Summary Subjective Data Collection

Cate gory Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions. Scored Items Experts selected these topics as essential components of a strong, thorough interview with this patient. Indicates an item that you found. Indicates an item that is available to be found. Patient Data Not Scored A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case. Chief Complaint Established chief complaint Reports leg pain Reports leg swelling Orientation Established orientation Oriented to person Oriented to place Oriented to time Oriented to situation History of Present Illness 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 characteristics of pain Describes pain as "nagging" Describes pain as sharp Denies stinging or burning pain Reports sensation of warmth 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 Past Medical History Asked about existing health conditions Reports hypertension Reports osteoarthritis