Shadow Health: Health Assessment
Allergies - ANS -• Penicillin: rash
• Cats: wheezing, itchy watery eyes, sneezing, asthma exacerbation
• No food allergies
• Not allergic to latex
\chief complaint - ANS -Right foot pain, fever, nausea
\Family History (3 generations) - ANS -• Father: died at age 58 in a car accident, history of hypertension, high cholesterol,
and type 2 diabetes
• Mother: hypertension, high cholesterol
• Brother: healthy
• Sister: asthma
• Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol
• Maternal grandfather: died at age 78 of a suspected myocardial infarction, history of hypertension, high cholesterol
• Paternal grandmother: still living, age 82, hypertension
• Paternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes
• Paternal uncle: alcoholism
\Gynecological History - ANS -Not sexually active, first sexual activity at age 18, never pregnant, last Pap smear more
than four years ago, tested for STIs at age 22, denies STI symptoms. From age 23 to age 26 took oral contraceptives as
only source of birth control, no condom use. Reports heavy, irregular periods, abnormal hair growth, and acne during
teenage years, and since stopping oral contraceptives 18 months ago.
\History of Present Illness - ANS -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
Allergies - ANS -• Penicillin: rash
• Cats: wheezing, itchy watery eyes, sneezing, asthma exacerbation
• No food allergies
• Not allergic to latex
\chief complaint - ANS -Right foot pain, fever, nausea
\Family History (3 generations) - ANS -• Father: died at age 58 in a car accident, history of hypertension, high cholesterol,
and type 2 diabetes
• Mother: hypertension, high cholesterol
• Brother: healthy
• Sister: asthma
• Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol
• Maternal grandfather: died at age 78 of a suspected myocardial infarction, history of hypertension, high cholesterol
• Paternal grandmother: still living, age 82, hypertension
• Paternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes
• Paternal uncle: alcoholism
\Gynecological History - ANS -Not sexually active, first sexual activity at age 18, never pregnant, last Pap smear more
than four years ago, tested for STIs at age 22, denies STI symptoms. From age 23 to age 26 took oral contraceptives as
only source of birth control, no condom use. Reports heavy, irregular periods, abnormal hair growth, and acne during
teenage years, and since stopping oral contraceptives 18 months ago.
\History of Present Illness - ANS -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
