Week 4 Health
History Tina Jones
Identifying Data & Reliability
Ms. Tina Jones is a 28 year old African American female who
present to the clinic with complaint of right food pain after
N/A
injuring it a week ago. Ms. Jones is alert and oriented with a
pleasant disposition. She is a good historian and the primary
source of all information.
General Survey
Ms. Jones is dress appropriately for the weather and appears
N/A
well nourish and groom. She is sitting upright on the exam table
and maintain eye contact throughout the interview.
Chief Complaint
Have a scrape on the right foot that is now draining what N/A
appears to be pus and is more painful in the last two days.
History of Present Illness N/A
Ms. Jones stated that she tripped going down the stair and scrape her right foot. She was seen in the ED b
negative for any fractures. She was prescribe tramadol 50 mg for
, the pain and sent home. Ms. Jones have been cleaning her wound at home twice a day with soap and water, s
Medications
Tramadol 50 mg three times a day for foot pain. Ibuprofen
200mg three tablets for menstrual cramps Tylenol 500-1000 mg N/A
(extra strength) PRN for headache. Albuterol 90mcg 2-3 puff
for Asthma.
Allergies
Penicillin-gets a rash Denies latex, environmental or food
N/A
allergies. Allergic to cats- sneezing, itchy eyes, and exacerbation
of Asthma symptoms.
Medical History N/A
Asthma Dx at 2 1/2 years old, treated with albuterol 90 mcg 2-3
puff. Last use three days ago, endorses relieve of symptoms
with medication. Last hospitalized for Asthma related symptom
in high school. Diabetes Dx at 24 years old, was order
Metformin
History Tina Jones
Identifying Data & Reliability
Ms. Tina Jones is a 28 year old African American female who
present to the clinic with complaint of right food pain after
N/A
injuring it a week ago. Ms. Jones is alert and oriented with a
pleasant disposition. She is a good historian and the primary
source of all information.
General Survey
Ms. Jones is dress appropriately for the weather and appears
N/A
well nourish and groom. She is sitting upright on the exam table
and maintain eye contact throughout the interview.
Chief Complaint
Have a scrape on the right foot that is now draining what N/A
appears to be pus and is more painful in the last two days.
History of Present Illness N/A
Ms. Jones stated that she tripped going down the stair and scrape her right foot. She was seen in the ED b
negative for any fractures. She was prescribe tramadol 50 mg for
, the pain and sent home. Ms. Jones have been cleaning her wound at home twice a day with soap and water, s
Medications
Tramadol 50 mg three times a day for foot pain. Ibuprofen
200mg three tablets for menstrual cramps Tylenol 500-1000 mg N/A
(extra strength) PRN for headache. Albuterol 90mcg 2-3 puff
for Asthma.
Allergies
Penicillin-gets a rash Denies latex, environmental or food
N/A
allergies. Allergic to cats- sneezing, itchy eyes, and exacerbation
of Asthma symptoms.
Medical History N/A
Asthma Dx at 2 1/2 years old, treated with albuterol 90 mcg 2-3
puff. Last use three days ago, endorses relieve of symptoms
with medication. Last hospitalized for Asthma related symptom
in high school. Diabetes Dx at 24 years old, was order
Metformin
