End_of_Life_Subjective_Data.pdf.pdf

Focused Exam: End of Life ResultsSubjective Data CollectionEstablished chief complaint Reports pain Orientation Established orientation Oriented to person Oriented to place Oriented to time Oriented to situation Patient Comfort and Status Asked about fluid intake and hydration Denies current thirst Reports very little water intake in the past weekAsked about urinary comfort Reports last urination was around 10 AM Denies pain or burning with urination Asked about most recent meal Denies current hunger Reports no food intake today Last meal was a few bites of yogurt last night Asked about preferences for hospice care Reports wanting to be in hospice care Asked about advanced directives Reports having an advanced directive History of Present Illness Asked about onset and duration of pain Pain became unbearable 2 days ago Reports pain increasing over the past 2 days Reports experiencing some pain most of the time Asked about location of pain Reports bone pain Reports pain in legs Reports pain in ribs Asked about characteristics of pain Describes pain as sharp Asked about aggravating factors of pain Reports that pain is constant - no periods of relief or worsening Asked about treatment and relieving factors of pain Reports that nothing relieves her current pain Reports prescription pain pill Asked about severity of pain Reports current pain is a 4/10 Reports pain before medication was a 9/10 Past Medical History Asked about existing health conditions Reports stage IV breast cancer with liver metastasisAsked about review of systems for HEENT Reports impaired vision Reports wearing glasses Denies impaired hearing