Tina Jones Health Assessment Shadow Health

Right foot pain, fever, nausea

History of Pt fell from step ladder scraping right foot. Pt treated with Ms. Jones is a pleasant 28-year-old African American woman who presented to the emergency department for evaluation of a right foot injury and was admitted for IV antibiotics. She is a good historian. She hurt the ball of her right foot by scraping it on

the edge of a metal step while changing a light bulb. The injury occurred about one week ago. Her pain has worsened, and the swelling has persisted. She tried ibuprofen, but it didn't work well. The foot feels better

Present Illness Neosporin, not effective. Presents when she rests, and it hurts more when she to ER with fever and painful, draining foot wound. walks on it. Her pain is a 9 when she tries to ambulate. She took her temperature at home and reports it was 102. She has not been eating much and has been staying in bed the last few days, per patient report. The scrape is red and swollen with exudate and has no odor; she reports the swelling and exudate started two days ago. She reports diarrhea overnight. Pain improved with oxycodone. Stomach upset.

Pain Assessment

Pt states pain is 7/10 sharp and throbbing past few days. Rated 10/10 before medication in ER

Pain is rated as 7. Pain is localized to ball of foot related to wound. Dull and constant ache. Patient has tried ibuprofen, but reports it does not work well. Patient states there is relief when foot is elevated, not walking on it. Patient answers questions clearly and consistently. Offers information without hesitation. Vital signs are within range.

• No food allergies • Not allergic to latex

Up-to-date. Received tetanus and HPV vaccines within the last year. Denies recent flu shot.

• Albuterol 90 mcg/spray MDI, 1-3 puffs, as

Proventil inhaler 90 mcg/spray 2- needed for wheezing • Acetaminophen 500

Medications

3 puffs, last dose 3 days ago Advil 200 mg 2 tabs as needed for pain, cramps

mg tabs by mouth, 1 - 2, as needed for pain or headache • Ibuprofen 200 mg tabs by mouth, 3 - 4, three times a day, as needed for cramps

Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler when she experiences exacerbations, such as from dust or cats; she never uses it more than twice a week. She was exposed to cats a few days ago and had to use her inhaler once. She is prescribed 1-

3 puffs as needed; she reports having to use

3 puffs occasionally, but usually 1-2. She

Medical History  Asthma diagnosed age 2 1/2 Type was last hospitalized for asthma in high 2 DM age 24 school. Never intubated. Type 2 diabetes, diagnosed at age 24. She used to take metformin but stopped taking it due to gastrointestinal problems. She doesn’t monitor her blood sugar. She was last seen by a primary care doctor a few years ago. Her last dental exam was over two years ago. Last eye exam was in childhood.

Previous

Hospitalizations

Multiple admissions as a child r/t asthma exacerbation, last age 16

Last hospitalized for asthma exacerbation in high school.

Gynecological

History

No pregnancies Periods are not regular LMP approx 3 weeks ago Flow generally heavy 4-5 days with cramping, takes advil Last Pap 4 yrs ago Not sexually active Not on birth control

Not sexually active, first sexual activity at age 18, never pregnant, last Pap smear more than four years ago, tested for STIs at age 22, denies STI symptoms. From age 23 to age 26 took oral contraceptives as only source of birth control, no condom use.

Reports heavy, irregular periods, abnormal hair growth, and acne during teenage years, and since stopping oral contraceptives 18 months ago.

Family History

(3 generations)

Sister- asthma Brother -healthy Father deceased, Type 2 DM, High cholesterol, HTN Mother

-high cholesterol, HTN Paternal GM age 82- HTN, high cholesterol Paternal GF,

deceased- high cholesterol, HTN, DM?, colon cancer Maternal GF deceased- high cholesterol, HTN

• Father: died at age 58 in a car accident, history of hypertension, high cholesterol, and type 2 diabetes • Mother: hypertension, high cholesterol • Brother: healthy • Sister: asthma • Maternal grandmother: died at age

73 of a stroke, history of hypertension, high cholesterol • Maternal grandfather: died at age 78 of a suspected myocardial infarction, history of hypertension, high cholesterol • Paternal grandmother: still living, age 82, hypertension • Paternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes • Paternal uncle: alcoholism

intimate relationship, ended a three-year serious monogamous relationship two years ago. She plans on getting married and having children someday. She denies suicidal and homicidal ideation.

Review of

Neuro- No dizziness HEENT- occ Head: Reports headaches that occur weekly

Systems

blurred vision, denies hearing problems, no oral or swallowing issues, irregular dental checkups Skin- right foot wound Lungs- Denies SOB, cough CV- Denies palpatations, no edema GI- Denies pain, last BM today, normal GYN- irregular periods, LMP 3 weeks ago GU- wnl

with reading in the past year. The headache lasts a few hours and is relieved with acetaminophen and sleep. Headaches are described as a “tight and throbbing feeling behind the eyes.” Denies head and neck trauma. Ears: Denies difficulty hearing, tinnitus, ear pain, and discharge. Eyes: Complains of blurred vision associated with “reading and studying,” which has

worsened over the past few years. No visual acuity testing since childhood. Does not wear corrective lenses. Reports eye itching associated with exposure to cats. Denies discharge and pain. Nose: Rhinitis and congestion related to cat allergy. Denies sinus problems, frequent colds/infections, epistaxis, and change in smell. Mouth: Denies dental pain or problems, oral

lesions, and dry mouth, and changes in taste. Throat and Neck: Denies sore throat, dysphagia, and changes to voice quality. Denies goiter, hyper/hypothyroidism. Respiratory: Denies history of pneumonia, tuberculosis, and chronic bronchitis. Denies cough, dyspnea, current wheezing, hemoptysis, or recent cough. Cardiovascular: Denies palpitations, dyspnea on exertion, orthopnea paroxysmal nocturnal dyspnea, peripheral edema, varicosities, and pain in lower extremities. Reports no blanching in fingertips when exposed to cold. Gastrointestinal: Denies digestive problems, reflux, dysphagia, nausea, vomiting, diarrhea, constipation, changes in bowel habits, jaundice, abdominal pain, and bloody stools. Denies gallbladder and liver disease. Reports