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Shadow_Health_COPD_Debbie_O.docx.pdf
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Shadow Health COPD DebbieO’Connor
Subjective Data Collection: 32 of 32
(100.0%)
Hover To Reveal...
Hover over the Patient Data items below to reveal important information,
including Pro Tips and Example Questions.
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 and reason for admittance
,
Finding:
Reports a bronchospasm three days ago
(Found)
Pro Tip: A patient's chief complaint establishes any illnesses or concerns they are
presenting. Asking about the chief complaint will allow the patient to voice any
concerns or symptoms the patient may have.
Example Question:
When did your symptoms start?
Finding:
Reports increased difficulty breathing
(Found)
Pro Tip: A patient's chief complaint establishes any illnesses or concerns they are
presenting. Asking about the chief complaint will allow the patient to voice any
concerns or symptoms the patient may have.
Example Question:
What are your symptoms?
Finding:
Reports desire for smoking cessation aids
(Found)
Pro Tip: A patient's chief complaint establishes any illnesses or concerns they are
presenting. Asking about the chief complaint will allow the patient to voice any
concerns or symptoms the patient may have.
Example Question:
What can I do for you?
,History of Present Illness
Finding:
Asked about additional symptoms
Finding:
Reports fatigue and weakness
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits
information relevant to the history of their present illness. Details of their current
complaint will help you follow-up on any present conditions or symptoms, such as
the location of their pain or the amount of pain they may be experiencing.
Example Question:
Do you feel fatigued?
Finding:
Reports purulent sputum
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits
information relevant to the history of their present illness. Details of their current
complaint will help you follow-up on any present conditions or symptoms, such as
the location of their pain or the amount of pain they may be experiencing.
Example Question:
Do you have purulent sputum?
Finding:
Reports cough
, (Found)
Pro Tip: Asking a patient about the length of their current health issues solicits
information relevant to the history of their present illness. Details of their current
complaint will help you follow-up on any present conditions or symptoms, such as
the location of their pain or the amount of pain they may be experiencing.
Example Question:
Do you have a cough?
Finding:
Reports feeling anxious about symptoms and worsening health issues
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits
information relevant to the history of their present illness. Details of their current
complaint will help you follow-up on any present conditions or symptoms, such as
the location of their pain or the amount of pain they may be experiencing.
Example Question:
How do you feel about your symptoms?
Finding:
Asked about onset and duration of symptoms
Finding:
Reports most severe fatigue and difficulty breathing began three days ago
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits
information relevant to the history of their present illness. Details of their current
complaint will help you follow-up on any present conditions or symptoms, such as
the location of their pain or the amount of pain they may be experiencing.
Example Question:
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