Shadow Health Comprehensive Assessment Tina Jones -
Documentation /Electronic Health Record.
,
, PART 1: COMPLETE CASE STUDY
Patient Profile
Attribute Details
Patient Name Tina Jones
Age 28 years old
Gender Female
Race/Ethnicity African American
Setting Shadow General Hospital, Medical-Surgical Unit
Reason for Visit Painful foot wound (infected diabetic foot ulcer)
Timeframe Day 1 of admission
Tina Jones is a 28-year-old African American female who has just been admitted to
Shadow General Hospital for a painful foot wound. She also requests an annual
exam, since she has not had one in at least two years. Tina was diagnosed with
asthma at age 5 and type 2 diabetes mellitus at age 17.
Chief Complaint
"I have a wound on my foot that has been getting worse and is very painful."
History of Present Illness
Tina reports that the wound began as a blister from new shoes approximately one
week ago. The blister ruptured and the wound has progressively worsened,
Documentation /Electronic Health Record.
,
, PART 1: COMPLETE CASE STUDY
Patient Profile
Attribute Details
Patient Name Tina Jones
Age 28 years old
Gender Female
Race/Ethnicity African American
Setting Shadow General Hospital, Medical-Surgical Unit
Reason for Visit Painful foot wound (infected diabetic foot ulcer)
Timeframe Day 1 of admission
Tina Jones is a 28-year-old African American female who has just been admitted to
Shadow General Hospital for a painful foot wound. She also requests an annual
exam, since she has not had one in at least two years. Tina was diagnosed with
asthma at age 5 and type 2 diabetes mellitus at age 17.
Chief Complaint
"I have a wound on my foot that has been getting worse and is very painful."
History of Present Illness
Tina reports that the wound began as a blister from new shoes approximately one
week ago. The blister ruptured and the wound has progressively worsened,
