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2026
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Chief Complaint
Scrape on foot. It is infected and causing pain(7
out of 10).
Right foot pain, fever, nausea
History of Present Illness
A week ago the scrape startedand the pain got a
lot worse in last few days.
, 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
6/7 out of 10
Pain is rated as 7. Pain is localized to ball of
foot related to wound. Dull and constant ache.
Patient has tried ibuprofen, but reports it does not
work well. Patient states there is relief when
foot is
elevated, not walking on it. Patient answers
questions clearly and consistently. Offers
information without hesitation. Vital signs are within
range.
Allergies
Allergic to penicillin, and also allergic to cats.
• Penicillin: rash
• Cats: wheezing, itchy watery eyes,
sneezing, asthma exacerbation
• No food allergies
• Not allergic to latex
Immunizations
Seasonal flu vaccine is not completed yet.
All other vaccines are given.
Up-to-date, tetanus booster within the last year.
Medications
Regular advil.