SHADOW HEALTH : Robert Hall - Mobility –
Subjective Complete Questions And Accurate
Answers
Established chief complaint - Correct Answer -reports leg pain
-reports leg swelling
Established orientation - Correct Answer -oriented to person
-oriented to place
-oriented to time
-oriented to situation
Asked about onset and duration of symptoms - Correct Answer -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 - Correct Answer -reports pain in left lower calf
Asked about characteristics of pain - Correct Answer -describes pain as "nagging"
-describes pain as sharp
-denies stinging or burning pain
-reports sensation of warmth
Asked about aggravating factors of pain - Correct Answer -reports pain worse with
walking
Asked about treatment and relieving factors of pain - Correct Answer -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 - Correct Answer -current pain level is 2/10
-pain level arriving at ER was 10/10
Asked about existing health conditions - Correct Answer -reports hypertension
-reports osteoarthritis
-reports prostate enlargement
, Followed up about hypertension diagnosis - Correct Answer -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 - Correct Answer -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 - Correct Answer -diagnosed at
age 69
Asked about allergies - Correct Answer -denies general allergies
-denies environmental allergies
-denies latex allergy
Asked specifically about medication allergies - Correct Answer -denies medication
allergies
Asked about home medications - Correct Answer -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 - Correct Answer -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. - Correct Answer -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
Subjective Complete Questions And Accurate
Answers
Established chief complaint - Correct Answer -reports leg pain
-reports leg swelling
Established orientation - Correct Answer -oriented to person
-oriented to place
-oriented to time
-oriented to situation
Asked about onset and duration of symptoms - Correct Answer -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 - Correct Answer -reports pain in left lower calf
Asked about characteristics of pain - Correct Answer -describes pain as "nagging"
-describes pain as sharp
-denies stinging or burning pain
-reports sensation of warmth
Asked about aggravating factors of pain - Correct Answer -reports pain worse with
walking
Asked about treatment and relieving factors of pain - Correct Answer -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 - Correct Answer -current pain level is 2/10
-pain level arriving at ER was 10/10
Asked about existing health conditions - Correct Answer -reports hypertension
-reports osteoarthritis
-reports prostate enlargement
, Followed up about hypertension diagnosis - Correct Answer -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 - Correct Answer -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 - Correct Answer -diagnosed at
age 69
Asked about allergies - Correct Answer -denies general allergies
-denies environmental allergies
-denies latex allergy
Asked specifically about medication allergies - Correct Answer -denies medication
allergies
Asked about home medications - Correct Answer -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 - Correct Answer -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. - Correct Answer -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
