10/23/23, 8:11 PM | Shadow Health® │ Digital Clinical Experiences™ from Elsevier
Subjective Data Collection: 94 of 100 (94.0%)
Chie
Hover To Reveal...
f
Hover over the Patient Data items Com
below to reveal important
information, including Pro plai
Tips and Example Questions.
nt
Hist
Categ Scored Items Patient Data ory
Not Scored of
ory Experts selected these topics as essential A combination of open and closed questions
components of a strong, thorough interview will yield better patient data. The following
Pres
with this patient. details are facts of the patient's case.
ent
Established chief complaint Reports pain
Illne
Reports foot wound ss
Asked to rate current pain level on a Reports current pain is 7/10 Past
scale
Med
ical
Reports pain is throbbing Hist
Reports pain is sharp when she attempts to stand
Reports pain has increased in the past 2 days ory
Reports feeling pain radiating into ankle
Reports pain prevents bearing weight on foot
Reports wound is on the plantar surface of her foot
Reports initial injury occurred 1 week ago
Reports mild ankle injury
Reports being barefoot at the time of injury
Reports going to the ER because she suspected an
ankle sprain
Reports receiving an X-ray at the ER
Reports X-ray showed no broken bones
Reports receiving a prescription for pain pills
Asked about drainage from the foot wound Reports that the wound bled a little after sustaining the
injury
Reports seeing pus draining from wound
Reports noticing pus 2 days ago
1/9
, 10/23/23, 8:11 PM | Shadow Health® │ Digital Clinical Experiences™ from Elsevier
Denies odor from the wound
Reports cleaning wound twice a day
Reports cleaning wound with hydrogen peroxide
Reports applying bacitracin, neomycin and polymyxin B
(Neosporin)
Reports swelling worsened in the past 2 days
Reports redness around the wound
Reports that the wound feels warm
daily living Reports pain affects ability to stand at work for long
periods of time
Reports pain prevented her from being able to walk to
class
Asked about preexisting medical conditions Reports diabetes
Reports asthma
Reports that her diabetes is Type 2
Asked about diabetes management through lifestyle
changes Reports drinking diet soda instead of regular
Asked about current diabetes medication use Reports that she does not currently take medication for
diabetes
Reports previous medication was prescription metformin
Reports last use of medication was 3 years ago
Reports infrequent blood glucose monitoring
Reports last glucose check was a week ago at the ER
Reports confusion about what the numbers mean
Asked about thirst Reports increased thirst
Reports increased water intake
Reports urinating every hour or two during the day
Reports urinating 2 to 3 times during the night
Reports increased appetite
Reports change in appetite began a month ago
Asked about weight change Reports recent loss of 10 lbs
Reports weight loss occurred over the past month
2/9
Subjective Data Collection: 94 of 100 (94.0%)
Chie
Hover To Reveal...
f
Hover over the Patient Data items Com
below to reveal important
information, including Pro plai
Tips and Example Questions.
nt
Hist
Categ Scored Items Patient Data ory
Not Scored of
ory Experts selected these topics as essential A combination of open and closed questions
components of a strong, thorough interview will yield better patient data. The following
Pres
with this patient. details are facts of the patient's case.
ent
Established chief complaint Reports pain
Illne
Reports foot wound ss
Asked to rate current pain level on a Reports current pain is 7/10 Past
scale
Med
ical
Reports pain is throbbing Hist
Reports pain is sharp when she attempts to stand
Reports pain has increased in the past 2 days ory
Reports feeling pain radiating into ankle
Reports pain prevents bearing weight on foot
Reports wound is on the plantar surface of her foot
Reports initial injury occurred 1 week ago
Reports mild ankle injury
Reports being barefoot at the time of injury
Reports going to the ER because she suspected an
ankle sprain
Reports receiving an X-ray at the ER
Reports X-ray showed no broken bones
Reports receiving a prescription for pain pills
Asked about drainage from the foot wound Reports that the wound bled a little after sustaining the
injury
Reports seeing pus draining from wound
Reports noticing pus 2 days ago
1/9
, 10/23/23, 8:11 PM | Shadow Health® │ Digital Clinical Experiences™ from Elsevier
Denies odor from the wound
Reports cleaning wound twice a day
Reports cleaning wound with hydrogen peroxide
Reports applying bacitracin, neomycin and polymyxin B
(Neosporin)
Reports swelling worsened in the past 2 days
Reports redness around the wound
Reports that the wound feels warm
daily living Reports pain affects ability to stand at work for long
periods of time
Reports pain prevented her from being able to walk to
class
Asked about preexisting medical conditions Reports diabetes
Reports asthma
Reports that her diabetes is Type 2
Asked about diabetes management through lifestyle
changes Reports drinking diet soda instead of regular
Asked about current diabetes medication use Reports that she does not currently take medication for
diabetes
Reports previous medication was prescription metformin
Reports last use of medication was 3 years ago
Reports infrequent blood glucose monitoring
Reports last glucose check was a week ago at the ER
Reports confusion about what the numbers mean
Asked about thirst Reports increased thirst
Reports increased water intake
Reports urinating every hour or two during the day
Reports urinating 2 to 3 times during the night
Reports increased appetite
Reports change in appetite began a month ago
Asked about weight change Reports recent loss of 10 lbs
Reports weight loss occurred over the past month
2/9
