Shadow Health Health Assessment
Shift Assessment - ANSWERS-...
chief complaint - ANSWERS-Right foot pain, fever, nausea
History of Present Illness - ANSWERS-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 - ANSWERS-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 - ANSWERS-• Penicillin: rash
• Cats: wheezing, itchy watery eyes, sneezing, asthma exacerbation
• No food allergies
• Not allergic to latex
Shift Assessment - ANSWERS-...
chief complaint - ANSWERS-Right foot pain, fever, nausea
History of Present Illness - ANSWERS-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 - ANSWERS-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 - ANSWERS-• Penicillin: rash
• Cats: wheezing, itchy watery eyes, sneezing, asthma exacerbation
• No food allergies
• Not allergic to latex
