Identifying Data & Reliability
Name; Tina Jones
Age 28 years
Sex: Female
Race; African American
Historian:Patient
General Survey
Miss Jones is alert and oriented x4 she is well groomed, speech is clear and coherent she appears awake well noursihed she has pain in her right foot with pain scale of 7/10 she interacts well and appropraitely, but appears mildly uncomfortable due to pain.
patient reported she visited the ER and Xray of the foot done. patient also reported swollen foot,
Miss Jones reports pain has gottten worse and also report pus like discharge from the scrape which was white or offwhite.
Chief Complaint
patient present to the facility with the complain of pain in an infected wound.
History Of Present Illness
Miss Jones who is a 28 year old African American female presents today with an infected wound. patient reports that the injury occurred a week ago as she was going down the back steps she tripped. she stated she caught the railing but turned her right ankle a little bit and scraped the ball of her right foot on the edge of the step. Patient said she was barefoot when the injury occurred .she visited the ER and xray was done which showed no fracture Tramadol 50mg TID was given for pain .
patient reported that the scrape and pain is getting progressively worse and constant in the last few days she also reported that the scrape is swollen with pus which is whitish in color comg out of the wound, the pain is throbbing and sharp when bearing weight the pain is alleviated with tramadol but pain continues when medication wears off. patient rated the pain as 7 out of 10 on Assessment
patient reported she was cleansing the scrape with soap and water , apply neosporin on it twice a day and let it dry
patient stated when it gets irritated she put peroxide and then rinse it off and keep it bandaged.
patient is concerned about the wound because she could not work well enough as she went back home from works two days ago and she has not been to work since then. The patient said that the scrape and pain have been getting worse and more constant over the last few days. She also said that the scrape is swollen and has white pus coming out of it. The pain is throbbing and sharp when the patient puts weight on it. Tramadol helps with the pain, but the pain comes back when the medication wears off. On Assessment, the patient said the pain was a 7 out of 10. She said she was cleaning the cut with soap and water, putting neosporin on it twice a day, and letting it dry.
Medications
Tramadol 50mg three times a day for foot pain
Proventil inhaler 90 mcg 2-3 puffs 2-3 times a week and PRN
Tylenol extra strenght 500mg for headache usually 2 tablets once in a week for headache
Advil 200mg 3 tablets takes up to three times a day for cramps.
Allergies
penicillins- rash hives when patient was a child
Cats and dust – sneezing, itchy eyes and difficulty in breathing ( excerbation of asthma)
Medical History
Asthma was diagnosed as a child about two and half year old.
Diabetes type 2 diagnosed 4 years ago. patient took metformin when she was diagnosed but patient stopped three years ago. patient has glucometer at home but does not monitor blood sugar frequently last random blood sugar was 238mg/dl stated she watches what she eats and stay away from sweets.
patient denies any previous surgical history.
darkened skin on the neck swollen foot blurry vision no eyeglasses/contacts
no history of STDs
patient admitted to recent change in urination appetite and weight
she admitted to frequent hospitalization
patient deneis having any flu vaccine at thos time but had couple in the past and patient feels it was not effective.
when she was younger due to asthmatic attack
Patient got tetanus booster about a year ago and stated she completed all her vaccinations
patient denies taking any vitamins or supplements
patient admitted to having high blood pressure but has not been following up with any primary care physcian.
last menstrual period was 3 weeks ago, denies any vaginal discharge, patient took oral contraceptives in the past, admits to blurry vision when she reads last eye exam was when she was a kid
Health Maintenance
Miss Jones is non complaint with diabetic regimen last pap smear was 4 years ago no regular exercise she states she is up on her feet all the time at work and considers that her exercise
she denies taking any vitamins or supplements
last dental exam was few years ago
no eye exam done since patient was a kid
patient had tetanus booster a year ago
she receievd all her childhood immunizations
she had chicken pox when she was a kid
patient diet include muffin or pumpkin bread in the moring eat subway or sandwich for lunch and meatloaf or chiken for dinner. patient drinks about four diet cokes and maybe a glass of water or two in a day she had her last flu vaccine some years back she had tetanus vaccine a year ago
Family History
Mother : high cholestrol , hyoertension
Father :hypertension high cholestrol diabets died in car accident at age 58
Sister; Asthma
Brother: Obesity
Paternal grandfather (deceased of colon cancer, hypertension Diabetes
Paternal Grandmother: hypertension hyperlipidemia
Maternal grandmother: ( deceased at 78year of stroke, hypertension , hyperlipidemia)
Maternal Grandfather: (deceased at 80 of heart attack,) hypertension hyperlipidemia
Social History
Miss Jones is a single woman no children works as a supervisor at Mid American copy and ship works 32 hours a week . has access to health insurance, starts drinking at age 15 or 16 denies smoking cigrette or tobacco smoke marijauna while in high school denies vaping or e- cigarette but patient is exposed to second hand smoking when out with friends, patient currently lives with mother and sister patient has 2 siblings reports strong support system from family and church and goes out with friends and church. her religious affliation is Baptist
she denies using any contraceptives at this time . patient is heterosexual she is sexually inactive at this time. patient has never been pregnant patient inability to work to walk was impared due to the wound and has affected her attendance at work she is presently working on her bachelors degree.
Objective
ms Jones wound measures 2.5cm*1.5cm*2.5cm
wound C&S will be done on on wound swab and senrt to lab
wound dressing would be done and sterile dressing will be applied.
Name:
Section:
Week 4
Shadow Health Digital Clinical Experience Health History Documentation
SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
Chief Complaint (CC):
History of Present Illness (HPI):
Medications:
Allergies:
Past Medical History (PMH):
Past Surgical History (PSH):
Sexual/Reproductive History:
Personal/Social History:
Immunization History:
Health Maintenance:
Significant Family History (Include history of parents, maternal/paternal Grandparents, siblings, and children):
Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History). Remember that the information you include in this section is based on what the patient tells you. To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.
General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.
HEENT:
Neck:
Breasts:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Psychiatric:
Neurological:
Skin:
Hematologic:
Endocrine:
