Tina Jones Shadow Health

Please use the patient information provided below for this paper.

This assignment assesses the intended course outcome(s)

  • Use the information found in patients’ health histories, genograms, and assessments to formulate an individualized plan of nursing care that focuses on the patient’s health promotion and disease prevention needs.

Students will use the information found in Tina’s history, physical exam, and problem list to formulate an individualized health promotion and disease prevention care plan. Recommendations should be evidence-based and from credible sources. The readings in module eight contain some suggested sources for obtaining health and screening recommendations for your patient.

The plan for addressing the health promotion and disease prevention needs of your patient should include the following:


  • Age, gender, and race of the patient
  • Education level (health literacy)
  • Access to healthcare

Tina Jones Comprehensive Assessment

Insurance/Financial Status

Can the patient afford medications, a healthy diet, and other out-of-pocket expenses?

Screening/Risk Assessment

Identified health concerns based on screening assessments and demographic information



  • What is the patient’s activity level?
  • Is the environment where the patient lives safe for activity?
  • Nutrition recommendations based on age, race, gender, and pre-existing medical conditions.
  • Activity recommendations

Social Support

  • Support systems, family members, community resources

Health Maintenance

  • Recommended health screening based on age, race, gender, and pre-existing medical conditions

Patient Education

  • Identified knowledge deficit areas/patient education needs (medication teaching etc.)
  • Self-care needs/ Activities of daily living.

* The paper should be written and referenced in APA format and be no longer than 4 pages (excluding the cover page and references).

Your paper will be evaluated based on the following criteria:


  • Level 3
  • Level 2
  • Level 1

Demographics (5%)

  • Includes age, race, and gender of the patient
  • Missing one data item
  • Missing 2 or more data items

Insurance/Financial Status (10%)

  • Includes information regarding the patient’s insurance status and ability to afford medications and other out-of-pocket expenses
  • Missing some information regarding insurance status and ability to pay for medications and other out-of-pocket expenses.
  • Missing information regarding the patient’s insurance status, ability to pay for medications and other out-of-pocket expenses

Screening /Risk Assessment (10%)

  • Identifies health concerns based on screening assessments and demographic information.
  • Missing some information regarding health concerns by excluding information from screening assessments and demographics
  • Health concerns are not identified due to information missing from screening assessments and demographics.

Nutrition/Activity (20%)

  • Completely assess the patient’s nutrition and activity levels and make recommendations based on age, race, gender, and pre-existing medical conditions.
  • Missing some information regarding the patient’s nutrition and activity levels, make recommendations based on age, race, gender, and pre-existing medical conditions.
  • Most information regarding the patient’s nutrition and activity levels is missing; recommendations are missing or not based on the patient’s age, race, gender, and pre-existing medical conditions.

Social Support (10%)

  • Identifies support systems such as family members and community resources
  • Missing some information regarding support systems such as family members and/or community resources
  • Little to no information regarding social support.

Health Maintenance (20%)

  • Overall health maintenance recommendations made based on age, race, gender, and pre-existing medical conditions
  • Missing some recommendations, mostly based on age, race, gender, and pre-existing medical conditions
  • Missing many recommendations loosely related to age, race, gender, and pre-existing medical conditions

Patient Education (20%)

  • Identified knowledge deficit areas/patient education needs, including self-care needs and activities of daily living
  • Missing one or more areas of knowledge deficit/patient education needs, including self-care and activities of daily living
  • Lacks identification of knowledge deficit areas/patient education needs. Does not consider self-care needs or activities of daily living.

Organization, Spelling And Grammar, APA (5%)

  • Organized, easy to read, no spelling or grammar mistakes, appropriate use of APA
  • Organized and easy to read, with few spelling or grammar mistakes and few errors in APA. Tina Jones shadow health
  • Disorganized, difficult to read, and has many spelling and grammar errors and mistakes. Does not use APA

Overall Score Points



Health History

  • Student Documentation
  • Model Documentation
  • Identifying Data & Reliability

Ms. Jones Is Xxxx

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 history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview.

General Survey

Tina Jones Is Alert And Xxxx

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 Visit

Presents To Xxx

“I came in because I’m required to have a recent physical exam for the health insurance at my new job.”

History Of Present Illness

The Patient Is A Xxx

Ms. Jones reports recently obtaining employment at Smith, Stevens, Stewart, Silver & Company. She needs to obtain a pre-employment physical before 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 tolerates well.

She has type 2 diabetes, which she controls 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, takes better care of herself than in the past, and looks forward to beginning the new job.


  • XXX Twice Daily XXXX
  • Fluticasone propionate, XXX(last use: this morning)
  • Drospirenone and XXXX (last use: this morning)
  • XXXX (last use: three months ago)
  • IXXXX (menstrual cramps: last taken 6 weeks ago)



 XXXX • Denies food and latex allergies • XXXXX. She states that she has XXXXX and increased asthma symptoms when exposed to allergens.

Medical History

Diabetes Type 2 – Diagnosed Xxx

XXXdiagnosed at age 2 1/2. She uses her XXXwhen she is around cats. Her last aXXXXX was in high school. Never intubated. XXXX. She began XXX months ago and initially had some gastrointestinal side effects, which have since dissipated. XXXXXXXX. No surgeries. OB/GYN: Menarche, age 11. First sexual encounter at age 18, sex with men, identify as heterosexual. Never pregnant. My last menstrual period was 2 weeks ago. Diagnosed with XXX.

For the past four months (after initiatingXXXX), cycles were regular (every 4 weeks) with moderate bleeding lasting 5 days. Has a new male relationship, sexual contact not initiated. She plans to use condoms with sexual activity. Tested XXX four months ago.

Health Maintenance

Ms. Jones Has Xxx

Last xxx 4 months ago. Last xxx three months ago. Last xxx months ago. xxx2 years ago. xxx: xxx was received within the past year, xxx is not current, and xxx has not been received. She reports she is currently on xxx and received the xxxx for xxx. Safety: Has smoke detectors in the home, wears a seatbelt in the car, and does not ride a bike. Uses six. Xx, having belonged to her dad, is in the home, locked in her parents’ room.

Family History

Her Mother Is Still Alive. She Has Xxx

Mother: age xxxx• Father: deceased in a car accident one year ago at age 58, xxx, and xxx • Brother (Michael, 25): overweight • Sister (Britney, 14): asthma • Maternal grandmother: died at age 73 of a xx, history of xxx

Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol • Paternal grandmother: still living, age 82, hypertension • Paternal grandfather: died at age 65 of xxxx • Paternal uncle: alcoholism • Negative for mental illness, other cancers, sudden death, kidney disease, sickle cell anemia, thyroid problems

Social History

Has Never Been Pregnant Xxx.

Never married, no children. Lived independently since age 19, currently lives with mother and sister in a single-family home, but will move into own apartment in one month. She will begin her new position at Smith, Stevens, Stewart, Silver, & Company in two weeks. She enjoys spending time with friends, reading, attending Bible study, volunteering in her church, and dancing. Tina is active in her church and describes a strong family and social support system. She states that family and church help her cope with stress.

No tobacco. Cannabis use from age 15 to age 21. Reports no use of cocaine, methamphetamines, and heroin. Uses alcohol when “out with friends, 2-3 times per month,” reports drinking no more than 3 drinks per episode.

Typical breakfast is a frozen fruit smoothie with unsweetened yogurt; lunch is vegetables with brown rice or a sandwich on wheat bread or low-fat pita; dinner is roasted vegetables and a protein; snack is carrot sticks or an apple.

Denies coffee intake but consumes 1-2 diet sodas daily. No recent foreign travel. No pets. Participates in mild to moderate exercise four to five times weekly: walking, yoga, or swimming.

Mental Health History

Denies Any Problems With Xxxx

Reports decreased stress and improved coping abilities have improved previous sleep difficulties. Denies current feelings of depression, anxiety, or thoughts of suicide. Alert and oriented to person, place, and time. Well-groomed, easily engages in conversation, and is cooperative. The mood is pleasant. No tics or facial fasciculation.

Example Question:

Do you have any family history of throat problems?


Denies family history of headaches or migraine



Color Nasal

  • Pale
  • Bluish

Discharge (No Point)

  • No discharge
  • Clear discharge
  • Bloody discharge
  • Purulent discharge

Turbinate Patency

  • Patent
  • Right: Tympanic Membrane Color Right And Left Ear
  • Pearly gray

Oral Mucosa (No Point)

  • Moist and pink
  • Tonsils
  • Edema

Tonsil Grade

  • 1+: Tonsils <25% of space between pillars

Posterior Oropharynx Color (1/6 Point)

  • Pink
  • Erythemic

Posterior Oropharynx Texture

  • Cobblestoning

Post Nasal Drip (No Point)

  • Clear discharge

Appearance Neck

  • Discoloration

Right: Retina

Cotton wool bodies



  • “It is possible to develop new allergies as an adult, and so I will take that into consideration as I try to determine the cause of your symptoms.”
  • “I’m sorry to hear you don’t feel well. I’ll ask you some questions to learn more about your symptoms, and we will make a plan to help you feel better.”
  • “Thank you for letting me know that you’re using throat drops in addition to the medications you usually take. I will ask you a few questions about how you use each medication.”

Student Response

After verifying vaccination history, you should be able to cross out certain diseases, such as diphtheria, and move on to assess for other relevant causes of the sore throat. I would consider hand-foot-mouth disease and bacterial or viral pharyngitis for his age. I would need to assess vital signs, including temperature, and obtain a rapid strep swab and a throat culture swab to assess for bacterial or viral properties and verify if an antibiotic would be needed. He would need an assessment involving his eyes, ear, head, neck, and throat. Looking for palpable nodes, redness, swelling, tenderness, drainage, loss of hearing, and pain.

Model Note

Differential diagnosis includes viral pharyngitis, strep throat, influenza, cold, and sinusitis. To rule out strep, rapid strep is indicated. Palpation of the cervical lymph nodes may demonstrate enlarged, tender cervical lymph nodes.

Visualization of the throat also gives clues to the diagnosis. White pus pockets and petechiae on the palate are classic signs of strep throat. Erythema alone may indicate viral infection or postnasal drip. If the purulent discharge is noted in the posterior pharynx, assess for nasal discharge and palpate the appropriate sinuses for the patient’s age.

Consider sinusitis if palpation elicits pain and purulent nasal discharge is reported over the last 7-10 days. A negative rapid flu test would rule out influenza.

Tina’s 76-year-old great-aunt comes into the clinic for a visit, and you find that she frequently asks you to repeat what you say. During the Rinne test, air conduction was greater than bone conduction in her left ear.

  • What is your differential diagnosis?
  • What additional assessments would you perform?

Model Note

Differential diagnosis includes sensorineural hearing loss and anatomical defects. Sensorineural hearing loss is common in old age and can be caused by heredity, diabetes, cerebrovascular disease, excessive noise, ototoxic medications, hyperlipidemia, hypothyroidism, and renal failure.

Assessments should include a history of hearing impairment and ear injuries. Inquiring about chronic ear infections or other trauma that leads to anatomical abnormalities is important. An analysis of Tina’s great aunt’s medications and past medications can be used to rule out ototoxicity. Fasting glucose levels and Hgb A1C can be tested to rule out diabetes.

TSH and T4 levels can rule out hypothyroidism. GFR or creatinine levels can rule out renal failure. Triglycerides, cholesterol, HDL, and LDL levels can be used to rule out hyperlipidemia. A neurological assessment should be completed to rule out cerebral ischemia. The hearing loss should be attributed to old age if no concrete diagnosis is made.


Suppose you had found that Tina’s pupils were reactive to both direct and consensual light, yet unequal in size. Which condition would you suspect?

Correct: Anisocoria is a condition where the pupils are unequal in size. Anisocoria can be found in about 20% of normal individuals.

  • Unequal visual acuity
  • Optic neuritis
  • Glaucoma
  • Anisocoria (Correct Response)

During your physical exam with Tina, imagine you had palpated an enlarged left supraclavicular lymph node. What would this finding have indicated?

Correct: Malignancies originating in the pelvis or abdomen are likely to metastasize to the left supraclavicular lymph node, also known as Virchow’s node.

  • Nothing, because this is a normal variant
  • A serious pathology (Correct Response)
  • A previous infection of the throat
  • Active infection of the throat

If you had observed Arteriovenous (AV) nicking during the retinal exam on Tina, what would you have seen?

Correct: AV nicking is the compression of the vein at arteriovenous crossings due to arterial stiffening. This results in bulging of the vein on either side of the artery making the vein appear to stop on either side of the artery. AV nicking is usually a result of chronic hypertension.

  • Transparent arterial walls
  • Opaque arterial walls
  • Tortuous arteries and veins
  • Vein stops on either side of the artery (Correct Response)

Suppose you detected a click while palpating Tina’s temporomandibular joint (TMJ).

What could have been the cause? Model Note: Crepitus, limited mobility, and pain in the jaw are probable indicators of temporomandibular joint dysfunction (TMJ syndrome). The clicking noises are most likely caused by disc displacement between the condyle and fossa (ball and socket) at the temporomandibular joint.

If Tina had reported new onset ear pain, what would have been the most useful finding to determine otitis media?

Model Note: A useful diagnostic finding that suggests otitis media is the lack of mobility of the tympanic membrane during insufflation. This immobility is caused by increased pressure of the middle ear when air or fluid is trapped due to infection and impairment of the Eustachian tube.

Imagine you inspected Tina’s throat and noted that her tonsils touched each other. How would you grade her tonsils on the tonsillar hypertrophy grading scale? Model Note: Using the standardized tonsillar hypertrophy grading scale, the tonsils are graded 4+ because they touch one another and, therefore, occupy more than 75% of the space between the posterior pillars of the throat.