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 03/17/20 9:09 AM MDT Tina Jones I was diagnosed when I was 24. - So do you know what type of diabetes you have? Question 03/17/20 9:10 AM MDT Tina Jones It's type 2. - Diabetes can be heavily impacted by diet and exercise Educate 03/17/20 9:10 AM MDT Tina Jones OK, I understand. - Do you follow a diabetic diet? Question 03/17/20 9:11 AM MDT Tina Jones I really try not to worry about what I eat, other than watching my sugar and trying to make healthy choices. - What kind of sugars do you consume? Question 03/17/20 9:11 AM MDT Tina Jones Most of the time I just drink Diet Cokes. - Do you drink regular soda or sugary drinks? Question 03/17/20 9:11 AM MDT Tina Jones I just stick to Diet Coke. - How long have you been drinking that? Question 03/17/20 9:12 AM MDT Tina Jones I guess I started drinking when I was in high school, so that was when I was maybe 15 or 16. - Were you 24 when you were diagnosed? (Clarified to How old were you when you were diagnosed with diabetes?.) Question 03/17/20 9:13 AM MDT Tina Jones I was diagnosed when I was 24. (Clarified to when I was diagnosed with diabetes.) - Do you currently take any medications for your diabetes? Question 03/17/20 9:13 AM MDT Tina Jones I don't take anything for my diabetes anymore. - When was the last time you took any medication for you diabetes? (Clarified to When was the last time you took medicine for your diabetes?.) Question 03/17/20 9:17 AM MDT Tina Jones I haven't taken it in about three years, honestly. (Clarified to when the last time I took my diabetes medication was.) - Why aren't you taking your diabetes medication? Question 03/17/20 9:18 AM MDT Tina Jones I just got sick of dealing with it! - what medication were you prescribed? Question 03/17/20 9:18 AM MDT Tina Jones It's called tramadol. - What diabetes medication were you taken? Question 03/17/20 9:19 AM MDT Tina Jones It was Metformin. - I understand that the medication can be a lot to deal with Empathize 03/17/20 9:20 AM MDT Tina Jones Thanks for saying that. - Did you have any side effects from it? Question 03/17/20 9:20 AM MDT Tina Jones No, I was okay taking it. - Do you monitor your blood sugar? Question 03/17/20 9:20 AM MDT Tina Jones I have a monitor at home, but to be honest I don't really use it that often. It's such a hassle to check my blood sugar, and my diabetes is under control right now so I don't really need to. - When was the last time you checked your blood sugar? Question 03/17/20 9:21 AM MDT Tina Jones I don't check it very often, honestly. . . I think the last time was about a month ago. - What are your normal blood sugars? Question 03/17/20 9:21 AM MDT Tina Jones I guess sometimes it's probably high, but I don't know the numbers. I almost never check it. I don't really get what the numbers mean. - I will set you up with a nutritionist and diabetes educator Educate 03/17/20 9:27 AM MDT Tina Jones That makes sense. - Have you been thirsty lately? Question 03/17/20 9:27 AM MDT Tina Jones You know, I did notice lately that I've been really thirsty. - Are you drinking more water that usual?Question 03/17/20 9:28 AM MDT Tina Jones I've definitely been drinking more water lately. - So have you been urinating more than usual lately? (Clarified to Have you been urinating more often than usual?.) Question 03/17/20 9:28 AM MDT Tina Jones Yeah, but I've been drinking more water. (Clarified to if I have had to urinate more often.) - How often do you urinate during the day Question 03/17/20 9:28 AM MDT Tina Jones I don't know. Every hour or two when I'm awake? - Do you have to wake up at night to urinate? Question 03/17/20 9:29 AM MDT Tina Jones Yeah, I definitely get up more than once during the night. - Does your urine have an odor? Question 03/17/20 9:29 AM MDT Tina Jones No. Gross. - How many meals do you eat a day Question 03/17/20 9:29 AM MDT Tina Jones Um, I usually have three meals a day. You know, breakfast, lunch, dinner. Plus some snacks. - What was your last meal? Question 03/17/20 9:30 AM MDT Tina Jones I had leftover chicken and mashed potatoes last night. - Did you eat breakfast this morning Question 03/17/20 9:30 AM MDT Tina Jones I haven't had anything yet. - What does your typical breakfast look like Question 03/17/20 9:30 AM MDT Tina Jones I'll usually have a muffin or pumpkin bread from the cafe near my house. - What does your normal lunch look like? Question 03/17/20 9:30 AM MDT Tina Jones Lunch is the meal I usually pick up near campus because of my schedule. I go to Subway mostly and get a turkey sandwich or something. - What about for dinner? (Clarified to What's a typical dinner?.) Question 03/17/20 9:31 AM MDT Tina Jones The usual stuff. . . meatloaf, chicken, casseroles, pasta. . . stuff like that. (Clarified to what I usually eat for dinner.) - What do you typically eat for snacks? Question 03/17/20 9:31 AM MDT Tina Jones I try to eat snacks that are kind of healthy like pretzels-sometimes I'll treat myself and get french fries, but I try not to do that too often. - Pretzels and french fries are high in carbohydrates which is bad for your blood sugar. Although they taste good, we should avoid those foods. Educate 03/17/20 9:32 AM MDT Tina Jones Alright, thanks for letting me know. - How is your appetite lately? (Clarified to How is your appetite?.) Question 03/17/20 9:38 AM MDT Tina Jones My appetite's been huge lately. . . I feel like I'm hungry all the time. (Clarified to how my appetite is.) - How long has it been huge? Question 03/17/20 9:38 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. - No, when did you notice your appetite was huge (Clarified to When did your appetite increase?.) Question 03/17/20 9:38 AM MDT Tina Jones I guess I started being starving all the time about a month ago. No matter how much I eat, I'm still hungry. (Clarified to when my appetite increased.) - So have you noticed any weight changes? Question 03/17/20 9:39 AM MDT Tina Jones Yeah, I've lost some weight recently. - Was the weight loss intentional? Question 03/17/20 9:39 AM MDT Tina Jones I've never tried to lose weight. I've always accepted my body as it was--I have a lot more important things to worry about than dieting or the way I look. - How much weight have you lost? Question 03/17/20 9:40 AM MDT Tina Jones It was about ten pounds in a little over a month, actually.