SHADOW HEALTH - EDWARD CARTER - PAIN –
SUBJECTIVE
Established chief complaint - Answers :-reports pain
-reports recent fall
-reports worry about worsening symptoms
Established orientation - Answers :-oriented to person
-oriented to place
-oriented to time
-oriented to situation
Asked about onset and duration of symptoms - Answers :-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 - Answers :-reports hip pain
-reports knee pain
Asked about characteristics of pain - Answers :-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 - Answers :-reports current pain is a 1
-reports pain before medication was a 9
Asked about non-medication relieving factors of pain - Answers :-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 - Answers :-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 - Answers :-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 - Answers :-reports osteoarthritis diagnosis
-reports hypertension diagnosis
-reports chronic kidney disease diagnosis
-reports atrial fibrillation diagnosis
Followed up about osteoarthritis diagnosis - Answers :-diagnosed age 66
Followed up about osteoarthritis symptoms and ADLs - Answers :-reports increasing
problems with gait
-reports increasing problems with exercise
Followed up about hypertension diagnosis - Answers :-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 - Answers :-diagnosed at age 61
-denies recent episodes of palpitations or problems
-denies pacemaker or surgical intervention
Followed up about chronic kidney disease diagnosis - Answers :-diagnosed at age 62
-reports disease is stage 2
Asked about allergies - Answers :-denies general allergies
-denies environmental allergies
-denies latex allergy
Asked specifically about medication allergies - Answers :-denies medication allergies
Asked about home medications - Answers :-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 - Answers :-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
SUBJECTIVE
Established chief complaint - Answers :-reports pain
-reports recent fall
-reports worry about worsening symptoms
Established orientation - Answers :-oriented to person
-oriented to place
-oriented to time
-oriented to situation
Asked about onset and duration of symptoms - Answers :-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 - Answers :-reports hip pain
-reports knee pain
Asked about characteristics of pain - Answers :-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 - Answers :-reports current pain is a 1
-reports pain before medication was a 9
Asked about non-medication relieving factors of pain - Answers :-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 - Answers :-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 - Answers :-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 - Answers :-reports osteoarthritis diagnosis
-reports hypertension diagnosis
-reports chronic kidney disease diagnosis
-reports atrial fibrillation diagnosis
Followed up about osteoarthritis diagnosis - Answers :-diagnosed age 66
Followed up about osteoarthritis symptoms and ADLs - Answers :-reports increasing
problems with gait
-reports increasing problems with exercise
Followed up about hypertension diagnosis - Answers :-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 - Answers :-diagnosed at age 61
-denies recent episodes of palpitations or problems
-denies pacemaker or surgical intervention
Followed up about chronic kidney disease diagnosis - Answers :-diagnosed at age 62
-reports disease is stage 2
Asked about allergies - Answers :-denies general allergies
-denies environmental allergies
-denies latex allergy
Asked specifically about medication allergies - Answers :-denies medication allergies
Asked about home medications - Answers :-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 - Answers :-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
