Subjective Data - Robert Hall - Mobility Shadow Health PDF

Preview

Summary

Shadow Health Simulation with Robert Hall - Mobility interview questions, empathy, transcript, objective and subjective...

Description

Shadow Health will be performing planned maintenance this Monday, from 7:00am until 7:30am Eastern. During this time assignment attempts will be disabled. Thank you for h improve your Shadow Health experience!

Focused Exam: Mobility Results | Turned In Complex Concepts of Adult Health Med/Surg 2 - Gerontology Assignments - Spring 2022, RNSG 1362 Return to Assignment (/assignments/602493/)

(/) (/)

Your Results

Reopen (/assignment_attempts/11535958/reope Lab Pass (/assignment_attempts/11535958/lab_pass.

Overview

Subjective Data Collection: 53 of 54 (98.1%)

Transcript Subjective Data Collection Hover To Reveal...

Indicates an item that you found.

Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.

Indicates an item that is available to be found.

Objective Data Collection Education & Empathy Documentation Care Plan Reflections

Category

Scored Items

Patient Data Not Scored

Experts selected these topics as essential components of a strong, thorough interview with this patient.

A combination of open and closed questions will yi better patient data. The following details are facts o 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 location of pain

Asked about characteristics of pain

Reports pain in left lower calf

Describes pain as "nagging" Describes pain as sharp Denies stinging or burning pain Reports sensation of warmth

Asked about aggravating factors of pain

Asked about treatment and relieving factors of pain

Reports pain is worse with walking

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 Reports prostate enlargement

Followed up about hypertension diagnosis

Hypertension diagnosed at age 57 Reports belief that hypertension is "okay" (wellcontrolled) 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

Asked about allergies

Diagnosed at age 69

Denies general allergies Denies environmental allergies Denies latex allergy

Asked specifically about medication allergies

Denies medication allergies

Home Medications

Asked about home medications

Reports 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

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 finances Denies difficulty obtaining medications because transportation

Followed up on last dose of home medications

Reports taking hypertension medication this morning Reports last dose of medication for prostate enlargement yesterday Reports last dose of sleep aid was earlier this week

Followed up on medication for hypertension

Reports taking metoprolol Reports metoprolol dosage: 25 mg Reports metoprolol frequency: 1x daily Denies metoprolol side effects

Followed up on medication for prostate enlargement

Reports taking Proscar (finasteride) Reports Proscar dosage: 5 mg Reports Proscar frequency: 1x daily Denies Proscar side effects

Followed up on sleep aid

Reports taking Benadryl to make him drowsy Reports Benadryl dosage: Isn't sure Reports Benadryl frequency: once or twice a wee Denies Benadryl side effects

Family History

Asked about relevant family history

Reports father died of colon cancer Reports mother died of heart failure

Social History

Asked about substance use

Reports occasional alcohol use Denies illicit drug use Reports past cigarette smoking

Followed up on alcohol use

Reports occasional beer or cocktails Reports drinking only at gatherings

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

Review of Systems

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

Asked about review of systems for psychological

Denies anxiety Denies recent mood changes Denies suicidal thoughts

Functional Status & Geriatric Syndromes

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 fe days

Asked about feeling safe at home

Asked about bathing

Reports feeling safe at home

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

Asked about evidence of falls

Reports recent fall Reports history of falls Reports falling twice in the last 6 months Reports recent dizziness Reports increased dizziness the past 2 weeks Reports dizziness gets worse when he stands

Asked about gait and ambulatory aids

Reports some gait impairment Denies bedrest Denies use of wheelchair Reports occasionally using cane to walk Reports balance problems

Asked about skin breakdown

Reports thin skin Denies open wounds Denies rashes or lesions Reports Bruising Denies pruritus, itching or scratching

Asked about weight changes

Reports weight loss Reports 10 lbs weight loss Reports weight loss occurred over the last 6 months Reports weight loss was unintentional

Asked about oral or dental problems

Denies tooth problems and dental pain Denies issues with mouth, jaw, or gums Reports no issues with being able to chew food

Asked about appetite changes

Reports anorexia Reports anorexia for the last few months Reports feeling full quickly

Asked about effects of health on social activity

Reports that health sometimes prevents him from engaging in social activity Denies that emotional problems prevent him from engaging in social activity

Asked about patient's perception of health

Asked about tiredness, energy levels, and fatigue

Reports poor health

Reports fatigue Reports activity increases fatigue Reports some fatigue most days

Asked about recent ER visits or hospitalizations

Reports ER visit in the last 3 months Denies hospitalization in the last 3 months Reports going to the ER after a fall Reports getting a hip x-ray Reports x-ray revealed no fracture Denies being admitted to hospital

Comments

If your instructor provides individual feedback on this assignment, it will appear here.

(https://w

ps://www.elsevier.com/)...