She reports that over the past two days the ball of the foot has become swollen

She reports that over the past two days the ball of

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She reports that over the past two days the ball of the foot hasbecome swollen and increasingly red; yesterday she noted discharge oozing from the wound. She denies any odor from the wound. Her shoes feel tight. She has been wearing slip-ons. She reports fever of 102 last night. She denies recent illness. Reports a 10-pound, unintentional weight loss over the month and increased appetite. Denies change in diet or level of activity.
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Student ResponseModel DocumentationMedicationsOver-the-counter Neosporin topically bid with dressing changeTramadol 50mg two tablets tid Albuterol MDI 90 micrograms two Puffs Acetaminophen 500 mg po 1-2 gel caps as needed Ibuprofen 600 mg PO tid Was previously taking metformin 500mg to control diabetes but stopped secondary to adverse side effectsAcetaminophen 500-1000 mg PO prn (headaches) • Ibuprofen 600 mg PO TID prn (menstrual cramps) • Tramadol 50 mg PO BID prn (foot pain) • Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (Wheezing: “when around cats,” last use three days ago)Allergiescats allergy causes sneezing, itchy eyes, and shortness of breath penicillin thinks rash/hives and instructed not to take again dust causese sneezing and itchy eyes Penicillin: rash • Denies food and latex allergies • Allergic to cats and dust. When she is exposed to allergens she states thatshe has runny nose, itchy and swollen eyes, and increased asthma symptoms.Medical Historystates she is up-to-date on her General immunizations and has received all of her childhood vaccinations. Patient declines receiving a flu vaccine also refusing vaccine at current. Educated the patient on the importance of receiving the flu vaccine. The patient has a tetanus shot within the past year thus one will not be ordered this office visit. Patient states she has asthma diagnosed at 2.5 years of age has been previously hospitalized for asthma attacks as a child. States she uses albuterol as needed for asthma attacks. States her asthma attacks have lessened in severity since getting older diabetes diagnosed at age 24 manages with diet and avaoidance of sweet foods c/o polyuria, polyphagia, polydypsia and recent weight loss Patient denies surgical history Menstruation occursAsthma diagnosed at age 2 1/2. She uses her albuterol inhalerwhen she is around cats and dust. She uses her inhaler 2 to 3 times per week. She was exposed to cats three days ago and had to use her inhaler once with positive relief of symptoms. She was last hospitalized for asthma “in high school”. Never intubated. Type 2 diabetes, diagnosed at age 24. She previously took metformin, but she stopped three years ago, stating that the pills made her gassy and “it was overwhelming, taking pills and checking my sugar.” She doesn't monitor her blood sugar. Last blood glucose was elevated last week in the emergency room. No surgeries.
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