Tina Jones Health History Narrative

TINA JONES HEALTH HISTORY NARRATIVE Introduction A complete health history based upon work in Shadow Health was completed on Tina Jones, a twenty-eight year old woman. Ms. Jones came in through the emergency department for an injury to her right foot. Utilizing interviewing and clinical skills, and clinical reasoning skills, the ability to perform a health history was successful. Health History Finding Data and Reliability Ms. Tina Jones is a pleasant twenty-eight year old African American woman. She is seated upright in her hospital bed. She was admitted for further evaluations of her right foot injury. She is the primary source of the history. She offers information freely. Her speech is clear and coherent. She maintains good contact throughout the interview. General Evaluation Ms. Jones is alert and oriented. She appears to be in pain. She is well nourished. She is well groomed, dressed appropriately, has good hygiene, and interacts appropriately. Chief Complaint Ms. Jones’s chief complaint is that “I hurt my right foot one week ago” They said I needed to get admitted to the hospital. History of Present Illness Ms. Jones has an open wound to her right foot located on the plantar surface. She has asthma and type II diabetes. She injured her foot by scraping the bottom of a stepping stool. She states that she was barefoot at the time of the injury. She states that her current pain is 7/10, and last received medication in the emergency department that seems to be helping. She states that her pain is made worse when she stands, and is unable to bear weight on her right foot. She does