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Docxshadow Health History
Docxshadow Health History
Jan 2018
General Survey
Chief Complaint
Ms. Jones reports that a week ago she tripped while walking on
concrete stairs outside, twisting her right ankle and scraping the
ball of her foot. She sought care in a local emergency department
where she had x-rays that were negative; she was treated with
tramadol for pain. She has been cleansing the site twice a day.
She has been applying antibiotic ointment and a bandage. She
reports that ankle swelling and pain have resolved but that the
bottom of the foot is increasingly painful. The pain is described
as “throbbing” and “sharp” with weight bearing. She states her
ankle “ached” but is resolved. Pain is rated 7 out of 10 after a
recent dose of tramadol. Pain is rated 9 with weight bearing. She
reports that over the past two days the ball of the foot has become
swollen and increasingly red; yesterday she noted discharge
oozing from the wound. She denies any odor from the wound.
Her shoes feel tight. She has been wearing slip-ons. She reports
fever of 102 last night. She denies recent illness. Reports a 10-
pound, unintentional weight loss over the month and increased
appetite. Denies change in diet or level of activity.
Medications
Allergies
Medical History
Health Maintenance
Last Pap smear 4 years ago. Last eye exam in childhood. Last
dental exam “a few years ago.” PPD (negative) ~2 years ago. No
exercise. 24-hour Diet Recall: States that she skipped breakfast
yesterday, and would typically have a baked good for breakfast, a
sandwich for lunch, and a meatloaf or chicken for dinner. Her
snacks consist of pretzels or French fries. Immunizations:
Tetanus booster was received within the past year, influenza is
not current, and human papillomavirus has not been received.
She reports that she believes she is up to date on childhood
vaccines and received the meningococcal vaccine in college.
Safety: Has smoke detectors in the home, wears seatbelt in car,
and does not ride a bike. Does not use sunscreen. Guns, having
belonged to her dad, are in the home, locked in parent’s room.
Family History
Social History
Never married, no children. Lived independently since age 20,
currently lives with mother and sister in a single family home to
support family after death of father one year ago. Employed 32
hours per week as a supervisor at Mid-American Copy and Ship.
She enjoys her work and was recently promoted to shift
supervisor. She is a part-time student, in her last semester to earn
a bachelor’s degree in accounting. She hopes to advance to an
accounting position within her company. She has a car, cell
phone, and computer. She receives basic health insurance from
work, but is deterred from healthcare due to out-of-pocket costs.
She enjoys spending time with friends, attending Bible study,
volunteering in her church, and dancing. Tina is active in her
church and describes a strong family and social support system.
She reports stressors relating to the death of her father and
balancing work and school demands, and finances. She states that
family and church help her cope with stress. No tobacco.
Occasional cannabis use from age 15 to age 21. Reports no use of
cocaine, methamphetamines, and heroin. Uses alcohol when “out
with friends, 2-3 times per month,” reports drinking no more than
3 drinks per episode. She drinks 4 caffeinated drinks per day (diet
soda). No foreign travel. No pets. Not currently in an intimate
relationship, ended a three-year serious monogamous relationship
two years ago. She plans on getting married and having children
someday.
Objective