7/12/2020 Health History | In Progress Attempt | Shadow Health
Health History (Part 3 of 3)
Advanced Health Assessment - Summer 2020, N5121
Return to Assignment (/assignments/336239/)
Self-Reflection
Activity Description:
These prompts help you think more deeply about your performance in the assignment. Reflective writing develops your clinical reasoning skills as you grow and improve as a
clinician, and gives your instructor insight into your learning process. The more detail and depth you provide in your responses, the more you will benefit from this activity.
Documentation Review
Document: Provide... Document: Provider Notes
Student Response Model Documentation
Identifying Data & Ms. Jones is seated on the exam table. She speaks clearly Ms. Jones is a pleasant, 28-year-old obese African Amer
Reliability and conherently. She answers questions freely and is a good single woman who presents to establish care and with a
source of information. recent right foot injury. She is the primary source of the
history. Ms. Jones offers information freely and without
contradiction. Speech is clear and coherent. She maintai
eye contact throughout the interview.
General Survey Ms. Jones is alert and oriented. She is dressed appropriately Ms. Jones is alert and oriented, seated upright on the
with good hygiene. She is in pain, but is interacting examination table, and is in no apparent distress. She is
appropriately. nourished, well-developed, and dressed appropriately wi
good hygiene.
Chief Complaint scrape on foot now healing and pain is getting worse “I got this scrape on my foot a while ago, and I thought it
would heal up on its own, but now it's looking pretty nast
And the pain is killing me!”
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, 7/12/2020 Health History | In Progress Attempt | Shadow Health
Student Response Model Documentation
History Of Present This 28-year-old African American female patient is new to Ms. Jones reports that a week ago she tripped while wal
Illness the practice. She scraped the bottom of her right foot a week on concrete stairs outside, twisting her right ankle and
ago when she tripped going down steps. Presented to the ER scraping the ball of her foot. She sought care in a local
then, no broken bones. She was prescribed Tramadol. The emergency department where she had x-rays that were
pain has gotten worse over the last few days. She developed negative; she was treated with tramadol for pain. She ha
fever last night and the pain is moving up to her ankle, been cleansing the site twice a day. She has been applyi
throbbing pain 7/10. The wound is red and swollen with white antibiotic ointment and a bandage. She reports that ankl
pus coming from the wound. She is unable to bear weight on swelling and pain have resolved but that the bottom of th
her right foot. foot is increasingly painful. The pain is described as
“throbbing” and “sharp” with weight bearing. She states h
ankle “ached” but is resolved. Pain is rated 7 out of 10 af
recent dose of tramadol. Pain is rated 9 with weight bear
She reports that over the past two days the ball of the fo
has become swollen and increasingly red; yesterday she
noted discharge oozing from the wound. She denies any
from the wound. Her shoes feel tight. She has been wea
slip-ons. She reports fever of 102 last night. She denies
recent illness. Reports a 10-pound, unintentional weight
over the month and increased appetite. Denies change i
or level of activity.
Medications Tramadol 100 mg PO TID PRN Acetaminophen 500-1000 mg PO prn (headaches) •
Proventil inhaler 90 mcg/actuation PRN 2 puffs Ibuprofen 600 mg PO TID prn (menstrual cramps) • Tram
Tylenol 500 mg PO PRN headaches 50 mg PO TID prn (foot pain) • Albuterol 90 mcg/spray M
Advil 600 mg PO PRN cramps puffs Q4H prn (Wheezing: “when around cats,” last use t
Denies taking any supplements or herbals days ago)
Allergies penicillin - mild hives and rash Penicillin: rash • Denies food and latex allergies • Allergic
Cats - induces asthma cats and dust. When she is exposed to allergens she sta
that she has runny nose, itchy and swollen eyes, and
increased asthma symptoms.
Medical History noncompliant Type 2 diabetic: diagnosed at age 24, Asthma diagnosed at age 2 1/2. She uses her albuterol
prescribed metformin, but stopped taking 3 years ago. She inhaler when she is around cats and dust. She uses her
does not monitor her blood glucose. inhaler 2 to 3 times per week. She was exposed to cats t
Asthma: induced by cats, chest and throat tighten, wheezing; days ago and had to use her inhaler once with positive r
She was hospitalized for her asthma at age 16 when her of symptoms. She was last hospitalized for asthma “in hi
inhaler would not work. school”. Never intubated. Type 2 diabetes, diagnosed at
Unintentional weight loss - lost 10 pounds last month 24. She previously took metformin, but she stopped thre
last menstrual period was 3 weeks ago, last gynecology years ago, stating that the pills made her gassy and “it w
appointment was 4 years ago. denies ever being pregnant. overwhelming, taking pills and checking my sugar.” She
Does not currently take birth control. doesn't monitor her blood sugar. Last blood glucose was
No history of surgeries. elevated last week in the emergency room. No surgeries
OB/GYN: Menarche, age 11. First sexual encounter at a
18, sex with men, identifies as heterosexual. Never preg
Last menstrual period 3 weeks ago. For the past year cy
irregular (every 4-8 weeks) with heavy bleeding lasting 9
days. No current partner. Used oral contraceptives in the
past. When sexually active, reports she did not use cond
Never tested for HIV/AIDS. No history of STIs or STI
symptoms. Last tested for STIs four years ago. Hematol
Denies bleeding, bruising, blood transfusions and history
blood clots. Skin: Reports acne since puberty and bumps
the back of her arms when her skin is dry. Complains of
darkened skin on her neck and increase facial and body
She reports a few moles but no other hair or nail change
https://app.shadowhealth.com/assignment_attempts/7315330 2/5
Health History (Part 3 of 3)
Advanced Health Assessment - Summer 2020, N5121
Return to Assignment (/assignments/336239/)
Self-Reflection
Activity Description:
These prompts help you think more deeply about your performance in the assignment. Reflective writing develops your clinical reasoning skills as you grow and improve as a
clinician, and gives your instructor insight into your learning process. The more detail and depth you provide in your responses, the more you will benefit from this activity.
Documentation Review
Document: Provide... Document: Provider Notes
Student Response Model Documentation
Identifying Data & Ms. Jones is seated on the exam table. She speaks clearly Ms. Jones is a pleasant, 28-year-old obese African Amer
Reliability and conherently. She answers questions freely and is a good single woman who presents to establish care and with a
source of information. recent right foot injury. She is the primary source of the
history. Ms. Jones offers information freely and without
contradiction. Speech is clear and coherent. She maintai
eye contact throughout the interview.
General Survey Ms. Jones is alert and oriented. She is dressed appropriately Ms. Jones is alert and oriented, seated upright on the
with good hygiene. She is in pain, but is interacting examination table, and is in no apparent distress. She is
appropriately. nourished, well-developed, and dressed appropriately wi
good hygiene.
Chief Complaint scrape on foot now healing and pain is getting worse “I got this scrape on my foot a while ago, and I thought it
would heal up on its own, but now it's looking pretty nast
And the pain is killing me!”
https://app.shadowhealth.com/assignment_attempts/7315330 1/5
, 7/12/2020 Health History | In Progress Attempt | Shadow Health
Student Response Model Documentation
History Of Present This 28-year-old African American female patient is new to Ms. Jones reports that a week ago she tripped while wal
Illness the practice. She scraped the bottom of her right foot a week on concrete stairs outside, twisting her right ankle and
ago when she tripped going down steps. Presented to the ER scraping the ball of her foot. She sought care in a local
then, no broken bones. She was prescribed Tramadol. The emergency department where she had x-rays that were
pain has gotten worse over the last few days. She developed negative; she was treated with tramadol for pain. She ha
fever last night and the pain is moving up to her ankle, been cleansing the site twice a day. She has been applyi
throbbing pain 7/10. The wound is red and swollen with white antibiotic ointment and a bandage. She reports that ankl
pus coming from the wound. She is unable to bear weight on swelling and pain have resolved but that the bottom of th
her right foot. foot is increasingly painful. The pain is described as
“throbbing” and “sharp” with weight bearing. She states h
ankle “ached” but is resolved. Pain is rated 7 out of 10 af
recent dose of tramadol. Pain is rated 9 with weight bear
She reports that over the past two days the ball of the fo
has become swollen and increasingly red; yesterday she
noted discharge oozing from the wound. She denies any
from the wound. Her shoes feel tight. She has been wea
slip-ons. She reports fever of 102 last night. She denies
recent illness. Reports a 10-pound, unintentional weight
over the month and increased appetite. Denies change i
or level of activity.
Medications Tramadol 100 mg PO TID PRN Acetaminophen 500-1000 mg PO prn (headaches) •
Proventil inhaler 90 mcg/actuation PRN 2 puffs Ibuprofen 600 mg PO TID prn (menstrual cramps) • Tram
Tylenol 500 mg PO PRN headaches 50 mg PO TID prn (foot pain) • Albuterol 90 mcg/spray M
Advil 600 mg PO PRN cramps puffs Q4H prn (Wheezing: “when around cats,” last use t
Denies taking any supplements or herbals days ago)
Allergies penicillin - mild hives and rash Penicillin: rash • Denies food and latex allergies • Allergic
Cats - induces asthma cats and dust. When she is exposed to allergens she sta
that she has runny nose, itchy and swollen eyes, and
increased asthma symptoms.
Medical History noncompliant Type 2 diabetic: diagnosed at age 24, Asthma diagnosed at age 2 1/2. She uses her albuterol
prescribed metformin, but stopped taking 3 years ago. She inhaler when she is around cats and dust. She uses her
does not monitor her blood glucose. inhaler 2 to 3 times per week. She was exposed to cats t
Asthma: induced by cats, chest and throat tighten, wheezing; days ago and had to use her inhaler once with positive r
She was hospitalized for her asthma at age 16 when her of symptoms. She was last hospitalized for asthma “in hi
inhaler would not work. school”. Never intubated. Type 2 diabetes, diagnosed at
Unintentional weight loss - lost 10 pounds last month 24. She previously took metformin, but she stopped thre
last menstrual period was 3 weeks ago, last gynecology years ago, stating that the pills made her gassy and “it w
appointment was 4 years ago. denies ever being pregnant. overwhelming, taking pills and checking my sugar.” She
Does not currently take birth control. doesn't monitor her blood sugar. Last blood glucose was
No history of surgeries. elevated last week in the emergency room. No surgeries
OB/GYN: Menarche, age 11. First sexual encounter at a
18, sex with men, identifies as heterosexual. Never preg
Last menstrual period 3 weeks ago. For the past year cy
irregular (every 4-8 weeks) with heavy bleeding lasting 9
days. No current partner. Used oral contraceptives in the
past. When sexually active, reports she did not use cond
Never tested for HIV/AIDS. No history of STIs or STI
symptoms. Last tested for STIs four years ago. Hematol
Denies bleeding, bruising, blood transfusions and history
blood clots. Skin: Reports acne since puberty and bumps
the back of her arms when her skin is dry. Complains of
darkened skin on her neck and increase facial and body
She reports a few moles but no other hair or nail change
https://app.shadowhealth.com/assignment_attempts/7315330 2/5
