Tina Jones Health History transcript, documentation and objective data

Identifying Data & Reliability

Ms. Tina Jones is a pleasant 28 year old African American female who presents to the clinic today to establish primary care. She also has a complaint of a right foot injury that occurred during a fall that happened two days ago. She is the primary and sole source of the interview. She is very knowledgable and easy to comprehend. She is alert and oriented X 4 and maintains eye contact throughout the interview Tina Jones Health History transcript, documentation and objective data.

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.

General Survey

Ms. Jones is alert and oriented. She answers questions accurately and is dressed appropriately. She doesnt exhibit any strange speech or behaviors. She doesnt appear to be under any distress.

Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. She is well-nourished, well-developed, and dressed appropriately with good hygiene.

Chief Complaint

Scrape on right foot with pain and symptoms of infection

“I got this scrape on my foot a while ago, and I thought it would heal up on its own, but now it’s looking pretty nasty. And the pain is killing me!”

History Of Present Illness

Ms. Jones greater foot about a week ago while being outside barefoot. She reported to the ER the night she injured her foot, where they gave her a prescription for Tramadol and treated the wound. She also received an x-ray. Her symptoms began to worsen two days ago. She began to notice increased pain, purulent drainage, warmth and swelling around the wound. She’s unable to put weight on the injured foot without sharp shooting pain. She has been changing the bandage and cleaning the wound with soap and water twice-daily. She also reports using Neosporin and peroxide occasionally.

Ms. Jones reports that a week ago she tripped while walking on concrete stairs outside, twisting her right ankle and scraping the ball of her foot. She sought care in a local emergency department where she had x-rays that were negative; she was treated with tramadol for pain. She has been…