Identifying Data and Reliability

April 8, 2020 Identifying data and reliability Tina Jones is a €28 female, presenting to the clinic as the patient and seems reliable. General survey Tina Jones appears awake alert and with notable discomfort to her right lower extremity. She is dressed appropriately without body odor but warm to touch. She appears overweight for her height. Chief complaint Tina states “I got this straight on my foot a while ago… It’s pretty nasty. And the pain is killing me!” History of present illness Tina presents to the clinic for recent scrape on the right lower extremity after tripping and falling downstairs. Tina states pain is a seven out of ten. Pain radiates upper ankle and is difficult to walk. This scrape happened a week ago but became painful a few days ago Tina describes the pain as throbbing and sharp if weight-bearing. Tina stated her pain improves slightly when she takes medication. She is currently taking 50 mg of tramadol PO, TID as needed for pain. Patient denies a loss of consciousness during fall. Denies injury to head. Tina stated she injured her ankle as well. Tina was assessed in an ED after a fall to rule out fractures. Tina noted drainage from scraped two days ago. She is been managing the wound at home by keeping a bandage and applying Neosporin BID. Tina also stated that the area surrounding her scrape was tender swollen and warm to touch. The pain is impacting her activities of daily living as she has difficulty walking on her foot. Reported fever and chills overnight. Review of systems General-reports fever last night and temp of 101 in the office with chills. Denies fatigue. Admits weight loss of 10 pounds. Denies weight gain. Skin – admits scrape to right foot after fall, red and swollen with purulent drainage. Denies other rashes or lesions. Neck-denies tenderness or stiffness Lung – denies cough or shortness of breath Cardio – denies chest pain or discomfort Abdomen – diarrhea or constipation Gu – reports urinary frequency, denies dysuria or urgency Gyn – denies pregnancy, admits to having menstrual cycles lasting 7 to 10 days as well as dysmenorrhea. Denies sexual intercourse in the past two years. Denies use of contraception. Psych – denies anxiety or depression Nuero- admits to occasional headaches but denies difficulties or fainting. Admits to falling last week. Medications Tina is currently taking 50 mg Tram at all PO TID as needed for pain, as prescribed by the emergency room with slight improvement of pain to four out of 10. Patient reports also prescribed albuterol 90 µg per path for asthma, using 2 to 3 times per week for relief of symptoms. Tina stated she was previously prescribed metformin for her diabetes but has since stopped taking it as she has “Got sick of dealing with it.” Tina denies taking any vitamins or herbal supplements. She reports taking 500 mg of Tylenol PO as needed for headaches and 600 mg of ibuprofen PO TID PRN for menstrual cramps. No other medications reported at this time. Allergies Tina reported penicillin allergies resulting in hives and allergy to cats with ocular pruritus, sneezing, and asthma flares. No other allergies reported at this time. Medical history Tina as a previous diagnosis of asthma, being managed with her albuterol inhaler. She reports that when she has an asthma flare she gets a tight throat and wheeze, feeling like she “can’t get enough air.” Tina’s asthma is triggered by cat, dust, and running upstairs. Tina is also diagnosed with type II diabetes. Tina was prescribed to Matt Foreman for her diabetes but hasn’t taken it in approximately 3 years. States she has been managing her diabetes by “trying to stay active, avoiding sugar and that seems to be working well.” And states that she “got sick of feeling gassy all the time and it was overwhelming remembering to take pills and check sugars.” Tina reports that she “almost never” checks her blood sugars because she “doesn’t understand what the numbers mean.” Tina states she doesn’t have a monitor for blood sugars at home. Tina reported recently she has noticed she feels increase in hunger and thirst as well as more frequent urination quantified at once every hour or two while awake. She also reports unintentional weight loss of 10 pounds in the past month. She denies any peripheral neuropathy. Health maintenance Tina is up to date on all of her childhood immunizations, reports that she had a tetanus vaccine last year. Denies getting her flu shot this year. Tina reports that her last Pap smear was four years ago. Family history Tina’s mother is alive and 50 years old, has medical history of hyperlipidemia and hypertension. Tina’s father deceased at age 58 with medical history of hyperlipidemia hypertension and diabetes mellitus. Tina’s brother alive and well 25 years old. Tina sister alive and well 14 years old. Tina’s maternal grandmother deceased at age 73 from TIA, history of hypertension and hyperlipidemia. Tina’s maternal grandfather deceased at 80 from myocardial infarction, history of hypertension and hyperlipidemia. Tina’s paternal grandmother alive 82 years old medical history of hypertension and hyperlipidemia. Tina’s paternal grandfather deceased in 60s from colon cancer medical history of hypertension and diabetes mellitus. Social history Tina states she’s currently working part-time and going to school to finish her bachelors degree. she lives at home with her mother and sister. she reports seeking medical attention is a hassle and tries to avoid it if possible but has active healthcare insurance. She states she feels safe at home and at work and denies any suicidal thoughts or ideations. Tina admits to alcohol intake on occasion socially having up to four drinks. Tina also admits to previously smoking marijuana but does not anymore. And denies any other illicit drug use. Tina denies tobacco product use but states she is exposed to secondhand smoke on occasion with her friends. Tina admits to drinking for diet Cokes a day and Says she tries to watch her sugar intake because of diabetes and has been managing it like that for years. She states she also isn’t mindful of sodium intake but doesn’t add it to her food. Objective Tina presents hypertensive at 142/82 and febrile at 101.1 all other vitals stable. Her random blood glucose is 238. Tina weighs 90 kg and her BMI is 31 she has notable wound to her right medial planter area of her foot the wound measures 2 cm x 1.5 cm and 2.5 cm deep. The wound is red and has purulent drainage.