NURS 3501 -Health History Shadow Assignment

NURS 3501 -Health History Shadow Assignment

NURS 3501 -Health History Shadow Assignment

Document: Provider Notes
Student Documentation Model Documentation
Identifying Data & Reliability
Ms. Jones is a 28 yo obese African American undergraduate female student. pt is the source of the history, she has no problem with her memory, and she is being honest
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 Her height is 170 cm, her weight is 90 kg, BMI 31, random blood glucose 238, temperature 101.1 F, blood pressure 142 over 82, respiration rate 19, O2 saturation 99%, heart rate 86, throbbing pain on the right foot 7 out of 10 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.

NURS 3501 -Health History Shadow Assignment

Chief Complaint
right foot wound x1 week
“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!”

Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Information Processing
Health History Tips and Tricks
Self-Reflection
Documentation / Electronic Health Record
https://www.

NURS 3501 -Health History Shadow Assignment

History Of Present Illness
pt come in today c/o right foot wound pain x1 week, her pain is 7/10, throbbing when resting and sharp when putting weight. she scraped her foot a week ago, brought to ER by her mother, Xray done with , tramodaol 50mg 2 tabs TID prescribed but pain was not well controlled, her wound measures 2 x 1.5 x 2.5 cm and is draining pus, she has fever of 101.1 F. her random blood glucose , noticed recent polyuria, polydipsia, and
polyphagia. pt also reported problem with breathing 3 days ago, she is using her albuterol inhaler for asthma 2-3 time/wk, 2 puffs each time (90mg/spray), pt has heavy menstration. pt c/o blurred vision recently.

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 cleansing the site twice a day. She has been applying antibiotic ointment and a bandage. She reports that ankle swelling and pain have resolved but that the bottom of the foot is increasingly painful. The pain is described as “throbbing” and “sharp” with weight bearing. She states her ankle “ached” but is resolved. Pain is rated 7 out of 10 after a recent dose of tramadol. Pain is rated 9
with weight bearing. She reports that over the past two days the ball of the foot has become swollen and increasingly red; yesterday she noted discharge oozing from the wound. She denies any odor from the wound. Her shoes feel tight. She has been wearing slip-ons. She reports fever of 102 last night. She denies recent illness. Reports a
10-pound, unintentional weight loss over the month and increased appetite. Denies change.

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