Exam (elaborations) NURS 201 Focused Exam Pain Completed Shadow Health Subjective.

NURS 201 Focused Exam Pain Completed Shadow Health Subjective. Subjective Data Collection: 55 of 58 (94.8%) Cate gory Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions. Scored Items Experts selected these topics as essential components of a strong, thorough interview with this patient. Indicates an item that you found. Indicates an item that is available to be found. Patient Data Not Scored A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case. Chief Complaint Established chief complaint Reports pain Reports recent fall Reports worry about worsening symptoms Orientation Established orientation Oriented to person Oriented to place Oriented to time Oriented to situation Patient Status ER Reports oxycontin has been effective History of Present Illness Asked about onset and duration of symptoms Reports recent episode of severe pain started this morning Reports pain has been getting progressively worse in the last few weeks Asked about location of pain Reports hip pain Reports knee pain Asked about characteristics of pain Describes pain as aching Describes pain as "deep" Denies shooting or sharp pain Reports occasional "grating" sensation in joints Denies burning pain Denies stinging pain Reports pain before medication was a 9 Asked about non-medication relieving factors of pain Reports that rest typically relieves the pain Reports not using any non-medication treatments to treat this morning's pain Reports occasional use of moist heat as treatment on hips Reports using range of motion exercises for knees Reports wearing elastic supports on knees bilaterally Denies use of ice as treatment Asked about aggravating factors of pain Reports that exercise exacerbates pain and stiffness Reports that weight bearing exacerbates pain and stiffness Reports that pain and stiffness are worse in the morning Reports that changes in weather exacerbate pain and stiffness Followed up on details of the fall Reports falling getting out of bed Reports hitting his back on bed frame Denies dizziness, syncope, or vertigo at time of fall Denies substance use that could have related to the fall ThiPs stuadyssoutrceMwas edowdnloiacdedabyl100H000i8s343t06o259rfyrom CourseH on :55:09 GMT -05:00 Asked about existing health conditions Reports osteoarthritis diagnosis Reports hypertension diagnosis Reports chronic kidney disease diagnosis Reports atrial fibrillation diagnosis Followed up about osteoarthritis diagnosis Diagnosed age 66 symptoms and ADLs Reports increasing problems with exercise diagnosis Reports belief that blood pressure is well- controlled Reports typical blood pressure as 130/85 Reports eating a low sodium diet diagnosis Denies recent episodes of palpitations or problems Denies pacemaker or surgical intervention disease diagnosis Reports disease is stage 2 Denies environmental allergies Denies latex allergy Asked specifically about medication allergies Denies medication allergies Home Medications Asked about home medications Reports medication for osteoarthritis Reports medications for atrial fibrillation Reports medication for hypertension Denies medication for chronic kidney disease Denies pain medication at home Denies taking vitamins Denies taking herbal supplements Asked about medication regimen adherence Reports using a pillbox to organize medications Denies missing doses of medication Denies missing doses of medication because of side effects Denies difficulty obtaining medications because of finances Denies difficulty obtaining medications because of transportation Followed up on last dose of home medications Reports taking naproxen at 5 am this morning to try to relieve pain Denies taking other medications today for atrial fibrillation Reports warfarin dosage: 2.5 mg Reports warfarin frequency: 1x daily Reports monthly blood tests to check warfarin effectiveness Denies warfarin side effects Followed up on calcium channel blocker medication for atrial fibrillation Reports taking verapamil Reports verapamil dosage: 80 mg Reports verapamil frequency: 3x daily Denies verapamil side effects Followed up on combination ARB / diuretic for hypertension Reports taking Hyzaar (losartan and hydrochlorothiazide combination) Reports Hyzaar dosage: 100 losartan /25 mg hydrochlorothiazide Reports Hyzaar frequency: 1x daily Denies Hyzaar side effects osteoarthritis Reports naproxen dosage: 220 mg Reports naproxen frequency: 2x daily Denies naproxen side effects Reports that naproxen is typically effective at reducing pain Reports that naproxen is OTC Followed up on injections for osteoarthritis Reports injections are kenalog (triamcinolone) Reports kenalog dosage: 10 mg/mL Reports kenalog frequency: 4 times per year Reports kenalog location: Injected into This study source was downloaded by from CourseH on :55e:0a9cGhMhTi-p05a:0n0d knee joint Denies side effects Reports that injections are effective in reducing pain Reports that last injection was "at least" 3 months ago Family History Denies family history of kidney stones Denies family history of chronic kidney disease Denies family history of atrial fibrillation Reports father and mother had hypertension Social History Asked about substance use Denies recent alcohol use Denies illicit drug use Denies use of tobacco and nicotine products