Exam (elaborations)
Tina Jones shadow health/66 Exam Questions And Answers
Tina Jones shadow health/66 Exam Questions And Answers
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Tina Jones shadow health/66 ExamQuestions And Answers
Chief Complaint - -
-Scrape on foot. It is infected and causing pain(7 out of 10). - -
-Right foot pain, fever, nausea - -
-History of Present Illness - -
-A week ago the scrape startedand the pain got a lot worse in last few days.
- -
-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 - -
-6/7 out of 10 - -
-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 - -
-Allergic to penicillin, and also allergic to cats. - -
-• Penicillin: rash - -
, -• Cats: wheezing, itchy watery eyes, sneezing, asthma exacerbation - -
-• No food allergies - -
-• Not allergic to latex - -
-Immunizations - -
-Seasonal flu vaccine is not completed yet. - -
-All other vaccines are given. - -
-Up-to-date, tetanus booster within the last year. - -
-Medications - -
-Regular advil. - -
-• Albuterol 90 mcg/spray MDI, 2 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 - -
-Asthma, Diabetes. - -
-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. - -
-Surgical History - -
-No surgeries. - -
-No surgeries - -
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