Assignment 2: Digital Clinical Experience (DCE): Health History Assessment NURS 6512N-32 Ms. Jones is a pleasant, 28-year-old obese African American single woman who presents to establish care and with a recent right foot injury. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview.

Shadow Health Digital Clinical Experience Health History Documentation SUBJECTIVE DATA:   Patient states she tripped on stairs  two weeks ago and scraped her foot.

Chief Complaint (CC): Infected wound on right plantar foot

History of Present Illness (HPI):  Tina Jones is a 28 year old female with chief complaints of an infected wound on right foot. Making it very difficult to walk.  Patient reports she tripped while walking upstairs outside, twisting her  right ankle and scraping the ball of her foot about a week ago . She also states it’s been draining white purulent, with no foul smells. She visited the emergency room where she got an X Ray , which showed no broken bones .Received Tramadol 50mg for the pain. Ms. Jones reports no relief from the tramadol.  She reports cleaning the wound twice a day with hydrogen peroxide and applies bacitracin, neomycin and polymyxin B (Neosporin). She complains of  a throbbing sharp pain of 7 on a scale of 1-10.

Medications:  Inhaler Proventil ,Tramadol 50 mg

stopped taking metformin 3 years ago.

OTC-  tylenol and ibuprofen for cramps

Allergies:  cats – sneezing and itchy eyes

penicillin- Rash

dust- wheezing, sneezing

Past Medical History (PMH):  Asthma, type 2 diabetes (diagnosed at 24)

Past Surgical History (PSH):  Pt reports no past surgical procedure

Sexual/Reproductive History: Not sexually active. No STIs. last pap smear was 4 years ago. Irregular menstrual cycle

Personal/Social History:  The Patient lives with  her mom and sister. States she’s usually independent with ADL’s until she acquired the wound on her foot. She has never used tobacco . Used to smoke marijuana . Drinks 1 – 2 glasses once or twice a week.

Immunization History:  Patient hasn’t received her flu shots for the season. However, up to date with most of her shots.

Health Maintenance:  She has not seen her PCP in more than 2 years. Had a pap smear four years ago.She stopped taking her Metformin 3 years ago. She reports that she does not exercise nor do she follow a diabetic diet.

Significant Family History Mother has HTN, and High cholesterol

Father had HTN, DM and high cholesterol. Sister has asthma. Brother has no known diagnoses.

Grandfather died of colon cancer.

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