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Shift Assessment • Not allergic to latex
chief complaint - ANSWER -Right foot pain,
fever, nausea Immunizations - ANSWER -Up-to-date.
Received tetanus and HPV vaccines within the
last year. Denies recent flu shot.
History of Present Illness - ANSWER -Ms.
Jones is a pleasant 28-year-old African American
woman who presented to the emergency Medications - ANSWER -• Albuterol 90
department for evaluation of a right foot injury mcg/spray MDI, 1-3 puffs, as needed for
and was admitted for IV antibiotics. She is a wheezing
good historian. She hurt the ball of her right foot • Acetaminophen 500 mg tabs by mouth, 1 - 2, as
by scraping it on the edge of a metal step while needed for pain or headache
changing a light bulb. The injury occurred about • Ibuprofen 200 mg tabs by mouth, 3 - 4, three
one week ago. Her pain has worsened, and the times a day, as needed for cramps
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. Medical History - ANSWER -Asthma
Her pain is a 9 when she tries to ambulate. She diagnosed at age 2 1/2. She uses her albuterol
took her temperature at home and reports it was inhaler when she experiences exacerbations,
102. She has not been eating much and has such as from dust or cats; she never uses it more
been staying in bed the last few days, per patient than twice a week. She was exposed to cats a
report. The scrape is red and swollen with few days ago and had to use her inhaler once.
exudate and has no odor; she reports the She is prescribed 1-3 puffs as needed; she
swelling and exudate started two days ago. She reports having to use 3 puffs occasionally, but
reports diarrhea overnight. Pain improved with usually 1-2. She was last hospitalized for asthma
oxycodone. Stomach upset. in high school. Never intubated. Type 2 diabetes,
diagnosed at age 24. She used to take metformin
but stopped taking it due to gastrointestinal
Pain Assessment - ANSWER -Pain is rated problems. She doesn't monitor her blood sugar.
as 7. Pain is localized to ball of foot related to She was last seen by a primary care doctor a few
wound. Dull and constant ache. Patient has tried years ago. Her last dental exam was over two
ibuprofen, but reports it does not work well. years ago. Last eye exam was in childhood.
Patient states there is relief when foot is
elevated, not walking on it. Patient answers
questions clearly and consistently. Offers Surgical History - ANSWER -No surgical
information without hesitation. Vital signs are history
within range.
Previous Hospitalizations - ANSWER -Last
Allergies - ANSWER -• Penicillin: rash hospitalized for asthma exacerbation in high
• Cats: wheezing, itchy watery eyes, sneezing, school.
asthma exacerbation
• No food allergies
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