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7/13/25, 4:33 PM | Shadow Health® │ Digital Clinical Experiences™ from Elsevier
Health History Results | Completed
Summer 2025 RN-BSN NSG 323_Session 1
Return to Assignment (/assignments/1183172/)
Your Results Turn In (/assignment_attempts/19135571/choose
Student Results Book (/assignments/1183172/results_books/1183172?section=16243
Lab Pass (/assignment_attempts/19135571/lab_pass.pd
Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Collection Nursing Notes Flowsheets
Education & Empathy
Nursing Notes
Documentation
Interpret Findings Student Documentation Model Documentation
SBAR Chief Complaint
Video Tutorial Wound to right foot, pain, fever
RIght foot pain, fever, nausea
Health History Tips and Tricks
Student Survey
Ms. Jones is a 28-year-old female who presented to t
emergency department for evaluation of a right foot in
and was admitted for IV antibiotics. She is a good
historian. She injured the plantar surface of her right f
by scraping it on the edge of a metal step while chang
History of Present Illness a light bulb.
Miss Jones is a 28 year old African-American woman The injury occurred about one week ago. She rates h
who presented to the emergency department for pain as 7/10. She states the pain has worsened over
evaluation of a right foot injury and was admitted for IV past 2 days and is radiating into her ankle. The swelli
antibiotics. She is a good historian. She heard the ball of has persisted.
her right foot by scraping it on the edge of a metal step
while changing a light bulb. The injury occurred one week She tried ibuprofen with minimal relief. The foot feels
ago. The pain has worsened and the swelling has better when she rests, and it hurts more when she
persisted. She initially tried ibuprofen and Neosporin, but ambulates. She has been cleaning and bandaging the
it didn't work well. She states that her foot feels better wound twice daily and applying bacitracin, neomycin,
when she rests and hurts more when she walks. Her polymyxin B ointment without improvement.
current pain level is a 7 out of 10. The scrape is red and
swollen with drainage, but no odor. She took her temperature at home and reported it wa
high as 38.9 degrees Celsius. She has not been eatin
much and has been staying in bed the last few days,
patient report. The scrape is red and swollen with
exudate and has no odor; she reports the swelling an
exudate started two days ago. Pain improved with
oxycodone.
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Student Documentation Model Documentation
Allergies
• Penicillin: rash
Penicillian: rash • Cats: wheezing, itchy watery eyes, snee
Cats: itchy, wheezing, sneezing, asthma exacerbation • Dust: wheezing, itchy watery eyes, snee
• No food allergies
No food or environmental allergies. Not allergic to latex. • Not allergic to latex
Immunizations
Up-to-date. Received tetanus and HPV va
up to date. denies recent flu shot. tetanus booster within the last year. Received COVID vaccination. Denies rece
Medications
• Albuterol 90 mcg/spray MDI, 1-3 puffs, a
Albuterol 90mcg/spray MDI: 1-3 puffs prn wheezing • Acetaminophen 500 mg tabs by mouth,
or headache
Acetaminophen 500mg tabs po prn headache • Ibuprofen 200 mg tabs by mouth, 3 – 4 t
needed for pain
Patient unsure of ibuprofen dose but states it is not the extra strength
Past Medical History
Asthma diagnosed at age 2 1/2. She uses
Asthma diagnosed at 2.5 years old. She uses albuterol inhaler as needed. experiences exacerbations, such as from
Never uses more than twice a week more than twice a week. She was expose
to use her inhaler once. She is prescribed
Type 2 DM diagnosed at age 24. Previously took Metformin but stopped having to use 3 puffs occasionally, but usu
taking it due to gastrointestinal problems. She does not monitor blood hospitalized for asthma in high school. Ne
sugar regularly. Last PCP visit was 3 years ago. Last dental exam was over diagnosed at age 24. She used to take me
a few years ago. Last vision exam in childhood. to gastrointestinal problems. She doesn’t
last seen by a primary care doctor a few y
Patient denies any surgies. Last hospitalized for asthma exacerbation in was over two years ago. Last eye exam w
high school.
Never married, no children. Lived indepen
lives with mother and sister to support fam
ago, anticipates moving out in a few mont
at home and denies any history of abuse.
She works 32 hours/week as a supervisor
Social History company and is in her last semester of a b
She hopes to advance to an accounting p
Patient denies anys sexual intercourse in the last two years. Patient reports car, cell phone, and computer. She receiv
heavy periods and denies pregnancy. Patient reports social alcohol use. work, but is deterred from healthcare due
Patient denies any current drug or tobacco use, but reports past history of
marijuana use during high school and right after. She is very active in her Baptist church, fa
church community is a large part of her so
wears her seat belt, drives frequently. Gun
Occasional alcohol (10 - 12 drinks/month)
Occasional cannabis use from age 15 to a
caffeinated drinks/day (diet soda). No fore
in an intimate relationship. She plans on g
children someday. She denies suicidal an
This study source was downloaded by 1827175 from cliffsnotes.com on 01-08-2026 20:28:52 GMT -06:00
2 https://app.shadowhealth.com/assignment_attempts/19135571 2/5
09/01/2026
https://www.cliffsnotes.com//study-notes/27987922
7/13/25, 4:33 PM | Shadow Health® │ Digital Clinical Experiences™ from Elsevier
Health History Results | Completed
Summer 2025 RN-BSN NSG 323_Session 1
Return to Assignment (/assignments/1183172/)
Your Results Turn In (/assignment_attempts/19135571/choose
Student Results Book (/assignments/1183172/results_books/1183172?section=16243
Lab Pass (/assignment_attempts/19135571/lab_pass.pd
Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Collection Nursing Notes Flowsheets
Education & Empathy
Nursing Notes
Documentation
Interpret Findings Student Documentation Model Documentation
SBAR Chief Complaint
Video Tutorial Wound to right foot, pain, fever
RIght foot pain, fever, nausea
Health History Tips and Tricks
Student Survey
Ms. Jones is a 28-year-old female who presented to t
emergency department for evaluation of a right foot in
and was admitted for IV antibiotics. She is a good
historian. She injured the plantar surface of her right f
by scraping it on the edge of a metal step while chang
History of Present Illness a light bulb.
Miss Jones is a 28 year old African-American woman The injury occurred about one week ago. She rates h
who presented to the emergency department for pain as 7/10. She states the pain has worsened over
evaluation of a right foot injury and was admitted for IV past 2 days and is radiating into her ankle. The swelli
antibiotics. She is a good historian. She heard the ball of has persisted.
her right foot by scraping it on the edge of a metal step
while changing a light bulb. The injury occurred one week She tried ibuprofen with minimal relief. The foot feels
ago. The pain has worsened and the swelling has better when she rests, and it hurts more when she
persisted. She initially tried ibuprofen and Neosporin, but ambulates. She has been cleaning and bandaging the
it didn't work well. She states that her foot feels better wound twice daily and applying bacitracin, neomycin,
when she rests and hurts more when she walks. Her polymyxin B ointment without improvement.
current pain level is a 7 out of 10. The scrape is red and
swollen with drainage, but no odor. She took her temperature at home and reported it wa
high as 38.9 degrees Celsius. She has not been eatin
much and has been staying in bed the last few days,
patient report. The scrape is red and swollen with
exudate and has no odor; she reports the swelling an
exudate started two days ago. Pain improved with
oxycodone.
This study source was downloaded by 1827175 from cliffsnotes.com on 01-08-2026 20:28:52 GMT -06:00
1 https://app.shadowhealth.com/assignment_attempts/19135571 1/5
09/01/2026
https://www.cliffsnotes.com//study-notes/27987922
, @2027// Q&A | 100% Verified Start your exams prepared! solutions.
7/13/25, 4:33 PM | Shadow Health® │ Digital Clinical Experiences™ from Elsevier
Student Documentation Model Documentation
Allergies
• Penicillin: rash
Penicillian: rash • Cats: wheezing, itchy watery eyes, snee
Cats: itchy, wheezing, sneezing, asthma exacerbation • Dust: wheezing, itchy watery eyes, snee
• No food allergies
No food or environmental allergies. Not allergic to latex. • Not allergic to latex
Immunizations
Up-to-date. Received tetanus and HPV va
up to date. denies recent flu shot. tetanus booster within the last year. Received COVID vaccination. Denies rece
Medications
• Albuterol 90 mcg/spray MDI, 1-3 puffs, a
Albuterol 90mcg/spray MDI: 1-3 puffs prn wheezing • Acetaminophen 500 mg tabs by mouth,
or headache
Acetaminophen 500mg tabs po prn headache • Ibuprofen 200 mg tabs by mouth, 3 – 4 t
needed for pain
Patient unsure of ibuprofen dose but states it is not the extra strength
Past Medical History
Asthma diagnosed at age 2 1/2. She uses
Asthma diagnosed at 2.5 years old. She uses albuterol inhaler as needed. experiences exacerbations, such as from
Never uses more than twice a week more than twice a week. She was expose
to use her inhaler once. She is prescribed
Type 2 DM diagnosed at age 24. Previously took Metformin but stopped having to use 3 puffs occasionally, but usu
taking it due to gastrointestinal problems. She does not monitor blood hospitalized for asthma in high school. Ne
sugar regularly. Last PCP visit was 3 years ago. Last dental exam was over diagnosed at age 24. She used to take me
a few years ago. Last vision exam in childhood. to gastrointestinal problems. She doesn’t
last seen by a primary care doctor a few y
Patient denies any surgies. Last hospitalized for asthma exacerbation in was over two years ago. Last eye exam w
high school.
Never married, no children. Lived indepen
lives with mother and sister to support fam
ago, anticipates moving out in a few mont
at home and denies any history of abuse.
She works 32 hours/week as a supervisor
Social History company and is in her last semester of a b
She hopes to advance to an accounting p
Patient denies anys sexual intercourse in the last two years. Patient reports car, cell phone, and computer. She receiv
heavy periods and denies pregnancy. Patient reports social alcohol use. work, but is deterred from healthcare due
Patient denies any current drug or tobacco use, but reports past history of
marijuana use during high school and right after. She is very active in her Baptist church, fa
church community is a large part of her so
wears her seat belt, drives frequently. Gun
Occasional alcohol (10 - 12 drinks/month)
Occasional cannabis use from age 15 to a
caffeinated drinks/day (diet soda). No fore
in an intimate relationship. She plans on g
children someday. She denies suicidal an
This study source was downloaded by 1827175 from cliffsnotes.com on 01-08-2026 20:28:52 GMT -06:00
2 https://app.shadowhealth.com/assignment_attempts/19135571 2/5
09/01/2026
https://www.cliffsnotes.com//study-notes/27987922
