Tina Jones shadow health Information Processing – Comprehensive Health History
Information Processing :
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
Priority 1 / 1 |
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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 0 / 2 |
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Relevant (None provided) Irrelevant “Measured wound: 2 cm x 1.5 cm, 2.5 mm deep” |
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 |
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Relevant 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 Assess – Integumentary: Assess wound parameters (size, depth). Intervene – Labs: Obtain a wound culture. Intervene – Labs: Obtain blood for culture x2 (blood from two sites). Intervene – Labs: Order a complete blood count test (CBC). Intervene – Prescribe: Prescribe antibiotics. |
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). |
Priority 1 / 1 |
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Student Response: High Correct Priority: High |
Priority Pro Tip: Treating this infection is a high priority, as failure to treat the infection may lead to it spreading to surrounding tissues or systemically. Treating the infection can prevent adverse events such as osteomyelitis and bacteremia. |
Evidence 0 / 2 |
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Relevant (None provided) Irrelevant “Measured wound: 2 cm x 1.5 cm, 2.5 mm deep” |
Evidence Pro Tip: Tina presents with an open wound on the plantar surface of the foot. The wound is red, swollen, warm, and produces purulent discharge. Tina reports that the appearance and level of discomfort have worsened with time- all of these factors support a diagnosis of acute infection. |
Planning 1 / 1 |
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Relevant Intervene – Other: Clean wound and cover with sterile dressing. Educate – Health Maintenance: Educate the patient on wound care procedure. Irrelevant (None provided) |
Planning Pro Tip: Assess the wound directly and obtain a culture so that the infectious organism may be identified, then clean and re-dress the wound. Regional lymph nodes may be swollen. Because the infection is the root cause of Tina’s other acute issues, prescribing an anti-infective will begin to resolve the issues; after receiving culture results, the specific anti-infective given may be changed. Ensure that Tina understands how to treat the wound, use the anti-infective effectively, and to report symptoms of a worsening infection. Foot care is especially important for diabetics, so you should help Tina better understand diabetes’ impact on wound healing and the need to proactively monitor her foot health. |
Priority 1 / 1 |
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Student Response: High Correct Priority: High |
Priority Pro Tip: Tina’s uncontrolled diabetes will delay her wound healing and places her at risk for end organ damage. The need to provide better glucose control for Tina makes this a high priority. |
Evidence 0 / 2 |
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Relevant (None provided) Irrelevant “Measured wound: 2 cm x 1.5 cm, 2.5 mm deep” |
Evidence Pro Tip: Tina’s current blood glucose level supports a diagnosis of uncontrolled type 2 DM. Tina reports symptoms consistent with poor control such as polyuria, polydipsia, and nocturia. |
Planning 1 / 1 |
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Relevant Educate – Health Maintenance: Educate the patient on self-monitoring of blood glucose level procedure and its role in treating diabetes. Educate – Health Maintenance: Educate the patient on the impact of diet, exercise, and weight loss on glycemic control. Irrelevant Educate – Health Maintenance: Educate the patient on the role of lifestyle changes, including diet and exercise, in improving health outcomes. |
Planning Pro Tip: Assess for impacts of Tina’s uncontrolled diabetes including diminished peripheral pulses, peripheral and sensory neuropathy, and retinopathy, and order labs to check for renal function and abnormal lipid levels. Establish a baseline fasting glucose level and educate Tina on the need to monitor her blood glucose and be aware of symptoms of hyperglycemia. Provide better control by prescribing a first-line drug for glucose control. As Tina’s diabetes is uncontrolled, educate her on appropriate diet, monitoring, and treatment regimens. |
Priority 1 / 1 |
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Student Response: Low Correct Priority: Low |
Priority Pro Tip: Although Tina requires education to better manage her asthma, she does not report active respiratory complaints, making this a lower priority diagnosis. |
Evidence 0 / 2 |
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Relevant (None provided) Irrelevant “Measured wound: 2 cm x 1.5 cm, 2.5 mm deep” |
Evidence Pro Tip: Tina reports a personal history of asthma, including past hospitalizations for asthma attacks, as well as her use of an albuterol inhaler. Her sibling’s asthma is of interest, given the strong genetic and environmental factors in the development of asthma. |
Planning 1 / 1 |
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Relevant Assess – Respiratory: Assess lung sounds with auscultation. Assess – Respiratory: Assess pulmonary function using spirometry. Assess – Respiratory: Assess respirations (rate, rhythm, depth, quality). Educate – Health Maintenance: Educate the patient on avoiding triggers of asthma. Educate – Health Maintenance: Educate the patient on enacting her asthma action plan including proper use of rescue inhaler. Irrelevant Assess – Respiratory: Assess for reduced forced expiratory volume using spirometry. |
Planning Pro Tip: Because Tina does not report treatment for maintenance of her asthma, instead relying on a rescue inhaler for sporadic attacks, educate her on developing and enacting a proactive plan to manage the disease. Though Tina does not report an active respiratory complaint, it is valuable to assess for abnormal findings that she may not report. |
Priority 0 / 1 |
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Student Response: (No Priority Selected) Correct Priority: Low |
Priority Pro Tip: This is a lower priority diagnosis for Tina because she is not currently menstruating; her current pain must be addressed immediately, but it is due to her foot wound. |
Evidence 0 / 2 |
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Relevant (None provided) Irrelevant (None provided) |
Evidence Pro Tip: Dysmenorrhea is the symptom of excessive pain with menstruation, which Tina directly reports when asked about the characteristics of her periods. |
Planning 0 / 1 |
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Relevant (None provided) Irrelevant (None provided) |
Planning Pro Tip: Menstrual pain can be reduced by the use of NSAIDs and/or oral contraceptives, so you should provide these options to Tina and educate her on their pros and cons. Urinalysis and a manual pelvic exam are useful tools to rule out causes other than her metabolic and endocrine issues. |
Priority 0 / 1 |
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Student Response: (No Priority Selected) 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 0 / 2 |
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Relevant (None provided) Irrelevant (None provided) |
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 0 / 1 |
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Relevant (None provided) Irrelevant (None provided) |
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. |
Priority 0 / 1 |
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Student Response: (No Priority Selected) Correct Priority: Low |
Priority Pro Tip: Menorrhagia is a secondary issue caused by Tina’s endocrine and metabolic disorders and thus is a lower priority diagnosis. |
Evidence 0 / 2 |
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Relevant (None provided) Irrelevant (None provided) |
Evidence Pro Tip: Tina reports menstruation lasting longer than 7 days, with heavy bleeding. Tina reports no recent sexual activity or potential for pregnancy, ruling out a common cause of irregular bleeding. Other potential causes ruled out by Tina’s history are hormone use, oral contraceptives, and intrauterine devices. |
Planning 0 / 1 |
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Relevant (None provided) Irrelevant (None provided) |
Planning Pro Tip: Endocrine disorders are the cause of Tina’s heavy and irregular menstruation, so order labs to evaluate for poly-cystic ovarian syndrome and thyroid disease. Inspect for both hair growth indicative of excessive androgen production and that indicative of deficient production, and inspect for acanthosis nigricans. Educate your patient on keeping a menstrual calendar to more precisely identify irregularities in her cycle, and using oral medications to reduce symptoms. |
Priority 0 / 1 |
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Student Response: (No Priority Selected) Correct Priority: Low |
Priority Pro Tip: Although Tina’s obesity should be addressed in this office visit, addressing it cannot appreciably alter the patient’s health in a single visit. |
Evidence 0 / 2 |
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Relevant (None provided) Irrelevant (None provided) |
Evidence Pro Tip: Based on the WHO’s BMI based classification, Tina’s BMI of 31 identifies her as obese. |
Planning 0 / 1 |
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Relevant (None provided) Irrelevant (None provided) |
Planning Pro Tip: Tina should be advised during this visit regarding diet and exercise interventions to reduce her body weight. Educate her on the risks of obesity and comorbidities. Assess Tina for the presence of comorbidities, such as hirsutism, acanthosis nigricans, sleep apnea, dyslipidemia, and non-alcoholic fatty liver disease. Test the patient’s thyroid function to rule out hypothyroidism as a contributing factor. |
Priority 0 / 1 |
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Student Response: (No Priority Selected) Correct Priority: Low |
Priority Pro Tip: Oligomenorrhea is a secondary issue caused by Tina’s endocrine and metabolic disorders and thus is a lower priority diagnosis. |
Evidence 0 / 2 |
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Relevant (None provided) Irrelevant (None provided) |
Evidence Pro Tip: Tina reports having about 6 periods per year, meeting the criteria for oligomenorrhea, which are periods more than 35 days apart or 9 per year. Her periods occur fewer than 90 days apart, making oligomenorrhea the correct diagnosis rather than amenorrhea. |
Planning 0 / 1 |
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Relevant (None provided) Irrelevant (None provided) |
Planning Pro Tip: Endocrine disorders are the cause of Tina’s irregular menstruation, so order labs to evaluate for poly-cystic ovarian syndrome and thyroid disease. Inspect for both hair growth indicative of excessive androgen production and that indicative of deficient production, and inspect for acanthosis nigricans. Educate your patient on keeping a menstrual calendar to more precisely identify irregularities in her cycle. |
Priority 0 / 1 |
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Student Response: (No Priority Selected) 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 0 / 2 |
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Relevant (None provided) 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 0 / 1 |
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Relevant (None provided) Irrelevant (None provided) |
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. |
