NURS 6512N Week 4 Shadow Health Tina Jones

Height: 170 cm Exam Action 03/17/20 8:44 AM MDT Weight: 90 kg Exam Action 03/17/20 8:44 AM MDT - BMI: 31 Exam Action 03/17/20 8:44 AM MDT - Random blood glucose: 238 Exam Action 03/17/20 8:44 AM MDT - Temperature: 101.1 F Exam Action 03/17/20 8:44 AM MDT - Blood pressure: 142/82 Exam Action 03/17/20 8:44 AM MDT - Respiratory rate: 19 Exam Action 03/17/20 8:44 AM MDT - O2 sat: 99% Exam Action 03/17/20 8:44 AM MDT - Heart rate: 86 Exam Action 03/17/20 8:44 AM MDT - Hello, my name is [ ] I'm a nurse practitioner student and I'm going to be taking care of you today. Greet 03/17/20 8:45 AM MDT Tina Jones Hey. - Can you verify your name and birthday for me? Question 03/17/20 8:45 AM MDT Tina Jones My name's Tina Jones, and my birthday's February 17th. - Ok great. What brings you in today? (Clarified to What brings you in today?.) Question 03/17/20 8:46 AM MDT Tina 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! (Clarified to why I came in.) - Oh I'm sorry to hear that. Empathize 03/17/20 8:46 AM MDT Tina Jones I appreciate you telling me that. - Where exactly is the pain at on your foot? Question 03/17/20 8:46 AM MDT Tina Jones It feels like the pain is just centered around the scrape, like around the ball of my foot. That's where it hurts the most, but my whole foot feels some pain. - Which foot did you injure? Question 03/17/20 8:47 AM MDT Tina Jones My right foot. - Can you rate the pain for me on a scale of 1 to 10? (Clarified to Can you rate your current pain level on a scale of 0 to 10?.) Question 03/17/20 8:47 AM MDT Tina Jones I'd say a 7. It hurts a lot, and the pain pills haven't kicked in yet. (Clarified to how I would rate my pain on a scale.) - What are you taking for the pain? Question 03/17/20 8:47 AM MDT Tina Jones It's called tramadol. - How did you get this medication? Do you normally take it? (No matching questions found.) Question 03/17/20 8:48 AM MDT - How did you get this medication? Question 03/17/20 8:48 AM MDT Tina Jones I was going down the back steps, and I tripped. . . I caught the railing, but I guess I kind of turned my ankle a little bit. And I scraped up my foot on the edge of the step. - where did you get the medication? Question 03/17/20 8:48 AM MDT Tina Jones The ER doctor prescribed them for me when I was in there a week ago. - So you fell one week ago? Question 03/17/20 8:49 AM MDT Tina Jones I was going down the back steps, and I tripped. . . I caught the railing, but I guess I kind of turned my ankle a little bit. And I scraped up my foot on the edge of the step. - Has your wound been draining any pus? Question 03/17/20 8:49 AM MDT Tina Jones Yeah, there's definitely pus. - Has your wound had pus in it all week? (Clarified to How long has the wound had pus in it?.) Question 03/17/20 8:50 AM MDT Tina Jones For two days. (Clarified to how long my wound has had pus.) - Can you describe your pain? Question 03/17/20 8:50 AM MDT Tina Jones It's throbbing and like, sharp if I try to put weight on it. - Is there anything that makes the pain worse? Question 03/17/20 8:51 AM MDT Tina Jones I'd say the pain is at its worst when I have to put any weight on my foot. . . otherwise, it's when the pain pills wear off. - What is the pain like when you stand on your foot? Question 03/17/20 8:51 AM MDT Tina Jones Yes! I mean, I literally can't put weight on my foot, the pain is so sharp. - When did the pain start? Question 03/17/20 8:51 AM MDT Tina Jones Well, I got the scrape a week ago, but the scrape and the pain got a lot worse in the last few days. - So the pain has changed over time? Question 03/17/20 8:52 AM MDT Tina Jones Yeah, it got a lot worse two days ago. It was noticeably more painful. - Does the pain radiate anywhere? Question 03/17/20 8:52 AM MDT Tina Jones The pain's worse in my foot, but I feel it moving up into my ankle, too. - So can't bear any weight on your foot? Question 03/17/20 8:52 AM MDT Tina Jones No, I can't. I can't put any weight on it without like, shooting pain. - That has to be frustrating. I'm sorry to hear that. Empathize 03/17/20 8:53 AM MDT Tina Jones Thanks. - So did you hurt anything else besides your foot? Question 03/17/20 8:53 AM MDT Tina Jones Well, at first I thought my ankle was sprained because it hurt a lot right after I fell. But, I mean, I guess I was over-estimating it, because the ankle felt pretty okay the next day and it wasn't a problem all week. - What kind of shoes did you have on when you fell? Question 03/17/20 8:54 AM MDT Tina Jones I wasn't wearing shoes. - Ok, we should always wear shoes when we're outside. There are numerous things you could hurt your feet on. Educate 03/17/20 8:55 AM MDT Tina Jones Alright, thanks for letting me know. - Were you drinking alcohol when you were injured? Question 03/17/20 8:55 AM MDT Tina Jones I haven't had any alcohol in at least three weeks. - How often do you drink alcohol? Question 03/17/20 8:55 AM MDT Tina Jones No more than once or twice a week, sometimes less. - Do you use any recreational drugs? Question 03/17/20 8:56 AM MDT Tina Jones Well, I used to smoke pot. . . but I don't do that anymore. - When was the last time you smoked pot? Question 03/17/20 8:56 AM MDT Tina Jones I haven't smoked pot since I was twenty or twenty-one. - Ok great. So who took you to the ER after you hurt your foot? (No matching questions found.) Question 03/17/20 8:57 AM MDT - Who took you to the ER after you hurt your foot? (Clarified to Who took you to the ER?.) Question 03/17/20 8:57 AM MDT Tina Jones My mom brought me in after I tripped, just to make sure my ankle wasn't broken. (Clarified to who brought me to the ER.) - Did your foot bleed? Question 03/17/20 8:58 AM MDT Tina Jones Yeah, right when I hurt it. - You said there was drainage, what color is the drainage in your foot? Question 03/17/20 8:58 AM MDT Tina Jones It's... white or maybe off-white. - Does it have an odor? (Clarified to Does your scrape have an odor?.) Question 03/17/20 8:58 AM MDT Tina Jones Um, no, not that I know of... That sounds gross. (Clarified to if my scrape has an odor.) - I understand that sounds gross. Assessing odor gives us an idea of what is going on with your foot. Empathize 03/17/20 8:59 AM MDT Tina Jones Thanks for understanding. - How have you been treating the wound at home? Question 03/17/20 8:59 AM MDT Tina Jones I made sure to clean it and just keep it bandaged. And I put Neosporin on it. - How often do you clean the wound? Question 03/17/20 9:00 AM MDT Tina Jones Twice a day -- every morning and every night. - Did you change the bandage that often too? (Clarified to How often do you change your bandage?.) Question 03/17/20 9:01 AM MDT Tina Jones Every morning and night. I was keeping an eye on it. (Clarified to how often I change my bandage.) - Is there any swelling around the wound? Question 03/17/20 9:01 AM MDT Tina Jones Yeah, it looks swollen around the scrape. - Does the wound feel warm? Question 03/17/20 9:02 AM MDT Tina Jones Yeah, it feels pretty warm. - I'm sorry to hear that Empathize 03/17/20 9:02 AM MDT Tina Jones Thanks for saying that. - Does this foot injury affect your work? (Clarified to How has the injury interfered with daily activities?.) Question 03/17/20 9:03 AM MDT Tina Jones I mean, the last two days I couldn't walk on my foot, so it's gotten in the way of everything -- I had to basically stay home and off my foot. I didn't think it could get to the point where it caused so many problems. (Clarified to how my injury has affected daily activities.) - Have you went to work on it? Question 03/17/20 9:04 AM MDT Tina Jones Well, I tried to go in two days ago but I couldn't walk well enough, so I just went home after a couple hours. And I didn't go in yesterday. My boss was understanding, but I need to be able to work! - Have you went to school? (Clarified to Did you go to school?.) Question 03/17/20 9:04 AM MDT Tina Jones I'm actually in college right now. (Clarified to if I have ever attended school.) - Has your injury prevented you from going to class? Question 03/17/20 9:04 AM MDT Tina Jones I had a class two days ago, and I skipped it. I haven't missed any classes before this, and I emailed my professor, so I should be okay. I don't want to get behind, so I need to get back to it! - I'm glad they were understanding. We'll try to get you healed up so you can go back Empathize 03/17/20 9:05 AM MDT Tina Jones I appreciate you saying that. - Have you ran a fever? Question 03/17/20 9:05 AM MDT Tina Jones Yeah, I was running a fever last night. - Do you feel feverish right now? Question 03/17/20 9:05 AM MDT Tina Jones I don't feel feverish right now, but last night I had a high temperature. - Did you do anything for your temperature? (No matching questions found.) Question 03/17/20 9:06 AM MDT - Did you take any medication for your temperature? Question 03/17/20 9:06 AM MDT Tina Jones I really didn't do much for it at home. - Ok. So I'm going to take a look at your foot right now. Educate 03/17/20 9:06 AM MDT Tina Jones That makes sense. - Measured wound: 2 cm x 1.5 cm, 2.5 mm deep Exam Action 03/17/20 9:07 AM MDT - Swabbed wound and sent to lab for C & S Exam Action 03/17/20 9:07 AM MDT - Cleansed and irrigated wound with normal saline and applied dry sterile dressing. Exam Action 03/17/20 9:07 AM MDT - I took a culture of the wound in the foot which will give us details about the drainage (No matching questions found.) Question 03/17/20 9:08 AM MDT - I took a culture of the wound in the foot which will give us details about the drainage Educate 03/17/20 9:08 AM MDT Tina Jones Thanks for telling me. - I went ahead and cleaned the wound and applied a sterile dressing also Educate 03/17/20 9:09 AM MDT Tina Jones Sure, I think I understand what you mean. - Do you have any medical questions Question 03/17/20 9:09 AM MDT Tina Jones I've been taking some pain medication. Other than that, I have my inhaler. - Do you have any medical conditions? Question 03/17/20 9:09 AM MDT Tina Jones Yeah. . . I have asthma and diabetes. - When were you diagnosed with diabetes? Question