SHADOW HEALTH: HEALTH ASSESSMENT ACTUAL EXAM
Shift Assessment - ANSWER-...
chief complaint - ANSWER-Right foot pain, fever, nausea
History of Present Illness - 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.
Pain Assessment - 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.
Allergies - ANSWER-• Penicillin: rash
• Cats: wheezing, itchy watery eyes, sneezing, asthma exacerbation
• No food allergies
• Not allergic to latex
Immunizations - ANSWER-Up-to-date. Received tetanus and HPV vaccines within the
last year. Denies recent flu shot.
Medications - ANSWER-• Albuterol 90 mcg/spray MDI, 1-3 puffs, as needed for
wheezing
• Acetaminophen 500 mg tabs by mouth, 1 - 2, as needed for pain or headache
• Ibuprofen 200 mg tabs by mouth, 3 - 4, three times a day, as needed for cramps
Medical History - ANSWER-Asthma diagnosed at age 2 1/2. She uses her albuterol
inhaler when she experiences exacerbations, such as from dust or cats; she never uses
it more than twice a week. She was exposed to cats a few days ago and had to use her
inhaler once. She is prescribed 1-3 puffs as needed; she reports having to use 3 puffs
occasionally, but usually 1-2. 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.
Shift Assessment - ANSWER-...
chief complaint - ANSWER-Right foot pain, fever, nausea
History of Present Illness - 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.
Pain Assessment - 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.
Allergies - ANSWER-• Penicillin: rash
• Cats: wheezing, itchy watery eyes, sneezing, asthma exacerbation
• No food allergies
• Not allergic to latex
Immunizations - ANSWER-Up-to-date. Received tetanus and HPV vaccines within the
last year. Denies recent flu shot.
Medications - ANSWER-• Albuterol 90 mcg/spray MDI, 1-3 puffs, as needed for
wheezing
• Acetaminophen 500 mg tabs by mouth, 1 - 2, as needed for pain or headache
• Ibuprofen 200 mg tabs by mouth, 3 - 4, three times a day, as needed for cramps
Medical History - ANSWER-Asthma diagnosed at age 2 1/2. She uses her albuterol
inhaler when she experiences exacerbations, such as from dust or cats; she never uses
it more than twice a week. She was exposed to cats a few days ago and had to use her
inhaler once. She is prescribed 1-3 puffs as needed; she reports having to use 3 puffs
occasionally, but usually 1-2. 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.
