NR 509 SHADOW HEALTH PHYSICAL ASSESSMENT WEEK 1 SHADOW HEALTH HISTORY ASSIGNMENT.
Document: Provider Notes
Student Response Model
... [Show More] Documentation
Identifyin g Data & Reliability
Tina Jones age: 28 African American female patient herself, seems reliable supervisor at Mid- American Copy & Ship
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.
Genera
Tina is a 28 year old
African Ms. Jones is alert and oriented, seated
upright on the examination table, and is in
l American female that appears healthy
Surve y
and stated age. Alert, oriented, and cooperative. No signs of distress.
no apparent distress. She is well- nourished, well-developed, and dressed appropriately with good hygiene.
Chief Complain t
"I got this scrape on my foot a while ago...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
First noticed scrape on right foot two days ago. Tripped and fell down steps, scraped foot on the edge of the step. Sharp, throbbing pain rated a 7
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
on 0-10 scale. White drainage. Unable care in a local emergency department to bear weight on right foot and has where she had x-rays that were negative;
missed two days of work. No chills or she was treated with tramadol for pain. She
fever noted. Reports temperature of 102 last night.
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
Student Response Model Documentation
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.
Tramadol 50 mg tablet, 2 tablets
by Acetaminophen 500-1000 mg PO prn
mouth three times a day as needed for (headaches) • Ibuprofen 600 mg PO TID
Medication s
pain Proventil 90 mcg/spray MDI, 2 puffs by mouth as needed for asthma No vitamins or herbal supplements
prn (menstrual cramps) • Tramadol 50 mg PO BID prn (foot pain) • Albuterol 90 mcg/spray MDI 2 puffs Q4H prn
Advil as needed for menstrual cramps (Wheezing: “when around cats,” last use
Allergie s
Allergic to penicillin, develops rash, hives. Allergic to cats, develops itchy eyes, shortness of breath. No food allergies. No seasonal allergies. No latex allergy.
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
Chickenpox in second or third grade. No measles, mumps, pertussis. Strep once a year as a child but not since high school. No rheumatic fever,
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
scarlet fever, or polio. Diagnosed with three days ago and had to use her inhaler asthma at age 2. Diagnosed with once with positive relief of symptoms. She diabetes a few years ago. Hospitalized was last hospitalized for asthma “in high
several times as a child for asthma attacks, last time was age 16.
Gravida 0/Para 0/Abortion 0. Recent weight loss of 10 pounds. No excessive bruising. No fever or sweats. No broken bones. No burns. No eczema or psoriasis.
Darkening of skin on neck reported.
Excessive dryness on [Show Less]