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Name: Tina Jones

Section:

Week 4

Shadow Health Digital Clinical Experience Health History Documentation

SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

Chief Complaint (CC):

History of Present Illness (HPI):

Medications:

Allergies:

Past Medical History (PMH):

Past Surgical History (PSH):

Sexual/Reproductive History:

Personal/Social History:

Immunization History:

Health Maintenance:

Significant Family History (Include history of parents, maternal/paternal Grandparents, siblings, and children):

Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History). Remember that the information you include in this section is based on what the patient tells you. To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.

General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.

HEENT:

Neck:

Breasts:

Respiratory:

Cardiovascular/Peripheral Vascular:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Psychiatric:

Neurological:

Skin:

Hematologic:

Endocrine:

Instructions

Complete your documentation using the documentation template

Included the Information in different attachment and template

VS: BP – 142/82 HR -86 RR-19 SPO2 99% – oral temperature 101.F , wt 90 kg BMI 31

© 2021 Walden University Page 1 of 1

Name: Tina Jones

Section:

Week 4

Shadow Health Digital Clinical Experience Health History Documentation

SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

Chief Complaint (CC):

History of Present Illness (HPI):

Medications:

Allergies:

Past Medical History (PMH):

Past Surgical History (PSH):

Sexual/Reproductive History:

Personal/Social History:

Immunization History:

Health Maintenance:

Significant Family History (Include history of parents, maternal/paternal Grandparents, siblings, and children):

Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History). Remember that the information you include in this section is based on what the patient tells you. To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.

General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.

HEENT:

Neck:

Breasts:

Respiratory:

Cardiovascular/Peripheral Vascular:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Psychiatric:

Neurological:

Skin:

Hematologic:

Endocrine:

© 2021 Walden University Page 1 of 1

DCE Provider Notes – Tina Jones Health History

Identifying Data

Ms. Jones is a pleasant 28-year-old, single, African American, female. She presents to the office
today for a physical examination and with a chief complaint of right foot pain after a recent
injury. She is the primary source of history obtained in addition to the use of her available
medical record. She is able to maintain good eye contact and clear speech throughout the
interview process, as she provides all information freely.

General Survey

Ms. Jones is alert and oriented, with relaxed posture during the assessment process. Her mood
appears to be stable, and she does not appear to be in any distress. Her immediate and remote
memory appear to be intact. She appears to have good hygiene and is dressed appropriately for
the current weather and occasion.

Chief Complaint: “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 presents today for a physical examination and with report of a scrape to the ball of her
right foot. She reports that she obtained the scrape 1 week ago when she tripped going down the
stairs and scraped her bare foot on the edge of the step. She reports bleeding at the time of injury,
and shares that she has been washing the wound with soap and water twice daily (morning and
night), and that she has been using Neosporin prior to keeping it bandaged. She added that she
sometimes uses peroxide and then rinses the area when it is irritated. She reports that the scrape
is not healing on its own, “is not looking well”, and is causing her pain. Her current pain level is
a 7/10, and she describes the pain as “throbbing” and “sharp” when weight is applied. She reports
that her entire right foot feels some pain, but the pain is the worst at the center/ball of her foot.
She added that the pain also radiates up her ankle. She has not been able to walk due to this pain.
She has been taking Tramadol 100 mg three times daily for pain, but feels that this only
alleviates the pain for a few hours. She reports that the area has been red and swollen with noted
pus, heat, and increased pain over the last 2 days ago. She denies noted odor.

Medications

? Tramadol 50 mg tablets. Taking 2 tablets (100 mg Total) 3 times daily for pain.
? Proventil Inhaler 90 mg 2- 3 puffs 2-3 times per week for asthma symptoms.
? Advil 200 mg tablets. Taking 3 tablets (600 mg Total) up to 3 times daily for menstrual

cramps.
o Patient self-discontinued Metformin and birth control pill use 3 years ago.
o She denies use of any other vitamins, supplements, or additional OTC medications.

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Allergies

? Penicillin (Rash/Hives. Last occurring in childhood)
? Cats (Itchy eyes, sneezing, wheezing)
? Dust (Itchy eyes, sneezing, wheezing)
o Denies Food Allergies.
o Denies Latex Allergies.
o Denies Seasonal Allergies.

Medical History

? Type 2 Diabetes: Diagnoses at age 24. Has a glucometer, but does not currently monitor
her blood glucose due to feeling it is a hassle. Not currently taking prescribed
medication. Was taking Metformin when first diagnosed but discontinued taking this 3
years ago due to not liking it. Does not follow a specific diabetic diet. Tries to make
healthy choices. Avoids excess carbohydrate and sugar intake (drinks diet versus regular
soda). Does not monitor her salt intake. She reports increased appetite, thirst, and water
intake. Reports unintentional weight loss of 10 lbs. over the last month. She also reports
more frequent urination.

? Asthma: Diagnosed as a child at age 2. Reports chest & throat tightness, wheezing, and
feels that she can’t take in enough air into her lungs during attacks. Reports dust, cats,
and exercise (such as running up the stairs) make breathing worse. Reports showering
helps with symptoms when exposed to cats. She reports that her asthma attacks are rare,
and that the last attack resulted in hospitalization when her inhaler was not working at
age 16. Reports using a prescribed Proventil Inhaler 90 mg 2- 3 puffs 2-3 times per week
as needed for asthma symptoms.

Health Maintenance

? Report that she is currently up-to-date on her immunizations. Received all childhood
vaccinations. Last tetanus booster was about 1 year ago. Last PPD test was a couple of
years ago. Last HPV test was a couple of years ago. Denies having a varicella vaccine dt
having chicken pox as a child. Denies having a diphtheria vaccine. Denies getting an
annual flu vaccine (with last received 6 years ago) due to feeling that they are
ineffective.

? Last physical was 2 years ago. Reports recent increase in stress and feeling of exhaustion
at end of day. Denies changes in sleep status (aside from when father died last year).
Reports that she has not been sleeping well lately d/t foot pain. Denies Depression.

? Reports declining vision over the last few years. Last eye exam was a child. Reports that
she has been experiencing headaches while studying.

? Reports brushing her teeth twice daily (AM & PM). Last dental exam was a few years
ago.

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? Reports increased facial and body hair growth. Medical record indicated dx of PCOS.
? Reports irregular menstrual cycle occurring from once monthly to every six months.

Reports heavy vaginal flow and bad cramping, for which she uses Advil with minimal
effect. Not currently sexually active. Report prior birth control use for 3 years during last
relationship w/ male partner. Denies current condom use.

? Denies daily exercise but reports an active job which requires her to be on her feet.

Family History

? Significant for: Diabetes, Hypertension, Hypercholesterolemia
? Denies family use of alcohol / illicit drugs.
? Denies family history of obesity, thyroid issues, substance abuse, headaches.

? Mother: Living. 50 y.o. High cholesterol & BP
? Father: Passed last year at 58 y.o. in a car accident. High BP & Chol & DM.
? Maternal GF “Poppa”: Passed via Heart attack at 80 y.o.. BP & Cholesterol issues.

Maternal GM “Nana”: Passed 5 yrs ago at 73 from a stroke: High BP & Chol
? Paternal GF: “Grandpa Jones”: Passed mid-60’s of colon cancer.
? Paternal GM “Granny”: Living. 82 y.o. on unknown RX for ? BP ? Chol.
? Paternal Uncle: Alcoholic
? Sister “Britney”: 14 y.o. w/ asthma no attacks. Also has allergies “hay fever”, which led to

an ER visit for a breathing treatment.
? Brother: 25 y.o. “heavy guy” no health problems

Social History

? Denies smoking tobacco
? Denies 2nd hand smoke exposure
? Reports occasional social ETOH intake (1-2 drinks/wk.)
? Reports prior Marijuana use in her 20’s.
? Current support system: Family, friends, Baptist church group
? Currently unable to work d/t injury.
? Profession: Supervisor at Mid-American Copy & Ship.

Review of Systems:

General: Ms. Jones is a 28 y.o. well-appearing African American female. She reports occasional
tiredness and fatigue. Reports that she has been experiencing a fever over the last 2 days since
her foot injury. She appears to have good hygiene and calm demeanor. She was able to answer all
questions appropriately.

HEENT: Reports occasional headaches while reading. Reports recent blurred vision and decline
in vision. Does not wear corrective lenses. Last eye exam was in childhood. Denies current

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change in hearing. Denies decline or change in sense of smell. Denies dental problems. Last
dental exam was several years ago. Denies sore throat.

Breasts:
Denies general breast problems or pain.

Respiratory:
Denies current breathing problems.

Cardiovascular:
Denies palpitations or noted ease in bruising.

Gastrointestinal:
Denies nausea, change in bowel movements, or diarrhea.

Genitourinary:
Denies painful or difficult urination. Reports awakening to urinate at night.

Reproductive:
Reports irregular menstrual periods that occur over 6 to 24 weeks. Reports heavy blood flow and
cramping that is treated with OTC medication at home. Denies recent sexual activity. Reports
prior sexual activity, with male partner 2 years ago. Has had a total of 3 prior sexual partners.
Denies current oral or hormonal birth control use. Reports prior condom and oral contraception
use a couple of years ago. Discontinued contraception use whenshe was no longer sexually
active. Unsure of prior STI testing. Last pap smear was 4 years ago. Denies prior pregnancies.

Musculoskeletal:
Denies muscle or joint pain.

Psychiatric:
Denies depression. Reports history of intermittent situational anxiety. Denies currently altered
sleep pattern.

Neurological:
Denies lightheadedness, tingling, loss of sensation, or seizures.

Integumentary/Hematologic/Lymphatic:
Denies history or frequent skin rashes. Reports rash with Penicillin use. Reports recent excessive
facial and body hair growth.

Endocrine:
Denies endocrine issues or hormonal disorder. Medical record indicated prior diagnosis of
PCOS.

Objective Data

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Height: 5′ 7″
Weight. 90 kg
BMI: 31.0
Blood Pressure: 142/82
Heart Rate: 86
Respiratory Rate: 19
Oxygen Level: 99% on Room Air
Temperature: 101.1 Oral
Blood Glucose: 238

Wound Measurement: 2 cm x 1.5 cm. 2.5 cm deep.

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