10/16/24, 2:11 Subjective data - Lecture notes Lecture
PM notes
Unguided Intermediate Patient Case Results | Turned In
Pharmacology - Remediation/Refresher - January 2021, CCE 705 and 701
Return to Assignment (/assignments/432434/)
Your Results Lab Pass
(/assignment_attempts/9682253/lab_pass.pdf)
Overvie
Subjective Data Collection: 36 of 36 (100.0%)
w
Transcri
pt
Subjective Data
Hover To Reveal... Indicates an item that
Collection Objective Data you found.
Hover over the Patient Data Indicates an item
Collection Education & items below to reveal that is available to be
important information, found.
Empathy
including Pro Tips and
Example Questions.
QSEN Competencies
Documentation
Care Plan
Category Scored Items Patient Data
Reflections
Not Scored
Student Experts selected these topics as essential A combination of open and closed questions will
components of a strong, thorough interview yield better patient data. The following details
Survey
with this patient. are facts of the patient's case.
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 this
morning Reports pain has been constant
about:bl 1
, 10/16/24, 2:11 Subjective data - Lecture notes Lecture
PM notes
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
Asked about location of pain Reports pain is in lower left side
(flank pain) Denies radiating pain
Asked about characteristics of pain Describes pain as sharp and shooting
Asked about aggravating factors of pain Reports nothing makes the pain worse
Asked about treatment and relieving Denies home treatment of pain
factors of pain Reports hydromorphone has significantly
reduced pain
Asked about severity of pain 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
Followed up about high blood Reports being diagnosed with high
pressure diagnosis blood pressure at age 55
Reports belief that blood pressure is well-
controlled
Reports typical blood pressure as 130/85
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
Followed up about chronic kidney Reports being diagnosed with chronic
disease diagnosis kidney disease at age 62
Reports disease is stage 2
Asked about allergies Denies general allergies
Denies environmental
allergies Denies latex
allergy
Asked specifically about medication allergies Denies medication allergies
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
about:bl 2
PM notes
Unguided Intermediate Patient Case Results | Turned In
Pharmacology - Remediation/Refresher - January 2021, CCE 705 and 701
Return to Assignment (/assignments/432434/)
Your Results Lab Pass
(/assignment_attempts/9682253/lab_pass.pdf)
Overvie
Subjective Data Collection: 36 of 36 (100.0%)
w
Transcri
pt
Subjective Data
Hover To Reveal... Indicates an item that
Collection Objective Data you found.
Hover over the Patient Data Indicates an item
Collection Education & items below to reveal that is available to be
important information, found.
Empathy
including Pro Tips and
Example Questions.
QSEN Competencies
Documentation
Care Plan
Category Scored Items Patient Data
Reflections
Not Scored
Student Experts selected these topics as essential A combination of open and closed questions will
components of a strong, thorough interview yield better patient data. The following details
Survey
with this patient. are facts of the patient's case.
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 this
morning Reports pain has been constant
about:bl 1
, 10/16/24, 2:11 Subjective data - Lecture notes Lecture
PM notes
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
Asked about location of pain Reports pain is in lower left side
(flank pain) Denies radiating pain
Asked about characteristics of pain Describes pain as sharp and shooting
Asked about aggravating factors of pain Reports nothing makes the pain worse
Asked about treatment and relieving Denies home treatment of pain
factors of pain Reports hydromorphone has significantly
reduced pain
Asked about severity of pain 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
Followed up about high blood Reports being diagnosed with high
pressure diagnosis blood pressure at age 55
Reports belief that blood pressure is well-
controlled
Reports typical blood pressure as 130/85
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
Followed up about chronic kidney Reports being diagnosed with chronic
disease diagnosis kidney disease at age 62
Reports disease is stage 2
Asked about allergies Denies general allergies
Denies environmental
allergies Denies latex
allergy
Asked specifically about medication allergies Denies medication allergies
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
about:bl 2
