Focused Exam: Mobility Results Robert Hall- Gerontologic Nursing-Subjective Data
Collection | Completed
Gerontologic Nursing - 2024
Your Results
Overview
Subjective Data Collection: 54 of 54 (100.0%)
Transcript
Subjective Data Collection
Hover To Reveal... Indicates an item that
Objective Data Collection you found.
Hover over the Patient Data Indicates an item that
Education & Empathy
items below to reveal important
is available to be found.
information, including Pro Tips
Documentation
and Example Questions.
Care Plan
Program Competency Progress
Category Scored Items Patient Data
Video Tutorial
Not Scored
Reflections
Experts selected these topics as essential A combination of open and closed questions
components of a strong, thorough interview will yield better patient data. The following
with this patient. details are facts of the patient's case.
Chief Complaint
Established chief complaint Reports leg pain
Reports leg swelling
Orientation
Established orientation Oriented to person
Oriented to place
Oriented to time
Oriented to situation
History of Present Illness
, Asked about onset and duration of Reports fall was 9 am this morning
symptoms 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 Reports pain is worse with walking
pain
Asked about treatment and relieving Reports taking Advil
factors of pain 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
Past Medical History
Asked about existing health conditions Reports hypertension
Reports osteoarthritis
Reports prostate enlargement
Followed up about hypertension Hypertension diagnosed at age 57
diagnosis 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 Arthritis diagnosed at age 57
diagnosis Reports hip pain
Reports knee pain
Collection | Completed
Gerontologic Nursing - 2024
Your Results
Overview
Subjective Data Collection: 54 of 54 (100.0%)
Transcript
Subjective Data Collection
Hover To Reveal... Indicates an item that
Objective Data Collection you found.
Hover over the Patient Data Indicates an item that
Education & Empathy
items below to reveal important
is available to be found.
information, including Pro Tips
Documentation
and Example Questions.
Care Plan
Program Competency Progress
Category Scored Items Patient Data
Video Tutorial
Not Scored
Reflections
Experts selected these topics as essential A combination of open and closed questions
components of a strong, thorough interview will yield better patient data. The following
with this patient. details are facts of the patient's case.
Chief Complaint
Established chief complaint Reports leg pain
Reports leg swelling
Orientation
Established orientation Oriented to person
Oriented to place
Oriented to time
Oriented to situation
History of Present Illness
, Asked about onset and duration of Reports fall was 9 am this morning
symptoms 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 Reports pain is worse with walking
pain
Asked about treatment and relieving Reports taking Advil
factors of pain 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
Past Medical History
Asked about existing health conditions Reports hypertension
Reports osteoarthritis
Reports prostate enlargement
Followed up about hypertension Hypertension diagnosed at age 57
diagnosis 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 Arthritis diagnosed at age 57
diagnosis Reports hip pain
Reports knee pain
