1. Shift Assessment: ...
2. chief complaint: Right foot pain, fever, nausea
3. History of Present Illness: Ms. Jones is a pleasant 28-year-old African
... [Show More] Amer- ican 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.
4. Pain Assessment: 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.
5. Allergies: • Penicillin: rash
• Cats: wheezing, itchy watery eyes, sneezing, asthma exacerbation
• No food allergies
• Not allergic to latex
6. Immunizations: Up-to-date. Received tetanus and HPV vaccines within the last year. Denies recent flu shot.
7. Medications: • 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
8. Medical History: 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 [Show Less]