1 Shadow Health Digital Clinical Experience Health History Documentation Student’s Name
2 Name:Tina Jones, Age:28, Race:African American,Sex:Female. SUBJECTIVE DATA Chief Complaint (CC):Wound on the right foot that is painful. History of present Illness (HPI):Tina is a 28-year-old African American female who walks into the clinic with an infected wound on her right foot. Over the past two days, the pain has become worse. The pain is 7/10. The patient states that the pain does not transfer to any other body parts. After injury, the foot became swollen and red. Weight bearing is the aggravating factor. Medication:Tramadol for pain 50 mg, 3 times a day. Proventil inhaler for asthma, 2-3 puffs daily. Tylenol 500mg 3 times daily, for headaches. Advil for cramps. Allergies:Penicillin: Rashes. Cat and dust: Wheezing and itchy eyes. Past Medical History:Patient was diagnosed with asthma at 21 years, hospitalized at 16 years. Uses Proventil to help manage her asthma, three times in a day in case of asthma attacks. Diabetes at 24 years and has not taken metformin in the last three years. Does not go for regular blood sugar checkups. Past Surgical History:No past surgeries. Sexual/Reproductive history:The patient presents as heterosexual. Uses condoms as a contraceptive to prevent pregnancy and STDs. No past pregnancy. Personal/ Social History:Patient occasionally drinks alcohol and loves going to club for fun. She has a bachelor’s degree in accounting. Has a supportive family and friends. No smoking tobacco or marijuana. Attends Baptist church