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REFER to Rhoads & Peterson Chapter 1 when completing this assignment.



Identifying Data & Reliability –name, gender, age, ethnicity. Identify the source of information and establish reliability.

pg. 9

Chief Complaint – reason for seeking care in patient’s own words.

pg. 10

History Of Present Illness

A thorough and comprehensive description of the symptoms for which the patient is seeking care for.  Use PQRST or OLDCARTS mnemonic to help guide your interview and documentation.

pgs. 10-11

Medications – complete information of current medications

pg. 12

Allergies – complete information of allergies

pg. 12

Medical History – major illnesses and conditions, hospitalizations, blood transfusions

pgs. 11- 12

Health Maintenance – immunization and screening exams

pg. 13

Family History – major illness and health status, genetic defects

pgs. 13-14

Social History – social aspects (e.g., occupation, socioeconomic status, drug use) of the patient\’s life that might be pertinent to the current medical condition

pgs. 14-17

Review of Systems (ROS) – review of symptoms for each system

pgs. 17 – 20



Patient Initials T.J Gender: Female, Age: 28 years Ethnicity: African American

Chief Informant: TJ (Patient herself) is reliable because she is literate and conversant with the language used during the interview. She maintains appropriate eye contact and has clear speech.

Chief Complaint: ‘I got a foot injury  a few days ago and expected the wound would heal without medication but it has got worse and the pain is excruciating’

History of Present Illness

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TJ reports she tripped on concrete stairs while walking about 7days ago where her ankle got twisted and she scrapped the ball of her feet. She visited the local ED where the X-rays turned negative and she was prescribed tramadol relieve the pain. She reports having been cleaning the wound two times a day besides applying an antibiotic ointment and some bandages. She states the ankle swelling and pain have resolved except for the bottom of the feet which continues to increase in pain intensity. She rates her pain at 7 out of 10 and 9 /10 on weight-bearing. She describes the pain as throbbing and sharp. She reports the foot has become swollen within the last 48 hours and reddish with some discharge. She denies any odor from the wound and reports the shoe is tight necessitating her to wear slip–ons. For the foot pain assessment using mnemonic OLD CHARTS, it is

Onset- seven days ago

Location/radiation– right ankle that radiates to the ball of the foot

Duration- one week

Character –throbbing and sharp pain

Aggravating factors– weight bearing

Relieving factors –tramadol as a pain- reliever

Timing -when bearing weight

Severity-7 out of 10 after tramadol but increases to 9 out of 10 on weight-bearing.

She reports having a fever of 102 F last night, negative for recent illness, and reports an unexplained weight loss over the past month with increased appetite. She is negative for changes in diet

Current Medications 

Acetaminophen 500-1000mgPO for headaches

Ibuprofen 600 mg PO TID PRN for menstrual cramps

Tramadol 50 mg PO TID PRN foot pain

Albuterol 90 mcg/spray

MDI2 puffs Q4H (wheezing when cats are around) were last used three days ago.


Medication allergies: Penicillin allergy reaction to a rash.

Animals and environmental allergen cats and dust.

Food allergens no known food allergens latex

She reports the allergens exacerbate her asthma symptoms, runny nose, and eyes get itchy and swollen when exposed to allergens. So keeps away from them.

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Medical History  

She was diagnosed with asthma at the age of 2 and a half years. She uses an albuterol inhaler when exposed to  cats or dust . Uses her inhaler two or three times a week last admitted to the hospital secondary to asthma exacerbation while in high school. Diagnosed with T2DM at the age 24 years. She was on metformin medication but stopped taking it due to side effects like getting gassy. She denies monitoring her blood sugar. Their last blood sugar level was elevated while at the ED. No history of surgeries.

OB/GYN Menarche11 years, first sexual encounter 18 years heterosexual. Never pregnant. Last Menstrual period 3 weeks ago. Irregular cycles 4-8 weeks with heavy bleeding lasting 9-10 days. No current partner used oral contraceptives in the past. Confirms she never used condoms when sexually active and never tested for HIV/AIDS or STIs. Last tested for STI four years

 Health Maintenance

Last Pap smear 4 years ago last eye checkup in childhood. Last dental exam a few years ago, PPD negative 24 months ago No exercise 24 hour diet recall l service Reports skipping breakfast yesterday, and would usually skip some meals.

Immunizations: Tetanus booster, influenza jab not updated HPV jab not received. With no proof reports, she believes she is up to date on childhood vaccines, with a meningococcal jab at college.

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Safety: Has installed smoke detectors at home, fastens the seatbelt while in care or driving, does not do bike riding. Is not into sunscreen use. Her dad used to have guns and so they are safely locked inhere parents’ room.

Family History

Mother is alive aged 50 years and living with hypertension and high levels of cholesterol. Her father was diagnosed with hypertension, high cholesterol, and T2DM but died in a car accident at age of 58 years. Her mother’s parents died in their seventies secondary to stroke and both had a history of hypertension and high cholesterol. Her Mather grandfather succumbed to colon cancer and had a history of T2DM. Her paternal grandmother is alive and living with high blood pressure at 82 years. The rest of the family history is noncontributory for cancers and negative for mental illnesses.

Social History

TJ is a single lady who is childless, currently living with her mother and sister but has plans to lease her own flat in months’ time. Has 32-hour week job at MidAmerican Copay and Ship. She loves her work and recently promoted to supervisor. She is a part-time student in her last semester doing an accounting degree. She got an automobile, a mobile phone, and a computer. She receives basic of health insurance from work and is deterred from healthcare. She an active churchgoer and a staunch Christian. She reports stressors concerning the loss of her dad and having to balance her work and school and the usual financial worries. She denies cocaine use but admits to using alcohol occasionally that is about 2- 3 times and only when partying with friends. She occasionally used bhang between the ages of 15 and 21. Denis uses hard drugs like cocaine methamphetamine and heroin. She does not travel abroad, keeps no pets, and currently does not have a boyfriend. She is recently separated from her spouse for two years now. She anticipates getting married and having some children someday.


Wound 2cm by 1.8 cm by 2 mm deep wound red wound ages, right ball of the foot, serosanguinous drainage, mild erythema wound no tracking, and no edema.

Review of Systems (ROS) – 

General:  TJ is a well-nourished healthy-looking female who is appropriately dressed for the occasion and weather. She sits with ease on the examination and is in no acute distress. She reports losing some weight recently.

Vitals: BP 188/90, Ht 171 cm Weight 91 kg, BMI 31 HR78, RR 18, O2 98%, Temp 102.4 F

HEENT:  On examination, the head is norm cephalic, negative for lesion, and has no scalp tenderness. Hair is normal and evenly distributed. Denies headaches, changes in vision, eye pain, eye itchiness, or discharge. The sclera is white, conjunctiva pink, PERRLA, and EOMs intact. She however has corrective glasses which she reports as having helped her deal with blurred images and Mild retinopathy changes. Vision 20/20 with corrective lenses. And headaches. She is negative for earache, and ear discharge. Ear canal pink, pearly gray tympanic membrane, and whispers heard bilaterally. She reports a no running nose of easy nose bleeding. No issues were found during her last dental exam.  Has a pink mucous membrane.  Positive for gag reflex swallows with no difficulties, Thyroid palpable with no growth noted. No signs of lymphadenopathy.

Skin, hair, and nails: Skin Reports acne since adolescence and bumps on arms when skin is dry. Complains of moles but negative for hair or nail changes.

Respiratory: Negative for shortness of breath, no breathing difficulties. No wheezing, runny nose, or cough. The last time to use a rescue inhaler was 90 days ago and twice over the last 12 months.

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Cardiovascular: Denies chest pains, palpitations, or swelling of limbs. Heart rate is regular, S1, S2, negative for murmurs, gallops, or rubs. No peripheral edema and capillary refills in less than 3 seconds.

Gastrointestinal: Denies nausea, vomiting, constipation, pain, or heartburn. On inspection, the abdomen is protuberant and symmetrical. Coarse hair growth from the pubis to the umbilicus. Normal Bowel Sounds and present in all four quadrants. The abdomen is soft with no tenderness or masses upon palpitation.

Genitourinary: No vaginal discharge, reports excessive thirst sometimes and frequent urination.

Musculoskeletal: Positive muscle / joint paint at right ankle pain or weakness. Uneven gait with unequal strides.

The patient is alert, awake, and oriented to person, place, and time. Denies dizziness, tingling, or loss of sensation. Can identify sharp dull and soft touches on hands and legs. Dual shoulder resistance can turn the head in both directions upon resistance. Can perform repetitive and alternating movements.

Hematological: denies bleeding, bruising, and history of blood clots

Endocrinological: Excessive thirst

Unusual Findings

According to TJ’s physical exam, some significant findings were abnormal. She has a wound 2cm by 1.8 cm by 2 mm deep wound red wound ages, right ball of the foot, serosanguinous drainage, and mild erythema wound no tracking, and no edema For example, her BMI indicates obese at 31. There is also reduced sensation in her feet which is indicative of peripheral neuropathy secondary to T2DM. According to Afaya et al (2020), these signs are indicative of both micro and macrovascular complications secondary to T2DM. Suffice it to say that TJ’s plan of care should address her T2DM, asthma, excessive weight, and wound. Care and pain management.

Plan of Care

According to Hsu et al (2019) medication- based intervention to help TJ manage acute pain and the musculoskeletal wound is to utilize multimodal analgesia instead of using opioid monotherapy for pain control. Commonly known as balanced analgesia involves the use of several analgesic medications be they opioid or non-opioid and no medication intervention designed to impact peripheral and or central nervous systems loci within the pain loci. Additionally, cryotherapy is recommended in TJ’s case as an adjunct therapy. This intervention entails the use of an external cold source to achieve the desired effect by dropping tissue temperature. Over and above these interventions helpful psychosocial interventions to reinforce the pain management measure to initiate psychosocial interventions to relieve pain symptoms of anxiety, depression, and other complications.

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Dorothea Orem’s self-care nursing model contends that self-care is a key factor in improving a patient’s health and expediting their recovery from diseases. The model propagates the notion that individuals would be responsible for their care. Subsequently is incumbent upon the nurse to identify the self-care deficits present in the patient (Petprin, 2016). From the outset, it is important to remember that TJ has taken serious and effective steps toward her health care by adhering to an exercise regime and a T2DM-friendly diet. Adherence to the prescribed medication is also necessary to treat and control her comorbidities. T2DM patient education so that the patient understands the modifiable and no modifiable risk factors and therefore takes the necessary measures. Some of the no modifiable risk factors are her pedigree of hypertension, and diabetes as indicated by her family medical history. The significance of taking her daily blood sugar levels is necessary and the role of diet in controlling and managing T2DM effectively. At this point in time, TJ’s asthma is under control but the five self-care needs to be reinforced. These are medication usage, use of the GINA, avoidance of allergens whenever possible, and proper use of inhaler amongst others. Last but not least is the need for TJ to get reproductive health education due to her current relationship. Pregnancy prevention and measures to prevent sexually transmitted infections is also necessary and should be imparted at this time.

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Afaya, R. A., Bam, V., Azongo, T. B., & Afaya, A. (2020). Knowledge of chronic complications of diabetes among persons living with type 2 diabetes mellitus in northern Ghana. Plos one15(10), e0241424.

Hsu, J. R., Mir, H., Wally, M. K., & Seymour, R. B. (2019). Clinical practice guidelines for pain management in acute musculoskeletal injury. Journal of orthopaedic trauma33(5), e158.

Papatheodorou, K., Banach, M., Bekiari, E., Rizzo, M., & Edmonds, M. (2018). Complications of diabetes 2017. Journal of diabetes research2018. Petiprin, A. (2016). Self-care deficit theory. Retrieved from http://www.nursing-theory.org/theories-and-models/orem-self-care-deficit-theory.php

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