Tina Jones Shadow Health Exam Latest Updated with Complete Solution 2025

Chief Complaint - ANSWER Scrape on foot. It is infected and causing pain(7 out of 10). - ANSWER Right foot pain, fever, nausea - ANSWER History of Present Illness - ANSWER A week ago the scrape startedand the pain got a lot worse in last few days. - 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. - ANSWER Pain Assessment - ANSWER 6/7 out of 10 - ANSWER 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. - ANSWER Allergies - ANSWER Allergic to penicillin, and also allergic to cats. - ANSWER • Penicillin: rash - ANSWER • Cats: wheezing, itchy watery eyes, sneezing, asthma exacerbation - ANSWER • No food allergies - ANSWER • Not allergic to latex - ANSWER Immunizations - ANSWER Seasonal flu vaccine is not completed yet. - ANSWER All other vaccines are given. - ANSWER Up-to-date, tetanus booster within the last year. - ANSWER Medications - ANSWER Regular advil. - ANSWER • Albuterol 90 mcg/spray MDI, 2 puffs, as needed for wheezing - ANSWER • Acetaminophen 500 mg tabs by mouth, 1 - 2, as needed for pain or headache - ANSWER • Ibuprofen 200 mg tabs by mouth, 3 - 4, three times a day, as needed for cramps - ANSWER Medical History - ANSWER Asthma, Diabetes. - ANSWER Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler when she is around cats. She rarely uses her inhaler. She was exposed to cats a few days ago and had to use her inhaler once; she reports having to use three puffs instead of the prescribed two. She was last hospitalized for asthma in high school. Never intubated. Type 2 diabetes, diagnosed at age 24. She used to take metformin but stopped taking it due to gastrointestinal problems. She doesn't monitor her blood sugar. She was last seen by a primary care doctor a few years ago. Her last dental exam was over two years ago. Last eye exam was in childhood. - ANSWER Surgical History - ANSWER No surgeries. - ANSWER No surgeries - ANSWER Previous Hospitalizations - ANSWER No hospital visit. - ANSWER