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Tina Jones Health History In Progress Attempt Shadow Health® │ Digital Clinical Experiences™ from Elsevier
Health Assessment and Promotion (NRSE 4520)
Ohio University
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Health History (Part 3 of 3)
Health Assessment - NRSE 4520 - March 2024
Self-Reflection
Activity Description: These prompts help you think more deeply about your performance in the assignment. Reflective writing develops your clinical reasoning skills as you grow and improve as a clinician, and gives your instructor insight into your learning process. The more detail and depth you provide in your responses, the more you will benefit from this activity.
Documentation Review
Shift Assessment
Student Response Model Documentation
Chief Complaint Arrived to hospital for possible infection from right foot injury
Right foot pain, fever, nausea
History of Present Illness
Patient slipped off ladder and scrapped right foot about a week ago. Patient states the site started to become edematous and erythematic about two days ago with a noted fever of 102F last night. Wound drainage is white to off-white in color. Patient denies any odor from drainage. Patient cleansed and applied bandage with topical neosporin BID to right foot wound. Patient reports taking two advil TID for pain.
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
Shift Assessment
Nursing Progress ...
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 Patient reports a continous, throbbing, pain level of 7 out of 10 for the past few days in their right foot.
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 Patient reports allergies to Penicillin. Reaction presents with hives and rash.
Allergies to cats
- Penicillin: rash
- Cats: wheezing, itchy watery eyes, sneezing, asthma exacerbation
- No food allergies
- Not allergic to latex
Immunizations Patient reports receiving Childhood scheduled vaccinations and a recent booster shot for tetanus within the last year. Patient denies receiving flu vaccination.
Up-to-date. Received tetanus and HPV vaccines within the last year. Denies recent flu shot.
Medications Advil two tablets TID for pain in the right foot
Tylenol 500mg to 1000mg occassionally for headaches
Albuterol 90mcg/puff two puff PRN; patient reports needing to use about twice a week
Patient denies taking metformin for type 2 diabetes due to being "sick of dealing with it"
Denies taking OTC medications or supplements.
- Albuterol 90 mcg/spray MDI, 1-3 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 Diabetes type two age 24. Patient non-compliant with medication. Denies daily blood glucose monitoring.
Asthma at age 2 triggered by cats, dust, and exercise.
Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler when she experiences exacerbations, such as from dust or cats; she never uses it more than twice a week. She was exposed to cats a few days ago and had to use her inhaler once. She is prescribed 1-3 puffs as needed; she reports having to use 3 puffs occasionally, but usually 1-2. 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.
Review of Systems
Head: Denies hair loss and Dandruff.
Eyes: Patient notes vision changes and blurry vision while reading and studying.
Ears: Denies changes to hearing.
Nose: occassional runny nose
Throat: Denies swallowing difficulties or changes to taste.
Neuro: Denies any numbness, tingling, burning. Patient noted to be a good historian and alert and oriented x4.
Respiratory: Denies shortness of breath, dyspnea, and wheezing.
Cardiac: Denies chest pain, palpitations, and lightheadedness
GI: Denies abdominal tendarness, constipation, nausea, and vomiting.
GU: Frequent urination once every hour or two. Denies difficulty with urination, burning, or blood in urine.
Skin: multiple moles with no changes noted. Patient states skin on their neck noted to be different.
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.
Ears: Denies difficulty hearing, tinnitus, ear pain, and discharge.
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.
Nose: Rhinitis and congestion related to cat allergy. Denies sinus problems, frequent colds/infections, epistaxis, and change in smell.
Mouth: Denies dental pain or problems, oral lesions, and dry mouth, and changes in taste.
Throat and Neck: Denies sore throat, dysphagia, and changes to voice quality. Denies goiter, hyper/hypothyroidism.
Respiratory: Denies history of pneumonia, tuberculosis, and chronic bronchitis. Denies cough, dyspnea, current wheezing, hemoptysis, or recent cough.
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.
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.
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.
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.
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.
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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Tina Jones Health History In Progress Attempt Shadow Health® │ Digital Clinical Experiences™ from Elsevier
Course: Health Assessment and Promotion (NRSE 4520)
University: Ohio University
