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.
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.
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