Tina Jones is a 28 year old female, African American, overweight, allergic to cats, dust, and penicillin. Past medical history of type 2 diabetes and asthma. Tina Jones’s chief complaint is a non-healing wound on the right foot. She states tripping down the stairs and scraping her foot on the cement. After 1 week the wound was red, swollen, and painful. Upon assessment the wound is found to be at the right foot at the ball of the foot, measuring 2 cm x 1.5 cm, 2.5 mm deep, with red wound edges, and serosanguinous drainage. The patient was seen at the emergency department and sent home with instructions to avoid weight bearing on the right foot, cleanse and dry wound, and a prescription for Tramadol 50mg TID. The patient’s last dose was this morning. The patient states cleaning the wound morning and night with peroxide, applying Neosporin, and covering with a dry dressing. Patient reports fever last night and the current temperature is 101. Patient reports increased hunger, thirst, and urination, and an unintentional weight loss of 10lbs in the last month. Home medication are Proventil inhaler PRN for asthma symptoms, Ibuprofen PRN for menstrual cramps, and Acetaminophen PRN for headaches. Family genogram reveals history of hypertension and hyperlipidemia from both paternal and maternal aspects. Type 2 diabetes and cancer is present of the paternal side. Ms. Jones has 2 younger siblings, a male who is 25 and has no significant medical history, and a female who is 14 and has a history of asthma.
Ms. Jones is at an increased risk for hyperlipidemia, hypertension, and stroke related to her family history and race. The patient is also at an increased risk for diabetes complications related to lack of knowledge on the management of her condition.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Mosby Elsevier.
Jarvis, C. (2012). Physical examination & health assessment (6th ed.). St. Louis, Mo: Elsevier/Saunders.
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