DCE Provider Notes - Tina Jones Health History

Identifying Data & Reliability

Ms. Jones is a pleasant 28-year-old obese African American single woman. She presents to the clinic with a complaint of right foot injury. She provides information freely and without any contradiction. Her speech is clear and coherent. She maintains eye contact throughout the interview.

General Survey

Ms. Jones is alert and oriented. she is seated upright and in no acute distress. She is well-dressed and looks obese. She has good hygiene.

Chief Complaint

Ms. Jones complains of recently hurting her right foot that does not heal on its own. She states that foot looks pretty nasty and the pain is killing her.

History of Present Illness

Ms. Jones has a medical history of asthma diagnosed at age 12 and type II diabetes diagnosed at age 23. She has never been tested for STIs. She states that her blood sugar serum is elevated and she stopped taking metformin for her diabetes because she does not like the pills. She denies chest pain, denies heavy bleeding during her periods. She denies any odor from the wound. She rated her pain 7 out of 10. She described the pain as throbbing and sharp with weight bearing. Yesterday, she noted discharge coming from the wound. She denies recent illness.

Medications

• Current medications include Acetaminophen 500-1000 mg PO pm for headaches. 
• Ibuprofen 600 mg PO TID for her menstrual cramps. 
• Tramadol 50 mg PO TID pm for foot pain. 
• Albuterol 90 mcg/spray MDI 2 puffs Q4H prn for asthma symptoms.

Allergies

• Ms. Jones is allergic to penicillin which causes rash. 
• Denies food and latex allergies. 
• Allergic to cats and dust which cause runny nose, itchy and swollen eyes and elevate asthma symptoms.

Medical History

• Ms. Jones states that she had asthma that was diagnosed at the age of 12 years old. she used Albuterol inhaler for her asthma symptoms triggered by cats and dust. She was exposed to dust and cats three days ago. She has never been hospitalized. 

• She has a history of Type II diabetes diagnosed at the age of 23 years old. She has not been monitoring her blood glucose. She stopped taking metformin pills because she did not like them. 

• Her first sexual encounter was t age 18. She has never gotten pregnant. She has never tested for STIs. Denies easy bruising. She reports skin acne.

Health Maintenance

Ms. Jones had her last pap smear 4 years ago. Last eye examination during childhood. Last dental exam was a few years ago. She reports that she skipped her breakfast today. She states that she has not had a flu shot this year. She does not use sunscreen.

Family History

Ms. Jones’ mother is aged 50 years with hypertension and high levels of cholesterol. Father deceased in a car accident a year ago at the age of 58, had hypertension, high cholesterol levels. Brother aged 25 is obese. Sister aged 14 has asthma. Only paternal grandpa is still alive and is aged 82, with hypertension.

Social History

Ms. jones reports to socialize with friends going out for drinks. She is involved in church activities and bible study. She denies substance abuse but reports to be smoking marijuana few years ago and stopped. She denies smoking. She is not sexually active and never married. She broke up with her boyfriend two years ago. She has plans for the future and hopes to finish her degree at the moment.

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Review of Systems

General: Alert, oriented to time, self, place, and situation. Well-groomed, noted with dark area around her neck with increased facial and body hair. 

HEENT: Client stated to have occasional headaches while reading. Recently, she stated to experience blurred vision and decline in vision. She does not wear corrective lenses. She denies recent eye examination but admits to have one during her childhood. She also denies change in smell, denies dental problems. Reports last dental examination was many years ago. She denied sore throat. 

Breast: She denies any breast problems. Cardiovascular: She denies palpitations or any easy bruising. 

Gastrointestinal: She denies nausea, problems with bowel movements or diarrhea. 

Genitourinary: She denies problems with urination. She reports awakening to urination at night. 

Reproductive: Reports sexual inactivity. Reports irregular periods that happen over six to 24 weeks. Reports heavy blood flow and cramping that is treated with OTC medication at home. Reports prior sexual activity was two years ago with male partner. Denies any use of oral or hormonal contraceptive several years ago. Stopped using oral contraceptive when she was no longer sexually active. She is not sure whether she has been tested for STIs during her hospital visits. The last pap smear was 4 years ago. Denies having a baby or prior pregnancy. 

Musculoskeletal: Denies any muscle or joint pain. 

Psychiatric: Denies being depressed. Denies current altered sleep pattern. 

Neurological: Denies seizures. 

Integumentary/Lymphatic/Hematologic: Denies any problems with skin. Denies skin rashes. Reports rashes with penicillin use. Reports recent excessive facial and pubic hair growth.

Objective

Vital signs: Height: 170 cm, Weight: 90 kg, BMI: 31, Random Blood Glucose: 238, Temperature: 1011.1F, Blood Pressure: 142/82, Respiratory: 19, O2 Sat: 99%, Heart Rate: 86. Wound measure 2 cm x 1.5 cm, 2.5 mm deep. Has red wound edges, right ball of foot, serosanguinous drainage. Mild erythema surrounding wound, no edema, no tracking.