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, TINA JONES – SHADOW HEATH
Health history
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History of Present Illness:
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.
Pain Assessment:N
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.
Allergies:
Penicillin: rash • Cats: wheezing, itchy watery eyes, sneezing, asthma exacerbation • No
food allergies • Not allergic to latex
Immunization: Up-to-date, tetanus booster within the last year.
Medications:
• Albuterol 90 mcg/spray MDI, 2 puffs, as needed for wheezing • Acetaminophen 500
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
Medical History:
,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.
No surgeries
Previous hospitalization: Last hospitalized for asthma exacerbation in high school.
Gynecological HX: 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 hx:
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
Social history:
Never married, no children. Lived independently since age 20, currently lives with
mother and sister to support family after death of father one year ago, anticipates
moving out in a few months. She works 32 hours/week as a supervisor at a printing and
shipping company and is in her last semester of a bachelor’s of accounting program.
She hopes to advance to an accounting position within her company. Has a car, cell
phone, and computer. She receives basic health insurance from work, but is deterred
from healthcare due to out-of-pocket costs. She is very active in her Baptist church, faith
is important to her, and church community is a large part of her social network. No
exercise. She wears her seat belt, drives frequently. Guns are locked up. No tobacco.
Occasional alcohol (10 - 12 drinks/month). No concerns about alcoholism. Occasional
cannabis use from age 15 to age 21. She drinks four caffeinated drinks/day (diet soda).
No foreign travel. No pets. Not currently in an 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 systems:
Head: Reports headaches that occur weekly 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 polyphagia, polydipsia, nocturia for
the past month and polyuria for past few months.
Genitourinary: Denies flank pain, dysuria, urgency, and cloudy urine. Denies history of
recurrent urinary tract infections and kidney stones. Denies vaginal discharge and
vaginal itching. Menses irregular. No history of sexually transmitted infections. No
pregnancies.
Musculoskeletal: Denies history of fractures, gout, and arthritis. Denies myalgias and
arthralgias. Denies back and neck pain and trauma. Denies generalized weakness. Does
not exercise regularly.
Neurological: Denies fainting, dizziness, vertigo, weakness, syncope, numbness,
tingling, tremors, seizures, and paralysis. Reports occasional clumsiness. Denies history
of traumatic brain injury and meningitis. Denies recent changes in memory and mood
changes.
Skin, Hair, and Nails: Reports acne since puberty and occasional dry skin. Complains of
darkened skin on her neck and increase facial and body hair. She reports a few moles
but no other hair or nail changes.
, TINA JONES – SHADOW HEATH
Health history
wo
History of Present Illness:
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.
Pain Assessment:N
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.
Allergies:
Penicillin: rash • Cats: wheezing, itchy watery eyes, sneezing, asthma exacerbation • No
food allergies • Not allergic to latex
Immunization: Up-to-date, tetanus booster within the last year.
Medications:
• Albuterol 90 mcg/spray MDI, 2 puffs, as needed for wheezing • Acetaminophen 500
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
Medical History:
,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.
No surgeries
Previous hospitalization: Last hospitalized for asthma exacerbation in high school.
Gynecological HX: 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 hx:
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
Social history:
Never married, no children. Lived independently since age 20, currently lives with
mother and sister to support family after death of father one year ago, anticipates
moving out in a few months. She works 32 hours/week as a supervisor at a printing and
shipping company and is in her last semester of a bachelor’s of accounting program.
She hopes to advance to an accounting position within her company. Has a car, cell
phone, and computer. She receives basic health insurance from work, but is deterred
from healthcare due to out-of-pocket costs. She is very active in her Baptist church, faith
is important to her, and church community is a large part of her social network. No
exercise. She wears her seat belt, drives frequently. Guns are locked up. No tobacco.
Occasional alcohol (10 - 12 drinks/month). No concerns about alcoholism. Occasional
cannabis use from age 15 to age 21. She drinks four caffeinated drinks/day (diet soda).
No foreign travel. No pets. Not currently in an 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 systems:
Head: Reports headaches that occur weekly 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 polyphagia, polydipsia, nocturia for
the past month and polyuria for past few months.
Genitourinary: Denies flank pain, dysuria, urgency, and cloudy urine. Denies history of
recurrent urinary tract infections and kidney stones. Denies vaginal discharge and
vaginal itching. Menses irregular. No history of sexually transmitted infections. No
pregnancies.
Musculoskeletal: Denies history of fractures, gout, and arthritis. Denies myalgias and
arthralgias. Denies back and neck pain and trauma. Denies generalized weakness. Does
not exercise regularly.
Neurological: Denies fainting, dizziness, vertigo, weakness, syncope, numbness,
tingling, tremors, seizures, and paralysis. Reports occasional clumsiness. Denies history
of traumatic brain injury and meningitis. Denies recent changes in memory and mood
changes.
Skin, Hair, and Nails: Reports acne since puberty and occasional dry skin. Complains of
darkened skin on her neck and increase facial and body hair. She reports a few moles
but no other hair or nail changes.
