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Tina jones health assessment
Course: Med Surg 2 (NUR240)
18 Documents
Students shared 18 documents in this course
University: Purdue University
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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.
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