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. Pain is rated 9 with weight bearing. She reports that over the past two days the ball of the foot has become 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. Medications Proventil 2-3 puffs for asthma Tramadol 50mg? TID for foot pain Neosporin ointment BID after cleaning foot Tylenol 500mg PRN for headaches Advil 200mg TID PRN for cramps Acetaminophen 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) Allergies Penicillin causes rash, hives Cats cause sneezing, itchy eyes, asthma Penicillin: rash • Denies food and latex allergies • Allergic to cats and dust. When she is exposed to allergens she states that she has runny nose, itchy and swollen eyes, and increased asthma symptoms.
Student Documentation Student Documentation Model Documentation Model Documentation Medical History Diabetes type 2- Diagnosed at age 24. Was taking Metformin but stopped due to feeling sick and gassy. Does not monitor BGL. Asthma- Diagnosed at age 2.5 irregular, painful periods reports acne reports polydipsia Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler when 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. OB/GYN: Menarche, age 11.
- Fall '15
- Tramadol, Shadow Health, Tina Jones, HHx