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Unguided Intermediate Patient Case Results | Turned In
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Subjective Data Collection: 36 of 36 (100.0%)
Chief Complaint Orientation
Your Results Lab Pass (/assignment_attempts/14875335/lab_pass.
Overview Transcript Subjective Data Collection Objective Data Collection Education & Empathy QSEN Competencies 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 question yield better patient data. The following deta are facts of the patient's case. Established chief complaint Reports pain Reports blood in urine Reports increased frequency of urination Asked about orientation Oriented to own person Oriented to place Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
History of Present Illness Past Medical History Oriented to situation Oriented to time Asked about onset and duration of symptoms Reports pain began 3 days ag Reports pain has gradually in Reports increased urinary fre Reports pinkish urine starting Reports pain has been consta Followed up on urinary frequency Reports urinating about once Reports waking up to use the Reports waking up four to five bathroom Asked about location of pain Reports pain is in lower left si Denies radiating pain Asked about characteristics of pain Describes pain as sharp and Asked about aggravating factors of pain Reports nothing makes the pa Asked about treatment and relieving factors of pain Denies home treatment of pa Reports hydromorphone has Asked about severity of pain Reports current pain level is 2 Reports pain level before med Asked about existing health conditions Reports high blood pressure Reports chronic kidney disea Reports atrial fibrillation diagn Reports occasional heartburn Followed up about high blood pressure diagnosis Reports being diagnosed with age 55 Reports belief that blood pres Reports typical blood pressur Followed up about atrial fibrillation diagnosis Reports being diagnosed with Denies recent episodes of pa Denies pacemaker or surgica Followed up about chronic kidney disease diagnosis Reports being diagnosed with
Family History Review of Systems Adverse Reactions Denies illicit drug use Denies use of tobacco and nicotine products Asked about activities of daily living Denies difficulty toileting alon Denies difficulty dressing Denies difficulty feeding self Denies difficulty walking Denies difficulty bathing Denies difficulty transferring i Asked about elder abuse Denies being physically abus Denies being sexually abused Denies being emotionally abu Denies being verbally abused Denies being financially abus Asked about relevant family history Denies family history of kidne Denies family history of chron Denies family history of atrial Reports father and mother ha Asked about constitutional health Denies feeling feverish Denies chills Denies night sweats Reports fatigue Reports poor sleep Denies swelling Denies weight changes Asked about neurological side effects from hydromorphone Denies confusion Denies sedation Denies dizziness Denies mood changes (dysph Denies hallucinations Denies headache Asked about EENT side effects from hydromorphone Denies blurred vision Denies double vision Asked about respiratory side effects from hydromorphone Reports breathing is normal
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