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Comprehensive i-Human Case Study: Tina Jones Virtual Patient Encounter with
Significant Family History of Hypertension, Hypercholesterolemia, Diabetes
Mellitus & Colon Cancer | Complete Patient Interview, Comprehensive HPI, Past
Medical History (PMH), Family History, Social History, Review of Systems (ROS),
Complete Physical Examination, Diagnostic Workup, Laboratory & Imaging
Interpretation, Differential Diagnoses, Final Diagnosis, Comprehensive SOAP
Note, Evidence-Based Treatment Plan, Patient Education, Follow-Up Care &
Clinical Documentation Guide
pg. 1
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TINA JONES – COMPREHENSIVE CASE STUDY Full Clinical Analysis, Health
History, SOAP Note, Clinical Judgment & Care Plan (Expanded Version for Exam
Submission – Nursing Tutor / Shadow Health Style – Updated 2026)
1. Identifying Data
• Patient: Tina Jones
• Age / Gender / Race: 28-year-old African American female
• Marital Status: Single
• Occupation: Supervisor at Mid-American Copy & Ship (part-time ~32
hours/week); currently pursuing Bachelor’s degree in Accounting
• Living Situation: Recently moved back in with her mother after the death of
her father
• Religion: Active in church
• Source of History: Patient (reliable, cooperative historian)
• Setting: Hospital / outpatient clinic evaluation for non-healing right foot
wound
2. Chief Complaint (CC)
“I got this scrape on my foot a while ago and it just won’t heal. My foot is killing
me.”
3. History of Present Illness (HPI) – Detailed OLDCARTS
• Onset: Approximately 1–2 weeks ago. Tina reports she tripped while
walking and scraped the bottom of her right foot.
• Location: Plantar surface of the right foot (ball of the foot / heel area).
• Duration: Continuous since injury; progressively worsening over the past
several days.
pg. 2
Comprehensive i-Human Case Study: Tina Jones Virtual Patient Encounter with
Significant Family History of Hypertension, Hypercholesterolemia, Diabetes
Mellitus & Colon Cancer | Complete Patient Interview, Comprehensive HPI, Past
Medical History (PMH), Family History, Social History, Review of Systems (ROS),
Complete Physical Examination, Diagnostic Workup, Laboratory & Imaging
Interpretation, Differential Diagnoses, Final Diagnosis, Comprehensive SOAP
Note, Evidence-Based Treatment Plan, Patient Education, Follow-Up Care &
Clinical Documentation Guide
pg. 1
, 2
TINA JONES – COMPREHENSIVE CASE STUDY Full Clinical Analysis, Health
History, SOAP Note, Clinical Judgment & Care Plan (Expanded Version for Exam
Submission – Nursing Tutor / Shadow Health Style – Updated 2026)
1. Identifying Data
• Patient: Tina Jones
• Age / Gender / Race: 28-year-old African American female
• Marital Status: Single
• Occupation: Supervisor at Mid-American Copy & Ship (part-time ~32
hours/week); currently pursuing Bachelor’s degree in Accounting
• Living Situation: Recently moved back in with her mother after the death of
her father
• Religion: Active in church
• Source of History: Patient (reliable, cooperative historian)
• Setting: Hospital / outpatient clinic evaluation for non-healing right foot
wound
2. Chief Complaint (CC)
“I got this scrape on my foot a while ago and it just won’t heal. My foot is killing
me.”
3. History of Present Illness (HPI) – Detailed OLDCARTS
• Onset: Approximately 1–2 weeks ago. Tina reports she tripped while
walking and scraped the bottom of her right foot.
• Location: Plantar surface of the right foot (ball of the foot / heel area).
• Duration: Continuous since injury; progressively worsening over the past
several days.
pg. 2
