Identifying Data & Reliability

Ms. Jones, a 28-year-old African Americanfemale , is present into the hospital beacuseof an infected wound on her foot. Herspeech is clear and concise and well-structured. Throughout the interview, shemaintain eye contact while freely sharinginformation.

N/A

General Survey

Ms. Jones is stting upright on the examtable, alert and oriented x3, friendly and wellnourished. She is calm and appropriatelydressed for the weather.

N/A

Chief Complaint

"I got this scrape on my foot a while ago,and I thought it would heal up on its own,but now it's looking pretty nasty. And thepain is killing me!"

N/A

History Of Present Illness

One week ago, Ms. Tina was going downher steps with no shoes and stumbledscratching her right foot on the edge of thestep and was taken to the emergency roomby her mother where an x-ray wasperformed and the site showed noabnormality. They cleaned her injuries andTremadol was reccomended for pain andshe was told to remain off of her foot and tokeep it very clean and dry at all times as shewas realeased home. her foot becameswollen 2 days aglo as the pain exacerbatedand she saw grayish whte pus draining fromthe wound and that is when she startedtaking Tramadol. She rated her agony ofpain as a 7 out of 10 on her wounded footnevertheless; she says it emanates to herwhole foot and that there was drainageinitially when the episode previoulsy began.Ms. Tina has been cleaning the injury withcleanser and soap and applying Neosporinto the wound two times each day andoccasionaly applied peroxide. The pain wasdepicted as throbbing and very still andsometimes sharp shooting pain or tormentwhen she puts weight on her foot. She cannot accomadate her tennis shoes on herright foot so she had been wearing fliptumbles or slippers everyday. The pai pillshave eased the excruciating pain for fewhours and she reported having fever. Shehas lost 10 pounds in barley a monthaccidentally and has work for two days asshe reported. She denied any ongoingsickness and feels hungrier than expected.Review of System: HEENT: Occasionalmigraines or headache when studying andshe takes Tylenil 500mg by mouth twice a

N/A

day. Ms. Tina reports more awful vision inthe course of recent months ands nocontact or restorative lenses. She deniesany congestions, hearing problem or soarthroat however, she admits infrequentrunning nose. Neurological: Occasionalmigrain revealed, no dizziness, syncope,loss of motivation, ataxia, loss of tingling inher extremities or furthest point.Respiratory: No brevity or shortness ofbreath, hac k or cough or sputum.Cardiovascular: No chest discomfort or painand absence of palpitation but mild edemaon the right foot. Gastrointestinal: Noanorexia, nsasuea sickness, regurgitating orvmitting, loss bowels or diarrhea

Medications

Metformin 850mg PO BID for diabetes (Shehas not taken the medication for a while).Albuterol Proventil inhaler 90mcg MDI 1-3puffs Q4hr PRN for Asthma (last use 3 daysago). Tramadol 50mg PO TID for pain (Lastuse this morning). Advil 600mg PO TID formenstrual cramps (Last use 3weeks ago).Tylenol 500mg-1000mg PO PRN forheadaches.

N/A

Allergies

Penicillin: Rash/hives Ms. Jones is allergicto cats and dust. She states that whenevershe is exposed to cats and dust, shedevelops runny nose, swollen and itcy eyes.She denies food and latex allergies.

N/A

Medical History

Ms. Jones was diagnosed with asthma atthe age of 2 1/2years. she had tons ofastham attack when she was a child,however, denied any ongoing attack. Herlast asthma attack was in high school andshe was hospitalized. Her last asthmaexacerbation was 3days ago and was reliefwith the use of the inhaler. She reportsusing the inhaler no more than 2-3times aweek Her asthmas is trigger by cat, dustand by running up stairs. She uses AlbuterolProvntil inhaler when she experienceexacerbations. At the age of 24 years oldshe was diagnosed with diabetes type2. shehad stop takin her diabetes medication,Metformin for a while and does not monitorher blood sugar at home in light of the factthat she is tired of manging it. she reportsthat the diabetes medication makes her feltsick constantly, and she was uncomfartable.She says she controls her diabetes bywatching what she eats and seetle on moreadvantageous nourishment decision,however, does not appear to be stressedover her regimen. She states that she had ablood surgar checked in the ER a week agoand was told that her blood surgar was highbut has forgotten the number. Her firstsexaul encounter was at the age of 18 withmen. She has used oral contraceptives inthe past and stopped using it a while ago.She last visited her OB/GYN four years agofor STI testing which was negative. Shereports uncertainty about past partners andSTI testing. Her last menstrual period was2weeks ago.

N/A

Health Maintenance

Ms. Jones last eye exam was when she wasa kid, and have not have an eye exam sincethen. Her last dental exam was a few yearsago when she was a kid. Her immunizationis up to date and report receiving allnecessary chilhood immunizations. Shereceived her last tetanus vaccine in the pastyear. She denies receiving the Humanpapillomavirus vaccine and the flu vaccine.She has not have the mammogram but hadan exam where the doctor felt her breastsaround for lumps. She has not had papsmear for the past years.

N/A

Family History

Ms. Jones father died in an auto collision atthe age of 58. He had hypertension, Type 2Diabetes (DM2), high cholesterol. she hastwo siblings, a 24 year old brother who isobese and a 14 years old sister who wasdiagnosed with asthma and hayfever. heruncle on father's side was alcoholdependent and her 82 year old paternalgrandmother had hypertension and highcholesterol. Her paternal grandfather died atage 65 from colon cancer and hadhypertension, Diabetes Type 2, highcholesterol. Her maternal grandfather diedat age 78 from stroke and had hypertensionand high cholesterol; maternal grandmotherdied of stroke at age 73 and hadhypertention and high cholesterol. Herpaternal grandmother is still living and isdiagnose with hypertension. She denies any

N/A

diagnoses of depression or mental health,thyroid issues, cancer.

Social History

It has been three weeks ago since Ms. Tinahad alvohol and drinks socially around twiceevery week, 4 or fewer beverages whenaround friends. She denied smokingcigarettes however, she used to smoke poteach of the week and halted or stopped,and has not smoked pot since 20 years ofage as it troubled her asthma. She isexposed to second hand smoke when outwith companions. She spends sometimeswatching television and going out to barsand clubs and also enjoys drinking dietcoke. She works as a supervisor at aMid-American Copy and Ship while in highschool and would be completing herbachelor's degree in accounting. She hasnever been pregnant, no children and hasnever been married but hopes to have afamily in the future. At the moment she isdwelling with her mother and her sisterfollwing the passing of her father. Ms. Tinadrives her sister to her appointments, forgrocery shopping and looks after hermother. She reports being increasinglyworried following the passing of her fatherfor a couple of months and did not completeschool and reports not having any desire toget up certain days. She has since takinggradually and has gotten back up withschool work and acknowledges confidnce isa major piece of her life and beingassociated with Baptist Church since shewas was a child. She appeared to beextemely worried about missing work.

N/A

School and stressed over her foot beinginfected.

Review of Systems

HEENT: Occasional migraines or headachewhen studying and she takes tylenol 500mgby mouth twice a day. Ms. Tina reports moreawful vision in the course of recent monthsand no contact or restorative lenses. Shedenies any congestions, hearing problem orsoar throat however, she admits infrequentrunning nose. Neurological: Occasionalmigrain revealed, no dizziness, syncope,loss of motion, ataxia, lost of tingling in herextremities or in furthest point. Respiratory:No brevity or shotness of breath, hack orcough or sputu. Cardiovascular: No chestdiscomfort or pain and absence ofpalpatation but mild edema on the right foot.Gasrintestinal: No anorexia, nasueasicknesss, regurgitating or vomiting, lossbowels or diarrhea. She has seen incrementin hunger thirst. Genotourinary: No ignitingwith burning urination, no present or pastpregnancy. At 11 year old startedmenstruating and her periods wereunpredictable and kept going for 9-10 daysand her last menstrual period was threeweeks ago. No adjustment or change inbladder or bowel control. Musculoskeltal: Nomucsle, joint, back pain or stifness, andprevious history of broken bones or wounds.Mental or psychiateic: Denies depression.Endochronology: Denied night sweatshowever, report of polyuria, polydipsia whichbegan about a month ago. Awakens morethan once pernight to urinate andsometimes every hour or two during the

(No Model Documentation Provided)

days. Hematologic: No frailty or anemia andno bleeding. Skin: Dark skinaround the neckand saw some facial hair development as oflate. No past surgeries. Denies sexualactivites. Last sexual activity was two yearsback and did not use condom as she wason conception prevention. Denied anysexually transmitted disease.

Objective

Ms. Tina weighs 90 kilograms, and she is170 centimeters tall with a Body Max Indexof 31. Her vital signs incorperates Bloodpressure 142/82, Pulse 86, Resporatory rate19, Temperature 101.1 Farenheit, PulseOximetery 99% on RA. Her Random BloodGlucose level is 238. Wound estimate ormeasure is 2cm x 1.5cm deep situated onthe ball of her right foot mild erythemaaround wound site and littleserousanguinous drainge. The roght footwound is swab and sent to the laboratory orprocessing center for culture and sensitivity.Wound is cleaned with normal saline andapplied dry sterile dressing that is intact orflawless.