Identifying Data & Reliability

Ms. jones is a twenty eight years old african american women. She is seated upright in her bed. Patient was admitted for further evluation of her right foot injury. She is receptive to information and articulate. patient answers questions freely . speech is clear and coherent. Patient maintains good eye contact and cooperates with asessment

Ms. Jones is a pleasant, 28-year-old obese African American single woman who presents to establish care and with a recent right foot injury. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview.

General Survey

Ms. Jones is alert and oriented. She appears to be in pain. patient is well nourished abd groomed, dressed appropriately, good hygiene and ADLs. patient makes appropiate interactions .

Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. She is well-nourished, well-developed, and dressed appropriately with good hygiene.

Chief Complaint

Ms. Jones chief complaint is that ” i got this scrape on my foot a while ago and i thought it would heal up on its own but its looking pretty nasty and the pain is killing me !”

“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

Ms. jones is presented with an open wound to her right foot. Patient has a history of asthma and Type ll diabetes. patient injured her foot by scraping the bottom of a stepping stool. She mentions that she was barefoot at the time of the injury. She states that her pain level is a 7/10. patient took her last pain pills at 8:30 in the morning. Patient does not monitor her sugar level and does is not taking any diabteic medications. Patient use to take Metformin about three years ago. she mentions her asthma is triggered by cats, dust,or running upstairs . Her blood pressure is high as well as being febrile with a tempreture of 101.1

Ms. Jones reports that a week ago she tripped while walking on concrete stairs outside, twisting her right ankle and scraping the ball of her foot. She sought care in a local emergency department where she had x-rays that were negative; she was treated with tramadol for pain. She has been cleansing the site twice a day. She has been applying antibiotic ointment and a bandage. She reports that ankle swelling and pain have resolved but that the bottom of the foot is increasingly painful. The pain is described as “throbbing” and “sharp” with weight bearing. She states her ankle “ached” but is resolved. Pain is rated 7 out of 10 after a recent dose of tramadol. Pain is rated 9 with weight bearing. She reports that over the past two days the ball of the foot has become swollen and increasingly red; yesterday she noted discharge oozing from the wound. She denies any odor from the wound. Her shoes feel tight. She has been wearing slip-ons. She reports fever of 102 last night. She denies recent illness. Reports a 10-pound, unintentional weight loss over the month and increased appetite. Denies change in diet or level of activity.

Medications

Patient uses proventil inhaler for asthma. She last used inhaler three days ago. patient takes Tradmadol for pain possibly 50 mg. she last took tramadol 8:30am . patient is taking extra stregnth acetaminophen 500mg. Patient remorts taking Metformin for diabetes last 3 years ago

Acetaminophen 500-1000 mg PO prn (headaches) • Ibuprofen 600 mg PO TID prn (menstrual cramps) • Tramadol 50 mg PO BID prn (foot pain) • Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (Wheezing: “when around cats,” last use three days ago)

Allergies

pateint is allergic to cats and penicillin. Cats trigger her asthma and penicillin causes rash and hives

Penicillin: rash • Denies food and latex allergies • Allergic to cats and dust. When she is exposed to allergens she states that she has runny nose, itchy and swollen eyes, and increased asthma symptoms.

Medical History

Ms. Jones has uncontrolled and unmonitored type two diabetes. She ahs a open right foot wound that she sustained one week ago while stepping on a stool barefoot, She has asthma and was last hospitalized for asthma at 16. she expecianced weight loss of ten pounds in a little over a month. pateint reports being excessively thirsty . Menstural cycle is irregular and heavy . Last menstural cycle was three weeks ago

Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler when she is around cats and dust. She uses her inhaler 2 to 3 times per week. She was exposed to cats three days ago and had to use her inhaler once with positive relief of symptoms. She was last hospitalized for asthma “in high school”. Never intubated. Type 2 diabetes, diagnosed at age 24. She previously took metformin, but she stopped three years ago, stating that the pills made her gassy and “it was overwhelming, taking pills and checking my sugar.” She doesn’t monitor her blood sugar. Last blood glucose was elevated last week in the emergency room. No surgeries. OB/GYN: Menarche, age 11. First sexual encounter at age 18, sex with men, identifies as heterosexual. Never pregnant. Last menstrual period 3 weeks ago. For the past year cycles irregular (every 4-8 weeks) with heavy bleeding lasting 9-10 days. No current partner. Used oral contraceptives in the past. When sexually active, reports she did not use condoms. Never tested for HIV/AIDS. No history of STIs or STI symptoms. Last tested for STIs four years ago. Hematologic: Denies bleeding, bruising, blood transfusions and history of blood clots. Skin: Reports acne since puberty and bumps on the back of her arms when her skin is dry. Complains of darkened skin on her neck and increase facial and body hair. She reports a few moles but no other hair or nail changes.

Health Maintenance

Ms. jones last papsmear was 4 years ago . Her last eye exam was during childhood and last dental exam was a few years ago. Last PPD was few years ago. Her typical diet consist of breakfast: a muffin or punkin bread, a sandwich for lunch and some kind of meat with vegetables for dinner; snaks : pretzel or french fries for when she wants to treat herself

Last Pap smear 4 years ago. Last eye exam in childhood. Last dental exam “a few years ago.” PPD (negative) ~2 years ago. No exercise. 24-hour Diet Recall: States that she skipped breakfast yesterday, and would typically have a baked good for breakfast, a sandwich for lunch, and a meatloaf or chicken for dinner. Her snacks consist of pretzels or French fries. Immunizations: Tetanus booster was received within the past year, influenza is not current, and human papillomavirus has not been received. She reports that she believes she is up to date on childhood vaccines and received the meningococcal vaccine in college. Safety: Has smoke detectors in the home, wears seatbelt in car, and does not ride a bike. Does not use sunscreen. Guns, having belonged to her dad, are in the home, locked in parent’s room.

Family History

Ms. jones’s mother is fifty years old. she has a medical problem. Her died passed away at age 50 from motor vehicle accident last year. Her father has a history of high blood pressure. hyperlipdemia and type 2 diabetes her paternal grandmother has a history of high blood pressure and paternal grandfather (Grandpa Jones) died in his mid sixties fromcolon cancer and had a history of diabetes type 2. Ms. Jones’s maternal grandmother, Nana died at age 73 from a stroke five years ago . Nanaa had high blood pressurse and hyperlipidemia. Her maternal grandfather poppa died at age 80 from a heart attack . He also had a history of hyperlipidemia and hypertension. Ms jones yonger sister also has asthma and her brother has no known medical conditions however he is overweight. Most of her family memebers are overweight.

• Mother: age 50, hypertension, elevated cholesterol • Father: deceased in car accident one year ago at age 58, hypertension, high cholesterol, and type 2 diabetes • Brother (Michael, 25): overweight • Sister (Britney, 14): asthma • Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol • Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol • Paternal grandmother: still living, age 82, hypertension • Paternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes • Paternal uncle: alcoholism • Negative for mental illness, other cancers, sudden death, kidney disease, sickle cell anemia, thyroid problems

Social History

Ms. jones is ver active in church and with family. she goes out occasionally with friends dancing. She enjoys bible study and volunteering with her church . She previously lived with her friend selena for a few years and then moved back with her mother after her father died to help with finaces. she is working on a bachelor’s degree in accounting. Ms. jones used drugs like pot but stopped at about age 21 . pateint is currently single and not sexually active. she is not on any contraceptives but used birth control pills in the past . she mentions she had only three sex partners and has never had any STI.

Never married, no children. Lived independently since age 20, currently lives with mother and sister in a single family home to support family after death of father one year ago. Employed 32 hours per week as a supervisor at Mid-American Copy and Ship. She enjoys her work and was recently promoted to shift supervisor. She is a part-time student, in her last semester to earn a bachelor’s degree in accounting. She hopes to advance to an accounting position within her company. She has a car, cell phone, and computer. She receives basic health insurance from work, but is deterred from healthcare due to out-of-pocket costs. She enjoys spending time with friends, attending Bible study, volunteering in her church, and dancing. Tina is active in her church and describes a strong family and social support system. She reports stressors relating to the death of her father and balancing work and school demands, and finances. She states that family and church help her cope with stress. No tobacco. Occasional cannabis use from age 15 to age 21. Reports no use of cocaine, methamphetamines, and heroin. Uses alcohol when “out with friends, 2-3 times per month,” reports drinking no more than 3 drinks per episode. She drinks 4 caffeinated drinks per day (diet soda). No foreign travel. No pets. Not currently in an intimate relationship, ended a three-year serious monogamous relationship two years ago. She plans on getting married and having children someday.

Objective

Wound measures 2cmx1.5cm, 2.5 mm deep swabbed wound and sent to lab for C&S of right foot drainage . Red wound edges, right ball of foot. serosanguinous drainage, mild erythema sourrounding wound . No edma . no tracking. Vital signs BP- 142/82, Pulse- 82, Blood glucose- 238, Tempreture- 101.1, weight -90K.

Wound: 2 cm x 1.5 cm, 2.5 mm deep wound, red wound edges, right ball of foot, serosanguinous drainage. Mild erythema surrounding wound, no edema, no tracking.