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Week4 DCE Tina Jones Comprehensive
Advanced Health Assessment (NURS 6512)
Walden University
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Documentation / Electronic Health Record
Document: Provider Notes
Document: Provider Notes
Student Documentation Model Documentation
Identifying Data & Reliability Tina Jones is 28-year-old obese African American female. Pleasant and cooperative. Present to the clinic with recent right foot injury. Speech is clear and coherent. Eye contact throughout the interview.
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General Survey Ms. Jones is well nourished and well developed, appropriately dressed with good hygiene: Not in acute distress.
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Chief Complaint "I scraped my foot a week ago and the wound is not healing. And the pain is getting worse."
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History Of Present Illness Ms. Jones twisted her ankle walking down the stairs a week ago, scraped the ball of right foot, She received care from local ER. XRay of the foot and wound care were provided in the ED. She was sent home with PRN tramadol for pain and Neosporin topical agent for wound. Right foot become red and swollen. C/O sharp and throbbing pain at right foot. Pain was 7/10, two hours after taking tramadol. Weight bearing as aggravating factor and tramadol as relieving factors. Reported of difficulty ambulating due to pain. she reported of fever 102 last night.
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Medications N/A
Student Documentation Model Documentation
OTC Tylenol PO 500-1000mg q6hr PRN (for headache), OTC Advil PO 600mg TID PRN (for menstrual cramps), Proventil 2 puffs q4hr PRN (for SOB), tramadol PO 50mg Q6hr PRN (for foot pain)
Allergies PCN (caused rash). allergy to cat and dust (caused SOB, runny nose, itchy eyes), denied other drug allergies. denied allergy to mold or pollen. Denied allergy to latex.
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Medical History Type 2 DM: diagnosed at age 24. was on metformin 500mg BID. Stopped taking med without medical advice due to feeling of "bloating and gassy." Try controlling DM with diet. Denied exercising. She stated of having home glucometer but denied monitoring blood glucose. Asthma: diagnosed at age 2. uses proventil 2-3 times a week. Last use of proventil was 3 days ago. Triggers for asthma are cat and dust. Symptoms include SOB, rhinitis and eyes redness. Last hospitalization for asthma when she was in high school.
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Health Maintenance Last saw primary care doctor two years ago. Last pap three years ago. Denied exercise. Breakfast: baked goods, lunch: sandwich, dinner: meatloaf or chicken. Immunization: up to date with childhood vaccines, tetanus, and meningococcal vaccines. Denied receiving HPV. Gun in the house but locked. Wears seat belt. Denied secondhand smoke. Reported mother, sister and church as support system.
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Family History Father, diseased, died at age 58 in car accident, HTN, high cholesterol. Mother, age 50, HTN, high cholesterol. Brother overweight. Sister asthma. Paternal grandmother, age 82, HTN. Paternal grandmother, diseased, died at from colon CA, T2DM, Maternal grandmother diseased, died at age 73 from stroke, Maternal grandfather diseased, died at age 78 of stroke,
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Student Documentation Model Documentation
CV: Denied chest discomfort, palpitation, history of murmur, or arrythmia. No edema. Peripheral vascular: No varicose vein. Denied leg pain or discoloration in lower extremities. Denied non-healing wounds.
GI: Denied nausea, vomiting, abdominal pain, or change in bowel pattern. Pt stated of eating 2-3 serving of fruits and vegetables a week. stated of increased appetite and intake with weight loss, 10lbs in the last 30 days.
GU: Pt stated of polydipsia and polyuria. denied incontinence or dysuria. Menarche at age 11, First sexual encounter at age 18, Sex with men only. Para 0. Irregular menses with heavy bleeding that last for 10 days, required change of tampon every 2-3 hours. Denied current partner or use of contraceptive. Never tested for HIV. Denied history of STI. Last pap 3 years ago.
Neurology: No change in mood, behavior or attention. Denied frequent headache or dizziness. No history of seizure.
Endocrine: Reported of polydipsia, polyuria and weight loss of 10lbs in the last month. Denied issues with thyroid functions. Denied temperature intolerance or diaphoresis.
Psychiatry: Denied depression. Denied mental or behavior issues.
Hematology or Lymphatic: Denied history of anemia or transfusion. No bleeding or bruising.
MS. Stated of inability to bear weight on right foot due to pain. No change in activities of daily functionality. Denied back pain or joint pain. Denied frequent fall.
Objective Wound at right ball of foot measured at 2cm by 1, 2 deep. Wound edge red with serosegious drain. No odor from wound. Mild edema at right ankle.
Week4 DCE Tina Jones Comprehensive
Course: Advanced Health Assessment (NURS 6512)
University: Walden University
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