Shadow Health Digital Clinical Experience Health History Documentation

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Shadow Health Digital Clinical Experience Health History Documentation

Student’s Name

Professor’s Name

Institution’s Name

Course

Date

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Name: Tina Jones, Age: 28, Race: African American, Sex: Female.

SUBJECTIVE DATA

Chief Complaint (CC): Wound on the right foot that is painful.

History of present Illness (HPI): Tina is a 28-year-old African American female who walks into

the clinic with an infected wound on her right foot. Over the past two days, the pain has become

worse. The pain is 7/10. The patient states that the pain does not transfer to any other body parts.

After injury, the foot became swollen and red. Weight bearing is the aggravating factor.

Medication: Tramadol for pain 50 mg, 3 times a day. Proventil inhaler for asthma, 2-3 puffs

daily. Tylenol 500mg 3 times daily, for headaches. Advil for cramps.

Allergies: Penicillin: Rashes.

Cat and dust: Wheezing and itchy eyes.

Past Medical History: Patient was diagnosed with asthma at 21 years, hospitalized at 16 years.

Uses Proventil to help manage her asthma, three times in a day in case of asthma attacks.

Diabetes at 24 years and has not taken metformin in the last three years. Does not go for regular

blood sugar checkups.

Past Surgical History: No past surgeries.

Sexual/Reproductive history: The patient presents as heterosexual. Uses condoms as a

contraceptive to prevent pregnancy and STDs. No past pregnancy.

Personal/ Social History: Patient occasionally drinks alcohol and loves going to club for fun.

She has a bachelor’s degree in accounting. Has a supportive family and friends. No smoking

tobacco or marijuana. Attends Baptist church.

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Immunization History: Patient received all her childhood vaccinations including polio,

hepatitis and chicken pox. Meningitis vaccine at 19 years. Tetanus booster last year, No influenza

and flu shot vaccine. Got HPV vaccine as a teenager.

Health Maintenance: Patient vaccination are up to date. No pelvic assessment, and the last pap

smear was three years ago. No regular blood sugar and blood pressure screening. No dental

check. Patient reports going to the gym, so she has a good physical hygiene.

Significant family history: Mother, 50 years, has high cholesterol. Father died at 58 due to a car

accident. Had diabetes and hypertension. Sister has asthma. Brother has no medical condition.

Maternal grandmother died at 73, from stroke. Maternal grandfather died at 78 from stroke.

Paternal grandfather died at 65 from colon cancer. Paternal grandmother is alive. No history of

addiction, mental health issues, headaches, cancers, and thyroid issues.

Review of symptoms

General: Tina is attentive, pleasant, and well oriented. She is also well groomed, answers

questions well and not in despair.

HEENT: Patient reports having headaches when studying. Has blurred vision but does not wear

spectacles. No runny nose, or ear discharge. No swollen throat and sore throat.

Neck: No lymph complications and inflammation around the neck.

Breasts: No nipple discharge or discomfort.

Respiratory: No shortness of breath, discomfort in the chest or tightness.

Cardiovascular/peripheral: No blood clots.

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Gastrointestinal: No changes in the bowel, constipation, or watery stool. Patient has increased

appetite and feeling thirsty.

Genitourinary: Patient has irregular periods.

Musculoskeletal: No muscle or back pain.

Psychiatric: No depression or hallucinations.

Neurological: No tingling or feeling dizzy.

Skin: No acnes or hair around the chin.

Hematologic: Patient has no history of excessive bleeding.

Endocrine: No sweating, chills, or fever.

Objective data

Vital signs: Weight, 90 kg. BMI 31, BP 142/82 HR 86 RR 19 T 101.1 Pulse oximetry 99%.

Wound measurement: 2cm x 1.5cm, 2.5 mm deep. No swelling around the wound.

Differential Diagnosis

1. Asthma

This condition occurs when the narrow airways secrete excess mucus making it difficult to

breath. The symptoms include shortness of breath, wheezing, coughing and having trouble

sleeping (Nakamura et al., 2020). Asthma is caused by flu, colds, and allergies like dust, pollen

and animal fur. The condition can be controlled by taking drugs. Asthma is the primary diagnosis

because the patient is allergic to cats and dust. She also complains of shortness of breath and

wheezing which are some of the symptoms of asthma.

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2. Local infection of skin and subcutaneous tissue of the foot.

The main cause of this condition is bacteria staphylococcus aureus. The condition arises from

skin irritation caused by cuts or wounds (Lipsky et al., 2016). The patient complains of having a

wound on the right leg so, she might have this condition.

3. Acute pain of the foot

This condition occurs due to a fall. It occurs as a sudden and severe pain (Chung et al., 2021).

The condition can last for a short time or be an ongoing issue for the patient. The patient stated

that she has a severe pain which she said that it was 7/10.

4. Uncontrolled type 2 diabetes.

With this condition, the patient experiences frequent urination, and loss. She might have

uncontrolled type 2 diabetes because she has increased thirst and stopped using her diabetic

medication three years ago (Pamungkas et al., 2019). Uncontrolled diabetes can occur due to the

same.

5. Polycystic ovary syndrome

This condition occurs due to excess androgen hormones in the body. The condition is

characterized by irregular periods (Azziz, 2018). The patient reports having irregular periods

which come after three months so, most likely she has this condition.

References

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Azziz, R. (2018). Polycystic Ovary Syndrome. Obstetrics & Gynecology, 132(2), 321–336.

https://doi.org/10.1097/aog.0000000000002698

Lipsky, B. A., Silverman, M. H., & Joseph, W. S. (2016). A Proposed New Classification of Skin

and Soft Tissue Infections Modeled on the Subset of Diabetic Foot Infection. Open Forum

Infectious Diseases, 4(1). https://doi.org/10.1093/ofid/ofw255

Chung, C. L., Paquette, M. R., & DiAngelo, D. J. (2021). Impact of a dynamic ankle orthosis on

acute pain and function in patients with mechanical foot and ankle pain. Clinical

Biomechanics, 83, 105281. https://doi.org/10.1016/j.clinbiomech.2021.105281

Pamungkas, R. A., Chamroonsawasdi, K., Vatanasomboon, P., & Charupoonphol, P. (2019).

Barriers to Effective Diabetes Mellitus Self-Management (DMSM) Practice for Glycemic

Uncontrolled Type 2 Diabetes Mellitus (T2DM): A Socio Cultural Context of Indonesian

Communities in West Sulawesi. European Journal of Investigation in Health, Psychology

and Education, 10(1), 250–261. https://doi.org/10.3390/ejihpe10010020

Nakamura, Y., Tamaoki, J., Nagase, H., Yamaguchi, M., Horiguchi, T., Hozawa, S., Ichinose,

M., Iwanaga, T., Kondo, R., Nagata, M., Yokoyama, A., & Tohda, Y. (2020). Japanese

guidelines for adult asthma 2020. Allergology International, 69(4), 519–548.

https://doi.org/10.1016/j.alit.2020.08.001

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