ACTUAL I-HUMAN TINA JONES CASE STUDY FEATURING POSITIVE FAMILY HISTORY OF HYPERTENSION, HYPERCHOLESTEROLEMIA, DIABETES MELLITUS & COLON CANCER | COMPLETE VIRTUAL PATIENT ENCOUNTER WITH FULL HISTORY TAKING, OPQRST ASSESSMENT, FAMILY & SOCIAL HIST

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ACTUAL I-HUMAN TINA JONES CASE STUDY FEATURING
POSITIVE FAMILY HISTORY OF HYPERTENSION,
HYPERCHOLESTEROLEMIA, DIABETES MELLITUS & COLON
CANCER | COMPLETE VIRTUAL PATIENT ENCOUNTER WITH
FULL HISTORY TAKING, OPQRST ASSESSMENT, FAMILY &
SOCIAL HISTORY



1. The "Big Picture" Framework (Pre-
Encounter)
With this specific family history, you are not
just treating a presenting complaint; you are
performing a cardiovascular and metabolic
risk assessment.
• The Core Question: Is this patient's
current complaint (likely foot pain or a
routine check-up) a red flag for
uncontrolled Type 2 Diabetes,
hypertension, or hyperlipidemia?

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• The Oncologic Red Flag: The family
history of colon cancer (especially if in a
first-degree relative under 60) means
you must ask about colonoscopy
screening, rectal bleeding, and changes
in bowel habits.


2. Full History Taking Script (What to Ask
and Why)
A. Presenting Complaint (Chief Complaint)
• Ask: "What brings you in today, Ms.
Jones?" (Likely: "My foot hurts" or "I'm
here for my annual physical").
• Why: Establishes the agenda.
B. OPQRST Assessment (For the Chief
Complaint, e.g., Foot Pain)