She rated her pain symptoms as 7 out of 10 upon

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.