ShadowHealth - Comprehensive Health History - Documentation|Documentation / Electronic Health Record

ShadowHealth - Comprehensive Health History - Documentation. Health History Results | Turned In Advanced Health Assessment - August 2019, N5544 Return to Assignment Your Results Reopen Lab Pass Documentation / Electronic Health Record Document: Provider Notes Document: Provider Notes Student Documentation Model Documentation Identifying Data & Reliability Miss Jones is a pleasant 28 year old overweight African-American woman who presents for an initial primary care visit with a recent injury to the right foot. Her speech is clear and coherent. She maintains appropriate eye contact throughout the interview. Miss Jones is the primary historian. 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 Miss Jones is alert and oriented. She is in no acute distress. Miss Jones appears healthy with appropriate clothing and hygiene. 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 Per Miss Jones, "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!" “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!” This study source was downloaded by from CourseH on :36:15 GMT -05:00 History Of Present Illness Miss Jones reports that about a week go, she tripped walking outside. She reports twisting her right ankle and scraping the ball of her foot. Miss Jones did go to the ER after her fall where x-rays were negative for fracture. She was given a tramadol prescription for the pain. She currently rates her pain at a 7/10. Miss Jones describes the pain as "throbbing" and "sharp" when she bears weight. Last dose of tramadol was this morning. Miss Jones reports that over the last two days, the ball of her foot has become swollen and red. She also noted that there is discharge coming fromt he wound that is white in color. She denies any odor coming from the wound. Miss Jones states that she has been applying neosporin, cleaning the site, and changing the bandage twice a day. She also reports having a fever last night. She denies any recent illnesses, reports unintentionally losing 10 pounds over the last month but denies any changes in her diet or level of activity. 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 50 mg PO BID PRN for foot pain - Albuterol inhaler 90 mcg/spray 2 puff PRN for asthma and wheezing - Ibuprofen 600 mg PO TID for menstrual cramps Acetaminophen 500-1000 mg PO prn (headaches) • Ibuprofen 600 mg PO TID prn (menstrual cramps) • Tramadol 50 mg PO TID prn (foot pain) • Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (Wheezing: “when around cats,” last use three days ago) Allergies Penicillin - hives Cats and dusts - runny nose, swollen eyes, itchy eyes, and asthma symptoms Denies food and latex 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. Medical History Miss Jones was diagnosed with asthma as child. She states that she was diagnosed when she "2 and 1/2 years old". Patient uses an albuterol inhaler for asthma attacks that are flared by exposure to cats and dust. She reports that she uses her inhaler about 2 to 3 times per week. Last inhaler usage was three days ago when she was around cats. She used the inhaler once and was relieved of her symptoms. Patient has been hospitalized for asthma before with the last admission when she was "in high school." Patient denies ever being intubated. Patient is a type 2 diabetic, diagnosed at 24 years old. Patient previously took metformin but stopped taking the medication three years ago because of the side effects. She also felt overwhelmed by having to check her blood sugar and taking the medication daily. Patient does not currently monitor her blood sugar. Patient denies having any surgeries. OB/GYN: Patient denies pregnancies. Her last menstrual cycle was 3 weeks ago. Patient states that she does have irregular cycles with heavy bleeding. She has used oral contraceptives in the past but is not currently using them. Patient is not currently sexually active and has no current partner. She denies any STIs or STDs. Skin: patient reports having acne. She is complaining of an increase in facial hair and body hair. She has also noticed darkened skin around her neck. Cardiovascular: Patient denies palpitations or heart arrythmias. Patient denies having high blood pressure. 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. Health Maintenance Patient's last pap smear was 4 years ago. Last dental exam was "a few years" ago. Last vision exam was "as a kid." Immunizations: tetanus booster received within the past year, influenza is not up to date. Miss Jones does believe she is up to date on her childhood vaccinations. Patient does have health insurance. Last Pap smear 4 years ago. Last eye exam in childhood. Last dental exam “a few years ago.” PPD (negative) ~2 years ago. No exercise. 24-hour Diet Recall: States that she skipped breakfast yesterday, and would typically have a baked good for breakfast, a sandwich for lunch, and a meatloaf or chicken for dinner. Her snacks consist of pretzels or French fries. Immunizations: Tetanus booster was received within the past year, influenza is not current, and human papillomavirus has not been received. She reports that she believes she is up to date on childhood vaccines and received the meningococcal vaccine in college. Safety: Has smoke detectors in the home, wears seatbelt in car, and does not ride a bike. Does not use sunscreen. Guns, having belonged to her dad, are in the home, locked in parent’s room. Student Documentation Model Documentation Family History Mother - HTN, HLD; age 50 - alive Father - HTN, HLD, DM2; age 58 - deceased r/t car accident one year ago Brother - overweight; age 25 - alive Sister - asthma; age 14 - alive Maternal grandmother - HTN, HLD - age 73 - deceased r/t stroke Maternal grandfather - HTN, HLD - age 87- deceased r/t stroke Paternal grandmother - HTN - age 83 - alive Paternal grandfather - Colon CA, DM2 - deceased r/t Colon CA Paternal uncle - alcoholic Patient denies any mental illness or additional cancers. • Mother: age 50, hypertension, elevated cholesterol • Father: deceased in car accident one year ago at age 58, hypertension, high cholesterol, and type 2 diabetes • Brother (Michael, 25): overweight • Sister (Britney, 14): asthma • Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol • Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol • Paternal grandmother: still living, age 82, hypertension • Paternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes • Paternal uncle: alcoholism • Negative for mental illness, other cancers, sudden death, kidney disease, sickle cell anemia, thyroid problems Social History Miss Jones currently lives with her mother and sister in a single family home. She is currently a supervisor at Mid-American Copy & Ship. She is also a college student. She is pursuing her bachelor's degree in accounting. Miss Jones is an active member in her church and describes them as being a strong social support system in addition to her family. Recent stressors in Miss Jones' life include the death of her father, school, work, and the recent injury to her right foot. Patient denies any tobacco usage but does report using cannabis in the past. She reported her last usage was at the age of 21. Patient denies any usage of illicit drugs or prescription drugs that do not belong to her. Patient reports occasional social alcohol usage about 2-3 times a month. She states that she does not drink more than 3 drinks per outing. Patient does drink diet soda. She reports eating a pastry for breakfast. A sandwich for lunch and for dinner, she has a protein with a side. For snacks, she prefers pretzels or French fries. Patient does is currently not in an intimate relationship. Never married, no children. Lived independently since age 20, currently lives with mother and sister in a single family home to support family after death of father one year ago. Employed 32 hours per week as a supervisor at Mid-American Copy and Ship. She enjoys her work and was recently promoted to shift supervisor. She is a part-time student, in her last semester to earn a bachelor’s degree in accounting. She hopes to advance to an accounting position within her company. She has a car, cell phone, and computer. She receives basic health insurance from work, but is deterred from healthcare due to out-of-pocket costs. She enjoys spending time with friends, attending Bible study, volunteering in her church, and dancing. Tina is active in her church and describes a strong family and social support system. She reports stressors relating to the death of her father and balancing work and school demands, and finances. She states that family and church help her cope with stress. No tobacco. Occasional cannabis use from age 15 to age 21. Reports no use of cocaine, methamphetamines, and heroin. Uses alcohol when “out with friends, 2-3 times per month,” reports drinking no more than 3 drinks per episode. She drinks 4 caffeinated drinks per day (diet soda). No foreign travel. No pets. Not currently in an intimate relationship, ended a three-year serious monogamous relationship two years ago. She plans on getting married and having children someday. Student Documentation Model Documentation Objective Wound located on right ball of foot with serosanguinous drainage. Measurement: 2 cm x 1.5 cm, 2.5 mm deep Wound has mild erythema surrounding wound with no edema. Vital Signs: Temp - 101.1 BP - 142/82 HR - 86 RR - 19 O2 saturation - 99% on RA RR Wound: 2 cm x 1.5 cm, 2.5 mm deep wound, red wound edges, right ball of foot, serosanguinous drainage. Mild erythema surrounding wound, no edema, no tracking. © Shadow Health®