1
Complete i-Human Virtual Patient Case Study – Tina Jones with Positive
Family History of Hypertension, Hyperlipidemia, Diabetes Mellitus & Colon
Cancer | Comprehensive Clinical Assessment, HPI, PMH, Family History,
Social History, ROS, Head-to-Toe Physical Examination, Diagnostic Workup,
Differential Diagnoses, Final Diagnosis, SOAP Note, Evidence-Based
Treatment Plan, Medications, Patient Education, Follow-Up Plan &
Submission-Ready Clinical Documentation
i-Human Case Study: Tina Jones – Complete Clinical Case Solution
28-year-old African American female, presenting with a painful, draining foot
wound and uncontrolled type 2 diabetes.
pg. 1
, 2
1. FULL PATIENT INTERVIEW & COMPREHENSIVE HISTORY TAKING
Chief Complaint
“I have a sore on the bottom of my right foot that’s been getting worse for a
week. It’s really painful, red, and there’s yellow stuff coming out.”
History of Present Illness
Tina Jones is a 28-year-old woman who reports she accidentally stepped on a
small nail while walking barefoot in her backyard 7 days ago. She removed the
nail immediately, cleaned the wound with soap and water, and applied a
bandage. The wound initially seemed minor, but over the past 3–4 days it has
become increasingly painful, red, swollen, and warm. Two days ago, she noticed
thick yellowish-green drainage and a foul odor. She reports low-grade fever, chills,
and feeling “run down.” Her home glucose readings (when she checks) have been
in the 250–350 mg/dL range. She has been unable to bear weight on the foot due
to pain, which she rates 8/10 (sharp, throbbing). She denies any previous similar
wounds. No known allergies to medications.
Past Medical History
• Type 2 diabetes mellitus: Diagnosed at age 24. Poorly controlled; last
HbA1c 9.5% (3 months ago).
• Hypertension: Diagnosed at age 26.
• Obesity: Weight has been gradually increasing since adolescence.
• Childhood illnesses: Chickenpox. No rheumatic fever.
• Adult illnesses: No history of coronary artery disease, stroke, or thyroid
disease.
• Surgeries: None.
• Hospitalizations: None since birth.
• Injuries: Sprained left ankle as a teenager; healed uneventfully.
• Immunizations: Up to date, including Tdap within 5 years.
pg. 2
Complete i-Human Virtual Patient Case Study – Tina Jones with Positive
Family History of Hypertension, Hyperlipidemia, Diabetes Mellitus & Colon
Cancer | Comprehensive Clinical Assessment, HPI, PMH, Family History,
Social History, ROS, Head-to-Toe Physical Examination, Diagnostic Workup,
Differential Diagnoses, Final Diagnosis, SOAP Note, Evidence-Based
Treatment Plan, Medications, Patient Education, Follow-Up Plan &
Submission-Ready Clinical Documentation
i-Human Case Study: Tina Jones – Complete Clinical Case Solution
28-year-old African American female, presenting with a painful, draining foot
wound and uncontrolled type 2 diabetes.
pg. 1
, 2
1. FULL PATIENT INTERVIEW & COMPREHENSIVE HISTORY TAKING
Chief Complaint
“I have a sore on the bottom of my right foot that’s been getting worse for a
week. It’s really painful, red, and there’s yellow stuff coming out.”
History of Present Illness
Tina Jones is a 28-year-old woman who reports she accidentally stepped on a
small nail while walking barefoot in her backyard 7 days ago. She removed the
nail immediately, cleaned the wound with soap and water, and applied a
bandage. The wound initially seemed minor, but over the past 3–4 days it has
become increasingly painful, red, swollen, and warm. Two days ago, she noticed
thick yellowish-green drainage and a foul odor. She reports low-grade fever, chills,
and feeling “run down.” Her home glucose readings (when she checks) have been
in the 250–350 mg/dL range. She has been unable to bear weight on the foot due
to pain, which she rates 8/10 (sharp, throbbing). She denies any previous similar
wounds. No known allergies to medications.
Past Medical History
• Type 2 diabetes mellitus: Diagnosed at age 24. Poorly controlled; last
HbA1c 9.5% (3 months ago).
• Hypertension: Diagnosed at age 26.
• Obesity: Weight has been gradually increasing since adolescence.
• Childhood illnesses: Chickenpox. No rheumatic fever.
• Adult illnesses: No history of coronary artery disease, stroke, or thyroid
disease.
• Surgeries: None.
• Hospitalizations: None since birth.
• Injuries: Sprained left ankle as a teenager; healed uneventfully.
• Immunizations: Up to date, including Tdap within 5 years.
pg. 2
