Identifying Data & Reliability

Tina is a 28 year old female with chief complaint of right foot wound

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General Survey

patient has wound to the bottom of the foot, complains of pain when she bears weight

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Chief Complaint

right foot pain

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History Of Present Illness

right foot wound infection with pain of 7/10

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Medications

proventil 2 puffs for asthma and tramadol 200mg tid for pain,tylenol 500 mg as needed for pain ,

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Allergies

PCN, Cats

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Medical History

Tina has diabetes type 2 and Asthma, allergies to PCN and cats

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Health Maintenance

diabetic diet

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Family History

mother has Hypertension, high cholesterol;Father has high cholesterol,hypertension, diabetes type 2

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Social History

smokes marijuana occassionally, no alcohol use

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Objective

patient noted to have levated temperature of 101.1 , blood sugar of 238,wound measurements 2cmx1.5cm, 2.5 mm deep, wound pink scant drainage noted.

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