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Tina Jones shadow health

Terms in this set (66)

Chief Complaint
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Scrape on foot. It is infected and causing pain(7 out of 10).
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Right foot pain, fever, nausea
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History of Present Illness
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A week ago the scrape startedand the pain got a lot worse in last few days.
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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.
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Pain Assessment
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6/7 out of 10
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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.
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Allergies
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Allergic to penicillin, and also allergic to cats.
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• Penicillin: rash
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• Cats: wheezing, itchy watery eyes, sneezing, asthma exacerbation
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• No food allergies
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• Not allergic to latex
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Immunizations
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Seasonal flu vaccine is not completed yet.
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All other vaccines are given.
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Up-to-date, tetanus booster within the last year.
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Medications
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Regular advil.
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• Albuterol 90 mcg/spray MDI, 2 puffs, as needed for wheezing
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• Acetaminophen 500 mg tabs by mouth, 1 - 2, as needed for pain or headache
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• Ibuprofen 200 mg tabs by mouth, 3 - 4, three times a day, as needed for cramps
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Medical History
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Asthma, Diabetes.
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Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler when she is around cats. She rarely uses her inhaler. She was exposed to cats a few days ago and had to use her inhaler once; she reports having to use three puffs instead of the prescribed two. 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. She was last seen by a primary care doctor a few years ago. Her last dental exam was over two years ago. Last eye exam was in childhood.
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Surgical History
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No surgeries.
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No surgeries
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Previous Hospitalizations
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No hospital visit.
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Last hospitalized for asthma exacerbation in high school.
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Gynecological History
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Bad periods.
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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.
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Family History (3 generations)
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High BP and high cholesterolon both sides and diabetes.
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Grandpa jones had colon cancer.
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• Father: died at age 58 in a car accident, history of hypertension, high cholesterol, and type 2 diabetes
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• Mother: hypertension, high cholesterol
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• Brother: healthy
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• Sister: asthma
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• Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol
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• Maternal grandfather: died at age 78 of a suspected myocardial infarction, history of hypertension, high cholesterol
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• Paternal grandmother: still living, age 82, hypertension
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• Paternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes
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• Paternal uncle: alcoholism
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Social History
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Sometimes drink, once or twice in a week, sometimes less.
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Never married, no children. Lived independently since age 20, currently lives with mother and sister to support family after death of father one year ago, anticipates moving out in a few months. She works 32 hours/week as a supervisor at a printing and shipping company and is in her last semester of a bachelor's of accounting program. She hopes to advance to an accounting position within her company. Has a car, cell phone, and computer. She receives basic health insurance from work, but is deterred from healthcare due to out-of-pocket costs. She is very active in her Baptist church, faith is important to her, and church community is a large part of her social network. No exercise. She wears her seat belt, drives frequently. Guns are locked up. No tobacco. Occasional alcohol (10 - 12 drinks/month). No concerns about alcoholism. Occasional cannabis use from age 15 to age 21. She drinks four caffeinated drinks/day (diet soda). No foreign travel. No pets. Not currently in an intimate relationship, ended a three-year serious monogamous relationship two years ago. She plans on getting married and having children someday. She denies suicidal and homicidal ideation.
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Review of Systems
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resiratory problems. asthma.
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Head: Reports headaches that occur weekly with reading in the past year. The headache lasts a few hours and is relieved with acetaminophen and sleep. Headaches are described as a "tight and throbbing feeling behind the eyes." Denies head and neck trauma.
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Ears: Denies difficulty hearing, tinnitus, ear pain, and discharge.
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Eyes: Complains of blurred vision associated with "reading and studying," which has worsened over the past few years. No visual acuity testing since childhood. Does not wear corrective lenses. Reports eye itching associated with exposure to cats. Denies discharge and pain.
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Nose: Rhinitis and congestion related to cat allergy. Denies sinus problems, frequent colds/infections, epistaxis, and change in smell.
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Mouth: Denies dental pain or problems, oral lesions, and dry mouth, and changes in taste.
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Throat and Neck: Denies sore throat, dysphagia, and changes to voice quality. Denies goiter, hyper/hypothyroidism.
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Respiratory: Denies history of pneumonia, tuberculosis, and chronic bronchitis. Denies cough, dyspnea, current wheezing, hemoptysis, or recent cough.
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Cardiovascular: Denies palpitations, dyspnea on exertion, orthopnea paroxysmal nocturnal dyspnea, peripheral edema, varicosities, and pain in lower extremities. Reports no blanching in fingertips when exposed to cold.
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Gastrointestinal: Denies digestive problems, reflux, dysphagia, nausea, vomiting, diarrhea, constipation, changes in bowel habits, jaundice, abdominal pain, and bloody stools. Denies gallbladder and liver disease. Reports polyphagia, polydipsia, nocturia for the past month and polyuria for past few months.
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Genitourinary: Denies flank pain, dysuria, urgency, and cloudy urine. Denies history of recurrent urinary tract infections and kidney stones. Denies vaginal discharge and vaginal itching. Menses irregular. No history of sexually transmitted infections. No pregnancies.
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Musculoskeletal: Denies history of fractures, gout, and arthritis. Denies myalgias and arthralgias. Denies back and neck pain and trauma. Denies generalized weakness. Does not exercise regularly.
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Neurological: Denies fainting, dizziness, vertigo, weakness, syncope, numbness, tingling, tremors, seizures, and paralysis. Reports occasional clumsiness. Denies history of traumatic brain injury and meningitis. Denies recent changes in memory and mood changes.
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Skin, Hair, and Nails: Reports acne since puberty and occasional dry skin. Complains of darkened skin on her neck and increase facial and body hair. She reports a few moles but no other hair or nail changes.
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