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Height: 170 cm
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Weight: 90 kg
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BMI: 31
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Random blood glucose: 238
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Temperature: 101.1 F
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Blood pressure: 142/82
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Respiratory rate: 19
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O2 sat: 99%
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Heart rate: 86
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Measured wound: 2 cm x 1.5 cm, 2.5 mm deep
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Swabbed wound and sent to lab for C & S
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Cleansed and irrigated wound with normal saline and applied dry sterile dressing.
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Hello.My name is Gisselle. i will interview you and later examine you.
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Hello.
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Hello. Mt name is xxx, I will interview you and later examine you.
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Greet |
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Hey.
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What is your name?
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Tina Jones.
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Why are you here today?
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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!
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Am sorry hear that.
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Empathize |
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I appreciate you telling me that.
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When did you get the scrape?
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Well, I got the scrape a week ago, but the scrape and the pain got a lot worse in the last few days.
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How severe is the pain?
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It’s really bad.
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Can you describe the pain?
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It’s throbbing and like, sharp if I try to put weight on it.
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Did you hurt any other part? (Clarified to Did you hurt anything else during the fall?.)
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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. (Clarified to if I hurt anything else during the fall.)
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How has the pain changed over time?
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At first, it seemed like it was healing up fine and it didn’t give me a lot of pain. But the last two days, the pain got way worse.
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Does the pain radiate?
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The pain’s worse in my foot, but I feel it moving up into my ankle, too.
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How did you hurt your ankle?
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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.
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Can you stand on your foot?
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No, I can’t put weight on my foot without really sharp pain.
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Can you rate your pain on a scale of 0 to 10?
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I’d say a 7. It hurts a lot, and the pain pills haven’t kicked in yet.
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Where is the pain located?
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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.
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Which foot did you injure?
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My right foot.
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Were you wearing shoes?
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No, I was barefoot.
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Did you have any alcoholic drinks before the injury?
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No, I was stone-cold sober. It was the middle of the day.
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Did you use home remedies? (Clarified to Did you use home remedies for your foot?.)
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Yeah, I made sure to clean it and keep it bandaged. (Clarified to if I use home remedies for my foot.)
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What did you use to clean it?
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Since it happened, I’ve been washing it with soap and water, and if it seemed irritated, I would put some peroxide on there and then rinse it off.
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When did you go to the ER?
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I went about an hour after I fell, I think.
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Did you get any medication at the ER?
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Yes, they wrote me a prescription for some pain pills.
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Do you know the name of the pain pills?
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It’s called tramadol.
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What dosage of tramadol?
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I’m not 100% sure, but I think they’re 50 milligrams.
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How often were you taking the tramadol?
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I’ve been taking the Tramadol morning, noon, and night. [AUDIO COMING SOON]
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Did tramadol relieve pain?/
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I’ve only been taking the pain pills the ER gave me and staying off it. . . and keeping the wound clean.
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Has your foot bled since the injury?
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It’s not bleeding anymore. It only bled right after I scraped it.
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What happened after you scraped your foot?
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I got the scrape to stop bleeding, and then I started to worry that I had sprained my ankle, so Mom and I decided better safe than sorry, and so we went to the ER.
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It is good to seek medical attention
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OK, I understand.
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How effective is the pain medication?
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They only help for a few hours at a time.
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Am sorry to hear that.
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Empathize |
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Thanks for saying that.
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How have you cared for the scrape?
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I made sure to clean it and just keep it bandaged. And I put Neosporin on it.
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How effective was the neosporin?
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Well, I had to come back to get my foot checked out even though I used the ointment. [AUDIO COMING SOON]
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How often have you been cleaning your scrape?
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Twice a day — every morning and every night.
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Great. It is good to keep it clean.
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Sure, I think I understand what you mean.
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Is the wound swollen?
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Yeah, it looks swollen around the scrape.
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Does your scrape have an odor?
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Um, no, not that I know of… That sounds gross.
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Any pus?
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Yeah, there’s definitely pus.
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What color is the pus?
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It’s… white or maybe off-white.
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Is the scrape red?
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Yeah, it’s red all around the scrape.
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Any temperature change around the scrape?
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No.
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Are you having problems getting around?
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Yes! I mean, I literally can’t put weight on my foot, the pain is so sharp.
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Am sorry to hear that.
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My hearing is fine.
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Am sorry to hear that
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Thanks for understanding.
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Who has been helping you at home since you hurt your foot?
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I’m lucky living at home because my mom is around to help me, and my sister too.
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Do you work?
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xxxxx
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I haven’t had a mammogram. I’ve just had the exam where the doctor felt around for lumps.
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Any pain in the breasts?
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No. Maybe some soreness before my period, but that seems pretty typical.
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Any nipple discharge?
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Uh, no, definitely not.
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Any nosebleed?
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No.
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Any chest pain?
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No, my chest feels tight when I have breathing problems, but it doesn’t hurt.
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Any difficulty moving your bowels?
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Not really.
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Any skin changes?
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Well…I guess I was noticing the other day that the skin around my neck is looking weird. Like the skin is getting darker. And my skin’s breaking out, but that’s how it is.
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What is your general health condition?
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Overall, my health is pretty good. I have a couple of problems, I guess, but they don’t bother me too much.
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Any fatigue?
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Most days I feel pretty exhausted by the end of the day…I’m tired now, too, but I think that’s just because I slept terribly.
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How is your sleep pattern?
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I try to be in bed by eleven or midnight, and I get up at seven or eight.
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Any hearing problems?
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No.
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Any ear discharge?
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No.
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Does your mother have any health problems?
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Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though.
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Does your father have medical problems?
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Well, he passed away. But he had a couple things . . . Type 2 diabetes, like me, and high cholesterol and blood pressure.
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Am sorry to hear that
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I appreciate you saying that.
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When did your father pass away?
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It was last year… I guess a little over a year ago.
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How did you cope with your father’s death?
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Well, right after he died, after the funeral and everything, I just tried to get through that. Mom was having such a hard time, crying a lot, everything made her sad, she was kinda depressed. So I guess at first I just focused on getting things done–groceries, laundry, insurance papers and stuff. Knowing that Mom needed me kinda helped me get through day by day. There was about a month where it was hard for us to get to church. Even getting up and ready for church was too overwhelming. But our church family helped us out, and gave us rides to church and brought meals and all that, so they really helped build us back up. Things were only hard like that for a few months.
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You are lucky to have a great support system
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I appreciate you telling me that.
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What was the cause of your father’s death?
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He died in a car accident.
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Am sorry to hear that.
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Thanks for saying that.
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How is your paternal grandfather?
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Grandpa Jones passed away when I was really little.
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Did Grandpa Jones have medical problems?
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Grandpa Jones had colon cancer, and that caused all kinds of problems for him. Plus, he had high blood pressure, and . . . I’m pretty sure he had diabetes.
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Does your paternal grandmother have health problems?
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She takes some blood pressure pills, and I think she has high cholesterol, but Granny’s doing great for 82.
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great to hear that.
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Thanks.
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Your maternal grandfather’s healthy?
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Well, Poppa died five years ago.
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How old was your maternal grandfather? (Clarified to How old was your maternal grandfather when he passed?.)
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He was almost 80, maybe like 78 or 79? (Clarified to how old my maternal grandfather lived to be.)
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Your maternal grandmother’s health?
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Nana was 73 when she died of a stroke about five years ago. I think she had high blood pressure and cholesterol, too.
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Does your brother have health issues?
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No, I don’t think so. He’s a little big, maybe.
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Does your sister have health issues?
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She’s pretty healthy. She has asthma but almost never has attacks.
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Does obesity run in your family?
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No, I don’t think so. My brother and my dad are kind of big, but I wouldn’t say they were obese or anything.
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Any family history of thyroid problems?
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No, I don’t think so.
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Any headaches?
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Yeah, I get them a lot when I’m studying.
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Any loss of consciousness?
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No.
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Any memory loss?
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No. I mean, sometimes, I freeze up during a test, but that’s everybody, right? I have a good head for names and directions, stuff like that.
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Any abnormal or excess hair? (Clarified to Do you have skin abnormalities?.)
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Well . . . I guess I was noticing the other day that the skin around my neck is looking weird. The skin is getting darker. And my skin’s breaking out, but that’s how it is. (Clarified to if I have skin abnormalities.)
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Any stomach upsets?
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No.
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Measured wound: 2 cm x 1.5 cm, 2.5 mm deep
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Swabbed wound and sent to lab for C & S
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Exam Action |
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Cleansed and irrigated wound with normal saline and applied dry sterile dressing.
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Exam Action |
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Measured wound: 2 cm x 1.5 cm, 2.5 mm deep
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Exam Action |
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Swabbed wound and sent to lab for C & S
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Exam Action |
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Cleansed and irrigated wound with normal saline and applied dry sterile dressing.
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Exam Action |
Struggling to meet your deadline ?
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shadow health Tina Jones Health History transcript
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