Tina Jones Health History
Identifying Data
Ms. Jones is a pleasant 28-year-old, single, African American, female. She presents to the office
today for a physical examination and with a chief complaint of right foot pain after a recent
injury. She is the primary source of history obtained in addition to the use of her available medical
record. She is able to maintain good eye contact and clear speech throughout the interview
process, as she provides all information freely.
General Survey
Ms. Jones is alert and oriented, with relaxed posture during the assessment process. Her mood
appears to be stable, and she does not appear to be in any distress. Her immediate and remote
memory appear to be intact. She appears to have good hygiene and is dressed appropriately for the
current weather and occasion.
Chief Complaint: "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!"
History of Present Illness
Ms. Jones presents today for a physical examination and with report of a scrape to the ball of her
right foot. She reports that she obtained the scrape 1 week ago when she tripped going down the
stairs and scraped her bare foot on the edge of the step. She reports bleeding at the time of
injury, and shares that she has been washing the wound with soap and water twice daily
(morning and night), and that she has been using Neosporin prior to keeping it bandaged. She
added that she sometimes uses peroxide and then rinses the area when it is irritated. She reports
that the scrape is not healing on its own, "is not looking well", and is causing her pain. Her
current pain level is a 7/10, and she describes the pain as "throbbing" and "sharp" when weight is
applied. She reports that her entire right foot feels some pain, but the pain is the worst at the
center/ball of her foot. She added that the pain also radiates up her ankle. She has not been able
to walk due to this pain. She has been taking Tramadol 100 mg three times daily for pain, but
feels that this only alleviates the pain for a few hours. She reports that the area has been red and
swollen with noted pus, heat, and increased pain over the last 2 days ago. She denies noted odor.
Medications
• Tramadol 50 mg tablets. Taking 2 tablets (100 mg Total) 3 times daily for pain.
• Proventil Inhaler 90 mg 2- 3 puffs 2-3 times per week for asthma symptoms.
• Advil 200 mg tablets. Taking 3 tablets (600 mg Total) up to 3 times daily for
menstrual cramps.
, o Patient self-discontinued Metformin and birth control pill use 3 years ago.
o She denies use of any other vitamins, supplements, or additional OTC medications.
Allergies
• Penicillin (Rash/Hives. Last occurring in childhood)
• Cats (Itchy eyes, sneezing, wheezing)
• Dust (Itchy eyes, sneezing, wheezing)
o Denies Food Allergies.
o Denies Latex Allergies.
o Denies Seasonal Allergies.
Medical History
• Type 2 Diabetes: Diagnoses at age 24. Has a glucometer, but does not currently monitor
her blood glucose due to feeling it is a hassle. Not currently taking prescribed
medication.
Was taking Metformin when first diagnosed but discontinued taking this 3 years ago due
to not liking it. Does not follow a specific diabetic diet. Tries to make healthy choices.
Avoids excess carbohydrate and sugar intake (drinks diet versus regular soda). Does not
monitor her salt intake. She reports increased appetite, thirst, and water intake. Reports
unintentional weight loss of 10 lbs. over the last month. She also reports more frequent
urination.
• Asthma: Diagnosed as a child at age 2. Reports chest & throat tightness, wheezing, and
feels that she can't take in enough air into her lungs during attacks. Reports dust, cats,
and
exercise (such as running up the stairs) make breathing worse. Reports showering helps
with symptoms when exposed to cats. She reports that her asthma attacks are rare, and
that the last attack resulted in hospitalization when her inhaler was not working at age 16.
Reports using a prescribed Proventil Inhaler 90 mg 2- 3 puffs 2-3 times per week
as needed for asthma symptoms.
Health Maintenance
• Report that she is currently up-to-date on her immunizations. Received all childhood
vaccinations. Last tetanus booster was about 1 year ago. Last PPD test was a couple
of
years ago. Last HPV test was a couple of years ago. Denies having a varicella vaccine dt
having chicken pox as a child. Denies having a diphtheria vaccine. Denies getting an
annual flu vaccine (with last received 6 years ago) due to feeling that they are ineffective.
• Last physical was 2 years ago. Reports recent increase in stress and feeling of exhaustion
at end of day. Denies changes in sleep status (aside from when father died last year).
Reports
that she has not been sleeping well lately d/t foot pain. Denies Depression.
Identifying Data
Ms. Jones is a pleasant 28-year-old, single, African American, female. She presents to the office
today for a physical examination and with a chief complaint of right foot pain after a recent
injury. She is the primary source of history obtained in addition to the use of her available medical
record. She is able to maintain good eye contact and clear speech throughout the interview
process, as she provides all information freely.
General Survey
Ms. Jones is alert and oriented, with relaxed posture during the assessment process. Her mood
appears to be stable, and she does not appear to be in any distress. Her immediate and remote
memory appear to be intact. She appears to have good hygiene and is dressed appropriately for the
current weather and occasion.
Chief Complaint: "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!"
History of Present Illness
Ms. Jones presents today for a physical examination and with report of a scrape to the ball of her
right foot. She reports that she obtained the scrape 1 week ago when she tripped going down the
stairs and scraped her bare foot on the edge of the step. She reports bleeding at the time of
injury, and shares that she has been washing the wound with soap and water twice daily
(morning and night), and that she has been using Neosporin prior to keeping it bandaged. She
added that she sometimes uses peroxide and then rinses the area when it is irritated. She reports
that the scrape is not healing on its own, "is not looking well", and is causing her pain. Her
current pain level is a 7/10, and she describes the pain as "throbbing" and "sharp" when weight is
applied. She reports that her entire right foot feels some pain, but the pain is the worst at the
center/ball of her foot. She added that the pain also radiates up her ankle. She has not been able
to walk due to this pain. She has been taking Tramadol 100 mg three times daily for pain, but
feels that this only alleviates the pain for a few hours. She reports that the area has been red and
swollen with noted pus, heat, and increased pain over the last 2 days ago. She denies noted odor.
Medications
• Tramadol 50 mg tablets. Taking 2 tablets (100 mg Total) 3 times daily for pain.
• Proventil Inhaler 90 mg 2- 3 puffs 2-3 times per week for asthma symptoms.
• Advil 200 mg tablets. Taking 3 tablets (600 mg Total) up to 3 times daily for
menstrual cramps.
, o Patient self-discontinued Metformin and birth control pill use 3 years ago.
o She denies use of any other vitamins, supplements, or additional OTC medications.
Allergies
• Penicillin (Rash/Hives. Last occurring in childhood)
• Cats (Itchy eyes, sneezing, wheezing)
• Dust (Itchy eyes, sneezing, wheezing)
o Denies Food Allergies.
o Denies Latex Allergies.
o Denies Seasonal Allergies.
Medical History
• Type 2 Diabetes: Diagnoses at age 24. Has a glucometer, but does not currently monitor
her blood glucose due to feeling it is a hassle. Not currently taking prescribed
medication.
Was taking Metformin when first diagnosed but discontinued taking this 3 years ago due
to not liking it. Does not follow a specific diabetic diet. Tries to make healthy choices.
Avoids excess carbohydrate and sugar intake (drinks diet versus regular soda). Does not
monitor her salt intake. She reports increased appetite, thirst, and water intake. Reports
unintentional weight loss of 10 lbs. over the last month. She also reports more frequent
urination.
• Asthma: Diagnosed as a child at age 2. Reports chest & throat tightness, wheezing, and
feels that she can't take in enough air into her lungs during attacks. Reports dust, cats,
and
exercise (such as running up the stairs) make breathing worse. Reports showering helps
with symptoms when exposed to cats. She reports that her asthma attacks are rare, and
that the last attack resulted in hospitalization when her inhaler was not working at age 16.
Reports using a prescribed Proventil Inhaler 90 mg 2- 3 puffs 2-3 times per week
as needed for asthma symptoms.
Health Maintenance
• Report that she is currently up-to-date on her immunizations. Received all childhood
vaccinations. Last tetanus booster was about 1 year ago. Last PPD test was a couple
of
years ago. Last HPV test was a couple of years ago. Denies having a varicella vaccine dt
having chicken pox as a child. Denies having a diphtheria vaccine. Denies getting an
annual flu vaccine (with last received 6 years ago) due to feeling that they are ineffective.
• Last physical was 2 years ago. Reports recent increase in stress and feeling of exhaustion
at end of day. Denies changes in sleep status (aside from when father died last year).
Reports
that she has not been sleeping well lately d/t foot pain. Denies Depression.
