Tina Jones Health History Information Processing

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

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. 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
“Yeah, it’s red all around the scrape.” Required Evidence
“At first, it seemed like it was healing up fine and it didn’t give me a lot of pain. But the last two days, the pain got way worse.” Supporting Evidence

Irrelevant
(None provided)

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

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 – Prescribe: Prescribe antibiotics.
Intervene – Other: Clean wound and cover with a 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 role of diabetes mellitus in the healing of wounds.

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 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.

3. Uncontrolled type 2 diabetes mellitus
4 of 4 points
Priority 1 / 1

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 2 / 2

Relevant
“Random blood glucose: 238” Required Evidence
“I don’t know. Every hour or two when I’m awake?” Supporting Evidence
“Yeah, I’ve been drinking tons of water lately.” Supporting Evidence

Irrelevant
(None provided)

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

Relevant
Assess – Neurological: Assess for peripheral neuropathy, by testing position sense and deep tendon reflex at the ankle.
Assess – Neurological: Assess for sensory neuropathy, by testing sensation in the feet, using monofilament.
Intervene – Labs: Order a basic metabolic panel to assess renal function.
Intervene – Labs: Order a fasting lipid panel to evaluate for dyslipidemia.
Intervene – Prescribe: Prescribe a first-line drug for blood glucose control, such as metformin.
Educate – Medication: Educate the patient on diabetes medication action, dose, and schedule.
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.
Educate – Disease Process: Educate the patient on diabetes pathophysiology, risks of morbidity and mortality, importance of self-care.
Educate – Disease Process: Educate the patient on the signs and symptoms of hyper- and hypoglycemia.

Irrelevant
(None provided)

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.

4. Asthma
4 of 4 points
Priority 1 / 1

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 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.
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 a rescue inhaler.

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.

5. Dysmenorrhea
4 of 4 points
Priority 1 / 1

Student Response: Low

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 2 / 2

Relevant
“My periods are always the same–they’re bad. Cramps. Lots of bleeding for more than a week.” Required Evidence

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 1 / 1

Relevant
Assess – Genitourinary: Perform a pelvic exam.
Intervene – Labs: Order urinalysis to assess for urinary tract infection.
Educate – Medication: Educate the patient on the use of oral contraceptives to reduce menstrual flow and regulate the menstrual cycle.

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

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.

6. Hypertension
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
“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.” Required Evidence

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 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 the relation of genetic and lifestyle factors, including diet, with hypertension.

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.

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
“My periods are always the same–they’re bad. Cramps. Lots of bleeding for more than a week.” Required Evidence

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 1 / 1

Relevant
Intervene – Labs: Order a test of the free androgen index.
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 in assessing her pattern.

Irrelevant
Educate – Medication: Educate the patient on the use of NSAIDs to relieve menstrual pain.

Planning Pro Tip: Endocrine disorders are the cause of Tina’s heavy and irregular menstruation, so order labs to evaluate for polycystic 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.

8. Obesity
4 of 4 points
Priority 1 / 1

Student Response: Low

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 2 / 2

Relevant
“BMI: 31” Required Evidence

Irrelevant
(None provided)

Evidence Pro Tip: Based on the WHO’s BMI-based classification, Tina’s BMI of 31 identifies her as obese.

Planning 1 / 1

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

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

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.

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
(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 the presence of axillary and pubic hair by inspection.
Assess – Integumentary: Assess the severity of hair growth at areas including the upper lip, chin, chest, thighs, upper arm, forearm, back, abdomen.
Intervene – Labs: Order a follicle-stimulating hormone test.
Intervene – Labs: Order a test of the 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 in 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 polycystic 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.

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 a lower priority than Tina’s acute problems; addressing her pain and hyperglycemia are more immediate needs to improve her status.

Evidence 2 / 2

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 the severity of hair growth at areas including the 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.