1
Shadow Health: Health Assessment
Allergies - ANSWER • Penicillin: rash
• Cats: wheezing, itchy watery eyes, sneezing, asthma exacerbation
m
• No food allergies
.co
• Not allergic to latex
ail
gm
chief complaint - ANSWER Right foot pain, fever, nausea
r@
Family History (3 generations) - ANSWER • Father: died at age 58 in a car accident,
he
history of hypertension, high cholesterol, and type 2 diabetes
hig
• Mother: hypertension, high cholesterol
• Brother: healthy
ing
• Sister: asthma
fly
• 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
, 2
• Paternal grandmother: still living, age 82, hypertension
• Paternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes
• Paternal uncle: alcoholism
Gynecological History - ANSWER Not sexually active, first sexual activity at age 18,
m
never pregnant, last Pap smear more than four years ago, tested for STIs at age 22, denies
.co
STI symptoms. From age 23 to age 26 took oral contraceptives as only source of birth
ail
control, no condom use. Reports heavy, irregular periods, abnormal hair growth, and
gm
acne during teenage years, and since stopping oral contraceptives 18 months ago.
r@
History of Present Illness - ANSWER Ms. Jones is a pleasant 28-year-old African
he
American woman who presented to the emergency department for evaluation of a right
hig
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.
ing
The injury occurred about one week ago. Her pain has worsened, and the swelling has
fly
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
Shadow Health: Health Assessment
Allergies - ANSWER • Penicillin: rash
• Cats: wheezing, itchy watery eyes, sneezing, asthma exacerbation
m
• No food allergies
.co
• Not allergic to latex
ail
gm
chief complaint - ANSWER Right foot pain, fever, nausea
r@
Family History (3 generations) - ANSWER • Father: died at age 58 in a car accident,
he
history of hypertension, high cholesterol, and type 2 diabetes
hig
• Mother: hypertension, high cholesterol
• Brother: healthy
ing
• Sister: asthma
fly
• 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
, 2
• Paternal grandmother: still living, age 82, hypertension
• Paternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes
• Paternal uncle: alcoholism
Gynecological History - ANSWER Not sexually active, first sexual activity at age 18,
m
never pregnant, last Pap smear more than four years ago, tested for STIs at age 22, denies
.co
STI symptoms. From age 23 to age 26 took oral contraceptives as only source of birth
ail
control, no condom use. Reports heavy, irregular periods, abnormal hair growth, and
gm
acne during teenage years, and since stopping oral contraceptives 18 months ago.
r@
History of Present Illness - ANSWER Ms. Jones is a pleasant 28-year-old African
he
American woman who presented to the emergency department for evaluation of a right
hig
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.
ing
The injury occurred about one week ago. Her pain has worsened, and the swelling has
fly
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
