Subjective Data Collection: 53 of 54 (98.1%)
Hover To Reveal... Indicates an item that you found.
Hover over the Patient Data items Indicates an item that is available to be
below to reveal important information, found.
including Pro Tips and Example
Questions.
Cate Scored Items Patient Data
Not Scored
gory Experts selected these topics as essential A combination of open and closed questions
components of a strong, thorough interview will yield better patient data. The following
with this patient. details are facts of the patient's case.
Chief Complaint
Established chief complaint Reports leg pain
Reports leg swelling
Orientation
Established orientation Oriented to person
Oriented to place
Oriented to time
Oriented to situation
History of Present Illness
Asked about onset and duration of Reports fall was 9 am this morning
symptoms Reports lower leg pain started 2 days ago.
Also reports mild constant pain in his knees
and hips due to arthritis.
Reports leg swelling started 2 days ago
Reports pain has been constant since
onset
Reports pain steadily gets worse
Asked about location of pain Reports pain in left lower calf
This study source was downloaded by 100000827506713 from CourseHero.com on 02-05-2022 04:08:52 GMT -06:00
https://www.coursehero.com/file/41757905/Focused-Exam-Mobility-Completed-Shadow-Health-subjectivepdf/
, Asked about characteristics of pain Describes pain as "nagging"
Describes pain as sharp
Denies stinging or burning pain
Reports sensation of warmth
Asked about aggravating factors of pain Reports pain is worse with walking
Asked about treatment and relieving Reports taking Advil
factors of pain Reports Advil did not relieve leg pain
Denies home treatments such as heating
or icing for pain today
Asked about severity of pain Current pain level is 2/10
Pain level arriving at ER was 10/10
Past Medical History
Asked about existing health conditions Reports hypertension
Reports osteoarthritis
Reports prostate enlargement
Followed up about hypertension Hypertension diagnosed at age 57
diagnosis Reports belief that hypertension is "okay"
(well-controlled)
Reports that typical number in the doctor's
office is "never above 140 for the first
number"
Reports that he doesn't check BP at home
Reports that he only checks BP at doctor's
office every few months
Denies checking BP before taking
medication
Followed up about osteoarthritis Arthritis diagnosed at age 57
diagnosis Reports hip pain
Reports knee pain
Reports morning stiffness
Reports using heat to relieve pain
Reports doing exercises to help symptoms
Followed up about prostate enlargement Diagnosed at age 69
diagnosis
Asked about allergies Denies general allergies
This study source was downloaded by 100000827506713 from CourseHero.com on 02-05-2022 04:08:52 GMT -06:00
https://www.coursehero.com/file/41757905/Focused-Exam-Mobility-Completed-Shadow-Health-subjectivepdf/
Hover To Reveal... Indicates an item that you found.
Hover over the Patient Data items Indicates an item that is available to be
below to reveal important information, found.
including Pro Tips and Example
Questions.
Cate Scored Items Patient Data
Not Scored
gory Experts selected these topics as essential A combination of open and closed questions
components of a strong, thorough interview will yield better patient data. The following
with this patient. details are facts of the patient's case.
Chief Complaint
Established chief complaint Reports leg pain
Reports leg swelling
Orientation
Established orientation Oriented to person
Oriented to place
Oriented to time
Oriented to situation
History of Present Illness
Asked about onset and duration of Reports fall was 9 am this morning
symptoms Reports lower leg pain started 2 days ago.
Also reports mild constant pain in his knees
and hips due to arthritis.
Reports leg swelling started 2 days ago
Reports pain has been constant since
onset
Reports pain steadily gets worse
Asked about location of pain Reports pain in left lower calf
This study source was downloaded by 100000827506713 from CourseHero.com on 02-05-2022 04:08:52 GMT -06:00
https://www.coursehero.com/file/41757905/Focused-Exam-Mobility-Completed-Shadow-Health-subjectivepdf/
, Asked about characteristics of pain Describes pain as "nagging"
Describes pain as sharp
Denies stinging or burning pain
Reports sensation of warmth
Asked about aggravating factors of pain Reports pain is worse with walking
Asked about treatment and relieving Reports taking Advil
factors of pain Reports Advil did not relieve leg pain
Denies home treatments such as heating
or icing for pain today
Asked about severity of pain Current pain level is 2/10
Pain level arriving at ER was 10/10
Past Medical History
Asked about existing health conditions Reports hypertension
Reports osteoarthritis
Reports prostate enlargement
Followed up about hypertension Hypertension diagnosed at age 57
diagnosis Reports belief that hypertension is "okay"
(well-controlled)
Reports that typical number in the doctor's
office is "never above 140 for the first
number"
Reports that he doesn't check BP at home
Reports that he only checks BP at doctor's
office every few months
Denies checking BP before taking
medication
Followed up about osteoarthritis Arthritis diagnosed at age 57
diagnosis Reports hip pain
Reports knee pain
Reports morning stiffness
Reports using heat to relieve pain
Reports doing exercises to help symptoms
Followed up about prostate enlargement Diagnosed at age 69
diagnosis
Asked about allergies Denies general allergies
This study source was downloaded by 100000827506713 from CourseHero.com on 02-05-2022 04:08:52 GMT -06:00
https://www.coursehero.com/file/41757905/Focused-Exam-Mobility-Completed-Shadow-Health-subjectivepdf/
