NURS 324 - Nursing Care of Adults II -Infection-Shadow Health

Chief Complaint Established chief complaint Reports pain Orientation Established orientation Oriented to person Disoriented to place Disoriented to time Oriented somewhat to situation Patient Status Asked about fluid intake and hydration Denies current thirst Reports does not remember eating today Reports does not remember drinking fluids today History of Presenting Illness Asked about onset, duration, and frequency of symptoms Reports pain began last night Reports pain has been constant Reports that pain increased this morning Asked about location of pain Reports generalized abdominal pain Reports back pain Reports pain during urination 4/17/2020 Focused Exam: Infection | Completed | Shadow Health Asked about characteristics of pain Reports pain during urination as "burning" Reports back and abdominal pain as "aching" Denies sharp or shooting pain Denies cramping pain Asked about aggravating factors of pain Reports no known aggravating factors Asked about treatment and relieving factors of pain Denies treatment with medication at home Denies use of heating pad Past Medical History Asked about severity of pain Patient is unable to quantify Asked about existing health conditions Reports history of UTIs as an adult Reports hypercholesterolemia Followed up on history of UTI Reports UTIs once or twice annually Reports typical UTI treatment is to see a doctor for antibiotics Followed up on hypercholesterolemia Diagnosed age 58 Asked about allergies Denies general allergies Denies environmental allergies Denies latex allergy Denies food allergies Home Medications Asked specifically about medication allergies Denies medication allergies