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Document: Provider Notes – NURS 6512
Name: MS. Tina Jones
Health History
Identifying Data
Ms. Tina is a 28-year-old African American single female. Patient is a student, and works as
supervisor at the Mild American copy and ship.
Tina appears calm, soft spoken, cooperative during assessment. No apparent acute distress. face
looks asymmetry, with mild acne, mucous membrane moist and intact. Skin color normal. No
rashes. No ovious skin tear noted. Skin around neck dry and dark. patient appears well kept. She
is financially stable, have great family support.
General Survey
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, Document: Provider Notes – NURS 6512
Right foot pain that radiated to the ankle.
Right wound infection that started as a scrapped
Chief Complaint
Patient said she hit het foot on the cement a week ago, and got a srapper under her foot, she had
a little bleeding at the time, then cleanse and covered with bandage. Then went to the ER were the
doctor presbcibe wound care treatment with peroxide, Neosporin twice daily, tamadol three times
and day for pain as needed, which had provide some relief. Patient presently complaint wih
increased foot pain radiated to ankle for the past two days, patient stated that the pain is trobbing
and sharp when putting weight on it, . Possible wound infection due to redness to surrounding
area, swollen, with large amount purulent discharge. Ms Tina stated that pain is about 7/10.
Preventing her from walking at times. Patient had temperature of 102 the night before. Her last
dose of tramadol 100mg was this morning at 08:30 and has not kicked yet. Temperature of 101.1
presently. Tina denies shortness of breath, no dizziness. No chest pain.
History of Present Illness
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Document: Provider Notes – NURS 6512
Name: MS. Tina Jones
Health History
Identifying Data
Ms. Tina is a 28-year-old African American single female. Patient is a student, and works as
supervisor at the Mild American copy and ship.
Tina appears calm, soft spoken, cooperative during assessment. No apparent acute distress. face
looks asymmetry, with mild acne, mucous membrane moist and intact. Skin color normal. No
rashes. No ovious skin tear noted. Skin around neck dry and dark. patient appears well kept. She
is financially stable, have great family support.
General Survey
This study source was downloaded by 100000851422688 from CourseHero.com on 09-20-2022 16:18:20 GMT -05:00
C o p y r i g h t © 2 0 1 9 || S h a d o w h e a l t h . c o m
https://www.coursehero.com/file/62996025/6512N-WK4Assign2docx/
1
, Document: Provider Notes – NURS 6512
Right foot pain that radiated to the ankle.
Right wound infection that started as a scrapped
Chief Complaint
Patient said she hit het foot on the cement a week ago, and got a srapper under her foot, she had
a little bleeding at the time, then cleanse and covered with bandage. Then went to the ER were the
doctor presbcibe wound care treatment with peroxide, Neosporin twice daily, tamadol three times
and day for pain as needed, which had provide some relief. Patient presently complaint wih
increased foot pain radiated to ankle for the past two days, patient stated that the pain is trobbing
and sharp when putting weight on it, . Possible wound infection due to redness to surrounding
area, swollen, with large amount purulent discharge. Ms Tina stated that pain is about 7/10.
Preventing her from walking at times. Patient had temperature of 102 the night before. Her last
dose of tramadol 100mg was this morning at 08:30 and has not kicked yet. Temperature of 101.1
presently. Tina denies shortness of breath, no dizziness. No chest pain.
History of Present Illness
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C o p y r i g h t © 2 0 1 9 || S h a d o w h e a l t h . c o m
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