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 reveal important information, including Pro Tips and Example Questions.
Found:
Indicates an item that you found.
Available:
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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
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)
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