Physical Measurements:
– Height: 170 cm
– Weight: 90 kg
– BMI: 31
– Random blood glucose: 238
– Temperature: 101.1°F
– Blood pressure: 142/82
– Respiratory rate: 19
– O2 sat: 99%
– Heart rate: 86
– Measured wound: 2 cm x 1.5 cm, 2.5 mm deep

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Wound Care Actions:
– Swabbed wound and sent to lab for C & S
– Cleansed and irrigated wound with normal saline and applied dry sterile dressing.

Introduction:
Hello. My name is Gisselle. I will interview you and later examine you.

Initial Greeting:
Hello. My name is [xxx]. I will interview you and later examine you.

Patient Identification:
– Patient: Tina Jones

Liam Fitzgerald Telehealth Follow Up Sick Visit: Management of Cardiovascular Conditions

Reason for Visit:
I got this scrape on my foot a while ago, and I thought it would heal up on its own, but now it’s looking pretty nasty. And the pain is killing me!

Empathy Response:
I am sorry to hear that.

Exploration of Injury:
– When did you get the scrape?
– How severe is the pain?
– Can you describe the pain?
– Did you hurt anything else during the fall?
– How has the pain changed over time?
– Does the pain radiate?
– How did you hurt your ankle?
– Can you stand on your foot?
– Can you rate your pain on a scale of 0 to 10?
– Where is the pain located?
– Which foot did you injure?
– Were you wearing shoes?
– Did you have any alcoholic drinks before the injury?
– Did you use home remedies for your foot?
– What did you use to clean it?
– When did you go to the ER?
– Did you get any medication at the ER?
– Do you know the name of the pain pills?
– What dosage of tramadol?
– How often were you taking the tramadol?
– Did tramadol relieve pain?
– Has your foot bled since the injury?
– What happened after you scraped your foot?
– How effective is the pain medication?
– How have you cared for the scrape?
– How effective was the Neosporin?
– How often have you been cleaning your scrape?
– Is the wound swollen?
– Does your scrape have an odor?
– Any pus?
– What color is the pus?
– Is the scrape red?
– Any temperature change around the scrape?
– Are you having problems getting around?

General Health Questions:
– Is your general health condition?
– Any fatigue?
– How is your sleep pattern?
– Any hearing problems?
– Any ear discharge?
– Does your mother have any health problems?
– Does your father have medical problems?
– When did your father pass away?
– How did you cope with your father’s death?
– What was the cause of your father’s death?
– How is your paternal grandfather?
– How old was your maternal grandfather when he passed?
– Your maternal grandmother’s health?
– Does your brother have health issues?
– Does your sister have health issues?
– Does obesity run in your family?
– Any family history of thyroid problems?
– Any headaches?
– Any loss of consciousness?
– Any memory loss?
– Do you have skin abnormalities?
– Any stomach upsets?

NUR7580 Advanced Health Assessment and Differential Diagnosis: Comprehensive Head-to-Toe Exam Video

Additional Measurements (Repeated):
– Measured wound: 2 cm x 1.5 cm, 2.5 mm deep
– Swabbed wound and sent to lab for C & S
– Cleansed and irrigated wound with normal saline and applied dry sterile dressing.

Transcription Continued on November 03, 2021