Where she had x rays that were negative and she does

where she had x-rays that were negative, and she does not know her
labs results. S he was prescribed tramadol for pain. She has been cleansing the site twice a day
with Neosporin and bandages . She reports that he has right 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. 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 is clear . She denies any odor from the wound. She also reported that she had a
fever around 102 F. Her past medical history indicated diabetes and asthma. She does not
monitor her blood sugar and does not take any medications to control her diabetes currently .
She reports that her asthma is triggered when exposed to cats, dust, or running upstairs. Her
blood pressure is also high 142/82mmhg.
Medications:
She uses a Proventil (Albuterol 90mcg/spray MDI) inhaler for asthma. She is not using on regular
bases . She needs inhaler 2 to 3 times a week especially when she come close to cats. Ms Jones
also take tramadol 50 mg 2 tab by mouth two to three times a day. She also take s Advil as
needed for headache . She denies taking any vitamins or herbal supplements.
Allergies:

Ms. Jones is allergic to cats and penicillin. Cats trigger her asthma. Her Penicillin allergy causes
rash and hives.
Medical History:
Ms. Jones has uncontrolled and unmonitored type II diabetes. She has a open right foot wound
that she sustained one week ago will stepping on a stool barefoot. She has asthma and was last
hospitalized for asthma when she was in high school. She has experienced an unexpected
weight loss of ten pounds. She states that she has been excessively thirsty. She is experiencing
nocturia.