Subjective Data Collection: 55 of 58 (94.8%)
Hover To Reveal... Indicates an item that you found.
Hover over the Patient Data items Indicates an item that is available to be
below to reveal important information, found.
including Pro Tips and Example
Questions.
Cate Scored Items Patient Data
Not Scored
gory 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.
m
er as
co
Chief Complaint
eH w
o.
rs e
Established chief complaint Reports pain
ou urc
Reports recent fall
Reports worry about worsening symptoms
o
aC s
Orientation
vi y re
Established orientation Oriented to person
ed d
Oriented to place
Oriented to time
ar stu
Oriented to situation
is
Patient Status
Th
Asked about medication administered in Reports receiving oxycontin
ER Reports oxycontin has been effective
sh
Asked about patient comfort and needs Denies needing to use the bathroom
History of Present Illness
This study source was downloaded by 100000805705997 from CourseHero.com on 03-28-2021 02:01:00 GMT -05:00
https://www.coursehero.com/file/41315316/Focused-Exam-Pain-Completed-Shadow-Health-Subjectivepdf/
, Asked about onset and duration of Reports recent episode of severe pain
symptoms started this 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
m
Asked about severity of pain Reports current pain is a 1
er as
Reports pain before medication was a 9
co
eH w
o.
Asked about non-medication relieving Reports that rest typically relieves the pain
rs e
factors of pain Reports not using any non-medication
ou urc
treatments to treat this morning's pain
Reports occasional use of moist heat as
treatment on hips
Reports using range of motion exercises
o
for knees
aC s
Reports wearing elastic supports on knees
vi y re
bilaterally
Denies use of ice as treatment
ed d
Asked about aggravating factors of pain Reports that exercise exacerbates pain
ar stu
and stiffness
Reports that weight bearing exacerbates
pain and stiffness
is
Reports that pain and stiffness are worse
in the morning
Th
Reports that changes in weather
exacerbate pain and stiffness
sh
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
Past Medical History
This study source was downloaded by 100000805705997 from CourseHero.com on 03-28-2021 02:01:00 GMT -05:00
https://www.coursehero.com/file/41315316/Focused-Exam-Pain-Completed-Shadow-Health-Subjectivepdf/
Hover To Reveal... Indicates an item that you found.
Hover over the Patient Data items Indicates an item that is available to be
below to reveal important information, found.
including Pro Tips and Example
Questions.
Cate Scored Items Patient Data
Not Scored
gory 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.
m
er as
co
Chief Complaint
eH w
o.
rs e
Established chief complaint Reports pain
ou urc
Reports recent fall
Reports worry about worsening symptoms
o
aC s
Orientation
vi y re
Established orientation Oriented to person
ed d
Oriented to place
Oriented to time
ar stu
Oriented to situation
is
Patient Status
Th
Asked about medication administered in Reports receiving oxycontin
ER Reports oxycontin has been effective
sh
Asked about patient comfort and needs Denies needing to use the bathroom
History of Present Illness
This study source was downloaded by 100000805705997 from CourseHero.com on 03-28-2021 02:01:00 GMT -05:00
https://www.coursehero.com/file/41315316/Focused-Exam-Pain-Completed-Shadow-Health-Subjectivepdf/
, Asked about onset and duration of Reports recent episode of severe pain
symptoms started this 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
m
Asked about severity of pain Reports current pain is a 1
er as
Reports pain before medication was a 9
co
eH w
o.
Asked about non-medication relieving Reports that rest typically relieves the pain
rs e
factors of pain Reports not using any non-medication
ou urc
treatments to treat this morning's pain
Reports occasional use of moist heat as
treatment on hips
Reports using range of motion exercises
o
for knees
aC s
Reports wearing elastic supports on knees
vi y re
bilaterally
Denies use of ice as treatment
ed d
Asked about aggravating factors of pain Reports that exercise exacerbates pain
ar stu
and stiffness
Reports that weight bearing exacerbates
pain and stiffness
is
Reports that pain and stiffness are worse
in the morning
Th
Reports that changes in weather
exacerbate pain and stiffness
sh
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
Past Medical History
This study source was downloaded by 100000805705997 from CourseHero.com on 03-28-2021 02:01:00 GMT -05:00
https://www.coursehero.com/file/41315316/Focused-Exam-Pain-Completed-Shadow-Health-Subjectivepdf/
