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 1 - Health History 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 refl ect on personal strengths, limitations, beliefs, prejudices, and values. Learning Objectives High Priority • Acute pain of the foot • Local infection of skin and subcutaneous tissue of the foot • Uncontrolled type 2 diabetes mellitus Low Priority: • Acanthosis nigricans • Asthma • Dysmenorrhea • Hirsutism • Hypertension • Menorrhagia • Obesity • Oligomenorrhea • Polycystic ovarian syndrome
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