TINA JONES HEALTH HISTORY NARRATIVE Musculoskeletal States that she injured her right foot one week ago. This has caused limited ability for her to be able to walk as well as not being able to bear any weight on her foot. This has caused her to limp. She states that her right ankle has felt stiff and swollen. She denies joint pain. She does not exercise. Neurological Tina states that she does get headaches when studying and reading for prolonged times. She states that she takes Tylenol when this occurs. She has not had an eye exam since she was in high school. She does not recall a recent headache. She notices that she has been having problems with her vision lately. She states her vision becomes blurry when reading and studying. She does not wear glasses or contacts. She states that her memory is good. She denies: any issues with her memory, consciousness, confusion, disorientation, decrease in sensation, dizziness, tremors, altered gait or balance, and tingling. She denies having difficulty swallowing. She states that her hearing is fine. She denies weakness and denies a decrease in strength. She denies a decrease in sensation. She denies any changes in her ability to taste and smell. Her mood and affect are appropriate. She is able to provide a clear account of historical and recent events. She denies any history of neurological injuries and complications. She reports headaches that occur once a week behind the eyes with prolonged reading. These headaches are resolved with acetaminophen and sleep. She denies fainting, dizziness, vertigo, weakness, syncope, numbness, tingling, tremors, seizures, and paralysis. She reports occasional clumsiness. Denies history of traumatic brain injury. Denies recent changes in memory and mood changes. 7
TINA JONES HEALTH HISTORY NARRATIVE Psychological Tina reports that she had a difficult time when her father died, but through the support of her family, friends, and church she is now doing well. She experiences anxiety from finances and from school. She denies current depression, feelings of hopelessness, suicidal thoughts, insomnia, or changes in mood, concentration, and any problems or changes with her attention span. She denies any changes in remote and recent memory. She is not having any problems with confusion. She denies any history of mental problems . Clinical Reasoning Using clinical reasoning while identifying abnormal findings through interviewing and patients chart and tests. These findings were localized anatomically and were interpreted. Her diagnoses include: asthma, fever, weight loss, diabetes, allergies, and right foot open wound. She will need to be assessed for infection; her asthma may need to be furthered assessed with possible medication changes. Her diabetes will be also need to be further assessed. Clinical reasoning was used to decide upon and list these diagnoses through notation and by localizing abnormal findings. Her family history also impacts the clinical reasoning of nurses.
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