with Tramadol. She rated her pain symptoms as 7 out of 10 upon evaluation. She reports fever up to 102 degrees last night and did not take any medication for the fever. She has been doing wound care in the morning and night and uses Neosporin and bandage to protect the wound. She is concerned about the wound and the pain affects her attendance at work. Medications 1. Tramadol 50 mg TID, Last dose 2 tablets priorto arrival. 2. Proventil inhaler 90 micrograms, 2-3 puffs, 2-3 times a week and as needed. Last dose was 3 days ago when she was at cousin's house who had cats. 3. Tylenol 500mg for headache, usually 1-2 tablets at night before bed. Last dose 2 tabs prior to arrival. 4. Advil 200 mg for cramps takes up to three times a day. Last dose was 3 weeks ago. 5. Metformin, unknown dosage and frequency, last taken 3 years ago. Stopped taking because she felt sick and gassy. N/A Allergies 1. Cats - difficulty breathings, sneezing itchy eyes 2. Penicillin- as a child, rash, hives 3. Dust- asthma attack N/A Medical History 1. Asthma, diagnosed as a child at about 2.5 years old. 2. Diabetes, type 2, diagnosed 4 years ago. Uncontrolled. She took metformin when first diagnosed but stopped 3 years ago and just watches her diet and avoids sweets. Last lab test for diabetes was 6 months after diagnosed. Denies any surgical history. N/A Health Maintenance Miss Jones' last visit to her primary doctor for a physical exam was about two years ago. Her last dental check up was a few years ago. Her vision was last tested when she was a kid. Her last pap smear was 4 years ago. Denies exercising, She denies going to the gym. She states she is up on her feet all the time at work and considers that her exercise. Her typical diet consists of N/A
Student Documentation Model Documentation muffin, pumpkin bread for breakfast, a sandwhich for lunch, and some kind of meat with vegetable for dinner.Her favorite food consist of pizza and mac and cheese. Miss Jones drinks diet coke. Denines adding salt to food. Immunizaton: She received her last influenza vaccine 5 or 6 years ago. Pneumococcal vaccine, unable to recall. She received a tetanus booster about a year ago. She received all childhood immunization. She had chicken pox when she was a kid. Sleeps adequately but have not been sleeping well in the past 2 days because of the foot pain. Family History 1. Mother has high cholesterol and hypertension. 2. Father had high blood pressure, cholesterol, and diabetes was diagnosed in his 30's. Died of a car accident at age 58. 3. Brother, overweight but denies any medical condition. 4. Sister has a history of asthma but well controlled. 5. Paternal grandfather died of colon cancer in his mid 60's. 6. Maternal grandfather died of heart attack at age 80. History of hypertension and high cholesterol. 7.Maternal grandmother died of stroke 5 years ago. History of asthma but almost never had attacks. She had a history of hypertension and high cholesterol 8. Paternal grandmother is 82 now. She has hypertension and high cholesterol.. 9. Paternal uncle was an alcoholic.
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