Shadow Health Digital Clinical Experience Health History Documentation SUBJECTIVE DATA: Chief Complaint (CC): Infected foot wound History of Present Illness (HPI): Tina Jones is a 28-year-old African American female presenting for evaluation and treatment of an infected foot wound that started a as scrape from a concrete stair a week ago.

Shadow Health Digital Clinical Experience Health History Documentation SUBJECTIVE DATA: Chief Complaint (CC): Infected foot wound History of Present Illness (HPI): Tina Jones is a 28-year-old African American female presenting for evaluation and treatment of an infected foot wound that started a as scrape from a concrete stair a week ago.

Shadow Health Digital Clinical Experience Health History Documentation

SUBJECTIVE DATA:

Chief Complaint (CC): Infected foot wound

History of Present Illness (HPI): Tina Jones is a 28-year-old African American female presenting

for evaluation and treatment of an infected foot wound that started a as scrape from a concrete

stair a week ago. Ms. Jones reports she scraped the bottom of her right foot during a stumble

and injured the ankle at that time as well. She was seen in ER and x-ray revealed no fracture, so

the patient was discharged home with prescription pain medication. Patient reports cleaning,

applying topical antibiotics and bandaging the wound twice a day. For the past two days white

purulent drainage has been noted with increased swelling at the site of the wound. Pain is a

throbbing 7/10 at rest and becomes shar 10/10 with weight bearing which is limiting her ability

to ambulate normally. Pain improves with rx Tramadol but is not completely alleviated. Patient

reports the pain will wake her from sleep when the pain medication wears off. Reports fever

starting last night.

Medications:

Albuterol inhaler 90 mcg/actuation 1-3 puffs as needed for asthma sx

Metformin unknown dose – no longer taking.

Tramadol 100 mg TID as needed for pain

Tylenol: 500-1000 mg for headache

Ibuprofen 600 mg TID for menstrual cramping

Denies supplements or vitamins

Historical rx for metformin, dose unknown, pt denies taking due to side effects

Allergies:

PCN: rash

Cats: itchy eyes, sneezing, wheezing/SOB

Dust: itchy eyes, sneezing, wheezing/SOB