Exam (elaborations)
Shadow Health - Robert Hall - Mobility – Subjective Exam- 53 Q’s And A’s
Shadow Health - Robert Hall - Mobility – Subjective Exam- 53 Q’s And A’s
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Shadow Health - Robert Hall - Mobility –Subjective Exam- 53 Q’s And A’s
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
-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 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 2/10
-pain level arriving at ER was 10/10
-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
-Asked specifically about medication allergies - --denies medication
allergies
-Asked about home medications - --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 - --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. - --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
-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
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