NURS 6512 DIGITAL CLINICAL EXPERIENCE (DCE): HEALTH HISTORY ASSESSMENT Identifying Data  Ms. Jones, a pleasant 28-year-old lady of African American descent, arrived at the clinic to begin treatment for a recent injury to her right foot.

NURS 6512 DIGITAL CLINICAL EXPERIENCE (DCE): HEALTH HISTORY ASSESSMENT

Identifying Data 

Ms. Jones, a pleasant 28-year-old lady of African American descent, arrived at the clinic to begin treatment for a recent injury to her right foot. She identified herself as the primary information provider. Throughout the evaluation, she speaks well and coherently while being open with her communication. She maintains amazing eye contact the whole exam. 

General Survey 

The patient is awake and has a good sense of place, time, and other people. As she takes a seat upright, she doesn’t exhibit any indications of concern. She has dressed appropriately for her age and appears to be well-developed, fed, and quite sanitary. 

Subjective Data 

Chief Complaint (CC): A painful wound on the right foot. 

History of Present Illness: An African American woman named Tina, 28, alleges that a week ago while walking, she stumbled over a concrete step and twisted her right ankle, scraping the ball of her foot in the process. She went to a neighboring emergency unit, where an X-ray was ordered and found to be negative. Tramadol was nonetheless provided to her to help with the discomfort. She says she cleans the wound twice daily, applies antibiotic cream, and wraps it in a bandage. Even though the pain and swelling at the location of the injury have fully subsided, she claims that the bottom of her foot is still quite uncomfortable. She describes the discomfort as being weight-bearing, throbbing, and intense. But, the discomfort in her ankle has already subsided. She continues to rate the pain as 7/10 even after a recent dose of tramadol. She gives the pain when bearing weight, a 9 out of 10. She describes a swollen football that has become redder over the last two days. A day before the current appointment, the wound was already dripping with an odorless discharge. She claims that recently, her shoes have been uncomfortable, so she has started wearing slippers instead. Her fever was 1020F last night. She, though, denies having been unwell recently. She reports an increase in hunger and an unintentional 10-pound weight reduction over the past month. She asserts that her diet and energy levels have not changed.  

Medications 

1. Ibuprofen 600mg orally three times each day for menstrual cramps. 

1. Acetaminophen 500-100 mg orally, as needed for headaches. 

1. Tramadol 50 mg orally twice a day if foot pain persists. 

1. Albuterol 90mcg/spray multiple-dose inhalation up to two puffs every 6 hours for wheeze caused by cat allergies. She had last used the medication around three days before the current appointment. 

Allergies 

1. There are no documented latex or food sensitivities. 

1. Penicillin hypersensitivity 

1. Establishes dust and cat allergies 

1. Allergic reaction: runny nose, puffy and itchy eyes, and worsening asthma symptoms. 

Medical History 

• At the age of two and a half years, was given an asthma diagnosis. Two to three times each week, she utilizes an Albuterol inhaler to control her symptoms when she is exposed to dust or cats. She was exposed to cats three days ago, and she used an inhaler, which was quite efficient in controlling the symptoms. She was hospitalized for asthma the last time she was in high school. She, on the other hand, denies ever being intubated. When she was 24, she was diagnosed with diabetes mellitus. She had been taking metformin but had discontinued roughly three years ago because of flatulence adverse effects. She also reports that taking the tablets and checking her blood glucose simultaneously has been exhausting. She denies that she has been monitoring her blood glucose levels since then. She claims that the last time her levels of sugar in her blood soared was a week ago at the emergency department.  
• Surgery: None 
• OB/GYN: At the age of 11, she had her first menstrual cycle. heterosexual; first sexual experience occurred at the age of 18. denies ever becoming a mother. Menstrual cycles have been heavy and irregular in the last year, lasting 9 to 10 days every 4 to 8 weeks, with the most recent period starting around 3 weeks before the current appointment. She acknowledges using oral contraceptives mostly in past, but she is now single. denies wearing condoms when engaging in sexual activity. Has no history of STIs and denies ever having had an HIV/AIDS test before. Her previous pap smear exam was roughly f