History of Present Illness One week after sustaining the cut, Tina Jones develops an infection in the cut on the bottom of her foot; she seeks treatment when the infection starts to swell and produce pus.
Day 1 (Onset
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History of Present Illness One week after sustaining the cut, Tina Jones develops an infection in the cut on the bottom of her foot; she seeks treatment when the infection starts to swell and produce pus.
Day 1 (Onset): Tina was at home, going down the back steps, and she tripped. She turned her ankle and scraped the bottom of her foot. The wound bled, but she stopped the bleeding quickly and cleaned the wound. She worried that she had sprained her ankle, and her mom drove her to the ER. (“a week ago”)
The ER did an xray (no broken bones), gave her a prescription for Tramadol, and sent her home. In the following days, her ankle seemed fine not as serious as she thought.
Day 2 - 4: She cleaned the wound dutifully, twice a day, with soap and water or hydrogen peroxide, let it dry, put Neosporin on it, and bandaged it. The wound wasn’t getting worse, but it wasn’t healing, either. She expresses that she “took really good care of it.” Tina was able to go to work and attend school.
Day 4: Tina went to her cousin’s house, where she encountered cats and experienced wheezing. She tried two puffs on her albuterol inhaler, and she had to do a third puff. (“three days ago”)
Day 5 - 6: Tina noticed pus in the wound, and swelling, redness and a warm feeling in her foot. Her pain increased to the point she was unable to walk. She began to take the Tramadol to try to manage the pain, but it didn’t resolve the pain completely. She missed class and work. (“two days ago”)
On the night of Day 6: Tina started to run a fever. They took her temperature at home, and it was 102. (“last night”)
Morning of Day 7: Tina finally recognizes that her foot infection is not going to get better, and her mom takes her to the nurse practitioner to get the foot looked at. Subjective and Objective Model Documentation Printable “Answer Key” available within the Shadow Health DCE. Chief Complaint • Symptoms - Foot pain and discharge • Diagnosis - Infected foot wound Vitals
• Weight (kg) - 88 • BMI - 30.5 • Heart Rate (HR) - 82
• Respiratory Rate (RR) - 16 Medications • Acetaminophen 500-1000 mg PO prn (headaches) • Ibuprofen 600 mg PO TID prn (menstrual cramps) • Tramadol 50 mg PO BID prn (foot pain) Allergies • 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. • • Pulse Oximetry - 99% • Blood Pressure (BP) - 139/87 • Blood Glucose - 117 • Temperature (F) - 98.9
• Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (last use: “a few months ago”)
Abnormal Findings
Reported during Chief Complaint interview • Reports open foot wound and throbbing pain • Rates present pain at a 7 out of 10 • Discharge, redness, swelling, and warmth around foot wound • Reports a fever last night and presents with a fever of 101.1 F • Pain affects ability to walk, job performance, and class attendance
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