Name:

Health History

Identifying Data

Tina Jones

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Tina Jones, 28 years old

Date of Birth: 2/17/1982

African American

Female

Document: Provider Notes – NURS 6512

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General Survey

Chief Complaint

1. Redness around the scrape2. Pain started as 5 or 6, but now a 10/10 with weight bearing3. Pain is worse during weight bearing, “throbbing and sharp” feeling, Tramadol effective

“I got this scrape on my foot a while ago”

Describes pain as “this pain is killing me”

Scrape happened “1 week ago,” but pain is “worse in the last few days.”

Document: Provider Notes – NURS 6512

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History of Present Illness

29-year-old AA female presents to clinic for complaints of aching pain 7/10 to bottom of right foot. Pain started 1 week ago after she scraped her foot, and pain has worsened in the “last few days.” She describes pain as “this pain is killing me.” New onset, 2 days ago of “white or off-white” purulent drainage, without odor. Aggravating symptoms are weight bearing resulting in increased pain 10/10. Relieving factors are the use of Tramadol and non-weight bearing activities. She is cleansing wound with hydrogen peroxide, and changing the bandage twice a day, every morning and night. Current dressing is moderately soiled, SS drainage observed seeping through dressing. She complains of a fever last night with oral temp of 102 degrees Fahrenheit.

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Medications

1. Tramadol 50 mg: She is taking 2 tabs three times a day (morning, noon, and night). Last dose taken this morning.

2. Proventil (Albuterol Sulfate) Inhaler 90 mcg: 2 puffs. Needs 2-3 times/week and has been needing up to 3 puffs lately. Last date taken unknown.

3. Takes Ibuprofen occasionally for cramps. 4. Denies vitamins or supplement use.

Document: Provider Notes – NURS 6512

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Allergies

Medical History

1. Cats: Sneezing, itchy eyes, wheezing, and asthma exacerbation2. Penicillin: Rashes and Hives3. Denies any food allergies4. Denies latex allergy

1. Asthma, well controlled: triggers are mostly cats, but also dust and running up the steps. Asthma attacks with feelings of chest and throat tightness, wheezing, and feelings of “not enough air.” Last asthma attack was in high school.

2. Diabetes Mellitus Type 2, poorly controlled. Diagnosed at 24 years of age3. Last Hospitalization was at age 16

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Health Maintenance

1. Last A1C unknown saying, “I was probably a kid.” BS today is 2382. Infrequent blood glucose monitoring3. Last took Metformin 3 years ago after taking for 1 year. Dose unknown. 4. Last seen provider 3 years ago, when 1st diagnosed with Diabetes Type II.5. Drinks diet sodas, avoids sweets, and denies adding salt to meals6. Eats 3 meals a day, carbohydrate intake unknown7. Education to be provided on Diabetes management. 8. Immunizations are up to date9. Tetanus vaccination received in the last year10. Denies ever receiving the Influenza vaccination

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Family History

1. Father: Diabetes Type II and HTN. Died in Car accident last year after car hydroplaned in rainy weather.

2. Mother: HTN, High Cholesterol. Mother was depressed after spouse’s death.3. 1 Sister with Asthma4. Brother without any health concerns 5. (P) Grandfather: Type II Diabetes, HTN. Died of Colon Cancer6. (P) Grandmother: High Cholesterol. Taking BP meds for HTN. Currently lives alone7. (M) Grandfather: HTN, MI. Died in car accident with patient was a child8. (M) Grandmother died 5 years ago, post CVA. She had High Cholesterol and HTN9. Paternal Uncle: Alcoholism10. Family History of Obesity

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Social History

Review of Systems

1. Single, never married, no children, 2. Resides with mother and sister3. Currently in college to obtain Bachelor’s in Accounting4. Denies any financial difficulties to pay for medications or treatments.5. Baptist, highly involved with family church6. Denies tobacco use and denies vaping7. Last smoke marijuana at age 20 or 218. “A few” Alcoholic beverages 1-2 times/week9. Identifies supportive network as several family members10. She grieved appropriately after father’s death

Subjective

 General: Fever last night of 102 degrees orally. Unintentional weight loss of 10 lbs in last month.  HEENT: Has occasional headaches. Has blurry vision, but does not wear corrective lenses. Last eye

exam was during childhood. Runny nose is infrequent. Denies difficulty with swallowing. Respiratory: Denies cough. Denies shortness of breath. Last asthma exacerbation wsa 3 days ago. Cardiovascular/Peripheral Vascular: Denies chest pain or discomfort. Denies any palpitations or

arrythmias. Denies hx of murmur.  Gastrointestinal: Denies N/V. Denies any abdominal pain. Denies diarrhea or loose stools.  Genitourinary: Increase in urination  Musculoskeletal: Denies arthralgia or myalgia. Denies any pain or discomfort with movement to

extremities. Denies history of trauma or fractures.  Psychiatric: Denies suicidal or homicidal ideation. Denies anxiety or depressive symptoms Neurological: Denies paresthesia, headaches, or dizziness.. Denies problems with gait or coordination.

Denies any falls or seizure activity.  Skin: Has a wound to bottom of right foot with aching pain. White or off-white purulent drainage

present without odor.  Hematologic: Denies any problems with bleeding. Denies any problems with clotting. Denies hx of any

blood clots.  Endocrine: Increase thirst and increased in water intake.

Objective

 Vital Signs: 142/82-86-19-99%. Oral temp 101.F Wt: 90 kg. BMI 31

Document: Provider Notes – NURS 6512

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