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Focused Exam Pain Completed Shadow Health Subjective

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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 Que... stions. 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 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 ThiPs stuadyssoutrceMwas edowdnloiacdedabyl100H000i8s159t48o112rfyrom CourseHero.com on 06-14-2021 16:25:10 GMT -05:00 .....................................................................continued,................................................................... [Show More]

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