Evaluating a virtual standardized patient in the Shadow Health Digital Clinical Experience (DCE) can be one of the most challenging milestones in a nursing student’s clinical training. Among the roster of digital patients, Tina Jones is the most complex, comprehensive, and widely assigned case.
Representing a 28-year-old African American woman admitted for a painful, infected foot wound, Tina’s case is a masterclass in clinical reasoning, diagnostic prioritization, and therapeutic communication. This guide provides a detailed breakdown of Tina’s case background, complete subjective and objective data answers, and a prioritized care plan to help you navigate this simulation and achieve a 100% Student Performance Index (SPI) score.
Comprehensive Assessment: Tina Jones Shadow Health Transcript
Examiner: Hello, my name is . I will be conducting an interview and later perform a physical exam.
Tina Jones: Hey.
Examiner: What is your name?
Tina Jones: Tina Jones.
Examiner: Your date of birth?
Tina Jones: February 17th.
Examiner: How old are you?
Tina Jones: I’m 28.
Examiner: What brought you into the clinic today?
Tina Jones: I came in because I’m required to have a recent physical exam for the health insurance at my new job.
Examiner: Do you have any current health problem?
Tina Jones: I don’t have anything specific going on today. I mean, I still have asthma and diabetes, but both of those are under control. I’m taking good care of my health these days.
Examiner: What is your new job?
Tina Jones: I’m going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. I’ll be helping a more experienced accountant with her clients, and then eventually I’ll get more responsibility, and build my own client list. I start in two weeks–I’m really excited!
Examiner: That is great.
Tina Jones: Thanks.
Examiner: When was your last physical exam?
Tina Jones: Let’s see . . . I had two doctor’s appointments earlier this year. About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. Then a few weeks later I saw a gynecologist for a pap smear.
Examiner: What did your gynecologist say?
Tina Jones: She said everything looked good, except that I had PCOS, which the nurse here had said was possible. She started me on birth control, and it seems to be helping things.
Examiner: How often do you take birth control?
Tina Jones: I take it every morning, with breakfast.
Examiner: What is the name of the birth control pill you took?
Tina Jones: They’re called Yaz.
Examiner: Has your menstrual cycle improved since taking Yaz?
Tina Jones: Now that I’m on the pill I’m getting my period every month.
Examiner: That is great. I am glad you are having your period every month.
Tina Jones: Thanks.
Examiner: How long have you had asthma.
Tina Jones: I’ve had asthma a long time. . . since I was really little.
Examiner: What age were you diagnosed with asthma?
Tina Jones: My doctor told me when I was pretty little… I think I was about two and a half? I used to have a lot of trouble with asthma attacks back then.
Examiner: I am sorry about the experience.
Tina Jones: Thanks.
Examiner: How do you manage your asthma?
Tina Jones: I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler.
Examiner: What are your triggers for asthma?
Tina Jones: Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. I haven’t had a full asthma attack in years, though.
Examiner: It is important to stay away
Tina Jones: Thanks for telling me.
Examiner: What happens when you are
Tina Jones: I used to have a reaction when I was in a dusty house for a long time. . . I would get allergies, like sneezing and stuff, and then my asthma would act up. But that hasn’t happened since I got my daily inhaler.
Examiner: What
Tina Jones: The daily
Examiner: How often do you use
Tina Jones: Twice a day.
Examiner: When did you most recently use the flovent inhaler?
Tina Jones: I use my Flovent inhaler two times a day.
Examiner: When did you last use your inhaler?
Tina Jones: I used my … problems. Once three months ago, and before that it had been months, too.
Examiner: How much Albuterol do you use?
Tina Jones: I have a few friends I’ve known since middle or high school, and we’re all pretty close. Plus I have my friends from church.
Examiner: What is your relationship like with your family?
Tina Jones: Things are pretty good between all of us–we’re a tight knit family. I think we’re pretty special, the way we all get along.
Examiner: That is great.
Tina Jones: Thanks.
Examiner: Are you involved in church?
Tina Jones: Yeah. We go to First Baptist, and we do a lot with our church community. We socialize before and after church, and I go to Bible study on Wednesdays, too.
Examiner: Are you feeling stressed?
Tina Jones: I’m actually feeling really good lately. . . not stressed at all.
Examiner: How do you cope with stress?
Tina Jones: I’ve realized that I got kind of overwhelmed with everything back when I was having those sleep problems. Just coming in and talking to someone here about it helped a little because I felt like I was doing something. So I’ve been trying to address problems as they come when I can, and that helps. That, plus the stuff I’ve always done–going to church, especially–is all working well for me.
Examiner: That is good to hear.
Tina Jones: Thanks.
Examiner: Are you feeling depressed?
Tina Jones: No, I’m actually feeling really good these days.
Examiner: How do you feel about your life?
Tina Jones: Well, I’m starting my new job in two weeks, and I’m really excited about that. I’m going to be an Accounting Clerk at this really nice accounting firm. I’m hoping I’ll learn a lot in that position, and within a couple years, I’ll get promoted and be given new responsibilities. I just always want to be learning new things and getting better at my job.
Examiner: Are you feeling anxious?
Tina Jones: I guess I had anxiety back when I was having those sleep problems. . . I’ve been feeling much better lately, though.
Examiner: Do you have sleeping problems?
Tina Jones: I’m sleeping a lot better now, which is a relief.
Examiner: Good to hear.
Tina Jones: Thanks.
Examiner: How many hours are you sleeping a night?
Tina Jones: I’m usually asleep by 11:30, and I wake up at 8, so. . . about 8 or 9 hours a night.
Examiner: That is great.
Tina Jones: Thanks.
Examiner: Have you ever smoked tobacco?
Tina Jones: No. I think it’s gross.
Examiner: Have you ever used cocaine?
Tina Jones: No way, I have no interest in that. That stuff can mess you up.
Examiner: Have you ever used heroin?
Tina Jones: Uh, no.
Examiner: Have you ever used illegal drugs?
Tina Jones: Well, I used to smoke pot. . . but I don’t do that anymore.
Examiner: What was the last time you smoked pot?
Tina Jones: I haven’t smoked pot since I was twenty or twenty-one.
Examiner: Do you have any family history of mental illness?
Tina Jones: No. They’re crazy, but nobody’s diagnosed with anything.
Examiner: Have you had suicidal thoughts?
Tina Jones: No, I’ve never done that.
Examiner: Any new family medical history report?
Tina Jones: My mom has some issues, and I think some of my grandparents did, too.
Examiner: How old is your mom?
Tina Jones: Mom is 50.
Examiner: What medical problems does your mum have?
Tina Jones: Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though.
Examiner: What medical problems did your father have?
Tina Jones: He had high blood pressure and cholesterol, and diabetes too…the same kind as me.
Examiner: How old is your brother?
Tina Jones: He’s almost 27.
Examiner: Does he have any medical issue? (Clarified to Does your younger sister have health problems?)
Tina Jones: She’s pretty healthy. She has asthma too, but she almost never has attacks. (Clarified to if my younger sister has health problems.)
Examiner: Does your bother have health issues? (Clarified to Does your brother have medical problems?)
Tina Jones: No, I don’t think so. He’s a little big, maybe. (Clarified to if my brother has health issues.)
Examiner: How old is your maternal grandmother?
Tina Jones: Nana was 73 when she died of a stroke about five years ago. I think she had high blood pressure and cholesterol, too.
Examiner: How old is your maternal grandfather?
Tina Jones: Poppa died of a heart attack when he was 80. . . he had some blood pressure and cholesterol issues when he was alive, too.
Examiner: Any medical history for your paternal grandmother?
Tina Jones: She takes some blood pressure pills, and I think she has high cholesterol, but Granny’s doing great for 82.
Examiner: Does your dad’s father have health issues?
Tina Jones: Grandpa Jones had colon cancer, and that caused all kinds of problems for him. Plus, he had high blood pressure, and…I’m pretty sure he had diabetes.
Examiner: Have you had any recent illness?
Tina Jones: No. . . the last time I was sick was when I was having those heartburn problems a while ago.
Examiner: Any fever?
Tina Jones: I haven’t had a fever.
Examiner: Any chills?
Tina Jones: Nope, no chills.
Examiner: Any acne?
Tina Jones: I took something for my acne. . . tetracycline, I think, back in high school. Since then I’ve just washed my face, I haven’t used anything special. But my zits have gotten better, and I think it’s because I’m on birth control now.
Examiner: Has your body hair improved?
Tina Jones: I think I have a little less body hair than I used to.
Examiner: Do your eyes feel itchy?
Tina Jones: They haven’t been itchy lately at all.
Examiner: Are you having any redness in your eyes?
Tina Jones: My eyes haven’t been red lately. . . not since I came in with those allergies a while ago.
Examiner: Are your eyes dry?
Tina Jones: My eyes don’t feel dry.
Examiner: Do you have any pain in your eyes?
Tina Jones: I haven’t had any eye problems lately–I went to the eye doctor a few months ago and got these glasses, and she checked everything out and said it looked good.
Examiner: Are you having any ear problems?
Tina Jones: My ears feel fine.
Examiner: Any changes in your hearing?
Tina Jones: My hearing is good.
Examiner: Any ear pain?
Tina Jones: My ears feel fine.
Examiner: Ear drainage? (Clarified to Do you have drainage from your ears?)
Tina Jones: Nothing is coming out of my ears. (Clarified to if I have ear drainage.)
Examiner: Any changes in your sense of smell?
Tina Jones: No.
Examiner: Any nose bleeds?
Tina Jones: Nope, my nose isn’t bleeding at all.
Examiner: Any sinus pressure?
Tina Jones: My sinuses have been fine.
Examiner: Has your sense of taste changed?
Tina Jones: No, I think my sense of taste is fine.
Examiner: Are you having dry mouth?
Tina Jones: My mouth hasn’t been dry.
Examiner: ANY pain in your mouth?
Tina Jones: No, my mouth feels fine.
Examiner: ANY sore throat?
Tina Jones: No, it’s fine.
Examiner: Any issue with your gums?
Tina Jones: My gums have been fine.
Examiner: Any issue with your tongue?
Tina Jones: My tongue feels fine….
Examiner: Any difficulties when swallowing?
Tina Jones: I can swallow fine.
Examiner: SORE throat?
Tina Jones: No, it’s fine.
Examiner: Any voice changes?
Tina Jones: My voice has been fine.
Examiner: Any swollen lymph nodes?
Tina Jones: My lymph nodes seem fine.
Examiner: Are you having any nausea?
Tina Jones: No, I haven’t been nauseous at all.
Examiner: Any vomiting?
Tina Jones: No.
Examiner: ANY pain in the abdomen?
Tina Jones: I haven’t really had any stomach problems since I came in with them a while ago.
Examiner: Any constipation?
Tina Jones: I don’t have that problem.
Examiner: Any diarrhea?
Tina Jones: No, my stomach has been fine.
Here is the formatted transcript section, with Your avatar replaced by Examiner:
Examiner: Any diarrhea?
Tina Jones: I haven’t had any problems with diarrhea.
Examiner: Excessive flatulence?
Tina Jones: I haven’t been having any gas lately. I had a little when I first started metformin, but I found out I could eat yogurt to help it, and it seems to have worked.
Examiner: Flatulence is one of the side effects of metformin.
Tina Jones: Thanks for telling me.
Examiner: Any food intolerance?
Tina Jones: I can eat just about anything.
Examiner: Any burning sensation when you urinate?
Tina Jones: No, it doesn’t burn when I pee.
Examiner: Any blood in your urine?
Tina Jones: No! That doesn’t sound like it would be good.
Examiner: Are you having any pain right now?
Tina Jones: I don’t have any pain anywhere.
Examiner: Any vaginal discharge?
Tina Jones: My discharge is normal, I think. . . I have a little, and it’s kind of clear, sometimes white-ish.
Examiner: Any vaginal itching?
Tina Jones: No, it feels normal.
Examiner: Do you have any problem with your breasts?
Tina Jones: No, my breasts feel fine.
Examiner: Any pain in the breasts?
Tina Jones: No, my breasts feel fine.
Examiner: Are you having any dizziness?
Tina Jones: I haven’t been getting dizzy at all.
Examiner: Any lightheadedness?
Tina Jones: No, I don’t really get lightheaded.
Examiner: Any tingling?
Tina Jones: Nope, no tingling.
Examiner: Any loss of balance?
Tina Jones: My balance is fine.
Examiner: Any changes in sensation?
Tina Jones: I haven’t noticed any changes.
Examiner: Any seizures?
Tina Jones: No, I’ve still never had problems with seizures, fortunately.
Examiner: Do you have memory problems?
Tina Jones: I think my memory has been fine.
Examiner: Any muscle pain?
Tina Jones: My muscles have felt great, especially since I started exercising more.
Examiner: Joint pain?
Tina Jones: My joints always seem fine.
Examiner: Any muscle weakness?
Tina Jones: No, I haven’t felt weak at all.
Examiner: Any swelling?
Tina Jones: Nothing is swollen.
Physical Exam Actions
Exam Action: Performed pulse oximetry
Exam Action: Performed spirometry
Exam Action: Inspected scalp
Exam Action: Inspected scalp
Exam Action: Inspected hair on scalp
Exam Action: Inspected scalp
Exam Action: Inspected right eyebrow and orbital area
Exam Action: Inspected left eyebrow and orbital area
Exam Action: Inspected mouth: Oral mucosa moist.
1. Case Background and Clinical Profile
To successfully assess Tina Jones, you must understand that she is not just a “foot wound case”. She is a complex patient with multiple overlapping chronic comorbidities and significant health literacy deficits.
- Demographic Profile: Tina is a 28-year-old African American single female who is currently completing her bachelor’s degree in accounting. She has recently secured a new job at an accounting firm and presents for a pre-employment physical required for her health insurance.
- Chief Complaint: Tina presents with a painful right foot wound that has become severely infected over the past week. She also experiences localized HEENT symptoms (runny nose, itchy eyes, and sore throat) that are consistent with acute environmental allergies.
- Underlying Comorbidities: Tina’s history reveals non-compliant Type 2 Diabetes Mellitus, uncontrolled Asthma, and Polycystic Ovarian Syndrome (PCOS).
- Health Literacy and Socioeconomic Gaps: Tina displays a critical health literacy deficit regarding her diabetes. She stopped taking her prescribed Metformin three years ago due to gastrointestinal side effects (flatulence and stomach upset) and feeling overwhelmed by blood sugar tracking. She erroneously believes her diabetes can be managed solely by “eating healthy” and avoiding “sweets”. Additionally, she has experienced significant emotional stress following her father’s sudden passing in a car accident one year ago.
2. Subjective Data Collection (100% Interview Key)
To score 100% in Subjective Data Collection, you must ask precise, clinically structured questions using a mix of open and closed phrasing. Below are the critical interview findings categorized by system.
History of Present Illness (HPI) & Chief Complaint
- Wound Onset: Scraped the ball of her right foot on the bottom metal rung of a stepstool 1 week ago while barefoot changing a lightbulb.
- Wound Pain: Currently rated as 7/10. Tina describes the pain as throbbing at rest and sharp when attempting to stand or bear weight. The pain prevents her from walking or attending classes.
- Wound Drainage & Symptoms: Noticed clear bleeding initially, which transitioned to thick white, off-white, or yellow pus drainage 2 days ago. Redness, severe swelling, and localized warmth have progressively worsened over the past 48 hours, with pain radiating up into her ankle.
- Home Treatment: Tina cleaned the wound twice daily, applied a bandage, and used polymyxin B/bacitracin/neomycin (Neosporin) ointment, which was completely ineffective. She took regular strength over-the-counter Advil (ibuprofen) monthly for menstrual cramps, and tried taking 2 pills at a time for her foot pain, but it only provided minor relief for a few hours. She denies seeing any other healthcare provider before this admission.
- Sore Throat: Onset 1 week ago, described as constant, mild to moderate, and worse in the morning. It is aggravated by swallowing. She treats it by sucking on lozenges and drinking water.
- Runny Nose & Itchy Eyes: Thin, clear nasal discharge and constant bilateral eye itching began 1 week ago. Denies sneezing, sinus pressure, nosebleeds, or facial pain. She has not taken any antihistamines or decongestants for these symptoms.
Past Medical History & Medication Reconciliation
- Diabetes Mellitus (Type 2): Diagnosed at age 24. Initially prescribed Metformin (500mg twice daily), but she has been completely non-compliant for 3 years. She does not monitor her blood glucose at home and lacks a lancet or test strip supply. She reports classic symptoms of diabetes, including polyuria (urinating every 1 to 2 hours), nocturia (waking up 2 to 3 times nightly to urinate), polydipsia (increased thirst), polyphagia (increased appetite), and an unintentional 10-pound weight loss over the last month.
- Asthma: Diagnosed at age 2.5. Experiencing chest tightness, throat tightness, and wheezing up to twice a week, indicating poorly controlled asthma. Her last severe asthma attack and subsequent hospitalization occurred at age 16. She has a history of approximately 5 pediatric asthma hospitalizations but was never intubated. Her sole current prescription is an albuterol rescue inhaler (Proventil, 90mcg/spray, 2 to 3 puffs as needed), which she last used 3 days ago.
- PCOS & GYN History: Menarche occurred at age 11. Diagnosed with PCOS 4 months ago by her gynecologist, who prescribed an oral contraceptive (drospirenone and ethinyl estradiol) to manage her irregular, heavy, and painful periods. Since starting the pill, her cycles are regular (every 4 weeks) with moderate bleeding lasting 5 days.
- Allergies: Severe, documented allergy to penicillin (causes itchy skin rashes). Environmental allergies to cats (causes wheezing, running nose, itchy eyes) and dust mites.
- Immunization Status: Up-to-date on childhood vaccines and college requirements. Received a tetanus booster 1 year ago for work. She has never received an annual influenza vaccine.
Social & Family History
- Social History: Lives with her mother and younger sister in a single-story suburban house. She is Baptist; her faith and church community serve as her primary coping mechanisms. Reports high academic and financial stress. She denies tobacco use, vaping, or exposure to secondhand smoke. Reports past recreational marijuana use from ages 15 to 21, but none since. Drinks alcohol occasionally when out with friends (2-3 times/month, maximum of 3 drinks per sitting).
- Family History: Her father passed away suddenly in a hydroplaning car accident one year ago at age 58; he had Type 2 diabetes, high cholesterol, and hypertension. Her mother (alive) has hypertension and hyperlipidemia. Her brother is overweight. Her sister has asthma. Paternal grandfather died of colon cancer (also had diabetes, HTN, and high cholesterol). Paternal grandmother has hypertension. Maternal grandmother Nana died of a stroke at 73, and maternal grandfather died 5 years ago.
3. Objective Data Collection (Physical Exam Findings)
To secure all objective performance points, students must conduct a systematic head-to-toe examination, paying close attention to vital signs and targeted systems.
Vital Signs & Physical Measurements
- Height: 170 cm (5’7″)
- Weight: 90 kg (198 lbs)
- BMI: 31 (indicates Class I Obesity)
- Temperature: 4°F (indicates acute fever secondary to wound infection)
- Blood Pressure: 138/90 mmHg (indicates elevated blood pressure / Stage 1 Hypertension)
- Heart Rate: 90 bpm (regular rhythm, S1 and S2 audible, no murmurs, rub, or gallop)
- Respiratory Rate: 18 rpm (regular, unlabored breathing)
- Oxygen Saturation: 98% on room air
- Random Blood Glucose: 238 mg/dL (indicates severe hyperglycemia)
Localized Foot Wound Exam
- Inspection: Scrape located on the plantar surface of the right foot (ball of the foot). Wound bed is erythematous, severely swollen, and actively draining a thick, purulent white, off-white, or yellow pus.
- Palpation: Markedly warm to the touch and highly tender to light palpation. Pain radiates up to the right ankle.
- Mobility: Inability to bear any weight on the right foot due to shooting, sharp pain.
Focused HEENT Findings
- Eyes: Significant bilateral scleral injection (redness). Ophthalmoscopic exam of the retinas reveals cotton wool spots (bodies) on the right retina, which is a clinical sign of early diabetic retinopathy. Visual acuity is 20/20 bilateral.
- Nose: Nasal mucosa appears pale and bluish with thin, clear discharge and clear post-nasal drip. Turbinates are patent.
- Throat/Mouth: Oral mucosa is moist and pink. Tonsils display edema and are graded as 1+ (less than 25% of space between pillars). The posterior oropharynx is erythematous (red) with a textured cobblestoning appearance, indicating chronic post-nasal drip irritation.
- Neck: Bilateral palpable lymph nodes. Notable skin hyperpigmentation and velvety discoloration on the back of her neck, consistent with Acanthosis Nigricans (a marker of severe insulin resistance commonly seen in uncontrolled Type 2 diabetes and PCOS).
Documentation / Electronic Health Record
| Student Documentation | Model Documentation |
|---|---|
128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs | • Height: 170 cm • Weight: 84 kg • BMI: 29.0 • Blood Glucose: 100 • RR: 15 • HR: 78 • BP:128 / 82 • Pulse Ox: 99% • Temperature: 99.0 F |
Health History
| Student Documentation | Model Documentation |
|---|---|
Identifying Data & ReliabilityThe patient is a 28-year-old female who presented for a pre-employment physical exam. She provided the health information freely during the interview. Ms. Jones’ speech is clear and coherent | Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview. |
General SurveyMs. Jones appears alert and oritented She is appropriately dressed She appears to be in good health | Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. She is well-nourished, well-developed, and dressed appropriately with good hygiene. |
Reason for VisitMs. Jones visited to have a physical exam for the health insurance at her new workplae | “I came in because I’m required to have a recent physical exam for the health insurance at my new job.” |
History of Present IllnessMs. Jones reported that she recently got a job at a new place and she is required to obtain a physical examination. She does not have any acute cincerns She was diagnosed with PCOS and oral contraceptives were prescribed She had type 2 diabetes and asthma She reports positive lifestyle modifications | Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. She needs to obtain a pre-employment physical prior to initiating employment. Today she denies any acute concerns. Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. She has no medication side effects at this time. She states that she feels healthy, is taking better care of herself than in the past, and is looking forward to beginning the new job. |
MedicationsMetformin 850 PO BID Flovent 2 puffs 88 mcg/spray BID Albuterol 90 mcg/spray MDI 2 puffs Q4H Drospirenone PO QD | • Fluticasone propionate, 110 mcg 2 puffs BID (last use: this morning) • Metformin, 850 mg PO BID (last use: this morning) • Drospirenone and ethinyl estradiol PO QD (last use: this morning) • Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (last use: three months ago) • Acetaminophen 500-1000 mg PO prn (headaches) • Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6 weeks ago) |
AllergiesAllergic to cats and dust Allergiic to penicillin Denies any food or latex allergy | • Penicillin: rash • Denies food and latex allergies • Allergic to cats and dust. When she is exposed to allergens she states that she has runny nose, itchy and swollen eyes, and increased asthma symptoms. |
Medical HistoryDiagnosed with asthma at 2 1/2 years DIagnosed with diabetes at age 24 years Last asthma exacerbation 3 months ago Diagnosed with PCOS four months ago and take Yaz Has a history of hypertension Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation | Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler when she is around cats. Her last asthma exacerbation was three months ago, which she resolved with her inhaler. She was last hospitalized for asthma in high school. Never intubated. Type 2 diabetes, diagnosed at age 24. She began metformin 5 months ago and initially had some gastrointestinal side effects which have since dissipated. She monitors her blood sugar once daily in the morning with average readings being around 90. She has a history of hypertension which normalized when she initiated diet and exercise. No surgeries. OB/GYN: Menarche, age 11. First sexual encounter at age 18, sex with men, identifies as heterosexual. Never pregnant. Last menstrual period 2 weeks ago. Diagnosed with PCOS four months ago. For the past four months (after initiating Yaz) cycles regular (every 4 weeks) with moderate bleeding lasting 5 days. Has new male relationship, sexual contact not initiated. She plans to use condoms with sexual activity. Tested negative for HIV/AIDS and STIs four months ago. |
Neurological
| Student Documentation | Model Documentation |
|---|---|
SubjectiveDenies any dizinness, ligh-headedness, loss of sensation, tingling, numbness Denies any seizures or sense of disequilibrium | Reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium. |
ObjectiveNormal graphesthesia, stereognosis and rapid alternating movements bilaterallly Tests of cerebellar function normal DRTs and equal bilaterally in upper and lower extremities Reduced sensation to monofilament in bilateral plantar surfaces | Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. Tests of cerebellar function normal. DTRs 2+ and equal bilaterally in upper and lower extremities. Decreased sensation to monofilament in bilateral plantar surfaces. |
Skin, Hair & Nails
| Student Documentation | Model Documentation |
|---|---|
SubjectiveReports imporved acne due to use of oral contraceptives Facial and body hair imporved Denies any nail or hair changes | Reports improved acne due to oral contraceptives. Skin on neck has stopped darkening and facial and body hair has improved. She reports a few moles but no other hair or nail changes. |
ObjectiveScattered pustules on face Facial hair on upper lip Acanthos nigricans on posterior neck Nails free of any abnormalities or ridges | Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. Nails free of ridges or abnormalities. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation |
