NUR 6001 Advanced Health Assessment Discussion:
Health History Documentation | Latest Actual verified
study complete Solutions | 2026 Updates | 100% correct
Health History Documentation
Marc Junchaya
William Paterson University
NUR 6001-808 - Advanced Health Assessment
Dr. Milagros Rojas
May 20, 2026
, Complete Health History
Subjective
● Identifying Data & Reliability: Mrs. Jones is a 28-year-old African American female,
presenting to the office with complaints of pain to right foot. Mrs. Jones is providing all
sources of history, and provides information freely without any issues. Mrs. Jones is clear
and concise during the interview
● Chief Complaint: Patient states, “I got a scrape on the right foot a while ago. I thought it
would heal on its own, but now it looks pretty nasty. And the pain is killing me!”
● History of Present Illness: Patient fell coming down a flight of stairs, twisting her ankle
and scraping her right foot. The patient went to the emergency room, where she received
an X-ray of the foot, which showed no abnormal findings, and the patient was discharged
with tramadol. The patient has performed wound care twice daily on the wound, ensuring
that the site is cleansed and bandaged. Despite this, the patient states that the wound has
progressively gotten worse with increasing pain. Patient states that last night she first
developed a fever and intense pain, which brought her into the clinic. The quality of the
pain is described as throbbing and radiating towards the ankle. Percepting factors include
weight bearing on the right side, as pain becomes more intense and becomes sharp.
Patient states the intensity of the pain while non-weight bearing is a seven out of ten,
while the patient applies weight to the right foot, the pain is ten out of ten. Patient
explains the timing of pain is constant and that tramadol only provides some relief for a
couple of hours. Patient notes wound presents with drainage of white pus.
● Home Medication: Patient states she is currently on two medications, being tramadol
and albuterol. Patient is unsure of the direct strength of the tramadol dose, states there
Health History Documentation | Latest Actual verified
study complete Solutions | 2026 Updates | 100% correct
Health History Documentation
Marc Junchaya
William Paterson University
NUR 6001-808 - Advanced Health Assessment
Dr. Milagros Rojas
May 20, 2026
, Complete Health History
Subjective
● Identifying Data & Reliability: Mrs. Jones is a 28-year-old African American female,
presenting to the office with complaints of pain to right foot. Mrs. Jones is providing all
sources of history, and provides information freely without any issues. Mrs. Jones is clear
and concise during the interview
● Chief Complaint: Patient states, “I got a scrape on the right foot a while ago. I thought it
would heal on its own, but now it looks pretty nasty. And the pain is killing me!”
● History of Present Illness: Patient fell coming down a flight of stairs, twisting her ankle
and scraping her right foot. The patient went to the emergency room, where she received
an X-ray of the foot, which showed no abnormal findings, and the patient was discharged
with tramadol. The patient has performed wound care twice daily on the wound, ensuring
that the site is cleansed and bandaged. Despite this, the patient states that the wound has
progressively gotten worse with increasing pain. Patient states that last night she first
developed a fever and intense pain, which brought her into the clinic. The quality of the
pain is described as throbbing and radiating towards the ankle. Percepting factors include
weight bearing on the right side, as pain becomes more intense and becomes sharp.
Patient states the intensity of the pain while non-weight bearing is a seven out of ten,
while the patient applies weight to the right foot, the pain is ten out of ten. Patient
explains the timing of pain is constant and that tramadol only provides some relief for a
couple of hours. Patient notes wound presents with drainage of white pus.
● Home Medication: Patient states she is currently on two medications, being tramadol
and albuterol. Patient is unsure of the direct strength of the tramadol dose, states there
