Shadow Health-Advanced Assessment-Health History

Jan 2018

Identifying Data & Reliability

Ms. Jones is a pleasant, 28-year-old obese African American single woman who presents to establish care and
with a recent right foot injury. She is the primary source of the history. Ms. Jones offers information freely and
without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview.

General Survey

Ms. Jones is alert and oriented, seated upright on the examination

table, and is in no apparent distress. She is well-nourished, well-
developed, and dressed appropriately with good hygiene.

Chief Complaint

“I got this scrape on my foot a while ago, and I thought it would

heal up on its own, but now it's looking pretty nasty. And the pain
is killing me!”

History Of Present Illness

Ms. Jones reports that a week ago she tripped while walking on
concrete stairs outside, twisting her right ankle and scraping the
ball of her foot. She sought care in a local emergency department
where she had x-rays that were negative; she was treated with
tramadol for pain. She has been cleansing the site twice a day.
She has been applying antibiotic ointment and a bandage. She
reports that ankle swelling and pain have resolved but that the
bottom of the foot is increasingly painful. The pain is described
as “throbbing” and “sharp” with weight bearing. She states her
ankle “ached” but is resolved. Pain is rated 7 out of 10 after a
recent dose of tramadol. Pain is rated 9 with weight bearing. She
reports that over the past two days the ball of the foot has become
swollen and increasingly red; yesterday she noted discharge
oozing from the wound. She denies any odor from the wound.
Her shoes feel tight. She has been wearing slip-ons. She reports
fever of 102 last night. She denies recent illness. Reports a 10-
pound, unintentional weight loss over the month and increased
appetite. Denies change in diet or level of activity.
Medications

Acetaminophen 500-1000 mg PO prn (headaches) • Ibuprofen

600 mg PO TID prn (menstrual cramps) • Tramadol 50 mg PO
BID prn (foot pain) • Albuterol 90 mcg/spray MDI 2 puffs Q4H
prn (Wheezing: “when around cats,” last use three days ago)

Allergies

Penicillin: rash • Denies food and latex allergies • Allergic to cats

and dust. When she is exposed to allergens she states that she has
runny nose, itchy and swollen eyes, and increased asthma
symptoms.

Medical History

Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler

when she is around cats and dust. She uses her inhaler 2 to 3
times per week. She was exposed to cats three days ago and had
to use her inhaler once with positive relief of symptoms. She was
last hospitalized for asthma “in high school”. Never intubated.
Type 2 diabetes, diagnosed at age 24. She previously took
metformin, but she stopped three years ago, stating that the pills
made her gassy and “it was overwhelming, taking pills and
checking my sugar.” She doesn't monitor her blood sugar. Last
blood glucose was elevated last week in the emergency room. No
surgeries. OB/GYN: Menarche, age 11. First sexual encounter at
age 18, sex with men, identifies as heterosexual. Never pregnant.
Last menstrual period 3 weeks ago. For the past year cycles
irregular (every 4-8 weeks) with heavy bleeding lasting 9-10
days. No current partner. Used oral contraceptives in the past.
When sexually active, reports she did not use condoms. Never
tested for HIV/AIDS. No history of STIs or STI symptoms. Last
tested for STIs four years ago. Hematologic: Denies bleeding,
bruising, blood transfusions and history of blood clots. Skin:
Reports acne since puberty and bumps on the back of her arms
when her skin is dry. 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.

Health Maintenance
Last Pap smear 4 years ago. Last eye exam in childhood. Last
dental exam “a few years ago.” PPD (negative) ~2 years ago. No
exercise. 24-hour Diet Recall: States that she skipped breakfast
yesterday, and would typically have a baked good for breakfast, a
sandwich for lunch, and a meatloaf or chicken for dinner. Her
snacks consist of pretzels or French fries. Immunizations:
Tetanus booster was received within the past year, influenza is
not current, and human papillomavirus has not been received.
She reports that she believes she is up to date on childhood
vaccines and received the meningococcal vaccine in college.
Safety: Has smoke detectors in the home, wears seatbelt in car,
and does not ride a bike. Does not use sunscreen. Guns, having
belonged to her dad, are in the home, locked in parent’s room.

Family History

Mother: age 50, hypertension, elevated cholesterol • Father:

deceased in car accident one year ago at age 58, hypertension,
high cholesterol, and type 2 diabetes • Brother (Michael, 25):
overweight • Sister (Britney, 14): asthma • Maternal
grandmother: died at age 73 of a stroke, history of hypertension,
high cholesterol • Maternal grandfather: died at age 78 of a
stroke, history of hypertension, high cholesterol • Paternal
grandmother: still living, age 82, hypertension • Paternal
grandfather: died at age 65 of colon cancer, history of type 2
diabetes • Paternal uncle: alcoholism • Negative for mental
illness, other cancers, sudden death, kidney disease, sickle cell
anemia, thyroid problems

Social History
Never married, no children. Lived independently since age 20,
currently lives with mother and sister in a single family home to
support family after death of father one year ago. Employed 32
hours per week as a supervisor at Mid-American Copy and Ship.
She enjoys her work and was recently promoted to shift
supervisor. She is a part-time student, in her last semester to earn
a bachelor’s degree in accounting. She hopes to advance to an
accounting position within her company. She 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 enjoys spending time with friends, attending Bible study,
volunteering in her church, and dancing. Tina is active in her
church and describes a strong family and social support system.
She reports stressors relating to the death of her father and
balancing work and school demands, and finances. She states that
family and church help her cope with stress. No tobacco.
Occasional cannabis use from age 15 to age 21. Reports no use of
cocaine, methamphetamines, and heroin. Uses alcohol when “out
with friends, 2-3 times per month,” reports drinking no more than
3 drinks per episode. She drinks 4 caffeinated drinks per 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.

Objective

Wound: 2 cm x 1.5 cm, 2.5 mm deep wound, red wound edges,

right ball of foot, serosanguinous drainage. Mild erythema
surrounding wound, no edema, no tracking.