Shadow Health Tina Jones.docx - Document Provider Notes \u2013 NURS 6512 Name Tina Jones Health History Open this PDF and type your narrative-style

Shadow Health Tina Jones.docx - Document Provider Notes...

This preview shows page 1 - 4 out of 8 pages.

Name:Health HistoryIdentifying DataTina JonesOpen this PDF and type your narrative-style documentation for each section into the corresponding dialogue box below. When you are ready to submit your documentation, ‘Save As’ a new PDF and enter your name. Upload the PDF with your name into Blackboard.Tina Jones, 28 years oldDate of Birth: 2/17/1982African AmericanFemaleDocument: Provider Notes – NURS 6512Copyright © 2019 ||Shadowhealth.com1
Background image
General SurveyChief Complaint1.Redness around the scrape2.Pain started as 5 or 6, but now a 10/10 with weight bearing3.Pain is worse during weight bearing, “throbbing and sharp” feeling, Tramadol effective“I got this scrape on my foot a while ago” Describes pain as “this pain is killing me” Scrape happened “1 week ago,” but pain is “worse in the last few days.”Document: Provider Notes – NURS 6512Copyright © 2019 ||Shadowhealth.com2
Background image
History of Present Illness 29-year-old AA female presents to clinic for complaints of aching pain 7/10 to bottom of right foot. Pain started 1 week ago after she scraped her foot, and pain has worsened in the “last few days.” She describes pain as “this pain is killing me.” New onset, 2 days ago of “white or off-white” purulent drainage, without odor. Aggravating symptoms are weight bearing resulting in increased pain 10/10. Relieving factors are the use of Tramadol and non-weight bearing activities. She is cleansing wound with hydrogen peroxide, and changing the bandage twice a day, every morning
Background image
Image of page 4

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture