hyperaldosteronism, pheochromocytoma, etc.
7.
4 of 4 points
8.
4 of 4 points
9.
4 of 4 points
10.
4 of 4 points
Priority 1 / 1
Student Response: Low
Correct Priority:Low
Priority Pro Tip: PCOS is the root cause of several of Tina’s symptoms and should be addressed. However it is lower priority than Tina’s acute problems; addressing her pain and hyperglycemia are more immediate needs to improve her status.
Evidence 2 / 2
Relevant
“Yeah, I’ve noticed some hairs on my chin that I have to pluck, and I’m…I guess you can see that I’m kind of getting a mustache, which I hate. I’m embarrassed about it. I think I need to start waxing it… I have some belly hair, too.” Required Evidence
“It’s not regular. Sometimes it’s every month, but sometimes it’s more like every two months. I don’t write it down or anything. I probably get…six periods a year.” Required Evidence
“It’s type 2.” Supporting Evidence
“BMI: 31” Supporting Evidence
Irrelevant
(None provided)
Evidence Pro Tip: The Rotterdam criteria should be used to establish a diagnosis of PCOS. At least two of the following must be present: ovulatory dysfunction (Tina reports infrequent menstruation), androgen excess (Tina reports excess hair in a male pattern), or poly-cystic ovaries. Diabetes, obesity, and acanthosis nigricans – all reported by Tina – are common signs and symptoms of PCOS.
Planning 1 / 1
Relevant
Assess – Genitourinary:Assess for enlarged ovaries by palpation.
Assess – Integumentary:Assess severity of hair growth at areas including upper lip, chin, chest, thighs, upper arm, forearm, back, abdomen.
Educate – Disease Process:Educate the patient on the pathophysiology of polycystic ovarian syndrome.
Irrelevant
Assess – Genitourinary:Perform pelvic exam.
Assess – Integumentary:Assess for presence of axillary and pubic hair by inspection.
Intervene – Labs:Order a pelvic ultrasound.
Planning Pro Tip: A pelvic exam should be performed in order to assess for palpable enlargement of the ovaries. An ultrasound may be needed to evaluate for cysts of the ovaries. Educate Tina regarding PCOS and its relationship to diabetes. Work with Tina to assist her in establishing GYN care. Further assessment and lab work may be performed to evaluate for androgen excess.

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