Shadow Health: Health Assessment
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1. Shift Assessment ...
2. chief complaint Right foot pain, fever, nausea
3. History of Pre- Ms. Jones is a pleasant 28-year-old African American woman who presented to the
sent Illness 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.
4. Pain Assessment 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.
5. Allergies • Penicillin: rash
• Cats: wheezing, itchy watery eyes, sneezing, asthma exacerbation
• No food allergies
• Not allergic to latex
6. Immunizations Up-to-date. Received tetanus and HPV vaccines within the last year. Denies recent
flu shot.
7. Medications
1/4
Study online at https://quizlet.com/_7fg4qs
1. Shift Assessment ...
2. chief complaint Right foot pain, fever, nausea
3. History of Pre- Ms. Jones is a pleasant 28-year-old African American woman who presented to the
sent Illness 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.
4. Pain Assessment 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.
5. Allergies • Penicillin: rash
• Cats: wheezing, itchy watery eyes, sneezing, asthma exacerbation
• No food allergies
• Not allergic to latex
6. Immunizations Up-to-date. Received tetanus and HPV vaccines within the last year. Denies recent
flu shot.
7. Medications
1/4
