Shadow Health - Tina Jones Health History

Health History Overview

• Tina Jones is a 28-year-old African American woman admitted for a painful foot wound.
• Main objectives include obtaining a comprehensive health history covering past and present conditions, psychosocial history, and family medical background.

Patient Description

• Presenting issue: infected scrape on the foot described as red, swollen, with pus, hot to touch, and painful.
• Vital signs: Height 170 cm, Weight 90 kg, BMI 31. Blood glucose 238, Temperature 102.4°F, Blood pressure 138/90 mmHg, Heart rate 90, Respiratory rate 18, O2 saturation 98%.

Medical History

• Pre-existing conditions: asthma and diabetes (diagnosed at age 24).
• Currently not taking diabetes medication; previously managed with metformin.
• Reports increased thirst and hunger recently, along with weight loss.

Asthma Management

• Triggers include cats, dust, and physical exertion.
• Usual management entails using an inhaler, primarily albuterol, with two to three puffs as needed.
• Historical frequency of asthma exacerbations: max twice a week.

Family Medical History

• Grandfather had colon cancer, high blood pressure, and diabetes.
• Mother's health includes high cholesterol and blood pressure issues.
• Father passed away due to a car accident; had type 2 diabetes and high cholesterol.
• Grandmother living independently but has health concerns related to blood pressure and cholesterol.

Psychological and Social Aspects

• Coping with father's death a year ago, supports mother emotionally.
• Currently experiencing stress due to hospital admission impacting education and work.
• Strong faith as a Baptist provides emotional support through tough times.

Health Beliefs and Practices

• Proactive in managing wound initially with cleaning and Neosporin; ultimately deemed ineffective.
• Engages in healthy eating but lacks consistent monitoring of blood glucose levels.

Allergy Information

• Allergies identified: penicillin and cats.
• No known food allergies; occasional asthma symptoms may occur around dust.

Education and Lifestyle

• Currently completing a bachelor's degree.
• Engages socially, drinking alcohol occasionally but in moderation.

Conclusion

• Importance of thorough health history: establishes a comprehensive understanding of the patient's overall health, enabling accurate treatment and care planning.### Drug Use
• Tina Jones previously smoked marijuana but no longer engages in drug use.
• She experimented with pot during her high school years and shortly after, with a cessation around the age of twenty or twenty-one.
• Tina confirms she has not used any drugs other than marijuana.

Smoking Habits

• Tina Jones has never smoked cigarettes and finds the practice unappealing.
• Although she avoids smoking, she is around friends who smoke when they socialize, particularly while drinking.

Family Background

• Tina's father passed away last year when she was 27 years old.
• His death was due to a car accident, not an illness.