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
... [Show More] right foot injury. 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.
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.
LearningObjectives
Develop strong communication skills
• Interview the patient to elicit subjective health information about her health and health history
• Ask relevant follow-up questions to evaluate patient condition
• Demonstrate empathy for patient perspectives, feelings, and sociocultural background
• Identify opportunities to educate the patient
Document accurately and appropriately
• Document subjective data using professional terminology
• Organize appropriate documentation in the EHR
Demonstrate clinical reasoning skills
• Organize all components of an interview
• Assess risk for disease, infection, injury, and complications
After completing the assessment, you will reflect on personal strengths, limitations, beliefs, prejudices, and values.
Module Features
• Information Processing Activity
• Student Performance Index - This style of rubric contains subjective and objective data categories. Subjective
data categories include interview questions and patient data. Objective data categories include examination
and patient data.
• Acute pain of the foot
• Local infection of skin and
subcutaneous tissue of the foot
• Uncontrolled type 2 diabetes
mellitus
• Acanthosis nigricans
• Asthma
• Dysmenorrhea
• Hirsutism
• Hypertension
• Menorrhagia
• Obesity
• Oligomenorrhea
• Polycystic ovarian syndrome
Underlying ICD-10 Diagnoses
High Priority Low Priority:
“
I got thisscrape on my foot a while ago, and I thought
it would heal up on its own, but now it’s looking
pretty nasty. And the pain is killing me!
A [Show Less]