Unit 2 Case Studies. Conducting interview for comprehensive subjective data. 1000w. due 3-17-23. APA format. 4 references.

Student Documentation Model Documentation

complete and comprehensive subjective data set

Chief Complaint

Patient has come to the hospital to seek help for an infected foot

with drainage and pain.

Right foot pain, fever, nausea

History of Present Illness

The patients current illness is a foot wound that is infected and

draining pus. She rates her pain as a 7 out of 10 currently. She

states the pain is throbbing and sharp. The wound is on the ball of

her right foot. She injured her foot while changing a lightbulb and

slipped and cut her foot on a metal stool. She states that the

drainage from her foot is pus and that it is white in color and there

is no odor that she can tell. She applied antibiotic ointment and

has been changing the dressing twice a day. The ointment hasn't

seemed to work so that's why she has sought help, that and the

pain as well. Her foot injury has hindered her from going to work

and school and she is unable to bear weight on it.

Ms. Jones is a pleasant 28-year-old African American woman w

presented to the emergency department for evaluation of a righ

foot injury and was admitted for IV antibiotics. She is a good

historian. She hurt the ball of her right foot by scraping it on the

edge of a metal step while changing a light bulb. The injury

occurred about one week ago. Her pain has worsened, and the

swelling has persisted. She tried ibuprofen, but it didn't work w

The foot feels better when she rests, and it hurts more when sh

walks on it. Her pain is a 9 when she tries to ambulate. She too

her temperature at home and reports it was 102. She has not b

eating much and has been staying in bed the last few days, pe

patient report. The scrape is red and swollen with exudate and

no odor; she reports the swelling and exudate started two days

ago. She reports diarrhea overnight. Pain improved with

oxycodone. Stomach upset.

Pain Assessment

Patient rates her current pain as a 7/10. She is able to tolerate a

pain scale of 3 or 4 out of 10. While taking Advil her pain was a

9/10.

Pain is rated as 7. Pain is localized to ball of foot related to wou

Dull and constant ache. Patient has tried ibuprofen, but reports

does not work well. Patient states there is relief when foot is

elevated, not walking on it. Patient answers questions clearly a

consistently. Offers information without hesitation. Vital signs a

within range.

Allergies

Penicillin

Cats

• Penicillin: rash

• Cats: wheezing, itchy watery eyes, sneezing, asthma

exacerbation

• No food allergies

• Not allergic to latex

Immunizations

Up to date on all vaccines. Had a tetnus booster about a year ago.

Up-to-date. Received tetanus and HPV vaccines within the last

year. Denies recent flu shot.

Medications

At home medications: Advil, Neosporin.

Hospital medications:

Clindamycin

Insulin

Oxycodone

Acetaminophen

• Albuterol 90 mcg/spray MDI, 1-3 puffs, as needed for wheezin

• Acetaminophen 500 mg tabs by mouth, 1 - 2, as needed for p

or headache

• Ibuprofen 200 mg tabs by mouth, 3 - 4, three times a day, as

needed for cramps

Medical History

The patient has a history of asthma and diabetes. She was

diagnosed with diabetes when she was 24 and asthma when she

was around 2 1/5 years old. She uses Proventil inhaler for her

asthma attacks. She hasn't seen a doctor for her asthma in 2

years. She has type 2 diabetes. She watches her diet and avoids

sugar. Currently she is not on any diabetes medicaiton and states

because she "didn't want to deal with it." She has a glucose

monitor but barely uses it. She doens't understand the glucose

numbers or what they mean. She has had an increase in thirst and

appetite for about a month. Also she lost 10 pounds unintentionally

in a month without diet change. She has also had frequent

urination that wakes her up at night. Things that exacerbate her

asthma are cats, dust, and physical activity. She develops

wheezing and chest tightness. She will then take 2-3 puffs of her

inhaler. Denies allergies to food or latex. Only allergies are to cats

and penicillin. She developed hives to Penicillin. Cats cause her to

have sneezing, watery eyes and asthma issues. Patient is up to

date on her vaccines and just had a tetnus booster last year. She

has only used Advil for the current pain and cramps. Takes Tylenol

for headaches sometimes. Has a history of using marijuana and

drinks occasionally. Denies tobacco use.

Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler

when she experiences exacerbations, such as from dust or cat

she never uses it more than twice a week. She was exposed to

cats a few days ago and had to use her inhaler once. She is

prescribed 1-3 puffs as needed; she reports having to use 3 pu

occasionally, but usually 1-2. She was last hospitalized for asth

in high school. Never intubated. Type 2 diabetes, diagnosed at

24. She used to take metformin but stopped taking it due to

gastrointestinal problems. She doesn’t monitor her blood suga

She was last seen by a primary care doctor a few years ago. H

last dental exam was over two years ago. Last eye exam was in

childhood.

Surgical History

No surgical history. No surgeries

Previous Hospitalizations

She has been hospitalized for asthma related issues in the past. Last hospitalized for asthma exacerbation in high school.

Gynecological History

Patient has not been to an obgyn in four years. Isn't currently

sexually active. Was sexually active two years ago when she was in

a long term relationship. She was on the pill at the time. Denied

using condoms. No history of pregnancy or STD's. She has a

history of heavy periods that are not regular. Claims she probably

gets six periods in a year. She also gets bad cramps with her

periods.

Not sexually active, first sexual activity at age 18, never pregna

last Pap smear more than four years ago, tested for STIs at age

denies STI symptoms. From age 23 to age 26 took oral

contraceptives as only source of birth control, no condom use.

Reports heavy, irregular periods, abnormal hair growth, and ac

during teenage years, and since stopping oral contraceptives 1

months ago.

Family History (3 generations)

Paternal Grandfather: Deceassed due to colon cancer. Had

hypertension, diabetes, and hypercholesterolemia.

Paternal Grandmother: Hypertension, hypercholesterolemia.

Mother: Hypercholesterolemia, hypertension.

Dad: Type 2 diabetes, hypercholesterolemia, hypertension.

Deceassed at 58 in a car accident a year ago.

Maternal Grandmother: Deceased from stroke 5 years ago.

Hypertension and hypercholesterolemia.

Maternal Grandfather: Deceased from a heart attack 5 years ago.

Brother: Big guy, healthy.

Sister: Asthma

Paternal Uncle: Alcoholic

• Father: died at age 58 in a car accident, history of hypertensio

high cholesterol, and type 2 diabetes

• Mother: hypertension, high cholesterol

• Brother: healthy

• Sister: asthma

• Maternal grandmother: died at age 73 of a stroke, history of

hypertension, high cholesterol

• Maternal grandfather: died at age 78 of a suspected myocard

infarction, history of hypertension, high cholesterol

• Paternal grandmother: still living, age 82, hypertension

• Paternal grandfather: died at age 65 of colon cancer, history o

type 2 diabetes

• Paternal uncle: alcoholism

Social History

Patient is finishing her bachelors degree. She feels really stressed

out right now due to her foot. Has had trouble sleeping while in the

hospital. Patient currently lives at her moms house, which is in the

suburbs. She is a baptist and goes to church. She denies any

abuse. Only has used marijuana in high school. Last time she

smoked was when she was 21. Denies any other drugs. Drinks

alcohol occasionally when she goes out. Hasn't had a drink in 3

weeks. Denies tobacco use. Only occasionally around second

hand smoke when out with friends.

Never married, no children. Lived independently since age 19,

currently lives with mother and sister to support family after de

of father one year ago, anticipates moving out in a few months

She works 32 hours/week as a supervisor at a printing and

shipping company and is in her last semester of a bachelor’s o

accounting program. She hopes to advance to an accounting

position within her company. Has a car, cell phone, and compu

She receives basic health insurance from work, but is deterred

from healthcare due to out-of-pocket costs. She is very active

her Baptist church, faith is important to her, and church commu

is a large part of her social network. No exercise. She wears he

seat belt, drives frequently. Guns are locked up. No tobacco.

Occasional alcohol (10 - 12 drinks/month). No concerns about

alcoholism. Occasional cannabis use from age 15 to age 21. S

drinks four caffeinated drinks/day (diet soda). No foreign travel

pets. Not currently in an intimate relationship, ended a three-ye

serious monogamous relationship two years ago. She plans on

getting married and having children someday. She denies suici

and homicidal ideation.

This study

Review of Systems

Patient describes her mental health currently as being stressed.

Was depressed after her father died but has coped with that. When

asked about head problems she noted having headaches

sometimes. Denies problems with her ears. When asked about her

eyes she mentioned that she has had blurry vision. Denies any

problems with her nose. Denies any issues with her mouth. Denies

any issues with her neck, throat, or glands. Denies any problems

with her breasts. Has a history of asthma with wheezing. Denies

cardiovascular problems. Denies any gastrointestinal issues. Has

noticed she is urinating more than usual. Has a history of heavy

periods. Denies any musculoskeletal issues. Denies any

neurological issues. Denies any skin issues other than acne.

Head: Reports headaches that occur weekly with reading in the

past year. The headache lasts a few hours and is relieved with

acetaminophen and sleep. Headaches are described as a “tigh

and throbbing feeling behind the eyes.” Denies head and neck

trauma.

Ears: Denies difficulty hearing, tinnitus, ear pain, and discharge

Eyes: Complains of blurred vision associated with “reading and

studying,” which has worsened over the past few years. No vis

acuity testing since childhood. Does not wear corrective lenses

Reports eye itching associated with exposure to cats. Denies

discharge and pain.

Nose: Rhinitis and congestion related to cat allergy. Denies sinu

problems, frequent colds/infections, epistaxis, and change in s

Mouth: Denies dental pain or problems, oral lesions, and dry

mouth, and changes in taste.

Throat and Neck: Denies sore throat, dysphagia, and changes

voice quality. Denies goiter, hyper/hypothyroidism.

Respiratory: Denies history of pneumonia, tuberculosis, and

chronic bronchitis. Denies cough, dyspnea, current wheezing,

hemoptysis, or recent cough.

Cardiovascular: Denies palpitations, dyspnea on exertion,

orthopnea paroxysmal nocturnal dyspnea, peripheral edema,

varicosities, and pain in lower extremities. Reports no blanchin

fingertips when exposed to cold.

Gastrointestinal: Denies digestive problems, reflux, dysphagia,

nausea, vomiting, diarrhea, constipation, changes in bowel hab

jaundice, abdominal pain, and bloody stools. Denies gallbladde

and liver disease. Reports polyphagia, polydipsia, nocturia for t

past month and polyuria for past few months.

Genitourinary: Denies flank pain, dysuria, urgency, and cloudy

urine. Denies history of recurrent urinary tract infections and kid

stones. Denies vaginal discharge and vaginal itching. Menses

irregular. No history of sexually transmitted infections. No

pregnancies.

Musculoskeletal: Denies history of fractures, gout, and arthritis

Denies myalgias and arthralgias. Denies back and neck pain an

trauma. Denies generalized weakness. Does not exercise regul

Neurological: Denies fainting, dizziness, vertigo, weakness,

syncope, numbness, tingling, tremors, seizures, and paralysis.

Reports occasional clumsiness. Denies history of traumatic bra

injury and meningitis. Denies recent changes in memory and m

changes.

Skin, Hair, and Nails: Reports acne since puberty and occasion

dry skin. Complains of darkened skin on her neck and increase

facial and body hair. She reports a few moles but no other hair

nail changes.