SHADOW HEALTH: PHARMACOLOGY | UNGUIDED INTERMEDIATE PATIENT CASE Latest Updated A+ Guide Solution

Scored Items Patient Data Chief Complaint: Established chief complaint • Reports pain • Reports blood in urine • Reports increased frequency of urination Orientation: Asked about orientation • Oriented to own person • Oriented to place • Oriented to situation • Oriented to time History of Present Illness: Asked about onset and duration of symptoms • Reports pain began 3 days ago • Reports pain has gradually increased since onset • Reports increased urinary frequency began 3 days ago • Reports pinkish urine starting early thi smorning • Reports pain has been constant History of Present Illness: Followed up on urinary frequency • Reports urinating about once an hour • Reports waking up to use the bathroom • Reports waking up four to five times a night to use the bathroom History of Present Illness: Asked about location of pain • Reports pain is lower in left side (flank pain) • Denies radiating pain History of Present Illness: Asked about characteristics of pain • Describes pain as sharp and shooting History of Present Illness: Asked about aggravating factors of pain • Reports nothing makes the pain worse History of Present Illness: Asked about treatment and relieving factors of pain • Denies home treatment of pain • Reports hydromorphone has significantly reduced pain History of Present Illness: Asked about severity of pain All the best from Dr. A Dr. Assessments Page 2 of 6 • Reports current pain level is 2/10 • Reports pain level before medication was a 9/10 Past Medical History: Asked about existing health conditions • Reports high blood pressure diagnosis • Reports chronic kidney disease diagnosis • Reports atrial fibrillation diagnosis • Reports occasional heartburn Past Medical History: Followed up about high blood pressure diagnosis • Reports being diagnosed with high blood pressure at age 55 • Reports belief that blood pressure is well-controlled • Reports typical blood pressure is 130/85 Past Medical History: Followed up about atrial fibrillation diagnosis • Reports being diagnosed with atrial fibrillation at age 61 • Denies recent episodes of palpitations or problems • Denies pacemaker or surgical intervention Past Medical History: Followed up about chronic kidney disease diagnosis • Reports being diagnosed with chronic kidney disease at age 62 • Reports disease is stage 2 Past Medical History: Asked about allergies • Denies general allergies • Denies environmental allergies • Denies latex allergy Past Medical History: Asked specifically about medication allergies • Denies medication allergies Past Medical History: Asked about home medications • Reports medications for atrial fibrillation • Reports medication for high blood pressure • Denies medication for chronic kidney disease • Reports taking occasional antacids • Denies taking supplements • Denies taking herbals Past Medical History: Followed up on last dose of home medications • Denies taking home medications today All the best from Dr. A Dr. Assessments Page 3 of 6 Past Medical History: Followed up on anticoagulant for atrial fibrillation • Reports taking anticoagulant (warfarin) • Reports anticoagulant dosage is 2.5mg • Reports anticoagulant is taken daily • Denies anticoagulant side effects Past Medical History: Followed up on medication rate control • Reports taking calcium channel blocker (verapamil) • Reports calcium channel blocker dosage is 80mg • Reports calcium channel blocker is taken 3 times daily • Denies calcium channel blocker side effects