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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


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.


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!”


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


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


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



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.


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.


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.


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


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.


School and stressed over her foot being

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

(No Model Documentation Provided)

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.


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

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