Subjective Data Collection

Asked about medication administered in Reports receiving oxycontin Asked about patient comfort and needs Denies needing to use the bathroom

Subjective Data Collection: 55 of 58 (94.8%)

Cate gory Hover To Reveal...Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.

Scored Items Experts selected these topics as essential components of a strong, thorough interview with this patient.Indicates an item that you found.Indicates an item that is available to be found.

Patient Data Not Scored A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case.

Chief Complaint

Established chief complaint Reports pain Reports recent fall Reports worry about worsening symptoms

Orientation

Established orientation Oriented to person Oriented to place Oriented to time Oriented to situation

Patient Status

ER Reports oxycontin has been effective

History of Present Illness

Asked about severity of pain Reports current pain is a 1 Asked about onset and duration of symptoms Reports recent episode of severe pain started this morning Reports pain has been getting progressively worse in the last few weeks

Asked about location of pain Reports hip pain Reports knee pain

Asked about characteristics of pain Describes pain as aching Describes pain as "deep" Denies shooting or sharp pain Reports occasional "grating" sensation in joints Denies burning pain Denies stinging pain

Reports pain before medication was a 9

Asked about non-medication relieving factors of pain Reports that rest typically relieves the pain Reports not using any non-medication treatments to treat this morning's pain Reports occasional use of moist heat as treatment on hips Reports using range of motion exercises for knees Reports wearing elastic supports on knees bilaterally Denies use of ice as treatment

Asked about aggravating factors of pain Reports that exercise exacerbates pain and stiffness Reports that weight bearing exacerbates pain and stiffness Reports that pain and stiffness are worse in the morning Reports that changes in weather exacerbate pain and stiffness

Followed up on details of the fall Reports falling getting out of bed Reports hitting his back on bed frame Denies dizziness, syncope, or vertigo at time of fall Denies substance use that could have related to the fall

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This study source was downloaded by 100000805751619 from CourseHero.com on 04-01-2021 15:45:23 GMT -05:00 https://www.coursehero.com/file/41315316/Focused-Exam-Pain-Completed-Shadow-Health-Subjectivepdf/

Asked about allergies Denies general allergies Asked about existing health conditions Reports osteoarthritis diagnosis Reports hypertension diagnosis Reports chronic kidney disease diagnosis Reports atrial fibrillation diagnosis

Followed up about osteoarthritis diagnosis Diagnosed age 66

symptoms and ADLs Reports increasing problems with exercise

diagnosis Reports belief that blood pressure is well- controlled Reports typical blood pressure as 130/85 Reports eating a low sodium diet

diagnosis Denies recent episodes of palpitations or problems Denies pacemaker or surgical intervention

disease diagnosis Reports disease is stage 2

Denies environmental allergies Denies latex allergy

Asked specifically about medication allergies Denies medication allergies

Home Medications

Asked about home medications Reports medication for osteoarthritis Reports medications for atrial fibrillation Reports medication for hypertension Denies medication for chronic kidney disease Denies pain medication at home Denies taking vitamins Denies taking herbal supplements Followed up about chronic kidney Diagnosed at age 62 Followed up about atrial fibrillation Diagnosed at age 61 Followed up about hypertension Diagnosed at age 55 Followed up about osteoarthritis Reports increasing problems with gait

https://www.coursehero.com/file/41315316/Focused-Exam-Pain-Completed-Shadow-Health-Subjectivepdf/

Asked about medication regimen adherence Reports using a pillbox to organize medications Denies missing doses of medication Denies missing doses of medication because of side effects Denies difficulty obtaining medications because of finances Denies difficulty obtaining medications because of transportation

Followed up on last dose of home medications Reports taking naproxen at 5 am this morning to try to relieve pain Denies taking other medications today

for atrial fibrillation Reports warfarin dosage: 2.5 mg

Reports warfarin frequency: 1x daily

Reports monthly blood tests to check warfarin effectiveness Denies warfarin side effects

Followed up on calcium channel blocker medication for atrial fibrillation Reports taking verapamil

Reports verapamil dosage: 80 mg

Reports verapamil frequency: 3x daily

Denies verapamil side effects

Followed up on combination ARB / diuretic for hypertension Reports taking Hyzaar (losartan and hydrochlorothiazide combination)

Reports Hyzaar dosage: 100 losartan /25

mg hydrochlorothiazide

Reports Hyzaar frequency: 1x daily

Denies Hyzaar side effects

osteoarthritis Reports naproxen dosage: 220 mg

Reports naproxen frequency: 2x daily

Denies naproxen side effects Reports that naproxen is typically effective at reducing pain Reports that naproxen is OTC

Followed up on injections for osteoarthritis Reports injections are kenalog (triamcinolone)

Reports kenalog dosage: 10 mg/mL

Reports kenalog frequency: 4 times per

year

Reports kenalog location: Injected into

This study source was downloaded by 100000805751619 from CourseHero.com on 04-01-2021 15:45 e

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Followed up on oral medication for Reports taking naproxen Followed up on anticoagulant medication Reports taking warfarin