Exam (elaborations)
Robert Hall Mobility Shadow Health Focused Exam- TRANSCRIPT (GRADED A, 2020)
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Robert Hall Mobility Shadow Health Focused Exam- TRANSCRIPT (GRADED A, 2020)
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Hello My name is GreetJames and i am going 10/06/18 12:16 PM EDT
to be your nurse.
Hello, hello.
Question
Can you tell me your name and date of birth? 10/06/18
12:19 PM EDT
Robert Hall, December 28th . . . [Mr. Hall reports correct birth
year.]
Question
How are you doing today? 10/06/18
12:37 PM EDT
Been better, been worse, I suppose. I'm honestly not feeling too
great about winding up here, but what can you do? As long as you
guys can help me out with this leg of mine and whatever's been
making me so dizzy, I'll be as right as rain.
Empathize
I'm sorry you feel that way. I am going to do what I can to help you
10/06/18
feel better.
12:37 PM EDT
Much appreciated.
, Question
Are you having any pain? 10/06/18
12:38 PM EDT
It doesn't hurt too bad right now. The meds they gave me in the
ER helped with that.
Question
Where do you hurt? 10/06/18
12:38 PM EDT
In my lower left leg, around the calf. It was getting hard to bear... I
was thinking of coming here even before I fell this morning.
How do you rate your leg pain on a scale of 1 to 10? (Clarified to Question
How would you rate your pain at its worst on a scale from 0 to 10/06/18
10?.) 12:38 PM EDT
When I got here after the fall, it was a 10 out of 10. Possibly the
worst pain I've felt. (Clarified to how I would rate my pain on a
scale at its worst.)
Question
And how is your pain now? 10/06/18
12:39 PM EDT
Without this pain medication, I'd call it very severe.
Question
How would you describe your leg pain? (Clarified to can you
10/06/18
describe your pain.)
12:39 PM EDT
,It's like a sharp, nagging feeling. Kind of like someone's been
jabbing my leg over and over again. (Clarified to what the pain is
like.)
Question
How did you hurt your leg? 10/06/18
12:40 PM EDT
I bruised up my legs in the fall, but that's not a serious injury. If
you're asking if this leg pain is from an injury, it isn't -- I've had that
for a couple days.
Question
What makes your leg pain better? (Clarified to what relieves your
10/06/18
pain.)
12:41 PM EDT
As far as I can tell, nothing but that pain medication the ER gave
me. (Clarified to what relieves the pain.)
Question
When did the leg pain start? 10/06/18
12:41 PM EDT
The pain and swelling in my leg started about two days ago.
Question
What cause the pain and swelling two days ago? (Clarified to what
10/06/18
do you think brought on the pain?.)
12:42 PM EDT
I'm not too sure, but it could be my arthritis I suppose... but this
pain is a lot different and a lot more intense from how my arthritis
usually is. And even if it was, that doesn't explain these dizzy spells
I'm getting. (Clarified to what I think caused my pain.)
, Question
When did you start getting dizzy spells? 10/06/18
12:42 PM EDT
Before these last two weeks I never had much trouble with it, but
lately I'm dizzy whenever I stand up.
Question
Do you have a history of falls? 10/06/18
12:43 PM EDT
To be honest, I haven't been the surest on my feet lately. I've
fallen once or twice before today in the last 6 months.
Question
Do you have any allergies? 10/06/18
12:44 PM EDT
Nope, I've always been allergy-free.
Question
Are you allergic to latex? 10/06/18
12:44 PM EDT
Nope, I'm allergy free.
Question
Are you currently taking any medications? 10/06/18
12:44 PM EDT
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