Free Paper Sample: Assessment and Health Plan for Tina Jones's Medical Condition

Introduction

Tina Jones is a 28-year-old lady, single lady, an African American individual who has recently presented to the clinic concerning her recent injury to the foot. Despite being an obese individual, Ms. Jones is a good historian and a pleasant individual. She is presented to get care for her right foot injury. She offers information for examination without contradiction and freely. Throughout the interview, she maintains eye contact, and she is coherent and clear.

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Chief Complaint

The patient presents at the healthcare complaining of an injury on her right foot. She says that she has recently sustained a scrap on the plantar foot surface. However, the cut would be currently draining with pus despite having no foul smell. Her primary concern is the resulting pain, which she claims is killing her. The problem has increased exponentially for the last two days hence in need of urgent care.

History of Present Illness

According to the patient's information, she was doing her back steps when she accidentally tripped and scrapped by the railing, which turned her ankles. At the edge of the step, she ended up scrapping her foot. Filled with concern that she had fractured her foot, she went to the ER for medical analysis. However, the x-ray obtained from the ankle shows negative results for any case of fracture. She was later prescribed tramadol, which she takes three times per day. However, the patient insists that, under the current medication, pain is relieved for a few hours, and then she feels a throbbing sensation again. Ms. Jones also claims to be continually cleaning her wound with soap and water with a Neosporin dressing. After dressing her, would she wrap it with a bandage twice every day? However, she complains that the situation is continually worsening. The current discharge in her would is very oozing. There is clear drainage with a feeling of getting warm and swollen. Consequently, she reported a case of having a fever of 102 degrees the previous night. Despite maintaining a diet, she says that she lost considerable weight almost a month ago without any trial.

Medications

To maintain pain, she has been medicated with Tramadol 50 mg and Ibuprofen 600 mg for maintaining pain due to muscle cramps. To overcome headache cases, she takes Tylenol 500-100 mg and an inhaler for Asthma (Albuterol 90mcg/spray) with a constant frequency of two puffs taken every four hours.

Allergies

The patient is currently allergic to dust and cats. When she is predisposed to allergens, she complains of itchy and swollen eyes and a runny nose. She also complains of being allergic to penicillin, characterized by having hives and rashes.

Patient Genome

Ms. Jones is a single woman with no child. Since the age of 20, she has been living independently, but since she lost her father last year, she has lived with her mother and sister to support them. She is employed as a Mid-America copy and ship supervisor, where she works for 32 hours per week. She loves her job, and for that recently, she was promoted to be a shift supervisor. Ms. Jones is also a part-time student enhancing her accounting skills to gain more positions in her job.

She has a stable life and can afford basic health care insurance from her job. Ms. Jones has friends who she likes hanging around with at the weekends. She enjoys drinking a little bit of alcohol but does not take any other form of illicit drugs.

Family History

Ms. Jones's family has had, a history of health problems. These problems include hypertension, colon cancer, high cholesterol, diabetes, heart disease, and stroke. Her grandmother died when she was 73 years old after she suffered from a stroke. Also, her grandfather died when he was 78 years old and was killed by a stroke. Ms. Jones lost her Paternal grandmother, who was 65 years old due to colon cancer. Her family has also struggled with mental illness, sudden deaths, sickle cell anemia, kidney diseases, and alcoholism.

Health Maintenance

For the past three years, Ms. Jones stopped picking up her diabetes drugs. She has been reluctant and does not regularly check her blood sugar levels. She does no exercises and consumes regular meals but tries to keep off foods with more sugar content. In contrast to that, Ms. Jones drinks adequate water for a day. She last visited OB/GYNE four years ago. She cleared all her childhood vaccinations, and she does apply sunscreen, although she tries to keep away from direct sunlight. Lastly, Ms. Jones keeps a healthy hygiene

Medical History

Ms. Jones was diagnosed with Asthma when she was 2 ½ years old. When she is exposed to cats and dust, she regularly uses her inhaler, which helps her. When she was 24 years old, she was diagnosed with type 2 diabetes. She has no surgical history records, no high blood pressure records, and no records of high cholesterol but has irregular menstruation period cycles. Although she has no form of a stroke, she suffers from a skin disorder.

Physical Examination

Denies any head trauma, and the head is normocephalic. Ms. Jones refuses any problems regarding her hair and scalp and states her hair texture is thick and coarse. Admits she experiences headaches once a week from prolonged reading. Current treatment Tylenol gels. Recently Ms. Jones described vision abnormalities, "and things start to get blurry." Denies any glasses or contact usage and has not had a vision exam as a young child in school. Pupils were equally round and reactive to light and accommodation. Ms. Jones denies any ear abnormalities, problems, and difficulty with hearing. Tina prohibits any nose pain, bleeding, and test smells. Tina, on occasion, has a runny nose with interactions with cats. Tina denies any problems associated with her oral cavity, or teeth, and has no loss of taste. Tina denies any throat problems since high school. She used to frequent strep throat. Tina refuses and has difficulty swallowing or moving her neck on occasion; she gets a stiff neck that she refers to as a "crick" when she reads. Tina also denies any problems moving her head as well.

Musculoskeletal

Tina denies any issues with her musculoskeletal system, pain, arthritis, fractures, or movement. Tina refuses back and neck pain, although she does not exercise Tina states due to her exhausted state from working. She claims to be on her feet all day and considers that as some exercise

Neurologic

Tina Jones denies any neurological deficits. She is not dizzy, had a fainting spell, pins, and needles, or tingling. She is AAOX3, States she is in the hospital, knows the correct date and president

Cardiovascular

Tina denies any cardiovascular issues even though her a family history. Tina's blood pressure is 138/90, with a heart rate of 90. Tina denied any palpitations and edema. She does have a little dyspnea on exertion she says she is short of breath when she has to hurry up the stairs to class or when she has to walk a long way somewhere.

Respiratory

Tina denies any respiratory issues such as infections such as bronchitis or pneumonia, and cough. Tina has Asthma and sneezes, a runny nose, watery eyes, and wheezing when she encounters cats.

Gastrointestinal

Tina denies any digestive problems like nausea, vomiting, reflux, or diarrhea. Tina states her bowel pattern is regular, and she went this afternoon with the characteristics of it being brown with no weird colors. Tina has mentioned increased thirst, urination, and appetite. Tina has also stated she lost ten pounds in a little over a month. Tina has not maintained compliance with her diabetes and eats most carbs but tries to avoid sugars.

Genitourinary

Tina denies any urinary symptoms, such as pain or discomfort. Tina reports her urine color as yellow, almost transparent. Tina has mentioned her increased urination and denies any UTIs or sexually transmitted diseases. Tina denies any vaginal itching and pain. Tina's discharge is clear, and there is not a large amount. Tina does have "bad periods." Her menses are irregular and can come every month out every two months, so she has six periods a year on average. The menstrual cycle has an average of 9-10 days with bad cramps ranging a 6-7 out of 10 on the pain scale, and the bleeding is heavy where Tina uses extra absorbent tampons that have to be changed every two or three hours. Tina has had no pregnancies and has practiced safe sex with birth control. Currently, Tina has no sexual partners.

Integumentary

Tina had acne when she hit puberty on and off. She currently treats it with a Neutrogena face wash but finds that it doesn't help. Tina reports her skin is dry and recently noticed the skin around her neck is looking weird. She states it's a darker line, which seems like she has acanthosis nigricans. Tina has moles, but too many cannot report any abnormalities. Tina says she has hair above her lips, chin, and belly. The hair on her head is thick and coarse and has no difficulty growing. Tina's nails are good as well, and she has not reported any other illness.

Conclusion

Based on the information provided by Ms. Jones's examination report, efforts should be made on how her current health condition can be improved. Therefore, it is essential to implement a healthy diet supplemented by regular exercise to improve her current health condition. Consequently, depending on her efforts to maintain an average blood sugar level, she has developed self-awareness of the importance of adhering to medication guidelines. Strict adherence to the prescribed medication has prevented her asthmatic condition exacerbation for the last three months. Regular checks on blood sugar levels should be maintained while ensuring she always takes Metformin to modify her diet according to the health requirements.