1
Comprehensive i-Human Virtual Patient Case Study: Tina Jones with
Significant Family History of Hypertension, High Cholesterol, Diabetes
Mellitus & Colon Cancer | Complete Clinical Assessment Package
Including Patient Interview, Comprehensive HPI, Past Medical History
(PMH), Surgical History, Medication Review, Allergies, Family History,
Social History, Review of Systems (ROS), Head-to-Toe Physical
Examination, Laboratory & Diagnostic Interpretation, Differential
Diagnoses, Final Diagnosis, Comprehensive SOAP Note, Evidence-
Based Treatment Plan, Medication Management, Patient Education,
Follow-Up Care, Clinical Documentation & Clinical Reasoning Guide
Tina Jones – Final Exam Submission Format
pg. 1
,2
i-Human Virtual Patient: 28-Year-Old Female with Foot Wound, Diabetes,
Hypertension
Final Diagnosis: Uncontrolled Type 2 Diabetes with Neuropathic Foot Ulcer,
Peripheral Neuropathy, Background Retinopathy, and Early Nephropathy;
Essential Hypertension; Obesity; Mixed Dyslipidemia
Complete & Submission-Ready – 100% Accurate
1. SUBJECTIVE DATA
Chief Complaint
“I’m here to get a physical for my new job at the warehouse. Also, I have this sore
on my foot that just won’t heal.”
History of Present Illness (OLDCARTS)
Element Findings
Foot wound started 2 weeks ago after wearing new shoes; polydipsia,
Onset
polyuria, fatigue, blurred vision for ~6–12 months.
Location Right foot, plantar surface near the first metatarsal head.
Duration Wound present for 2 weeks; constitutional symptoms for about 1 year.
Shallow ulcer with pink granulation tissue and moderate serosanguinous
Characteristics drainage; no foul odor. Numbness, tingling, burning in both feet, worse at
night.
Aggravating
Walking and standing increase foot pain.
Factors
Relieving Factors Elevating foot, ibuprofen 400 mg PRN gives mild relief.
pg. 2
, 3
Element Findings
OTC ibuprofen; topical antibiotic ointment. Previously prescribed metform
Treatments 500 mg BID and lisinopril 10 mg daily but stopped both 3 months ago (“ra
out”).
Severity Foot pain 4/10; overall fatigue 6/10.
Frequent urination (nocturia ×3–4), excessive thirst, unintentional weight
Associated
loss of 15 lb in 6 months, blurred vision intermittently, recurrent vaginal
Symptoms
yeast infections (3 in the past year).
Pertinent Denies fever, chills, chest pain, shortness of breath, leg swelling, calf
Negatives tenderness, or trauma. No loss of protective sensation in hands.
Past Medical History
• Type 2 diabetes mellitus – diagnosed 2 years ago; never consistently
treated; no home glucose monitoring.
• Hypertension – diagnosed 1 year ago; poor medication adherence.
• Obesity – longstanding.
• Childhood illnesses: Chickenpox, mumps.
• Injuries: Right ankle sprain 5 years ago, resolved.
• Hospitalizations: None.
• Surgeries: Wisdom teeth extraction at age 20.
• Obstetric history: Gravida 0.
• Immunizations: Tetanus 6 years ago, influenza vaccine last year, COVID-19
series complete; no pneumococcal vaccine.
Medications (Prior to Visit)
pg. 3
Comprehensive i-Human Virtual Patient Case Study: Tina Jones with
Significant Family History of Hypertension, High Cholesterol, Diabetes
Mellitus & Colon Cancer | Complete Clinical Assessment Package
Including Patient Interview, Comprehensive HPI, Past Medical History
(PMH), Surgical History, Medication Review, Allergies, Family History,
Social History, Review of Systems (ROS), Head-to-Toe Physical
Examination, Laboratory & Diagnostic Interpretation, Differential
Diagnoses, Final Diagnosis, Comprehensive SOAP Note, Evidence-
Based Treatment Plan, Medication Management, Patient Education,
Follow-Up Care, Clinical Documentation & Clinical Reasoning Guide
Tina Jones – Final Exam Submission Format
pg. 1
,2
i-Human Virtual Patient: 28-Year-Old Female with Foot Wound, Diabetes,
Hypertension
Final Diagnosis: Uncontrolled Type 2 Diabetes with Neuropathic Foot Ulcer,
Peripheral Neuropathy, Background Retinopathy, and Early Nephropathy;
Essential Hypertension; Obesity; Mixed Dyslipidemia
Complete & Submission-Ready – 100% Accurate
1. SUBJECTIVE DATA
Chief Complaint
“I’m here to get a physical for my new job at the warehouse. Also, I have this sore
on my foot that just won’t heal.”
History of Present Illness (OLDCARTS)
Element Findings
Foot wound started 2 weeks ago after wearing new shoes; polydipsia,
Onset
polyuria, fatigue, blurred vision for ~6–12 months.
Location Right foot, plantar surface near the first metatarsal head.
Duration Wound present for 2 weeks; constitutional symptoms for about 1 year.
Shallow ulcer with pink granulation tissue and moderate serosanguinous
Characteristics drainage; no foul odor. Numbness, tingling, burning in both feet, worse at
night.
Aggravating
Walking and standing increase foot pain.
Factors
Relieving Factors Elevating foot, ibuprofen 400 mg PRN gives mild relief.
pg. 2
, 3
Element Findings
OTC ibuprofen; topical antibiotic ointment. Previously prescribed metform
Treatments 500 mg BID and lisinopril 10 mg daily but stopped both 3 months ago (“ra
out”).
Severity Foot pain 4/10; overall fatigue 6/10.
Frequent urination (nocturia ×3–4), excessive thirst, unintentional weight
Associated
loss of 15 lb in 6 months, blurred vision intermittently, recurrent vaginal
Symptoms
yeast infections (3 in the past year).
Pertinent Denies fever, chills, chest pain, shortness of breath, leg swelling, calf
Negatives tenderness, or trauma. No loss of protective sensation in hands.
Past Medical History
• Type 2 diabetes mellitus – diagnosed 2 years ago; never consistently
treated; no home glucose monitoring.
• Hypertension – diagnosed 1 year ago; poor medication adherence.
• Obesity – longstanding.
• Childhood illnesses: Chickenpox, mumps.
• Injuries: Right ankle sprain 5 years ago, resolved.
• Hospitalizations: None.
• Surgeries: Wisdom teeth extraction at age 20.
• Obstetric history: Gravida 0.
• Immunizations: Tetanus 6 years ago, influenza vaccine last year, COVID-19
series complete; no pneumococcal vaccine.
Medications (Prior to Visit)
pg. 3
