Shadow Health - Robert Hall - Mobility – Subjective. Summary paper

Established chief complaint - -reports leg pain -reports leg swelling Established orientation - -oriented to person -oriented to place -oriented to time -oriented to situation Asked about onset and duration of symptoms - -reports fall was 9 am this morning -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 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 worse with walking Asked about treatment and relieving factors of pain - -reports taking Advil -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 Asked about existing health conditions - -reports hypertension -reports osteoarthritis -reports prostate enlargement Followed up about hypertension diagnosis - -hypertension diagnosed at age 57 -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 diagnosis - -arthritis diagnosed at age 57 -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 diagnosis - -diagnosed at age 69 Asked about allergies - -denies general allergies