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Lab Pass
Subjective Data Collection: 25 of 28 (89.3%)
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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.
Chief Complaint
Established chief complaint Reports sore throat Reports itchy throat Reports itchy eyes Reports runny nose
History of Present Illness
Asked about onset of symptoms Reports sore throat began "about a week
ago"
Reports runny nose began "about a week ago"
Reports itchy eyes began "about a week ago"
Asked about aggravating factors for throat symptoms
Reports throat pain is constant Reports throat pain is worse in the
morning
Reports some soreness with swallowing
Asked severity of throat discomfort Describes sore throat as mild to moderate
Asked about frequency and duration of runny nose
Reports nose is runny "pretty much all day"
Asked about character of nasal symptoms
Denies itchy nose Denies sinus pain Denies sinus pressure Denies sneezing
Followed up about character of nasal discharge
Reports clear discharge Reports thin discharge Denies purulent discharge
Asked about eye symptoms Reports eye itching is constant Reports eye redness
Asked related respiratory symptoms Reports breathing isn't affected
Denies cough
Denies chest tightness
Asked about related asthma symptoms Denies recent wheezing
Denies increase in recent asthma symptoms
Asked about exposure to allergens Reports no exposure to cats
Reports no exposure to mold or mildew Reports no exposure to dust
Reports no known exposure to irritants in work environment
Reports changing bedding "once a week"
Asked about perceived cause of symptoms
Describes symptoms as similar to allergies
Reports that the symptoms don't seem like a common cold
Describes similarity to her sister's hay fever symptoms
Reports no history of cigarette smoking Reports no recent exposure to
secondhand smoke
Medical History
Confirmed use of medications Confirmed medications from previous visit
(no new medications)
Followed up about inhaler use Uses an inhaler to treat asthma symptoms
Inhaler is Proventil
Last use of inhaler was last week
Reports typical inhaler use is 2 - 3 times a week
Reports using 2 - 3 puffs of inhaler when used
Prescribed dosage is 2 puffs
Followed up about medications and relieving factors for nose and eye symptoms
Reports no treatment for itchy eyes Reports no treatment for nasal symptoms Reports no antihistamine
Reports no decongestant
Followed up about medications and relieving factors for throat symptoms
Reports lozenges as treatment Reports lozenges reduce symptoms Reports ingesting lozenges every few
hours
Reports drinking water reduces symptoms
Confirmed allergies Reports known allergy to cats Reports known allergy to dust Reports no previous problems with
seasonal allergies
Review of Systems
Asked about general symptoms Denies recent or frequent illnesses
Denies chills Denies fever
Reports low energy level [Show Less]