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where she had x-rays that were negative,and she does not know her labs results. She was prescribed tramadol for pain. She has been cleansing the site twice a daywith Neosporinand bandages. She reports that he has right ankle swelling and pain have resolved but that the bottom of the footis 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 ofthe foot has become swollen and increasingly red; yesterday she noted discharge oozing from the woundis clear. She denies any odor from the wound. She also reported that she had afever 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 high142/82mmhg. Medications:She uses a Proventil (Albuterol 90mcg/spray MDI) inhaler for asthma. She is not using on regularbases. 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 takesAdvil as needed for headache.She deniestaking any vitamins orherbal 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.