Shadow Health Pneumonia, Anita Douglas
Subjective Data Collection: 28 of 30 (93.3%)
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Hover over the Patient Data items below to
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Found:
Indicates an item that you found.
Available:
Indicates an item that is available to be found.
Category
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.
Chief Complaint
Finding:
Established chief complaint
Finding:
Reports sporadic chest pain
(Found)
Pro Tip: Chest pain can be a sign of many health problems, some serious and some less serious. It is important to follow up with discovery of chest pain by asking about its characteristics and severity.
Example Question:
Do you have chest pain?
History of Present Illness
Finding:
Asked about onset of pain
Finding:
Reports chest pain started appearing in the past month
(Found)
Pro Tip: Establishing the onset of a patient's pain is essential in diagnosing its severity as well as the comfort of the patient.
Example Question:
When did your chest pain start?
Finding:
Asked about location of pain
Finding:
Reports pain is in center of the chest
(Found)
Pro Tip: Identifying the location of a patient's pain is essential in determining which body systems are affected, the underlying cause of the pain, and how best to treat it.
Example Question:
Where is the pain?
Finding:
Reports pain does not radiate
(Found)
Pro Tip: Pain radiation is an important symptom that can be helpful in understanding the cause of pain and narrowing the diagnosis.
Example Question:
Does the pain radiate?
Finding:
Denies arm pain
(Found)
Pro Tip: When combined with chest pain, arm pain can be a telling sign that the complaint may be cardiac in nature.
Example Question:
Are you experiencing arm pain?
Finding:
Denies shoulder pain
(Found)
Pro Tip: When combined with chest pain, shoulder pain can be a telling sign that the complaint may be cardiac in nature.
Example Question:
Are you experiencing shoulder pain?
Finding:
Denies back pain
(Found)
Pro Tip: When combined with chest pain, back pain can be a telling sign that the complaint may be cardiac in nature.
Example Question:
Are you experiencing back pain?
Finding:
Denies neck pain
(Found)
Pro Tip: When combined with chest pain, neck pain can be a telling sign that the complaint may be cardiac in nature.
Example Question:
Are you experiencing neck pain?
Finding:
Asked about duration of pain episodes
Finding:
Reports each episode lasted "several" minutes
(Found)
Pro Tip: Knowing the duration of a patient's pain gives you a more complete picture of its severity and potential impact on the patient's health.
Example Question:
How long does your chest pain last?
Finding:
Asked about frequency of pain
Finding:
Reports 3 episodes in past month
(Found)
Pro Tip: Establishing a timeline for a patient's symptoms can help you to better diagnose his condition and most effectively treat him.
Example Question:
How many times in the last month have you had chest pain?
Finding:
Reports that episodes did not seem related
(Found)
Pro Tip: Asking your patient if the episodes seem associated can point to possible factors that aggravate the episodes or trigger symptoms, and can help narrow your diagnosis.
Example Question:
Did the episodes seem associated?
Finding:
Asked about severity of pain
Finding:
Reports current pain is 0 out of 10
(Found)
Pro Tip: For many patients, it is difficult to clearly describe pain. Asking Brian to rate his pain on a scale from 0 to 10 develops a consistent measure of pain severity.
Example Question:
How would you rate your pain on a scale of zero to ten?
Finding:
Reports pain severity at its worst is 5 out of 10
(Found)
Pro Tip: For many patients, it is difficult to clearly describe pain. Asking Brian to rate his pain at its worst gives a clearer picture of the pain's severity.
Example Question:
How would you rate your pain on a scale of zero to ten?
Finding:
Asked about character of pain
Finding:
Describes pain as tight and uncomfortable
(Found)
Pro Tip: Asking Brian to describe his pain helps identify the cause and the severity of his discomfort. Patients may not know how to answer, so you may need to suggest words like sharp, dull, crushing, gnawing, or burning.
Example Question:
Can you describe your pain?
Finding:
Denies crushing pain
(Found)
Pro Tip: Asking Brian to describe his pain helps identify the cause and the severity of his discomfort. Patients may not know how to answer, so you may need to suggest words like sharp, dull, crushing, gnawing, or burning.
Example Question:
Is the pain crushing?
Finding:
Denies gnawing pain
(Available)
Pro Tip: Asking Brian to describe his pain helps identify the cause and the severity of his discomfort. Patients may not know how to answer, so you may need to suggest words like sharp, dull, crushing, gnawing, or burning.
Example Question:
Is the pain gnawing?
Finding:
Denies burning pain
(Found)
Pro Tip: Asking Brian to describe his pain helps identify the cause and the severity of his discomfort. Patients may not know how to answer, so you may need to suggest words like sharp, dull, crushing, gnawing, or burning.
Example Question:
Is the pain burning?
Finding:
Asked about aggravating factors
Finding:
Reports pain is aggravated by activity
(Found)
Pro Tip: Aggravating factors reveal further information about the nature of the pain and the body systems affected.
Example Question:
What makes the pain worse?
Finding:
Pain occurred with yard work and taking stairs
(Found)
Pro Tip: Determining the activity that may have caused the patient's complaint is crucial because it may reveal the root cause of the complaint.
Example Question:
What activity triggered the pain?
Finding:
Pain does not worsen with eating
(Found)
Pro Tip: It is important to ask about the patient's diet and its impact on his complaint because cardiac complaints and gastrointestinal pain can be very similar and are frequently conflated. Ruling out one or the other can assist your diagnosis.
Example Question:
Is the pain worse when you eat?
Finding:
Pain does not worsen after spicy foods
(Found)
Pro Tip: It is important to ask about the patient's diet and its impact on his complaint because cardiac complaints and gastrointestinal pain can be very similar and are frequently conflated. Ruling out one or the other can assist your diagnosis.
Example Question:
Is the pain worse after you eat spicy food?
Finding:
Pain does not worsen after high-fat foods
(Found)
Pro Tip: It is important to ask about the patient's diet and its impact on his complaint because cardiac complaints and gastrointestinal pain can be very similar and are frequently conflated. Ruling out one or the other can assist your diagnosis.
Example Question:
Is the pain worse after you eat high-fat foods?
Finding:
Asked about relieving factors
Finding:
Reports pain relief with brief period of rest
(Found)
Pro Tip: It's important to assess the nature of pain by asking about relief. Relieving factors can help narrow the body system and assist in a more accurate diagnosis.
Example Question:
What relieves your pain?
Finding:
Reports no medication to treat chest pain
(Found)
Pro Tip: It's important to assess the nature of pain by asking about relief. Discovering any pain medication Brian takes can help you assess the nature and severity of his pain and avoid any unwanted medication interactions.
Example Question:
Did you take anything for the chest pain?
Medical History
Finding:
Confirmed use of medications
Finding:
Confirms medications
(Found)
Pro Tip: Determining what, if any, medications a patient is taking is a crucial element of a thorough health history and will help you avoid unwanted drug interactions.
Example Question:
What medications do you take?
Finding:
Reports taking hypertension medication
(Found)
Pro Tip: The medication that a patient takes will indicate any relevant health conditions, their treatment plan, and how well they comply with it. Asking about relevant medication will help you to treat your patient.
Example Question:
Do you take medication for hypertension?
Finding:
Reports taking hyperlipidemia medication
(Found)
Pro Tip: The medication that a patient takes will indicate any relevant health conditions, their treatment plan, and how well they comply with it. Asking about relevant medication will help you to treat your patient.
Example Question:
Do you take medication for hyperlipidemia?
Finding:
Reports occasional ibuprofen use
(Found)
Pro Tip: The medication that a patient takes will indicate any relevant health conditions, their treatment plan, and how well they comply with it. Asking about relevant medication will help you to treat your patient.
Example Question:
Do you take over the counter medications?
Finding:
Reports taking fish oil
(Found)
Pro Tip: The medication that a patient takes will indicate any relevant health conditions, their treatment plan, and how well they comply with it. Asking about relevant medication or supplements will help you to treat your patient.
Example Question:
Do you take any supplements?
Finding:
Denies aspirin regimen
(Found)
Pro Tip: The medication that a patient takes will indicate any relevant health conditions, their treatment plan, and how well they comply with it. Asking about relevant medication will help you to treat your patient.
Example Question:
Do you take aspirin?
Finding:
Followed up on hypertension treatment
Finding:
Medication is Lopressor
(Found)
Pro Tip: Discovering which specific medications a patient takes helps you assess his health conditions, effectiveness of treatment, and guards against unwanted medication interactions.
Example Question:
What medication do you take for hypertension?
Finding:
Lopressor dose is 100mg
(Found)
Pro Tip: The current dose of any patient's prescription medications is important to learn about because it provides useful information about the patient's treatment plan as well as potential medication interactions.
Example Question:
What dose of medication do you take for hypertension?
Finding:
Takes Lopressor once daily
(Found)
Pro Tip: The frequency with which a patient takes his medications is an essential element of the complete picture of his medication treatment plan.
Example Question:
How frequently do you take medication for hypertension?
Finding:
Followed up on hyperlipidemia treatment
Finding:
Medication is Lipitor
(Found)
Pro Tip: Discovering which specific medications a patient takes helps you assess his health conditions, effectiveness of treatment, and guards against unwanted medication interactions.
Example Question:
What medication do you take for hyperlipidemia?
Finding:
Lipitor dose is 20mg
(Available)
Pro Tip: The current dose of any patient's prescription medications is important to learn about because it provides useful information about the patient's treatment plan as well as potential medication interactions.
Example Question:
What dose of medication do you take for hyperlipidemia?
Finding:
Takes Lipitor once daily
(Found)
Pro Tip: The frequency with which a patient takes his medications is an essential element of the complete picture of his medication treatment plan.
Example Question:
How frequently do you take medication for hyperlipidemia?
Finding:
Takes Lipitor at bedtime
(Available)
Pro Tip: The medication that a patient takes will indicate any relevant health conditions, their treatment plan, and how well they comply with it. Asking about relevant medication information, like at what time of day Brian takes Lipitor, will help you to treat your patient.
Example Question:
What time of day do you take your lipitor?
Finding:
Has taken Lipitor for 1 year
(Available)
Pro Tip: The medication that a patient takes will indicate any relevant health conditions, their treatment plan, and how well they comply with it. Asking about relevant medication will help you to treat your patient.
Example Question:
How long have you taken lipitor?
Finding:
Confirmed allergies
Finding:
Confirms allergies (no new allergies reported)
(Available)
Pro Tip: Asking Tina if she has any new allergies will allow you to understand how, beyond the chief complaint, Tina's health has been. [Show Less]