Tina Health History Documentation.pdf - Health History |...

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8/26/2018Health History | Completed | Shadow Health1/5Health History Results | Turned InAdvanced Health Assessment Practicum - Fall 2018, NURS 812Return to AssignmentYour ResultsReopenReopenLab PassLab PassDocument: Provider NotesDocument: Provider NotesStudent DocumentationStudent DocumentationModel DocumentationModel DocumentationIdentifying Data & ReliabilityMs. Jones who is 28 yrs. old, obese AfricanAmerican single woman who presents to establishcare and with a right foot injury. She is the primarysouce of the history. Without contradtion, she freelyprovides specific details of her injury and of hervisit. Her speech is clear.Ms. Jones is a pleasant, 28-year-old obese AfricanAmerican single woman who presents to establishcare and with a recent right foot injury. She is theprimary source of the history. Ms. Jones offersinformation freely and without contradiction.Speech is clear and coherent. She maintains eyecontact throughout the interview.General SurveyPatient is 28 yr.old single African American; alert,awake, and oriented x 3. She is pleasant; herspeech is clear and coherent. Appears healthy,well developed and well nourished. obese. VSobtained BP 142/82, HR 86, RR 19, T 101.1,SPO2 99%, blood sugar 235. Weighs 90kg andBMI is 31.Ms. Jones is alert and oriented, seated upright onthe examination table, and is in no apparentdistress. She is well-nourished, well-developed,and dressed appropriately with good hygiene.Chief ComplaintSymptoms: Right foot pain accompanied bydrainage. Pain affects ability to walk or put weighton it. Also, affects sleep. Pain 7 out of 10. Diagnosis: infected right foot wound.“I got this scrape on my foot a while ago, and Ithought it would heal up on its own, but now it'slooking pretty nasty. And the pain is killing me!”OverviewTranscriptSubjective Data CollectionObjective Data CollectionEducation & EmpathyDocumentationInformation ProcessingHealth History Tips and TricksSelf-ReflectionDocumentation / Electronic Health RecordThis study resource wasshared via CourseHero.com
8/26/2018Health History | Completed | Shadow Health2/5Student DocumentationStudent DocumentationModel DocumentationModel DocumentationHistory Of Present IllnessTina fell going down the back steps of her house.She tripped and scraped the sole of her right foot.Her wound bled and she was able to stop thebleeding. She cleaned the wound and went to theER fearing that she sprained her ankle. ER X-rayed her foot and reported no fracture seen. Theygave her a prescription for a 5-day supply ofTramadol 50 mg. She cleaned her wound twicedaily with soap and water or hydrogen peroxide, letit dry, and then she would put neosporin on thescrape and covered with a dressing. The woundwasn't getting worse, but it wasn't getting anybetter. Two days ago she noticed pus was in thewound, and that there was swelling and redness

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