September 24, 2023

Rubric for grading subjective Documentation in Provider Note Template: Subjective narrative documentation in Provider Note Template is detailed and organized and inc

Rubric for grading

subjective Documentation in Provider Note Template: Subjective narrative documentation in Provider Note Template is detailed and organized and includes: Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS)ROS: covers all body systems that may help you formulate a list of differential diagnoses. You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

The Conversation with Tina Jones to work on

Name : Tina Jones

Age: 28

Sex: Female

Race: African American

Chief Complaint: Patient presents for an initial primary care visit today complaining of an infected foot wound.

Weight: 90 kg

BMI: 31

Blood sugar: 238

RR: 19

HR: 86

BP 142/82

PULSE Ox: 99%

Temperature: 101.1

Identifying Data & Reliability

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 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, seated upright on the examination table, and is in no distress. She has good hygiene and dressed well.

Chief Complaint

A scrape on the ball of the right foot, and i thought it will heal up on its own, but now it's looking nasty and the pain is killing me.

History Of Present Illness/ Subjective data

Ms. jones reports that she was going down the back steps, and she tripped causing her right ankle to turned a little bit and scraping the ball of her right foot. she went to ER where she had x-ray that were negative. She treated with tramadol for pain. She has been cleansing the site twice a day. She has been applying oitment 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 swollenand increasingly red, yesterday she noted discharge oozing from the wound. She denies anyodor from the wound. She reports fever of 102 last light. She denies recent illness. Reports 10 pound, unintentional weight loss over the monthand increased appetite. Denies change in diet or level of activity.

Medications

Acetaminophen 500-1000 mg PO prn (headaches) 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

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

Asthma diagnosed at age 2 1/2. she uses her albuterol inhaler when she is around cats and dust. She uses her inhaler2 to 3 times per week. She was exposed to cats three days agoand had to use her inhaler once with postive relief of symptoms. She was las hospitalized for asthma in high school. Never inbuted. Type 2 diabetes, diagnosed at age 24. She previously took metformin, but she stopped three years ago, statingthat the pills made her gassy and it was overwhelming, taking pills and checking her blood sugar. Last blood glucose was elevated last week in the ER. No surgeries. OB/GYN: Menarche, age 11. First sexual 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 DTIs or STI symptoms. Last tested for STIs four years ago. Hematologic: Denies bleeding, bruising, blood tranfusions and history of blood clots. Skin: Reports acne since puberty and bumps on the backof her arms when her skin is dry.

Health Maintenance

Last Pap smear 4 years ago. Last eye exam in childhood. Last dental exam a few years ago. No exercise. she believes she is up to date on immunizations and received the meningococcal vaccine in college. does not smoke. Has smoke detectors in the home. wear seat beltin car, and does not ride a bike. Does not use sunscreen

Family History

Mother: age 50, HTN, high cholesterol Father: deceased in car accident one year ago at age 58, HTN, high cholesterol, and type 2 diabetes. Brother: age 25 overweight Sister: age 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 HTN and high cholesterol. Paternal grandmother: still living, age 82, history of HTN. Paternal grandfather: died at age 65 of colon cancer history of type 2 diabetes. Paternal uncle: alcoholism. No history of mental illness

Social History

Never married, no children. Lived independently since age 20, currently lives with mother and sister in a single family home to support family after the death of her father a year ago. Employed 32 hour per week as a supervisor. She is part-time student, in her last semester to earn a bachelor's degree in accounting. She hopes to advance to anaccounting position within her company. She has a car, cell phone, and computer. She have health insurance from work. She enjoys spending time with friends, attending bible study, volunteering in her church, and dancing. She reports stressor realting to the death of her father and balancingwork and school demands, and finances. She states that family and church help her cope with stress. No tobacco use. Uses alcohol when out with friends, 2-3 times per month, reports drinking no more than 3 drinks per episode. No foreign travel. No pets. Not currently in an intimate relationship. She plans on getting married and having children in the future.

Objective

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

Name:

Section:

Week 4

Shadow Health Digital Clinical Experience Health History Documentation

SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

Chief Complaint (CC):

History of Present Illness (HPI):

Medications:

Allergies:

Past Medical History (PMH):

Past Surgical History (PSH):

Sexual/Reproductive History:

Personal/Social History:

Immunization History:

Health Maintenance:

Significant Family History (Include history of parents, maternal/paternal Grandparents, siblings, and children):

Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History). Remember that the information you include in this section is based on what the patient tells you. To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.

General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.

HEENT:

Neck:

Breasts:

Respiratory:

Cardiovascular/Peripheral Vascular:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Psychiatric:

Neurological:

Skin:

Hematologic:

Endocrine:

Differential diagnosis

1. Acute pain of the foot

2. Uncontrolled type 2 diabetes mellitus

3. obesity

Shadow Health Digital Clinical Experience Health History Documentation

Student’s Name

Professor’s Name

Institution’s Name

Course

Date

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Name: Tina Jones, Age: 28, Race: African American, Sex: Female.

SUBJECTIVE DATA

Chief Complaint (CC): Wound on the right foot that is painful.

History of present Illness (HPI): Tina is a 28-year-old African American female who walks into

the clinic with an infected wound on her right foot. Over the past two days, the pain has become

worse. The pain is 7/10. The patient states that the pain does not transfer to any other body parts.

After injury, the foot became swollen and red. Weight bearing is the aggravating factor.

Medication: Tramadol for pain 50 mg, 3 times a day. Proventil inhaler for asthma, 2-3 puffs

daily. Tylenol 500mg 3 times daily, for headaches. Advil for cramps.

Allergies: Penicillin: Rashes.

Cat and dust: Wheezing and itchy eyes.

Past Medical History: Patient was diagnosed with asthma at 21 years, hospitalized at 16 years.

Uses Proventil to help manage her asthma, three times in a day in case of asthma attacks.

Diabetes at 24 years and has not taken metformin in the last three years. Does not go for regular

blood sugar checkups.

Past Surgical History: No past surgeries.

Sexual/Reproductive history: The patient presents as heterosexual. Uses condoms as a

contraceptive to prevent pregnancy and STDs. No past pregnancy.

Personal/ Social History: Patient occasionally drinks alcohol and loves going to club for fun.

She has a bachelor’s degree in accounting. Has a supportive family and friends. No smoking

tobacco or marijuana. Attends Baptist church.

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Immunization History: Patient received all her childhood vaccinations including polio,

hepatitis and chicken pox. Meningitis vaccine at 19 years. Tetanus booster last year, No influenza

and flu shot vaccine. Got HPV vaccine as a teenager.

Health Maintenance: Patient vaccination are up to date. No pelvic assessment, and the last pap

smear was three years ago. No regular blood sugar and blood pressure screening. No dental

check. Patient reports going to the gym, so she has a good physical hygiene.

Significant family history: Mother, 50 years, has high cholesterol. Father died at 58 due to a car

accident. Had diabetes and hypertension. Sister has asthma. Brother has no medical condition.

Maternal grandmother died at 73, from stroke. Maternal grandfather died at 78 from stroke.

Paternal grandfather died at 65 from colon cancer. Paternal grandmother is alive. No history of

addiction, mental health issues, headaches, cancers, and thyroid issues.

Review of symptoms

General: Tina is attentive, pleasant, and well oriented. She is also well groomed, answers

questions well and not in despair.

HEENT: Patient reports having headaches when studying. Has blurred vision but does not wear

spectacles. No runny nose, or ear discharge. No swollen throat and sore throat.

Neck: No lymph complications and inflammation around the neck.

Breasts: No nipple discharge or discomfort.

Respiratory: No shortness of breath, discomfort in the chest or tightness.

Cardiovascular/peripheral: No blood clots.

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Gastrointestinal: No changes in the bowel, constipation, or watery stool. Patient has increased

appetite and feeling thirsty.

Genitourinary: Patient has irregular periods.

Musculoskeletal: No muscle or back pain.

Psychiatric: No depression or hallucinations.

Neurological: No tingling or feeling dizzy.

Skin: No acnes or hair around the chin.

Hematologic: Patient has no history of excessive bleeding.

Endocrine: No sweating, chills, or fever.

Objective data

Vital signs: Weight, 90 kg. BMI 31, BP 142/82 HR 86 RR 19 T 101.1 Pulse oximetry 99%.

Wound measurement: 2cm x 1.5cm, 2.5 mm deep. No swelling around the wound.

Differential Diagnosis

1. Asthma

This condition occurs when the narrow airways secrete excess mucus making it difficult to

breath. The symptoms include shortness of breath, wheezing, coughing and having trouble

sleeping (Nakamura et al., 2020). Asthma is caused by flu, colds, and allergies like dust, pollen

and animal fur. The condition can be controlled by taking drugs. Asthma is the primary diagnosis

because the patient is allergic to cats and dust. She also complains of shortness of breath and

wheezing which are some of the symptoms of asthma.

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2. Local infection of skin and subcutaneous tissue of the foot.

The main cause of this condition is bacteria staphylococcus aureus. The condition arises from

skin irritation caused by cuts or wounds (Lipsky et al., 2016). The patient complains of having a

wound on the right leg so, she might have this condition.

3. Acute pain of the foot

This condition occurs due to a fall. It occurs as a sudden and severe pain (Chung et al., 2021).

The condition can last for a short time or be an ongoing issue for the patient. The patient stated

that she has a severe pain which she said that it was 7/10.

4. Uncontrolled type 2 diabetes.

With this condition, the patient experiences frequent urination, and loss. She might have

uncontrolled type 2 diabetes because she has increased thirst and stopped using her diabetic

medication three years ago (Pamungkas et al., 2019). Uncontrolled diabetes can occur due to the

same.

5. Polycystic ovary syndrome

This condition occurs due to excess androgen hormones in the body. The condition is

characterized by irregular periods (Azziz, 2018). The patient reports having irregular periods

which come after three months so, most likely she has this condition.

References

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Azziz, R. (2018). Polycystic Ovary Syndrome. Obstetrics & Gynecology, 132(2), 321–336.

https://doi.org/10.1097/aog.0000000000002698

Lipsky, B. A., Silverman, M. H., & Joseph, W. S. (2016). A Proposed New Classification of Skin

and Soft Tissue Infections Modeled on the Subset of Diabetic Foot Infection. Open Forum

Infectious Diseases, 4(1). https://doi.org/10.1093/ofid/ofw255

Chung, C. L., Paquette, M. R., & DiAngelo, D. J. (2021). Impact of a dynamic ankle orthosis on

acute pain and function in patients with mechanical foot and ankle pain. Clinical

Biomechanics, 83, 105281. https://doi.org/10.1016/j.clinbiomech.2021.105281

Pamungkas, R. A., Chamroonsawasdi, K., Vatanasomboon, P., & Charupoonphol, P. (2019).

Barriers to Effective Diabetes Mellitus Self-Management (DMSM) Practice for Glycemic

Uncontrolled Type 2 Diabetes Mellitus (T2DM): A Socio Cultural Context of Indonesian

Communities in West Sulawesi. European Journal of Investigation in Health, Psychology

and Education, 10(1), 250–261. https://doi.org/10.3390/ejihpe10010020

Nakamura, Y., Tamaoki, J., Nagase, H., Yamaguchi, M., Horiguchi, T., Hozawa, S., Ichinose,

M., Iwanaga, T., Kondo, R., Nagata, M., Yokoyama, A., & Tohda, Y. (2020). Japanese

guidelines for adult asthma 2020. Allergology International, 69(4), 519–548.

https://doi.org/10.1016/j.alit.2020.08.001

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