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Shadow Health Tina Jones
Cardiovascular LATEST UPDATE WELL
RESERCHED CASE STUDY 2023-2024
Asked about heart problems - ANSWER>>Denies heart problems
Asked about heartbeat - ANSWER>>- reports normal heartbeat
- reports normal heart rate
- denies palpitations
- denies arrhythmia
Asked about high blood pressure - ANSWER>>- denies high blood pressure
- reports last blood pressure check Finding:
- reports last blood pressure check 140 over 80 or 90
- reports belief that current blood pressure is on the high side of normal rangeShadow Health -Tina Jones, Health History With Complete SolutionChief Complaint –Ms Jones.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 -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 se -Surgical History -No surgeries. -No surgeries -Previous Hospitalizations -No hospital visit. -Last hospitalized for asthma exacerbation in high school. -Gynecological History -Bad periods. -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. -Family History (3 generations) -High BP and high cholesterolon both sides and diabetes. -Grandpa jones had colon cancer. -• Father: died at age 58 in a car accident, history of hypertension, high cholesterol, and type 2 diabetes -• Mother: hypertension, high cholesterol -• Brother: healthy -• Sister: asthma -• Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol -• Maternal grandfather: died at age 78 of a suspected myocardial infarction, 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 -Social History -Sometimes drink, once or twice in a week, sometimes less. -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 deter -Review of Systems -resiratory problems. asthma. -
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