Shadow Health - Edward Carter - Pain – Subjective Latest Update Graded A+

Shadow Health - Edward Carter - Pain – Subjective Latest Update Graded A+ Established chief complaint -reports pain -reports recent fall -reports worry about worsening symptoms Established orientation -oriented to person -oriented to place -oriented to time -oriented to situation Asked about onset and duration of symptoms -reports recent episode of severe pain started in the 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 Asked about severity of pain -reports current pain is a 1 -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 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 Followed up about osteoarthritis symptoms and ADLs -reports increasing problems with gait -reports increasing problems with exercise Followed up about hypertension diagnosis -diagnosed at age 55 -reports belief that blood pressure is well-controlled -reports typical blood pressure as 130/85 -reports eating a low sodium diet Followed up about atrial fibrillation diagnosis -diagnosed at age 61 -denies recent episodes of palpitations or problems -denies pacemaker or surgical intervention Followed up about chronic kidney disease diagnosis -diagnosed at age 62 -reports disease is stage 2 Asked about allergies -denies general allergies -denies environmental allergies -denies latex allergy Asked specifically about medication allergies -denies medication allergies Asked about home medications -reports medication for osteoarthritis -reports medication 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 in obtaining medications because of finances -denies difficulty in 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 Followed up on anticoagulant medication for atrial fibrillation -reports taking apixaban -reports apixaban dosage: 2.5 mg -reports apixaban frequency: 1x daily -denies apixaban 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 hydrpchlorothiazide -reports Hyzaar frequency: 1x daily -denies Hyzaar side effects Followed up on oral medication for osteoarthritis -reports taking naproxen -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 each hip and knee joint -denies side effects -reports that injections are effective in reducing pain -reports that last injection was "at least" 3 months ago Asked about medication administered in ER -reports receiving morphine -reports morphine has been effective Asked patient about comfort and needs -denies needing to use the bathroom Asked about substance use -denies recent alcohol use -denies illicit drug use -denies use of tobacco and nicotine products Asked about relevant family history -denies family history of osteoarthritis -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 Asked about general symptoms -denies fever -denies chills -denies night sweats Asked about review of systems for HEENT -denies impaired hearing -denies vision problems Asked about review of systems for respiratory -denies cough -denies shortness of breath -denies dyspnea on exertion -denies wheezing Asked about review of systems for cardiovascular -denies chest pain -denies palpitations -denies edema -denies claudication Asked about review of systems for gastrointestinal -denies abdominal pain -denies difficulty swallowing -denies nausea -denies vomiting -denies constipation -denies diarrhea -denies changes in stool or bowel patterns Asked about review of systems for neurological -reports weakness in lower extremities -reports sore lower back -denies frequent headaches -denies numbness or tingling -denies changes in coordination -denies changes in memory Asked about review of systems for musculoskeletal -denies predisposing traumatic injuries -reports limited range of motion in joints -denies muscle spasms Asked about review of systems for psychological -denies mood changes -denies suicidal thoughts Asked about living environment -reports living at home -reports living with wife -reports appropriate levels of privacy -reports enjoying his home life -denies loneliness Asked about feeling safe at home -reports feeling safe at home Asked about depression -denies depression Asked about bathing -reports being able to bathe independently -reports being able to reach all parts of his body -reports being able to get out of shower safely by being "extra careful" Asked about dressing -reports being able to retrieve clothing -reports being able to put on clothes -denies difficulty with buttons or zippers -denies difficulty tying shoes Asked about toileting -reports being able to get up from the toilet with support (uses bathroom sink for support) -reports being able to arrange clothing during toileting -reports being able to clean genital area without help Asked about transferring -reports difficulty getting out of bed in the morning -reports some difficulty getting out of chairs -reports occasional use of cane to transfer Asked about continence -reports full control over bowels -reports full control over bladder Asked about feeding and eating -reports being fully able to eat and feed himself -reports being fully able to get food from plate to mouth -reports being able to prepare food Asked about sleeping habits -reports that sleep is good -denies insomnia -denies frequent waking -denies oversleeping Asked about confusion -denies confusion Asked about evidence of falls -denies previous calls -denies dizziness, syncope, or vertigo Asked about gait and ambulatory aids -reports some problems with gait -denies bed rest -denies use of wheelchair -reports occasional use of cane to walk -reports occasional use of furniture as support while walking -reports occasional problems with balance because of arthritis pain Asked about skin breakdown -reports that his skin seems thin -denies open wounds -denies rashes or lesions -denies bruising (may have bruising on back from fall, but it hasn't appeared yet) -denies pruritis Asked about weight changes -denies weight changes Asked about dental or oral problems -denies tooth problems and dental pain -denies issues with mouth, jaw, or gums -reports no issues with being able to chew food Asked about appetite changes -denies changes in appetite -denies feeling full quickly Asked about effects of health on social activity -reports that social activity has remained the same, although he has to sit through some events -reports feeling worried about reduced mobility and independence Asked about patient's perception of health -describes health as fair Asked about tiredness, energy levels, and fatigue -reports increased fatigue and low energy -describes fatigue as "having hardly any energy" and "needing to rest much more than usual" -reports fatigue occurs in the afternoons -reports fatigue for the last 3 months Asked about recent ER visits or hospitalizations -denies ER visits or hospitalizations in the last 3 months -reports last hospitalization was 3 years ago -reports last hospitalization was for kidney stones