NURS 612 Shadow Health All Modules Cases Instructor Keys.
ADVANCED HEALTH ASSESSMENT
Health History - TINA JONES
Module 1 - Health History
Ms. Jones is a pleasant, 28 -year- old obese African American single woman who presents to establish care and with
a recent right foot injury. She is the primary source of the history. Ms. Jones off ers information freely and without
contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview.
Timeframe: 1 week after fall (Age: 28)
Reason for visit: Patient presents for an initial primary care visit today complaining of an infected foot wound.
Module 2 - HEENT
For the last week, Tina has experienced sore, itchy throat, itchy eyes, and runny nose. She states that these symptoms
started spontaneously and have been constant in nature. She has treated her throat pain with occasional throat
lozenges which has “helped a little”. She states that her nose “runs all day” and has clear discharge. She denies cough
and recent illness. S
