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Subjective Data - Robert Hall - Mobility Shadow Health
Complex Concepts of Adult Health (RNSG 1343 )
Lone Star College System
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Focused Exam: Mobility Results | Turned In
Complex Concepts of Adult Health Med/Surg 2 - Gerontology Assignments - Spring 2022, RNSG 1362
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Subjective Data Collection: 53 of 54 (98%)
Chief Complaint
Orientation
History of Present Illness
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Overview Transcript
Subjective Data Collection Objective Data Collection Education & Empathy Documentation Care Plan Reflections
Indicates an item that you found. Indicates an item that is available to be found.
Category Scored Items
Experts selected these topics as essential components of a strong, thorough interview with this patient.
Patient Data
Not Scored A combination of open and closed questions will yie better patient data. The following details are facts o patient's case.
Established chief complaint Reports leg pain Reports leg swelling
Established orientation Oriented to person Oriented to place Oriented to time Oriented to situation
Asked about onset and duration of symptoms Reports fall was 9 am this morning
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Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
Past Medical History
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 Reports pain in left lower calf
Asked about characteristics of pain Describes pain as "nagging" Describes pain as sharp Denies stinging or burning pain Reports sensation of warmth
Asked about aggravating factors of pain Reports pain is worse with walking
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/ Pain level arriving at ER was 10/
Asked about existing health conditions Reports hypertension Reports osteoarthritis Reports prostate enlargement
Followed up about hypertension diagnosis 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 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
Diagnosed at age 69
Asked about allergies Denies general allergies Denies environmental allergies Denies latex allergy
Review of Systems
Reports drinking less than 1 drink per week Reports that drinking often gives heartburn so he tends to avoid alcohol
Followed up on cigarette smoking Reports started smoking age 20 Reports quitting smoking age 60 (20 years ago) Reports smoking 1 pack a day when actively smoking
Asked about exercise Reports occasional exercise Reports enjoying walking, but only short distances, as he does not have the energy any mo to walk long distances. Reports that dizziness has interfered with walking
Asked about general symptoms Denies feeling feverish Denies chills Denies night sweats
Asked about review of systems for HEENT Reports hearing loss Reports wearing a hearing aid Reports vision problems Reports wearing glasses for reading and watchin TV
Asked about review of systems for respiratory Denies shortness of breath Denies cough Denies dyspnea on exertion Denies wheezing
Asked about review of systems for cardiovascular
Denies history of blood clots Denies history of DVT Denies chest pain Denies palpitations Reports claudication
Asked about review of systems for gastrointestinal
Denies abdominal pain Denies difficulty swallowing Denies nausea Denies vomiting Denies constipation Denies diarrhea Denies changes in stool or bowel patterns
Asked about review of systems for musculoskeletal
Reports occasional joint pain from arthritis Reports erythema of joints Reports edema of joints
Asked about review of systems for neurological Reports overall weakness Denies frequent headaches Reports numbness and tingling in left lower leg Denies numbness / tingling elsewhere in body
Functional Status & Geriatric Syndromes
Asked about review of systems for psychological Denies anxiety Denies recent mood changes Denies suicidal thoughts
Asked about depression
Asked about living environment Reports living in a house Reports living alone Reports some loneliness Reports visits from one of his daughters every few days
Asked about feeling safe at home Reports feeling safe at home
Asked about bathing Reports being able to bathe independently Reports being able to reach all parts of his body Reports being able to get out of shower safely Reports that his daughter installed a bar in the shower
Asked about dressing Reports being able to retrieve clothing Reports being able to put on clothes Denies difficulty with buttons and zippers Denies difficulty tying shoes
Asked about toileting Reports being able to get up from the toilet with support (uses cane) Reports being able to arrange clothing during toileting Reports being able to clean genital area without help
Asked about transferring Reports difficulty getting out of bed in the mornin Reports some difficulty getting out of chairs Reports occasional use of cane to transfer
Asked about continence Reports full control over bowels Reports occasional urinary incontinence from prostate enlargement
Asked about ability to eat independently Reports being fully able to eat and feed himself Reports being fully able to get food from plate to mouth Reports being able to prepare food
Asked about sleeping habits Reports poor sleep Reports occasional insomnia Reports frequent waking Denies oversleeping
Asked about confusion Denies confusion
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Subjective Data - Robert Hall - Mobility Shadow Health
Course: Complex Concepts of Adult Health (RNSG 1343 )
University: Lone Star College System
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