Student
Response
Model Documentation
Identifying
Data &
Reliability
A 28y / o African American
brightly impacting female; 90
kg, pt 142/82 BP, Temp 101.1,
238mg / dl Blood sugar. Pt has
a 2cmx1.5cmx2.5 mm cut on
the right foot. Wound is
yellowish, with granulation
throughout.
Ms. Jones is a 28-year-old friendly, fat, African
American single woman, posing recruiting and recently
injuring her right foot. Ms. Jones provides free and
contradicted information. Simple and reliable voice.
Voice.
General
Survey
With clear thinking the patient
is alert and focused x4. Pt have
hx of asthma and diabetes
Ms. Jones sits upright on the examining table, alert and
focused, and is not in apparent distress. It's nutritious,
well-developed and well hygienically dressed.
Chief
Complaint
Right foot scrape with
excruciating pain She describes the pain as too much and nasty.
History Of
Present
Illness
A severe right foot injury
occurs in a 28 y / or female
patient. Her pain is
characterized as strong and
consistent by the patient. Out
of 10 patients are scoring their
pain 7. Patient records pulling
and holding scrapes on her
right foot. Her foot injury is
identified by the patient as dry,
swollen and red with purgent
drainage. Patients say ahe is
using tramadol 50 mg to treat
their discomfort.
Ms. Jones says that a week ago she twisted her right
ankle She was receiving treatment in a local emergency
room with negativex-rays. Tramadol was treated for
pain. Twice a day, she's cleaned the ground. The
antibiotic ointment was applied and the bandage was
used. She says the knee swelling and discomfort have
been fixed but the foot is getting more and more
painful. She claims "fell" her knee, but has been
determined. Pain. She notes that the football has
swollen and reddened in the last two days. She refuses
to feel the burn. She feels comfortable in her feet. She
was wearing slippers.
Medications Tramadol 50mg twice a day
Proventil 90mcg Advil Tylenol
• Ibuprofen 600 mg to relieve menstrual cramps
• Tramadol to relieve pain
Allergies Penicillin, Cat Penicillin: rash• she is not allergic to food and
condoms.
Medical
History
Asthma, Diabetes Diagnosed with Asthma at 21.
Student
Response
Model Documentation
At 24, she was diagnosed with Diabetes of type 2
No partner at the moment. Oral
contraceptives have been used in the
past. She did not use contraceptives while
she was sexually active. HIV / AIDS has
never been tested. No STIs or STI
records. No context. Four years ago, last
screened for STIs
Health
Maintenance
The patient's diabetic regimen
is incompatible. After
consulting her doctor, Patient
starts taking Metformin.
Alcohol is smoking Patient.
Increased sodium is absorbed
by Patient. Patient was not
vaccinated against her
influenza and she does not do
an self-examination. As a boy,
Patient's got holiday. Take
moves to college and she is
living productive life
Four years ago, the last Pap smear. Childhood last eye
check. Don't do a workout. Remember: notes that they
missed breakfast yesterday with normally baked goods,
lunch sandwiches, and meatloaf or chicken for dinner.
Her snacks are made from friezes or pretzels. Safety:
has fumes in the house, wears car seatbelt, and is not
riding a bike. Safety: You are not using a sunscreen.
Guns belonging to her father are locked at home in the
room of the parent.
Family
History
His father died from colone
cancer in his 1960s. Mom's dad
had a history of hypertension
and high blood pressure and
high cholesterol He had a
history of hypertension and
mammy's high cholesterol.
Dad died at 73 years of age of
st rotting.
Daddy: died in car crash, • Sister (Great Britain, 14):
asthma• Mama Grandma: dead at age 73, history of
high cholesterol hypertonia • Father Grandpa: died at
age 78, history of hypertensity, history of stroke
hypertension • Mom's Grandpa, died at age 78, history
of high blood blood pressure•
Social
History
Patient's a Shadowville State
College resident. Pt doesn't
have sex so he's girlfriends
business
No children, never married. She wants to switch to her
company's accounting role. She's got a car, laptop, and
PC. She has limited workplace health benefits, but her
healthcare is being affected due to out - of-pocket costs.
She likes to spend time with friends, study the Bible,
volunteer in her church and dance. Tina has a good
family and social support network in her community.
She notes pressures on her father's death and manages
Student
Response
Model Documentation
jobs, school demands and finances. He says family and
church are helping her deal with tension. No smoking.
Records When you go out with friends, you use alcohol
2-3 times a month. It states that you drink no more than
3 drinks per season. No travel abroad. No animals. She
plans to be married and one day she plans to have
children.
Objective
With painful grimaces the
patient has flat impact. The
patient was assessed
cooperatively. The right foot
fracture of a patient is
2cmx1.5cmx2.5 cm. Wound
has purulent drainage and is
covered by granulating tissue
of yellowish slough.
Cut: 2 cm x 1.5 cm, 2,5 mm deep fracture, red edges of
cut, right football, serosanguine drainage. Mild wound
erythema, no edema, no monitoring.
