Focused Exam: Community-Acquired Pneumonia Results | Completed
Advanced Pharmacology - Summer 2019, NURS 5304
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Lab Pass
Subjective Data Collection: 28 of 29 (96.6%)
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Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
Category Scored Items
Experts selected these topics as essential components of a strong, thorough interview with this patient.
Chief Complaint
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Indicates an item that is available to be found.
Patient Data
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A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case.
Established chief complaint and reason for admittance
Reports fever Reports chest pain Reports cough
History of Present Illness
Asked about additional symptoms Reports fatigue
Reports coughing up sputum Reports sinus congestion Reports muscle soreness
Asked about onset and duration of symptoms
Reports fatigue began 3 days ago Reports chest pain began 3 days ago Reports productive cough began 3 days
Reports sinus congestion began 3 days ago
Reports fever began 1 day ago
Asked about frequency of symptoms Reports fatigue is constant
Reports fever is constant Reports congestion is constant
Reports less severe chest pain is constant Reports more severe chest pain occurs
with coughing
Reports coughing every few minutes
Followed up on location of pain Reports pain in lower right side of chest
Followed up on characteristics of pain Reports chest pain is dull
Followed up on characteristics of discharge
Reports coughing up rust-colored sputum Reports nasal mucus varies from yellow to
green in color
Asked about aggravating factors Reports deep breathing aggravates chest
pain
Reports speaking aggravates chest pain Reports physical exertion aggravates
chest pain and fatigue
Asked about non-medicational relieving factors
Reports resting provides relief Reports tea provides relief
Reports humidifier steam provides slight relief
Asked about severity of pain Reports chest pain when not coughing is 2 out of 10
Reports chest pain during normal coughing is 5 out of 10
Past Medical History
Asked about pre-existing health conditions
Reports chronic kidney disease stage 2 Reports hypertension
Asked about onset and duration of pre- existing health conditions
Reports chronic kidney disease was diagnosed 9 years ago
Reports hypertension was diagnosed 14 years ago
Asked about hospitalizations Denies recent hospitalizations
Asked about allergies Denies allergies
Asked about vaccines Reports receiving pneumococcal vaccine 12 years ago
Reports receiving flu vaccine 3 months ago
Home Medications
Asked about home medications Reports taking trandolapril/verapamil
combination drug
Reports taking chlorothiazide Reports taking aspirin
Followed up on trandolapril/verapamil Reports taking trandolapril/verapamil for
hypertension and chronic kidney disease Reports pill contains 2 milligrams of
trandolapril and 180 milligrams of verapamil
Reports taking trandolapril/verapamil pill once a day
Reports having taken trandolapril/verapamil for 9 years
Reports last dose of trandolapril/verapamil was this morning
Denies adverse effects from trandolapril/verapamil
Followed up on chlorothiazide Reports taking chlorothiazide for hypertension
Reports chlorothiazide pill is 500 milligrams
Reports taking chlorothiazide pill twice a day
Reports having taken chlorothiazide for 14 years
Reports last dose of chlorothiazide was this morning
Reports chlorothiazide increases frequency of urination
Followed up on aspirin Reports taking aspirin for pain and fever Reports aspirin pill is 325 milligrams Reports taking 2 aspirin pills every 6
hours, 3 times a day
Reports having taken aspirin pills for 3 days
Reports last dose of aspirin was this
Denies adverse effects from aspirin
Asked about vitamins and supplements Reports taking calcium supplement
Reports taking vitamin D supplement
Followed up on calcium supplement Reports taking calcium supplement for
chronic kidney disease
Reports calcium supplement is 1200 milligrams
Reports taking calcium supplement once a day
Reports having taken calcium supplement for 9 years
Reports last dose of calcium supplement was this morning
Denies adverse effects from calcium supplement
Followed up on vitamin D supplement Reports taking vitamin D supplement for
chronic kidney disease
Reports vitamin D supplement is 15 micrograms
Reports taking vitamin D supplement once a day
Reports having taken vitamin D supplement for 9 years
Reports last dose of vitamin D was this morning
Denies adverse effects from vitamin D
Asked about medication regimen adherence
Denies missing medication doses Reports being able to afford medication Reports using pillbox
Social History
Asked about history of antibiotic use Denies recent antibiotic regimen
Asked about substance use Reports drinking 1-2 glasses of wine per week
Denies tobacco use Denies illicit drug use
Asked about exercise Reports taking 10 minute walks 2-3 times per week
Asked about diet Reports being a lacto-ovo-vegetarian
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