tina jones health assessment.

(No Documentation Made) Ms. Jones is a pleasant, 28-year-old obese African Apresents to establish care and with a recent right fooof the history. Ms. Jones offers information freely aclear and coherent. She maintains eye contact throuGeneral Survey Calm and cooperative Ms. Jones is alert and oriented, seated upright on thapparent distress. She is well-nourished, well-develwith good hygiene. Chief Complaint Infected foot wound with increasing pain. “I got this scrape on my foot a while ago, and I thounow it's looking pretty nasty. And the pain is killingHistory Of Present Illness Poorlu healing foot wound Ms. Jones reports that a week ago she tripped whiletwisting her right ankle and scraping the ball of her emergency department where she had x-rays that wtramadol for pain. She has been cleansing the site twantibiotic ointment and a bandage. She reports that resolved but that the bottom of the foot is increasing“throbbing” and “sharp” with weight bearing. She sresolved. Pain is rated 7 out of 10 after a recent dosweight bearing. She reports that over the past two dswollen and increasingly red; yesterday she noted dShe denies any odor from the wound. Her shoes feeons. She reports fever of 102 last night. She denies unintentional weight loss over the month and increaor level of activity. Medications Tramadol, proventil inhaler Acetaminophen 500-1000 mg PO prn (headaches) •(menstrual cramps) • Tramadol 50 mg PO BID prn MD