Tina Jones Health History transcript, documentation and objective data – assignmenthandlers
Height: 170 cm
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07/17/22 1:35 AM MDT
Weight: 90 kg
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BMI: 31
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Random blood glucose: 238
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Temperature: 101.1 F
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Blood pressure: 142/82
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Respiratory rate: 19
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O2 sat: 99%
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Heart rate: 86
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07/17/22 1:35 AM MDT
Hello Tina my name is xxx and I’m your nurse today
Greet
07/17/22 1:35 AM MDT
Hey.
Can you confirm your name
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07/17/22 1:35 AM MDT
Tina Jones.
What brings you in today
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07/17/22 1:36 AM MDT
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! Tina Jones Health History transcript, documentation and objective data
I am so sorry you’re going through that
Empathize
07/17/22 1:36 AM MDT
Thanks for understanding.
What additional symptoms have you experienced (Clarified to Do you have any other symptoms?.)
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07/17/22 1:36 AM MDT
I mean, it’s all red and swollen, and there’s pus, it feels hot, it hurts like hell… It’s got all that going on. (Clarified to if I have other symptoms.)
Can you rate your current pain level on a scale of zero to ten
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07/17/22 1:37 AM MDT
I’d say a 7. It hurts a lot, and the pain pills haven’t kicked in yet.
What pain pills have you taken
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07/17/22 1:37 AM MDT
It’s called tramadol.
What dose of Tramadol
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07/17/22 1:37 AM MDT
I’m not 100% sure, but I think they’re 50 milligrams.
How often do you take Tramadol
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07/17/22 1:37 AM MDT
I’ve been taking the Tramadol morning, noon, and night. [AUDIO COMING SOON]
When was the last time you took Tramadol
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07/17/22 1:38 AM MDT
This morning I took two pain pills right before I came here, at around 8:30.
Does a Tramadol typically work for your pain Tina Jones Health History transcript, documentation and objective data
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07/17/22 1:38 AM MDT
Yeah, the pain pills help, but only for a few hours.
Can you describe your pain
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07/17/22 1:38 AM MDT
It’s throbbing and like, sharp if I try to put weight on it.
How did you hurt your foot
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07/17/22 1:38 AM MDT
I was going down the back steps, and I tripped. . . I caught the railing, but I guess I kind of turned my ankle a little bit. And I scraped up my foot on the edge of the step.
How’s your foot been draining any liquids
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07/17/22 1:39 AM MDT
Yeah, there’s definitely pus.
What color is the pus
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07/17/22 1:39 AM MDT
It’s… white or maybe off-white.
What have you done to treat your foot after the accident (Clarified to How have you been treating your foot?.)
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07/17/22 1:39 AM MDT
I made sure to clean it and just keep it bandaged. And I put Neosporin on it. (Clarified to what I did for my foot at home.)
How effective was the Neosporin
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07/17/22 1:40 AM MDT
Well, I had to come back to get my foot checked out even though I used the ointment. [AUDIO COMING SOON]
Are you able to walk
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07/17/22 1:40 AM MDT
No, I can’t. I can’t put any weight on it without like, shooting pain.
What pre-existing medical conditions do you have
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07/17/22 1:42 AM MDT
Well, in terms of general health stuff, I have asthma and diabetes.
When were you diagnosed with diabetes
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07/17/22 1:42 AM MDT
I was diagnosed when I was 24.
What medications did you take for your diabetes
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07/17/22 1:42 AM MDT
It was Metformin.
Do you still currently take Metformin
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07/17/22 1:42 AM MDT
I don’t take anything for my diabetes anymore.
What made you start taking medication for your diabetes (Clarified to What made you stop taking your diabetes medication?.)
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07/17/22 1:43 AM MDT
I guess I just got sick of feeling sick and gassy all the time, and it was overwhelming, remembering to take pills and check my sugar. I feel a lot better now that I’m just eating healthier than I did when I was taking the pills. (Clarified to what happened that caused me to stop taking my diabetes medication.)
Diabetes is a very serious condition that has to be treated very carefully
Educate
07/17/22 1:44 AM MDT
Sure, I think I understand what you mean.
Do you monitor your blood glucose
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07/17/22 1:44 AM MDT
I have a monitor at home, but to be honest I don’t really use it that often. It’s such a hassle to check my blood sugar, and my diabetes is under control right now so I don’t really need to.
What is your current diet like
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07/17/22 1:44 AM MDT
It’s pretty good, I think. I’m not a huge health nut or anything.
Have you had any change in your appetite
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07/17/22 1:45 AM MDT
Yeah, lately I’ve definitely been much hungrier than usual.
Has there been any change in your weight
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07/17/22 1:45 AM MDT
Yeah, I’ve lost some weight recently.
How frequently do you urinate
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07/17/22 1:45 AM MDT
I don’t know. Every hour or two when I’m awake?
