Shadow Health - Regina Walker - End of
Life - Subjective
Established chief complaint - -reports pain
Established orientation - -oriented to person
-oriented to place
-oriented to time
-oriented to situation
Asked about fluid intake and hydration - -denies current thirst
-reports very little water intake in the past week
-reports a few sips of ginger ale today
Asked about urinary comfort - -reports last urination was around 10 am
-denies pain or burning with urination
Asked about most recent meal - -denies current hunger
-reports no food intake today
-last meal was a few bites of yogurt last night
Asked about preferences for hospice care - -reports wanting to be in hospice care
Asked about advanced directives - -reports having an advanced directive
Asked about onset and duration of pain - -pain became unbearable 2 days ago
-reports pain increasing over the past 2 days
-reports experiencing some pain most of the time
Asked about location of pain - -reports bone pain
-reports pain in legs
-reports pain in ribs
Asked about characteristics of pain - -describes pain as sharp
Asked about aggravating factors of pain - -reports that pain is constant - no periods of
relief or worsening
Asked about treatment and relieving factors of pain - -reports that nothing relieves
current pain
, -reports prescription pain pill
Asked about severity of pain - -reports current pain is a 4/10
-reports pain before medication was a 9/10
Asked about existing health conditions - -reports stage IV breast cancer with liver
metastasis
-reports hypertension diagnosis
Asked about allergies - -denies general allergies
-denies latex allergy
Asked specifically about medication allergies - -reports allergy to penicillin
Followed up about penicillin allergy - -reports last taken in childhood
-reports reaction was a rash
Asked about home medications - -reports taking long-acting morphine
-reports taking immediate release morphine
-denies taking vitamins
-denies taking herbal supplements
Followed up on long-acting morphine - -reports morphine dosage: 60 mg
-reports morphine frequency: every 12 hours
-reports morphine is typically effective at reducing overall pain level
Followed up on immediate release morphine - -reports morphine dosage: 20 mg
-reports morphine frequency: as needed
-reports morphine is typically effective at reducing breakthrough pain
Asked about substance use - -denies recent alcohol use
-denies illicit drug use
-denies use of tobacco and nicotine products
Asked about general symptoms - -denies fever
-denies chills
-denies night sweats
Asked about review of systems for HEENT - -reports impaired vision
-reports wearing glasses
-denies impaired hearing
Asked about review of systems for respiratory - -denies shortness of breath
-denies cough
-denies dyspnea on exertion
-denies wheezing
Life - Subjective
Established chief complaint - -reports pain
Established orientation - -oriented to person
-oriented to place
-oriented to time
-oriented to situation
Asked about fluid intake and hydration - -denies current thirst
-reports very little water intake in the past week
-reports a few sips of ginger ale today
Asked about urinary comfort - -reports last urination was around 10 am
-denies pain or burning with urination
Asked about most recent meal - -denies current hunger
-reports no food intake today
-last meal was a few bites of yogurt last night
Asked about preferences for hospice care - -reports wanting to be in hospice care
Asked about advanced directives - -reports having an advanced directive
Asked about onset and duration of pain - -pain became unbearable 2 days ago
-reports pain increasing over the past 2 days
-reports experiencing some pain most of the time
Asked about location of pain - -reports bone pain
-reports pain in legs
-reports pain in ribs
Asked about characteristics of pain - -describes pain as sharp
Asked about aggravating factors of pain - -reports that pain is constant - no periods of
relief or worsening
Asked about treatment and relieving factors of pain - -reports that nothing relieves
current pain
, -reports prescription pain pill
Asked about severity of pain - -reports current pain is a 4/10
-reports pain before medication was a 9/10
Asked about existing health conditions - -reports stage IV breast cancer with liver
metastasis
-reports hypertension diagnosis
Asked about allergies - -denies general allergies
-denies latex allergy
Asked specifically about medication allergies - -reports allergy to penicillin
Followed up about penicillin allergy - -reports last taken in childhood
-reports reaction was a rash
Asked about home medications - -reports taking long-acting morphine
-reports taking immediate release morphine
-denies taking vitamins
-denies taking herbal supplements
Followed up on long-acting morphine - -reports morphine dosage: 60 mg
-reports morphine frequency: every 12 hours
-reports morphine is typically effective at reducing overall pain level
Followed up on immediate release morphine - -reports morphine dosage: 20 mg
-reports morphine frequency: as needed
-reports morphine is typically effective at reducing breakthrough pain
Asked about substance use - -denies recent alcohol use
-denies illicit drug use
-denies use of tobacco and nicotine products
Asked about general symptoms - -denies fever
-denies chills
-denies night sweats
Asked about review of systems for HEENT - -reports impaired vision
-reports wearing glasses
-denies impaired hearing
Asked about review of systems for respiratory - -denies shortness of breath
-denies cough
-denies dyspnea on exertion
-denies wheezing
