Identifying Data & Reliability
Ms. Jones, a 28-year-old African American female , is present into the hospital beacuse of an infected wound on her foot. Her speech is clear and concise and well- structured. Throughout the interview, she maintain eye contact while freely sharing information.
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General Survey
Ms. Jones is stting upright on the exam table, alert and oriented x3, friendly and well nourished. She is calm and appropriately dressed for the weather.
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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 the pain is killing me!”
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History Of Present Illness
One week ago, Ms. Tina was going down her steps with no shoes and stumbled scratching her right foot on the edge of the step and was taken to the emergency room by her mother where an x-ray was performed and the site showed no abnormality. They cleaned her injuries and Tremadol was reccomended for pain and she was told to remain off of her foot and to keep it very clean and dry at all times as she was realeased home. her foot became swollen 2 days aglo as the pain exacerbated and she saw grayish whte pus draining from the wound and that is when she started taking Tramadol. She rated her agony of pain as a 7 out of 10 on her wounded foot nevertheless; she says it emanates to her whole foot and that there was drainage initially when the episode previoulsy began. Ms. Tina has been cleaning the injury with cleanser and soap and applying Neosporin to the wound two times each day and occasionaly applied peroxide. The pain was depicted as throbbing and very still and sometimes sharp shooting pain or torment when she puts weight on her foot. She can not accomadate her tennis shoes on her right foot so she had been wearing flip tumbles or slippers everyday. The pai pills have eased the excruciating pain for few hours and she reported having fever. She has lost 10 pounds in barley a month accidentally and has work for two days as she reported. She denied any ongoing sickness and feels hungrier than expected. Review of System: HEENT: Occasional migraines or headache when studying and she takes Tylenil 500mg by mouth twice a
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day. Ms. Tina reports more awful vision in the course of recent months ands no contact or restorative lenses. She denies any congestions, hearing problem or soar throat however, she admits infrequent running nose. Neurological: Occasional migrain revealed, no dizziness, syncope, loss of motivation, ataxia, loss of tingling in her extremities or furthest point. Respiratory: No brevity or shortness of breath, hac k or cough or sputum. Cardiovascular: No chest discomfort or pain and absence of palpitation but mild edema on the right foot. Gastrointestinal: No anorexia, nsasuea sickness, regurgitating or vmitting, loss bowels or diarrhea
Medications
Metformin 850mg PO BID for diabetes (She has not taken the medication for a while). Albuterol Proventil inhaler 90mcg MDI 1-3 puffs Q4hr PRN for Asthma (last use 3 days ago). Tramadol 50mg PO TID for pain (Last use this morning). Advil 600mg PO TID for menstrual cramps (Last use 3weeks ago). Tylenol 500mg-1000mg PO PRN for headaches.
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Allergies
Penicillin: Rash/hives Ms. Jones is allergic to cats and dust. She states that whenever she is exposed to cats and dust, she develops runny nose, swollen and itcy eyes. She denies food and latex allergies.
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Medical History
Ms. Jones was diagnosed with asthma at the age of 2 1/2years. she had tons of astham attack when she was a child, however, denied any ongoing attack. Her last asthma attack was in high school and she was hospitalized. Her last asthma exacerbation was 3days ago and was relief with the use of the inhaler. She reports using the inhaler no more than 2-3times a week Her asthmas is trigger by cat, dust and by running up stairs. She uses Albuterol Provntil inhaler when she experience exacerbations. At the age of 24 years old she was diagnosed with diabetes type2. she had stop takin her diabetes medication, Metformin for a while and does not monitor her blood sugar at home in light of the fact that she is tired of manging it. she reports that the diabetes medication makes her felt sick constantly, and she was uncomfartable. She says she controls her diabetes by watching what she eats and seetle on more advantageous nourishment decision, however, does not appear to be stressed over her regimen. She states that she had a blood surgar checked in the ER a week ago and was told that her blood surgar was high but has forgotten the number. Her first sexaul encounter was at the age of 18 with men. She has used oral contraceptives in the past and stopped using it a while ago. She last visited her OB/GYN four years ago for STI testing which was negative. She reports uncertainty about past partners and STI testing. Her last menstrual period was 2weeks ago.
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Health Maintenance
Ms. Jones last eye exam was when she was a kid, and have not have an eye exam since then. Her last dental exam was a few years ago when she was a kid. Her immunization is up to date and report receiving all necessary chilhood immunizations. She received her last tetanus vaccine in the past year. She denies receiving the Human papillomavirus vaccine and the flu vaccine. She has not have the mammogram but had an exam where the doctor felt her breasts around for lumps. She has not had pap smear for the past years.
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Family History
Ms. Jones father died in an auto collision at the age of 58. He had hypertension, Type 2 Diabetes (DM2), high cholesterol. she has two siblings, a 24 year old brother who is obese and a 14 years old sister who was diagnosed with asthma and hayfever. her uncle on father’s side was alcohol dependent and her 82 year old paternal grandmother had hypertension and high cholesterol. Her paternal grandfather died at age 65 from colon cancer and had hypertension, Diabetes Type 2, high cholesterol. Her maternal grandfather died at age 78 from stroke and had hypertension and high cholesterol; maternal grandmother died of stroke at age 73 and had hypertention and high cholesterol. Her paternal grandmother is still living and is diagnose with hypertension. She denies any
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diagnoses of depression or mental health, thyroid issues, cancer.
Social History
It has been three weeks ago since Ms. Tina had alvohol and drinks socially around twice every week, 4 or fewer beverages when around friends. She denied smoking cigarettes however, she used to smoke pot each of the week and halted or stopped, and has not smoked pot since 20 years of age as it troubled her asthma. She is exposed to second hand smoke when out with companions. She spends sometimes watching television and going out to bars and clubs and also enjoys drinking diet coke. She works as a supervisor at a Mid-American Copy and Ship while in high school and would be completing her bachelor’s degree in accounting. She has never been pregnant, no children and has never been married but hopes to have a family in the future. At the moment she is dwelling with her mother and her sister follwing the passing of her father. Ms. Tina drives her sister to her appointments, for grocery shopping and looks after her mother. She reports being increasingly worried following the passing of her father for a couple of months and did not complete school and reports not having any desire to get up certain days. She has since taking gradually and has gotten back up with school work and acknowledges confidnce is a major piece of her life and being associated with Baptist Church since she was was a child. She appeared to be extemely worried about missing work.
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School and stressed over her foot being infected.
Review of Systems
HEENT: Occasional migraines or headache when studying and she takes tylenol 500mg by mouth twice a day. Ms. Tina reports more awful vision in the course of recent months and no contact or restorative lenses. She denies any congestions, hearing problem or soar throat however, she admits infrequent running nose. Neurological: Occasional migrain revealed, no dizziness, syncope, loss of motion, ataxia, lost of tingling in her extremities or in furthest point. Respiratory: No brevity or shotness of breath, hack or cough or sputu. Cardiovascular: No chest discomfort or pain and absence of palpatation but mild edema on the right foot. Gasrintestinal: No anorexia, nasuea sicknesss, regurgitating or vomiting, loss bowels or diarrhea. She has seen increment in hunger thirst. Genotourinary: No igniting with burning urination, no present or past pregnancy. At 11 year old started menstruating and her periods were unpredictable and kept going for 9-10 days and her last menstrual period was three weeks ago. No adjustment or change in bladder or bowel control. Musculoskeltal: No mucsle, joint, back pain or stifness, and previous history of broken bones or wounds. Mental or psychiateic: Denies depression. Endochronology: Denied night sweats however, report of polyuria, polydipsia which began about a month ago. Awakens more than once pernight to urinate and sometimes every hour or two during the
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days. Hematologic: No frailty or anemia and no bleeding. Skin: Dark skinaround the neck and saw some facial hair development as of late. No past surgeries. Denies sexual activites. Last sexual activity was two years back and did not use condom as she was on conception prevention. Denied any sexually transmitted disease.
Objective
Ms. Tina weighs 90 kilograms, and she is 170 centimeters tall with a Body Max Index of 31. Her vital signs incorperates Blood pressure 142/82, Pulse 86, Resporatory rate 19, Temperature 101.1 Farenheit, Pulse Oximetery 99% on RA. Her Random Blood Glucose level is 238. Wound estimate or measure is 2cm x 1.5cm deep situated on the ball of her right foot mild erythema around wound site and little serousanguinous drainge. The roght foot wound is swab and sent to the laboratory or processing center for culture and sensitivity. Wound is cleaned with normal saline and applied dry sterile dressing that is intact or flawless
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CLICK HERE TO MAKE YOUR ORDER on Ms. Jones, a 28-year-old African American female , is present into the hospital beacuse of an infected wound on her foot.