Shadow Health Digital Clinical Experience Health History Documentation Patient Name: Tina Jones Age: 28

Shadow Health Digital Clinical Experience Health History Documentation Patient Name: Tina Jones Age: 28

Sex: Female

SUBJECTIVE DATA: “I got this scrape on my foot, the pain is killing me.”

Chief Complaint (CC): Patient is complaining of 7/10 pain to her right foot.

History of Present Illness (HPI): Ms. Jones is a 28-year-old African American female. A week

ago, she scratched her right foot on a cement step. At the time of the injury, the patient was

barefoot and injured her ankle and right foot. Patient complained of 7/10 sharp, throbbing pain.

Patient reports a temperature of 102 F last night. Patient noticed white and yellow drainage about

two days ago. Patient reported going to the ER where a right foot X-Ray was taken and showed

no broken bones. Patient was sent home with a prescription tramadol for pain and Neosporin for

her right foot wound. Patient reports difficulty ambulating, and weight-bearing makes the pain

worse while tramadol gives her some relief.

Medications:

Tylenol as needed for headache

Advil as needed for menstrual cramps

Tramadol 50mg as needed for foot pain

Neosporin for foot wound

Proventil 1- 3 puffs as needed for asthma

Allergies:

Penicillin: patient had hives after taking penicillin as a child

Cat: sneezing, itchy eyes, wheezing

Dust: sneezing, itchy eyes, wheezing

Past Medical History (PMH):

Diabetes type 2: patient was diagnosed with diabetes at 24 years old. Patient has been

non-compliant with her metformin because she was felt bloated and gassy and stopped