History of Present Illness
Medications
Past Medical
History
Family Health History
Social History
Review of
Relevant Systems
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Categ
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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 questions will yield
better patient data. The following details are facts of
the patient's case.
Confirmed guardian's relationship to patient Jennifer reports being patient's mother
Jennifer reports working during the day
Vivian reports being patient's mother
Vivian reports being primary caregiver during the
day
Confirmed chief complaint Reports patient has a bad cold
Reports patient is having difficulty breathing
Asked about patient symptoms Reports patient is congested and has a runny
nose
Reports patient has a cough
Reports patient has a fever
Followed up on fever Reports patient's fever was 101 degrees today
Reports taking patient's temperature rectally
Asked about reason for coming to ED Reports patient shows signs of labored
breathing
Reports being warned about retractions at
primary care
Asked about onset and duration of symptoms Reports patient's congestion and runny nose
began 5 days ago
Reports patient's cough began 2 days ago
Reports patient's fever started today
Reports patient got sick a few days after 100
day party
Followed up on onset Reports patient interacted with many new
people at party
Reports not remembering anyone being sick at
party
Asked about seeking medical treatment Reports Jennifer brought patient to primary care
Denies pediatrician prescribing medication
Reports pediatrician said to treat symptoms at
home
Asked about nasal symptoms Reports patient has excessive mucus
Reports patient's mucus is clear
Asked about characteristics of cough Reports nonproductive cough
Reports patient coughing frequently
Asked about aggravating factors for symptoms Denies specific triggers for symptoms
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