Posted: September 20th, 2022

Identifying Data & Reliability

Identifying Data & Reliability
Title; Tina Jones
Age 28 years
Intercourse: Feminine
Race; African American
Historian:Affected person

Normal Survey
Miss Jones is alert and oriented x4 she is effectively groomed, speech is obvious and coherent she seems awake effectively noursihed she has ache in her proper foot with ache scale of seven/10 she interacts effectively and appropraitely, however seems mildly uncomfortable as a result of ache.
affected person reported she visited the ER and Xray of the foot executed. affected person additionally reported swollen foot,
Miss Jones experiences ache has gottten worse and in addition report pus like discharge from the scrape which was white or offwhite.

Chief Grievance
affected person current to the ability with the complain of ache in an contaminated wound.

Historical past Of Current Sickness
Miss Jones who’s a 28 12 months previous African American feminine presents at present with an contaminated wound. affected person experiences that the damage occurred per week in the past as she was taking place the again steps she tripped. she said she caught the railing however turned her proper ankle just a little bit and scraped the ball of her proper foot on the sting of the step. Affected person mentioned she was barefoot when the damage occurred .she visited the ER and xray was executed which confirmed no fracture Tramadol 50mg TID was given for ache .
affected person reported that the scrape and ache is getting progressively worse and fixed in the previous few days she additionally reported that the scrape is swollen with pus which is whitish in coloration comg out of the wound, the ache is throbbing and sharp when bearing weight the ache is alleviated with tramadol however ache continues when remedy wears off. affected person rated the ache as 7 out of 10 on analysis
affected person reported she was cleaning the scrape with cleaning soap and water , apply neosporin on it twice a day and let it dry
affected person said when it will get irritated she put peroxide after which rinse it off and hold it bandaged.
affected person is worried in regards to the wound as a result of she couldn’t work effectively sufficient as she went again residence from works two days in the past and he or she has not been to work since then. The affected person mentioned that the scrape and ache have been getting worse and extra fixed over the previous few days. She additionally mentioned that the scrape is swollen and has white pus popping out of it. The ache is throbbing and sharp when the affected person places weight on it. Tramadol helps with the ache, however the ache comes again when the remedy wears off. On analysis, the affected person mentioned the ache was a 7 out of 10. She mentioned she was cleansing the reduce with cleaning soap and water, placing neosporin on it twice a day, and letting it dry.

Drugs
Tramadol 50mg 3 times a day for foot ache
Proventil inhaler 90 mcg 2-Three puffs 2-Three instances per week and PRN
Tylenol additional strenght 500mg for headache often 2 tablets as soon as in per week for headache
Advil 200mg Three tablets takes as much as 3 times a day for cramps.

Allergy symptoms
penicillins- rash hives when affected person was a baby
Cats and dirt – sneezing, itchy eyes and issue in respiratory ( excerbation of bronchial asthma)

Medical Historical past
Bronchial asthma was recognized as a baby about two and half 12 months previous.
Diabetes sort 2 recognized four years in the past. affected person took metformin when she was recognized however affected person stopped three years in the past. affected person has glucometer at residence however doesn’t monitor blood sugar continuously final random blood sugar was 238mg/dl said she watches what she eats and steer clear of sweets.
affected person denies any earlier surgical historical past.
darkened pores and skin on the neck swollen foot blurry imaginative and prescient no eyeglasses/contacts
no historical past of STDs
affected person admitted to current change in urination urge for food and weight
she admitted to frequent hospitalization
affected person deneis having any flu vaccine at thos time however had couple up to now and affected person feels it was not efficient.
when she was youthful as a result of asthmatic assault
Affected person received tetanus booster a couple of 12 months in the past and said she accomplished all her vaccinations
affected person denies taking any nutritional vitamins or dietary supplements
affected person admitted to having hypertension however has not been following up with any main care physcian.
final menstrual interval was Three weeks in the past, denies any vaginal discharge, affected person took oral contraceptives up to now, admits to blurry imaginative and prescient when she reads final eye examination was when she was a child

Well being Upkeep
Miss Jones is non grievance with diabetic routine final pap smear was four years in the past no common train she states she is up on her ft on a regular basis at work and considers that her train
she denies taking any nutritional vitamins or dietary supplements
final dental examination was few years in the past
no eye examination executed since affected person was a child
affected person had tetanus booster a 12 months in the past
she receievd all her childhood immunizations
she had hen pox when she was a child
affected person weight loss program embrace muffin or pumpkin bread within the moring eat subway or sandwich for lunch and meatloaf or chiken for dinner. affected person drinks about 4 weight loss program cokes and possibly a glass of water or two in a day she had her final flu vaccine some years again she had tetanus vaccine a 12 months in the past

Household Historical past
Mom : excessive cholestrol , hyoertension
Father :hypertension excessive cholestrol diabets died in automobile accident at age 58
Sister; Bronchial asthma
Brother: Weight problems
Paternal grandfather (deceased of colon most cancers, hypertension Diabetes
Paternal Grandmother: hypertension hyperlipidemia
Maternal grandmother: ( deceased at 7812 months of stroke, hypertension , hyperlipidemia)
Maternal Grandfather: (deceased at 80 of coronary heart assault,) hypertension hyperlipidemia

Social Historical past
Miss Jones is a single lady no youngsters works as a supervisor at Mid American copy and ship works 32 hours per week . has entry to medical health insurance, begins ingesting at age 15 or 16 denies smoking cigrette or tobacco smoke marijauna whereas in highschool denies vaping or e- cigarette however affected person is uncovered to second hand smoking when out with pals, affected person presently lives with mom and sister affected person has 2 siblings experiences sturdy help system from household and church and goes out with pals and church. her spiritual affliation is Baptist
she denies utilizing any contraceptives presently . affected person is heterosexual she is sexually inactive presently. affected person has by no means been pregnant affected person incapacity to work to stroll was impared as a result of wound and has affected her attendance at work she is presently engaged on her bachelors diploma.

Goal
ms Jones wound measures 2.5cm*1.5cm*2.5cm
wound C&S shall be executed on on wound swab and senrt to lab
wound dressing could be executed and sterile dressing shall be utilized.

Title:
Part:

Week four
Shadow Well being Digital Medical Expertise Well being Historical past Documentation

SUBJECTIVE DATA: Embody what the affected person tells you, however manage the knowledge.

Chief Grievance (CC):
Historical past of Current Sickness (HPI):
Drugs:
Allergy symptoms:
Previous Medical Historical past (PMH):
Previous Surgical Historical past (PSH):
Sexual/Reproductive Historical past:
Private/Social Historical past:
Immunization Historical past:
Well being Upkeep:
Important Household Historical past (Embody historical past of oldsters, maternal/paternal Grandparents, siblings, and kids):

Assessment of Methods: From head-to-toe, embrace every system that covers the Chief Grievance, Historical past of Current Sickness, and Historical past). Do not forget that the knowledge you embrace on this part is predicated on what the affected person tells you. To make sure that you embrace all necessities in your case, check with Chapter 2 of the Sullivan textual content.

Normal: Embody any current weight adjustments, weak spot, fatigue, or fever, however don’t restate HPI knowledge right here.
HEENT:
Neck:
Breasts:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Psychiatric:
Neurological:
Pores and skin:
Hematologic:
Endocrine:

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Tags: Identifying Data & Reliability