NR509 History Assignment Subjective Shadow

Your Results Overview Transcript Subjective Data Collection: 94 of 104 (90.4%) Subjective Data Collection Objective Data Collection Education & Empathy Documentation Information Processing Health History Tips and Tricks Self-Reflection Category 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 open foot wound History of Present Illness Asked for details about the pain Asked to rate pain on a scale © Shadow Health® 2018 Describes the pain as throbbing Describes the pain as sharp when she attempts to stand Initial injury occurred 1 week ago Pain has increased in the past 2 days Reports feeling pain radiating into ankle Pain prevents bearing weight on foot Rates present pain at a 7 out of 10 1 of 12 11/20/2018, 5:30 PM History Assignment | Completed | Shadow Health https://chamberlain.shadowhealth.com/assignment_attempts/4119094 Clarified location of wound Confirmed that right foot is injured Confirmed that wound is on the plantar surface of her foot Determined details of the injury Scraped foot on a cement step Reports mild ankle injury Was not drinking at the time of the injury Was not wearing shoes at the time of injury Asked about the assessment of the injury at the ER Went to the ER after sustaining the injury Decided to go because she suspected an ankle sprain Received an x-ray X-ray showed no broken bones Received a prescription for pain pills Asked about drainage from the foot wound Reports that the wound bled a little after sustaining the injury Reports seeing pus draining from wound Began noticing pus 2 days ago Followed up about character of drainage from the foot wound Describes pus as white or yellow in color Reports no odor from the wound Asked about home treatment of foot wound Describes wound care regimen of cleaning and bandaging Cleaned wound twice a day Cleaned wound with hydrogen peroxide Changed bandage twice a day Applied neosporin Asked about other foot wound symptoms Reports swelling around foot wound Noticed swelling getting worse in the past 2 days Reports redness around the wound Reports that the wound feels warm Explored impact of patient's foot injury on activities of daily living Asked about recent fever Medical History: Medication Pain affects ability to walk Pain affects job performance Pain prevented her from attending class Reports a fever last night