Tina Jones shadow health
Chief Complaint - Answer
Scrape on foot. It is infected and causing pain(7 out of 10). - Answer
Right foot pain, fever, nausea - Answer
History of Present Illness - Answer
A week ago the scrape startedand the pain got a lot worse in last few days. - Answer
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 when she rests, and it hurts more when she
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. - Answer
Pain Assessment - Answer
6/7 out of 10 - Answer
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. - Answer
Allergies - Answer
Allergic to penicillin, and also allergic to cats. - Answer
• Penicillin: rash - Answer
• Cats: wheezing, itchy watery eyes, sneezing, asthma exacerbation - Answer
• No food allergies - Answer
• Not allergic to latex - Answer
Immunizations - Answer
Seasonal flu vaccine is not completed yet. - Answer
, Tina Jones shadow health
All other vaccines are given. - Answer
Up-to-date, tetanus booster within the last year. - Answer
Medications - Answer
Regular advil. - Answer
• Albuterol 90 mcg/spray MDI, 2 puffs, as needed for wheezing - Answer
• Acetaminophen 500 mg tabs by mouth, 1 - 2, as needed for pain or headache -
Answer
• Ibuprofen 200 mg tabs by mouth, 3 - 4, three times a day, as needed for cramps -
Answer
Medical History - Answer
Asthma, Diabetes. - Answer
Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler when she is around
cats. She rarely uses her inhaler. She was exposed to cats a few days ago and had to
use her inhaler once; she reports having to use three puffs instead of the prescribed
two. She was last hospitalized for asthma in high 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. - Answer
Surgical History - Answer
No surgeries. - Answer
No surgeries - Answer
Previous Hospitalizations - Answer
No hospital visit. - Answer
Last hospitalized for asthma exacerbation in high school. - Answer
Gynecological History - Answer
Bad periods. - Answer
Chief Complaint - Answer
Scrape on foot. It is infected and causing pain(7 out of 10). - Answer
Right foot pain, fever, nausea - Answer
History of Present Illness - Answer
A week ago the scrape startedand the pain got a lot worse in last few days. - Answer
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 when she rests, and it hurts more when she
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. - Answer
Pain Assessment - Answer
6/7 out of 10 - Answer
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. - Answer
Allergies - Answer
Allergic to penicillin, and also allergic to cats. - Answer
• Penicillin: rash - Answer
• Cats: wheezing, itchy watery eyes, sneezing, asthma exacerbation - Answer
• No food allergies - Answer
• Not allergic to latex - Answer
Immunizations - Answer
Seasonal flu vaccine is not completed yet. - Answer
, Tina Jones shadow health
All other vaccines are given. - Answer
Up-to-date, tetanus booster within the last year. - Answer
Medications - Answer
Regular advil. - Answer
• Albuterol 90 mcg/spray MDI, 2 puffs, as needed for wheezing - Answer
• Acetaminophen 500 mg tabs by mouth, 1 - 2, as needed for pain or headache -
Answer
• Ibuprofen 200 mg tabs by mouth, 3 - 4, three times a day, as needed for cramps -
Answer
Medical History - Answer
Asthma, Diabetes. - Answer
Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler when she is around
cats. She rarely uses her inhaler. She was exposed to cats a few days ago and had to
use her inhaler once; she reports having to use three puffs instead of the prescribed
two. She was last hospitalized for asthma in high 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. - Answer
Surgical History - Answer
No surgeries. - Answer
No surgeries - Answer
Previous Hospitalizations - Answer
No hospital visit. - Answer
Last hospitalized for asthma exacerbation in high school. - Answer
Gynecological History - Answer
Bad periods. - Answer
