Shadow Health - Health History Exam
Why is it important to obtain a patient's complete health history? - ANSWER
Introduction to Tina - ANSWER My name is Kayla and I am a nursing student at Wichita
St. I will be completing your comprehensive health assessment today.
CC - ANSWER Do you know what brings you to the hospital today?
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T - 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.
Onset - When did your foot first start to hurt? - ANSWER Received scrape a week ago
and the pain got a lot worse in last few days.
Location - Where is the scrape located? Which foot? - ANSWER On the ball of R foot
How did you scrape your foot? - ANSWER She hurt the ball of her right foot by scraping
it on the edge of a metal step while changing a light bulb.
Duration - - ANSWER Constant pain.
Characteristics - ANSWER Pt describes pain as throbbing and sharp with ambulation.
Foot is red and swollen, hot
Pain Now: 7/10, Best: 4/10 w/ Advil Worst: 9/10 Tolerable: 3/10
Reports no odor. White pus.
How to ask tolerable pain - ANSWER What level of pain is acceptable to you?
Why is it important to obtain a patient's complete health history? - ANSWER
Introduction to Tina - ANSWER My name is Kayla and I am a nursing student at Wichita
St. I will be completing your comprehensive health assessment today.
CC - ANSWER Do you know what brings you to the hospital today?
O
L
D
C
A
R
T - 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.
Onset - When did your foot first start to hurt? - ANSWER Received scrape a week ago
and the pain got a lot worse in last few days.
Location - Where is the scrape located? Which foot? - ANSWER On the ball of R foot
How did you scrape your foot? - ANSWER She hurt the ball of her right foot by scraping
it on the edge of a metal step while changing a light bulb.
Duration - - ANSWER Constant pain.
Characteristics - ANSWER Pt describes pain as throbbing and sharp with ambulation.
Foot is red and swollen, hot
Pain Now: 7/10, Best: 4/10 w/ Advil Worst: 9/10 Tolerable: 3/10
Reports no odor. White pus.
How to ask tolerable pain - ANSWER What level of pain is acceptable to you?
