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Scored Items Patient Data Chief Complaint: Established chief complaint • Reports pain • Reports blood in urine • Reports increased frequency of urination Orientation: Asked about orientation • Oriented to own person • Oriented to place • Oriented to situation • Oriented to time History of Present Illness: Asked about onset and duration of symptoms • Reports pain began 3 days ago • Reports pain has gradually increased since onset • Reports increased urinary frequ...

All the best from Dr. A Dr. Assessments Page 1 of 7 Established chief complaint Reports sleep problems Asked about onset and frequency of sleep problems Reports sleep problems for the past 10+ years Reports having problems sleeping most nights of the week Asked about sleep quality and characteristics Reports recent sleep problems include nightmares. Reports falling asleep often takes more than an hour. Reports waking up two or three times during the night for "at least ten minutes"...

All the best from Dr. A Dr. Assessments Page 1 of 12 The nurse is preparing a diet plan for a pregnant client with preeclampsia. Which would the nurse include in the client's diet? Select all that apply. Food with a low sodium content Food with a high zinc content Six to eight glasses of water per day Food with a low fiber content Four to five cups of coffee per day Food with a low sodium content Food with a high zinc content Six to eight glasses of water per day Which is a subject...

All the best from Dr. A Dr. Assessments Page 1 of 4 Asked about heart problems -Denies heart problems Asked about heartbeat -- reports normal heartbeat - reports normal heart rate - denies palpitations - denies arrhythmia Asked about high blood pressure -- denies high blood pressure - reports last blood pressure check Finding: - reports last blood pressure check 140 over 80 or 90 - reports belief that current blood pressure is on the high side of normal range Asked about heart ...

Review of Systems Head: Reports headaches that occur weekly with reading in the past year. The headache lasts a few hours and is relieved with acetaminophen and sleep. Headaches are described as a "tight and throbbing feeling behind the eyes." Denies head and neck trauma. Ears: Denies difficulty hearing, tinnitus, ear pain, and discharge. Eyes: Complains of blurred vision associated with "reading and studying," which has worsened over the past few years. No visual acuity testing s...

All the best from Dr. A Dr. Assessments Page 1 of 10 What brings you in today?? Reports frequently occurring stomach pain How long have you had stomach pain? Noticing pain for at least a month Did the pain start suddenly? Pain increased gradually Do you have stomach pain every day? Reports pain daily How many times a week does your stomach hurt? Reports 3-4 episodes a week that are more severe How long after a meal does the pain start? Right after finishing a meal How many hours do...

All the best from Dr. A Dr. Assessments Page 1 of 3 Chief Complaint Ms. Abigail Harris is an 86-year-old African American woman who presented in the ED with weakness and fatigue. History of Present Illness Reports weakness and fatigue for last month, increasing over last 7 days. Ms. Harris is occasionally unable to get out of bed in the morning. The timing of fatigue is every morning. Reports that her fatigue is somewhat alleviated by lying down, and that she has slightly more energy in...

Bedside Shift Report Holly: Mr. Liu, this is your new nurse. They'll be taking over for me. Samuel: Hello. Nice to meet you. I'll be checking in with you every hour or so. Holly: All right, Mr. Liu, I'm going to hand you off to your new nurse using a Bedside Shift Report. At Shadow General, we perform our handoffs at the patient's bedside to make sure that you can stay involved in your care. Samuel: Sounds good. Holly: OK, I'm going to start with Mr. Liu's Situation . . . Holly:...

Established chief complaint? Reports cough Asked about onset of cough? Reports cough started 3 days ago Asked about characteristics of cough? Reports cough is wet Reports clear sputum with cough Asked about frequency and duration of cough? Reports coughing every few minutes Reports coughs last a few seconds Asked about aggravating factors for cough? Reports cough is worse at night Denies smoking Reports being exposed to secondhand smoke through father Reports he doesn't know what ...

Asked about current health problems? Denies current acute health problems Reports diabetes Reports asthma Asked about last visit to a healthcare provider? Reports last visit to a healthcare provider was 4 months ago Reports reason for last visit was annual gynecological exam Reports last general physical examination was 5 months ago Asked about current prescription medications? Reports taking diabetes medication Reports having an inhaler Reports taking prescription birth control pill...