Patient encounter

36496Evaluated lab results to determine the actual and/or potential diseases for which patient is at risk 4
Explained history and physical assessment results that contribute to AC’s risk. 4
Cited lab results correlate with the assessment findings to help determine risk 4

Format: 2 points possible Points possible Points earned Comments
Follows a structure that is clear, concise, and free of grammar, spelling, and syntax errors 1
Provides an appropriate level of detail in explanation 1

Points earned/possible

Grading criteria needed for Angela cortez
In Week 4, you will perform an assessment on
the i-Human Patients® patient, Angela Cortez. This assignment is designed to help guide that assessment.
AC is a 17-year-old high-school senior who presents for a yearly physical at her mother’s insistence for evaluation of fatigue. The mother, who accompanies her today, notes that AC is “tired all the time.” AC states that this has been going on for several months and, when questioned further, she acknowledges irritability, tearfulness, decline in grades, and lack of enjoyment and participation in her usual activities (track team, choir). AC has had difficulty falling asleep at night. She has gained approximately 15 pounds over the past few months due to poor dietary habits (skips breakfast, late-night eating, French fries two to three times per week), and lack of physical activity. AC acknowledges that she has been stressed due to her pending college applications, previous break up with her boyfriend, and loss of a valued part-time job. She has been sexually active in the past, but is not currently. She acknowledges infrequent alcohol and marijuana use, but denies substance abuse. She has been spending increasing amounts of time using the Internet, rather than engaging in social activities. AC acknowledges feelings of hopelessness and states that she feels that she “won’t amount to anything” unless she gets a college acceptance and a scholarship, yet she denies any thoughts of hurting herself. Her mother is very concerned about these behaviors.
Based on the information you have about AC’s situation, determine which of the following variable types are important to focus on for her assessment:
• Physiological
• Psychological
• Spiritual
• Sociocultural
• Developmental