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History of Presenting Illness: Foot Wound
Finding:
Established chief complaint
Finding:
Reports pain
(Found)
Pro Tip: Beginning your conversation with your patient by asking an openended question is a best practice for gauging your patient's general condition.
Example Question:
How severe is the pain?
Finding:
Reports open foot wound
(Found)
Pro Tip: If a patient mentions pain, it's important to determine what specifically is causing her pain.
Example Question:
What's causing your pain?
Finding:
Asked to rate pain on a scale
Finding:
Rates present pain at a 7 out of 10
(Found)
Pro Tip: Asking your patient to rate her pain on a scale of 0 to 10 is important to gauge how it ebbs and flows while she is in your care.
Example Question:
Can you rate the pain on a scale of 0 to 10?
Finding:
Asked for details about the pain
Finding:
Describes the pain as throbbing
(Found)
Pro Tip: Determining how your patient describes the characteristics of the pain can be important data to support the cause of the pain.
Example Question:
Can you please describe the pain?
Finding:
Describes the pain as sharp when she attempts to stand
(Found)
Pro Tip: Determining how your patient describes the characteristics of the pain can be important data to support the cause of the pain.
Example Question:
Finding:
Pain prevents bearing weight on foot
(Found)
Pro Tip: Determining if your patient can bear weight on an injury is important to determine their risk for falls while in your care.
Example Question:
Can you bear weight on your foot?
Finding:
Clarified location of wound
Finding:
Confirmed that right foot is injured
(Available)
Pro Tip: Confirming which extremity an injury is located is a best practice for your patient's safety.
Example Question:
Which foot is in pain?
Finding:
Confirmed that wound is on the plantar surface of her foot
(Found)
Pro Tip: Confirming where a wound is located ensures you are aware of your patient's biggest complaint.
Example Question:
Where is the wound?
Finding:
Determined details of the injury
Finding:
Scraped foot on bottom rung of a step stool
(Found)
Pro Tip: Discovering how an injury happened helps to assess your patient's risk factors for injury.
Example Question:
How did your injury happen?
Finding:
Reports no other injuries besides foot wound
(Found)
Pro Tip: Discovering additional injuries can reveal more information about the circumstances that caused the presenting injury.
Example Question:
Did you injure anything besides your foot?
Finding:
Was not drinking at the time of the injury
Finding:
Reports that the wound bled a little after sustaining the injury
(Found)
Pro Tip: Asking about bleeding helps you determine the characteristics of a wound.
Example Question:
Did your foot bleed?
Finding:
Reports seeing pus draining from wound
(Found)
Pro Tip: Asking about discharge helps you determine the characteristics of a wound.
Example Question:
Did you notice any discharge from the wound?
Finding:
Began noticing pus 2 days ago
(Found)
Pro Tip: Pinpointing exactly when the patient noticed the arrival of pus gives you an important data point for when an active infection began.
Example Question:
When did you first notice the pus?
Finding:
Followed up about character of drainage from the foot wound
Finding:
Describes pus as white or yellow in color
(Found)
Pro Tip: The color of discharge from a wound can provide insight into its severity and characteristics.
Example Question:
What color is the drainage from your wound?
Finding:
Reports no odor from the wound
(Found)
Pro Tip: The odor of discharge from a wound can provide insight into its severity and characteristics.
Example Question:
Does the wound have an odor?
Finding:
Asked about home treatment of foot wound
Finding:
Describes wound care regimen of cleaning and bandaging
(Found)
Pro Tip: Asking specifically how often a patient changed a bandage will let you know if an infection spread through improper hygiene, or for other reasons such as uncontrolled blood sugar.
Example Question:
How often do you change your bandage?
Finding:
Applied neosporin
(Found)
Pro Tip: Determining what products a patient used to sterilize or treat a wound establishes home care routines and health literacy.
Example Question:
Did you use any ointment on the wound?
Finding:
Asked about other foot wound symptoms
Finding:
Reports swelling around foot wound
(Found)
Pro Tip: Asking about the presence of swelling helps you gather information about your patient's complaint, as well as potential related illnesses.
Example Question:
Is there swelling around the wound?
Finding:
Noticed swelling getting worse in the past 2 days
(Found)
Pro Tip: Finding out how long swelling appeared will help you understand the timeline for the infection progression.
Example Question:
How long have you noticed swelling around the wound?
Finding:
Reports redness around the wound
(Found)
Pro Tip: Asking about redness will help you understand the timeline for the infection progression.
Example Question:
Did you notice any redness around the wound?
Finding:
Reports that the wound feels warm
(Found)
Pro Tip: Asking about warmth will help you understand the timeline for the infection progression.
Example Question:
Does the wound feel warm?
Finding:
Finding:
Asked about recent fever
Finding:
Reports recent feverish episode
(Found)
Pro Tip: The presence or absence of fever can indicate if an infection is approaching sepsis, a lifethreatening condition.
Example Question:
Are you feeling feverish right now?
Past Medical History: Diabetes
Finding:
Asked details about diabetes diagnosis
Finding:
Diagnosed as an adult
(Found)
Pro Tip: Learning the diagnosis date of your patient's illness is an essential element of the illnesses history.
Example Question:
When were you diagnosed with diabetes?
Finding:
Specific age of diagnosis is 24 years old
(Found)
Pro Tip: Learning the diagnosis date of your patient's illness is an essential element of the illnesses history.
Example Question:
At what age were you diagnosed with diabetes?
Finding:
Reports that her diabetes is Type 2
(Found)
Pro Tip: The type of diabetes your patient has will drastically affect how you care for her,
Example Question:
Do you know what type of diabetes you have?
Finding:
Asked about diabetes management through diet
Finding:
Reports that she tries to manage diabetes with diet
(Found)
Pro Tip: Understanding how your patient cares for her diabetes is an essential element to learning the history of her illness.
Example Question:
Pro Tip: Asking about diabetes medication is important to understanding if your patient's disease is under control.
Example Question:
Do you take prescribed medication for your diabetes?
Finding:
Asked about past diabetes medication use
Finding:
Used to take diabetes medication
(Found)
Pro Tip: Asking about diabetes medication is important to understanding if your patient's disease is under control.
Example Question:
Have you ever taken medication for your diabetes?
Finding:
Previous medication was prescription metformin
(Found)
Pro Tip: Asking about diabetes medication is important to understanding if your patient's disease is under control.
Example Question:
Do you remember what you were prescribed for diabetes?
Finding:
Last use of medication was 3 years ago
(Found)
Pro Tip: Asking about diabetes medication is important to understanding if your patient's disease is under control.
Example Question:
When was the last time you took your diabetes medication on a regular basis?
Finding:
Explored the reasons the patient stopped her diabetes regimen
Finding:
Reports that she "got sick of dealing with it"
(Found)
Pro Tip: Asking reasons for noncompliance can reveal information about your patient's health literacy, side effects, financial situation, and more.
Example Question:
Why aren't you taking your diabetes medication?
Finding:
Reports disliking metformin side effects
(Found)
Pro Tip: Asking about side effects from medication can provide information about your patient's reaction to treatment.
Example Question:
Did the metformin cause any side effects?
Example Question:
How often do you check your blood sugar?
Finding:
Reports confusion about "what the numbers mean"
(Available)
Pro Tip: Your patient's blood sugar monitoring habits are an important part of her health literacy and home treatment.
Example Question:
What are your usual blood sugar levels?
Finding:
Asked about increased thirst
Finding:
Reports increased thirst
(Found)
Pro Tip: Your patient's thirst and fluid intake can offer insight into underlying medical conditions.
Example Question:
Have you been more thirsty lately?
Finding:
Reports increased water intake
(Found)
Pro Tip: Your patient's thirst and fluid intake can offer insight into underlying medical conditions.
Example Question:
Are you drinking more water than normal?
Finding:
Asked about frequency of urination
Finding:
Reports more frequent urination
(Found)
Pro Tip: Your patient's urination habits can offer insight into underlying medical conditions and general health.
Example Question:
Have you been urinating more often than usual?
Finding:
Reports urinating "every hour or so" during the day
(Found)
Pro Tip: Your patient's urination habits can offer insight into underlying medical conditions and general health.
Example Question:
How often do you urinate during the day?
