Shadow Health - Robert Hall - Mobility – Subjective Already Passed

Shadow Health - Robert Hall - Mobility – Subjective Already Passed Established chief complaint -reports leg pain -reports leg swelling Established orientation -oriented to person -oriented to place -oriented to time -oriented to situation Asked about onset and duration of symptoms -reports fall was 9 am this morning -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 pain -reports pain worse with walking Asked about treatment and relieving factors of pain -reports taking Advil -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 Asked about existing health conditions -reports hypertension -reports osteoarthritis -reports prostate enlargement Followed up about hypertension diagnosis -hypertension diagnosed at age 57 -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 diagnosis -arthritis diagnosed at age 57 -reports hip pain -reports knee pain -reports morning stiffness -reports using heat to relieve pain -reports doing exercises to help symptoms Followed up about prostate enlargement diagnosis -diagnosed at age 69 Asked about allergies -denies general allergies -denies environmental allergies -denies latex allergy Asked specifically about medication allergies -denies medication allergies Asked about home medications -report medication for hypertension -reports medication for prostate enlargement -reports occasionally taking a sleep aid -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 hypertension medication this morning -reports last dose of prostate enlargement medication was yesterday -reports last dose of sleep aid was earlier this week Followed up on medication for hypertension -reports taking metoprolol -reports metoprolol dosage: 25 mg -reports metoprolol frequency: 1x daily -denies metoprolol side effects Followed up on medication for prostate enlargement -reports taking Proscar (finasteride) -reports Proscar dosage: 5 mg -reports Proscar frequency: 1x daily -denies Proscar side effects Asked about relevant family history -reports father died of colon cancer -reports mother died of heart failure Asked about substance use -reports occasional alcohol use -denies illicit drug use -reports past cigarette smoking Followed up on alcohol use -reports occasional beer or cocktails -reports drinking only at gatherings -reports drinking less than 1 drink per week -reports that drinking often gives him heartburn so he tends to avoid alcohol Followed up on cigarette smoking -reports started smoking age 20 -reports quitting smoking age 60 (20 years ago) -reports smoking 1 pack a day when actively smoking Asked about exercise -reports occasional exercise -reports enjoying walking, but only short distances, as he does not have the energy any more to walk long distances -reports that dizziness has interfered with walking Asked about general symptoms -denies feeling feverish -denies chills -denies night sweats Asked about review of systems for HEENT -reports hearing loss -reports wearing a hearing aid -reports vision problems -reports wearing glasses for reading and watching TV Asked about review of systems for respiratory -denies shortness of breath -denies cough -denies dyspnea on exertion -denies wheezing Asked about review of systems for cardiovascular -denies history of blood clots -denies history of DVT -denies chest pain -denies palpitations -reports 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 pattern Asked about review of systems for musculoskeletal -reports occasional joint pain from arthritis -reports erythema of joints -reports edema of joints Asked about review of systems for neurological -reports overall weakness -denies frequent headaches -reports numbness and tingling in lower left leg -denies numbness/tingling elsewhere in body Asked about review of systems for psychological -denies anxiety -denies recent mood changes -denies suicidal thoughts Asked about depression -denies depression Asked about living environment -reports living in a house -reports living alone -reports some loneliness -reports visits from one of his daughters every few days Asked about feeling safe at home -reports feeling safe at home 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 -reports that his daughter installed a bar in the shower 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 cane) -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 occasional urinary incontinence from prostate enlargement Asked about ability to eat independently -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 poor sleep -reports occasional insomnia -reports frequent waking -denies oversleeping Asked about confusion -denies confusion Asked about evidence of falls -reports recent fall -reports history of falls -reports falling twice in the last 6 months -reports recent dizziness -reports increased dizziness in the past 2 weeks -reports dizziness gets worse when he stands Asked about gait and ambulatory aids -reports some gait impairment -denies bedrest -denies use of wheelchair -reports occasionally using cane to walk -reports balance problems Asked about skin breakdown -reports thin skin -denies open wounds -denies rashes or lesions -reports bruising -denies pruritis, itching or scratching Asked about weight changes -reports weight loss -reports 10 lbs weight loss -reports weight loss occurred over the last 6 months -reports weight loss was unintentional Asked about oral or dental 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 -reports anorexia -reports anorexia for the last few months -reports feeling full quickly Asked about effects of health on social activity -reports that health sometimes prevents him from engaging in social activity -denies that emotional problems prevent him froM engaging in social activity Asked about patient's perception of health -reports poor health Asked about tiredness, energy levels, and fatigue -reports fatigue -reports activity increases fatigue -reports some fatigue most days Asked about recent ER visits or hospitalizations -reports ER visit in the last 3 months -denies hospitalization in the last 3 months -reports going to the ER after a fall -reports getting a hip x-ray -reports x-ray revealed no fracture -denies being admitted to hospital