Download FOCUSED EXAM COMPLETED SHADOW HEALTH SUBJECTIVE APPROPRIATE QUESSTIONS AND ANSWERS and more Exams Nursing in PDF only on Docsity!
APPROPRIATE QUESSTIONS AND ANSWERS
Asked about medication administered in Reports receiving oxycontin
Asked about patient comfort and needs Denies needing to use the bathroom
Category
Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
Scored Items
Experts selected these topics as essential components of a strong, thorough interview with this patient.
Indicates an item that you found. Indicates an item that is available to be found.
Patient Data
Not Scored
A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case.
Chief Complaint
Established chief complaint Reports pain Reports recent fall Reports worry about worsening symptoms
Orientation
Established orientation Oriented to person Oriented to place Oriented to time Oriented to situation
Patient Status
ER Reports oxycontin has been effective
History of Present Illness
APPROPRIATE QUESSTIONS AND ANSWERS
Asked about severity of pain Reports current pain is a 1
Asked about onset and duration of symptoms
Reports recent episode of severe pain started this morning Reports pain has been getting progressively worse in the last few weeks
Asked about location of pain Reports hip pain Reports knee pain
Asked about characteristics of pain Describes pain as aching Describes pain as "deep" Denies shooting or sharp pain Reports occasional "grating" sensation in joints Denies burning pain Denies stinging pain
Reports pain before medication was a 9
Asked about non-medication relieving factors of pain
Reports that rest typically relieves the pain Reports not using any non-medication treatments to treat this morning's pain Reports occasional use of moist heat as treatment on hips Reports using range of motion exercises for knees Reports wearing elastic supports on knees bilaterally Denies use of ice as treatment
Asked about aggravating factors of pain Reports that exercise exacerbates pain and stiffness Reports that weight bearing exacerbates pain and stiffness Reports that pain and stiffness are worsein the morning Reports that changes in weather exacerbate pain and stiffness
Followed up on details of the fall Reports falling getting out of bed Reports hitting his back on bed frame Denies dizziness, syncope, or vertigo at time of fall Denies substance use that could have related to the fall
APPROPRIATE QUESSTIONS AND ANSWERS
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 naproxen at 5 am this morning to try to relieve pain Denies taking other medications today
for atrial fibrillation (^) Reports warfarin dosage: 2.5 mg Reports warfarin frequency: 1x daily Reports monthly blood tests to check warfarin effectiveness Denies warfarin side effects
Followed up on calcium channel blocker medication for atrial fibrillation
Reports taking verapamil Reports verapamil dosage: 80 mg Reports verapamil frequency: 3x daily Denies verapamil side effects
Followed up on combination ARB / diuretic for hypertension
Reports taking Hyzaar (losartan and hydrochlorothiazide combination) Reports Hyzaar dosage: 100 losartan / mg hydrochlorothiazide Reports Hyzaar frequency: 1x daily Denies Hyzaar side effects
osteoarthritis Reports naproxen dosage: 220 mg Reports naproxen frequency: 2x daily Denies naproxen side effects Reports that naproxen is typically effectiveat reducing pain Reports that naproxen is OTC
Followed up on injections for osteoarthritis
Reports injections are kenalog (triamcinolone) Reports kenalog dosage: 10 mg/mL Reports kenalog frequency: 4 times per year Reports kenalog location: Injected into knee joint
Followed up on oral medication for Reports taking naproxen
Followed up on anticoagulant medication Reports taking warfarin
APPROPRIATE QUESSTIONS AND ANSWERS
Asked about relevant family history Denies family history of osteoarthritis
Asked about general symptoms Denies fever
Denies side effects Reports that injections are effective in reducing pain Reports that last injection was "at least" 3 months ago
Family History
Denies family history of kidney stones Denies family history of chronic kidney disease Denies family history of atrial fibrillation Reports father and mother had hypertension
Social History
Asked about substance use Denies recent alcohol use Denies illicit drug use Denies use of tobacco and nicotine products
Review of Systems
Denies chills Denies night sweats
Asked about review of systems for HEENT
Denies impaired hearing Denies vision problems
Asked about review of systems for respiratory
Denies cough Denies shortness of breath Denies dyspnea on exertion Denies wheezing
Asked about review of systems for cardiovascular
Denies chest pain Denies palpitations Denies edema Denies claudication
APPROPRIATE QUESSTIONS AND ANSWERS
Asked about continence Reports full control over bowels
Asked about sleeping habits Reports that sleep is good
Asked about confusion Denies confusion
Asked about evidence of falls Denies previous falls
Asked about gait and ambulatory aids Reports some problems with gait
Denies difficulty tying shoes
Asked about toileting Reports being able to get up from the toilet with support (uses bathroom sink for support) 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 morning Reports some difficulty getting out of chairs Reports occasional use of cane to transfer
Reports full control over bladder
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
Denies insomnia Denies frequent waking Denies oversleeping
Denies dizziness, syncope, or vertigo
Denies bedrest Denies use of wheelchair Reports occasional use of cane to walk Reports occasional use of furniture as support while walking Reports occasional problems with balance because of arthritis pain
Asked about skin breakdown Reports that his skin seems thin
APPROPRIATE QUESSTIONS AND ANSWERS
Asked about weight changes Denies weight changes
Denies open wounds Denies rashes or lesions Denies bruising (may have bruising on back from fall, but it hasn't appeared yet) Denies pruritus
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 Denies changes in appetite Denies feeling full quickly
Asked about effects of health on social activity
Reports that social activity has remained the same, although he has to sit through some events Reports feeling worried about reduced mobility and independence
Asked about patient's perception of health
Describes health as fair
Asked about tiredness, energy levels, and fatigue
Reports increased fatigue and low energy Describes fatigue as "having hardly any energy" and "needing to rest much more than usual" Reports fatigue occurs in the afternoons Reports fatigue for the last 3 months
Asked about recent ER visits or hospitalizations
Denies ER visits or hospitalization in the last 3 months Reports last hospitalization was 3 years ago Reports last hospitalization was for kidney stones
