Sample Tina Jones Documentation Latest Updated 2021/2022 Graded A

Student Response Model Documentation Identifying Data & Reliability A 28y/o African American female with bright affect ; pt weighs 90kg, BP 142/82, temp 101.1, Blood sugar 238mg/dl. Pt has a wound on the right ...

Student Response Model Documentation Identifying Data & Reliability A 28y/o African American female with bright affect ; pt weighs 90kg, BP 142/82, temp 101.1, Blood sugar 238mg/dl. Pt has a wound on the right foot measuring 2cmx1.5cmx2.5mm. Wound has yellowish sloughing with surrounding granulation. Ms. Jones is a pleasant, 28-year-old obese African American single woman who presents to establish care and with a recent right foot injury. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview. General Survey Patient is alert and oriented x4, with clear thought process. Pt has hx of diabetes and asthma Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. She is well-nourished, well-developed, and dressed appropriately with good hygiene. Chief Complaint Right foot scrape with excruciating pain “I got this scrape on my foot a while ago, and I thought it would heal up on its own, but now it's looking pretty nasty. And the pain is killing me!” History Of Present Illness A 28 y/o female patient presents with a painful right foot injury. Patient describes her pain as sharp and constant. Patient rates her pain 7 out of 10. Patient reports tripping on a stair and twisting her right foot, sustaining scrapes. Patient describes her foot injury as hot, swollen and red with purulent drainage. patients states ahe manages her pain with tramadol 50mg. Ms. Jones reports that a week ago she tripped while walking on concrete stairs outside, twisting her right ankle and scraping the ball of her foot. She sought care in a local emergency department where she had x-rays that were negative; she was treated with tramadol for pain. She has been cleansing the site twice a day. She has been applying antibiotic ointment and a bandage. She reports that ankle swelling and pain have resolved but that the bottom of the foot is increasingly 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 Tramadol 50mg twice a day Acetaminophen 500-1000 mg PO prn (headaches) • Ibuprofen 600 mg PO TID prn (menstrual cramps) • This study source was downloaded by 100000831988016 from CourseHero.com on 03-14-2022 05:44:13 GMT -05:00 https://www.coursehero.com/file/37197543/sample-tina-jones-documentationodt/ Student Response Model Documentation Proventil 90mcg Advil Tylenol 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 Cat 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. Medical History Asthma Diabetes 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. First sexual encounter at age 18, sex with men, identifies as heterosexual. Never pregnant. Last menstrual period 3 weeks ago. For the past year cycles irregular (every 4-8 weeks) with heavy bleeding lasting 9-10 days. No current partner. Used oral contraceptives in the past. When sexually active, reports she did not use condoms. Never tested for HIV/AIDS. No history of STIs or STI symptoms. Last tested for STIs four years ago. Hematologic: Denies bleeding, bruising, blood transfusions and history of blood clots. Skin: Reports acne since puberty and bumps on the back of her arms when her skin is dry. Complains of darkened skin on her neck and increase facial and body hair. She reports a few moles but no other hair or nail changes.