Identifying data and reliability shadow health

Identifying Data & Reliability Ms. Jones is a pleasant, 28-year-old obese African American single woman who presents for complete physical examination and evaluation for right foot injury. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview. General Survey Ms. Jones is alert and oriented, is seated upright on the examination table, and is in no apparent distress. She is well-nourished, well-developed, and dressed appropriately with good hygiene. Chief Complaint “My foot is killing me. It really hurts.” History of Present Illness Ms. Jones reports that two weeks 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 when she showers. She has been applying antibiotic ointment with a Band-Aid. 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, shooting” with weight bearing. She states her ankle “ached” but is resolved. Pain is rated 5 to 6 out of 10 after a recent dose of tramadol. Pain is rated 9 with weight bearing. She feels she “cannot walk on it.” She reports that over the past two days the ball of the foot has become swollen and increasingly red; yesterday she noted some “blood and pus” oozing from the wound, requiring her to apply a bandage. She denies any odor from the wound. Her shoes feel tight. She has been wearing slip-ons. She reports subjective fevers over the past two days with an episode “just the other day I felt feverish, hot and cold.” She denies recent illness. Reports a 20-pound, unintentional weight loss over the past two months and increased appetite. Denies change in diet or level of activity. Medications Acetaminophen 500-1000 mg PO prn (headaches) • Ibuprofen 600 mg PO TID prn (cramps) • Tramadol 50 mg PO BID prn (foot pain) • Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (Wheezing: “when around cats,” last use three days ago) Allergies Penicillin: rash • Denies food and latex allergies • Cats: sneezing, itchy eyes, wheezing Medical History Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler when she is around cats. She rarely uses her inhaler. She was exposed to cats a few days ago and had to use her inhaler once. She was last hospitalized for asthma in high school. Never intubated. Type 2 diabetes, diagnosed at age 24. She used to take metformin, but she stopped taking it th.ree years ago, stating that the pills made her gassy and “it felt like I was taking pills and checking my sugar all the time, it was a pain to get refills so I just stopped.” She doesn't monitor her blood sugar. Last blood glucose was elevated at the hospital. No surgeries. OB/GYN: Menarche, age 11. First sexual encounter at age 18, sex with men, identifies as heterosexual. Never pregnant. Last menstrual period 6 weeks ago. For the past year cycles irregular (every 4-8 weeks) with heavy bleeding lasting 9-10 days. No current partner. Used oral contraceptives in the past. When sexually active, reports she did not use condoms. Never tested for HIV/AIDS. No history of STIs or STI symptoms. Last tested for STIs at age 22.