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Exam (elaborations)

Focused Exam: Infection Results | Completed

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Your Results Turn In (/assignment_attempts//cho Reopen (/assignment_attempts//reope Lab Pass (/assignment_attempts//lab_pass. Overview Transcript Subjective Data Collection: 52 of 53 (98.1%) Subjective Data Collection Objective Data Collection Education & Empathy QSEN Competencies Documentation Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions. Indicates an item that you found. Indicates an item that is available to be found. Care Plan Reflections Category Scored Items Experts selected these topics as essential components of a strong, thorough interview with this patient. Patient Data Not Scored A combination of open and closed questions will yi better patient data. The following details are facts o patient's case. Chief Complaint Established chief complaint Reports pain Orientation Established orientation Oriented to person Disoriented to place Disoriented to time Oriented somewhat to situation Patient Status Asked about fluid intake and hydration Denies current thirst Reports does not remember eating today Reports does not remember drinking fluids today Support History of Presenting Illness Asked about onset, duration, and frequency of symptoms Reports pain began last night Reports pain has been constant Reports that pain increased this morning Asked about location of pain Reports generalized abdominal pain Reports back pain Reports pain during urination Asked about characteristics of pain Reports pain during urination as "burning" Reports back and abdominal pain as "aching" Denies sharp or shooting pain Denies cramping pain Asked about aggravating factors of pain Reports no known aggravating factors Asked about treatment and relieving factors of pain Denies treatment with medication at home Denies use of heating pad Past Medical History Asked about severity of pain Patient is unable to quantify Asked about existing health conditions Reports history of UTIs as an adult Reports hypercholesterolemia Followed up on history of UTI Reports UTIs once or twice annually Reports typical UTI treatment is to see a doctor for antibiotics Followed up on hypercholesterolemia Diagnosed age 58 Asked about allergies Denies general allergies Denies environmental allergies Denies latex allergy Denies food allergies Home Medications Asked specifically about medication

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Uploaded on
January 1, 2025
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