Tina Jones Health History shadow health Information Processing

Tina Jones Health History shadow health Information Processing

Information Processing : 39 of 40 (97.5%)

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
    • Tina Jones Health History shadow health Information Processing
    • 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

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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. Tina Jones Health History shadow health Information Processing

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. Tina Jones Health History shadow health Information Processing

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

Intervene – Labs: Order a fasting lipid panel to evaluate for dyslipidemia.

Intervene – Labs: Order a test of thyroid stimulating hormone.

 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). Tina Jones Health History shadow health Information Processing
 2. Local infection of skin and subcutaneous tissue of the foot
4 of 4 points

Priority 1 / 1

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 2 / 2

Relevant

“Yeah, it looks swollen around the scrape.” Required Evidence

“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!” Supporting Evidence

Irrelevant

Tina Jones Health History shadow health Information Processing

“Yeah, there’s definitely pus.”

 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. Tina Jones Health History shadow health Information Processing

Planning 1 / 1

Relevant

Assess – Integumentary: Assess wound parameters (size, depth).

Assess – Lymphatic: Assess lymph nodes regional to legs and feet.

Intervene – Labs: Obtain a wound culture.

Intervene – Other: Clean wound and cover with sterile dressing.

Educate – Medication: Educate the patient on the course of antibiotics, importance of taking all prescribed antibiotics, and side-effects.

Educate – Health Maintenance: Educate the patient on the importance of screening tests and foot care, as relates to diabetes.

Educate – Disease Process: Educate the patient on the signs and symptoms of worsening infection.

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. Tina Jones Health History shadow health Information Processing
 3. Uncontrolled type 2 diabetes mellitus
3 of 4 points
 4. Asthma
4 of 4 points

Priority 1 / 1

Student Response:  Low

Correct Priority: Low

Tina Jones Health History shadow health Information Processing

 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. Tina Jones Health History shadow health Information Processing

Evidence 2 / 2

Relevant

“Um, the only things I know I’m diagnosed with are diabetes. And asthma.” Required Evidence

“It’s really rare for me to have an attack now. Three days ago I had some breathing problems, but I guess probably my last full attack was in high school.” Required Evidence

Irrelevant

(None provided)

 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

Relevant

Assess – Respiratory: Assess lung sounds with auscultation.

Tina Jones Health History shadow health Information Processing

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. Tina Jones Health History shadow health Information Processing

Irrelevant

(None provided)

 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. Tina Jones Health History shadow health Information Processing
 5. Dysmenorrhea
4 of 4 points
 6. Hypertension
4 of 4 points
 7. Menorrhagia
4 of 4 points

Priority 1 / 1

Student Response:  Low

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 2 / 2

Relevant

“I’d say it’s heavy. I use the like, extra absorbent tampons, and I still have to change it every two or three hours.” Required Evidence

Irrelevant

“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.”

 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. Tina Jones Health History shadow health Information Processing

Planning 1 / 1

Relevant

Intervene – Labs: Order a test of free androgen index.

Educate – Medication: Educate the patient on the use of NSAIDs to reduce menstrual blood flow.

Educate – Medication: Educate the patient on the use of oral contraceptives to reduce menstrual flow and regulate the menstrual cycle.

Educate – Health Maintenance: Educate the patient to keep a menstrual calendar to assist assessing her pattern. Tina Jones Health History shadow health Information Processing

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. Tina Jones Health History shadow health Information Processing. 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.
 8. Obesity
4 of 4 points
 9. Oligomenorrhea
4 of 4 points

Priority 1 / 1

Student Response:  Low

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 2 / 2

Relevant

“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

Irrelevant

Tina Jones Health History shadow health Information Processing

(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 1 / 1

Relevant

Assess – Integumentary: Assess for presence of axillary and pubic hair by inspection.

Assess – Integumentary: Assess severity of hair growth at areas including upper lip, chin, chest, thighs, upper arm, forearm, back, abdomen.

Intervene – Labs: Order a follicle-stimulating hormone test.

Intervene – Labs: Order a test of free androgen index.

Intervene – Labs: Order a test of free testosterone.

Intervene – Labs: Order a test of thyroid stimulating hormone.

Educate – Health Maintenance: Educate the patient to keep a menstrual calendar to assist assessing her pattern.

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. Tina Jones Health History shadow health Information Processing. Educate your patient on keeping a menstrual calendar to more precisely identify irregularities in her cycle. Tina Jones Health History shadow health Information Processing
 10. Polycystic ovarian syndrome
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

“BMI: 31” Supporting 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

Irrelevant

“Weight: 90 kg”

 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. Tina Jones Health History shadow health Information Processing

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

(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. Tina Jones Health History shadow health Information Processing

Other Diagnoses Identified

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