Subjective
Chief Complaint
Finding:
Established chief complaint
Finding:
Reports increased breathing problems and shortness of breath
(Found)
Pro Tip: Foundational questions about general well-being are important in
assessing how a patient feels at the current moment. This creates a space
for Tina to contextualize her current feeling in relation to a chief complaint.
Example Question:
What brings you in today?
Finding:
Reports decreased effectiveness of inhaler
(Found)
Pro Tip: Initially establishing a chief complaint allows the patient to express
their reason for seeking care, primary concerns, or condition they are
presenting with.
Example Question:
Why did you decide to seek treatment?
History of Presenting Illness
Finding:
Asked about onset of symptoms
,Finding:
Reports symptoms began two days ago
(Found)
Pro Tip: Determining the onset of a health problem is the first step to
understanding if the underlying condition is acute or chronic.
Example Question:
How long have you had breathing problems?
Finding:
Asked about frequency and duration of SOB episodes
Finding:
Reports exacerbations lasting several minutes
(Found)
Pro Tip: Knowing the duration of an asthma or shortness of breath episode
will give you insight into how effective the patient's interventions are, and
how severe the episode is.
Example Question:
How long do your asthma episodes last?
Finding:
Reports exacerbated breathing about every 4 hours since original episode
(Found)
Pro Tip: The frequency of asthma episodes or shortness of breath might vary
over time. Asking Tina about her recent experience will expound upon her
current condition.
Example Question:
How many times have you had breathing problems in the past two days?
,
Finding:
Reports waking up twice a night with asthma the past 2 nights
(Found)
Pro Tip: Many patients with asthma report trouble sleeping. Asking Tina if she
has trouble sleeping can indicate the severity of her asthma.
Example Question:
How many times in the past two nights did asthma wake you up?
Finding:
Asked about severity of symptoms
Finding:
Describes asthma severity as "not full attack," but worse than usual
(Found)
Pro Tip: Asthma severity might change over time for a variety of reasons.
Asking Tina about the severity of her asthma will allow her to assess her
condition.
Example Question:
How severe is your asthma?
Finding:
Reports asthma has been interfering with activities of daily life
(Found)
Pro Tip: Severe asthma can interfere with daily life. Asking Tina the degree to
which asthma impacts her daily life can be illustrative of the relative severity
of her asthma.
Example Question:
, Is there anything you can't do because of your asthma?
Finding:
Asked about character of symptoms
Finding:
Reports recent wheezing
(Found)
Pro Tip: Some people who experience chronic asthma may be accustomed to
wheezing and, as a result, might not volunteer this information. Asking Tina if
she's been wheezing illustrates how her asthma is presenting.
Example Question:
Do you wheeze during an asthma exacerbation?
Finding:
Reports chest tightness
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina to describe
what happens when her asthma acts up will indicate how her individual
symptoms manifest.
Example Question:
What happens when your asthma acts up?
Finding:
Denies chest pain
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina whether
she experiences chest pain during an attack will indicate how her individual
symptoms manifest.
Chief Complaint
Finding:
Established chief complaint
Finding:
Reports increased breathing problems and shortness of breath
(Found)
Pro Tip: Foundational questions about general well-being are important in
assessing how a patient feels at the current moment. This creates a space
for Tina to contextualize her current feeling in relation to a chief complaint.
Example Question:
What brings you in today?
Finding:
Reports decreased effectiveness of inhaler
(Found)
Pro Tip: Initially establishing a chief complaint allows the patient to express
their reason for seeking care, primary concerns, or condition they are
presenting with.
Example Question:
Why did you decide to seek treatment?
History of Presenting Illness
Finding:
Asked about onset of symptoms
,Finding:
Reports symptoms began two days ago
(Found)
Pro Tip: Determining the onset of a health problem is the first step to
understanding if the underlying condition is acute or chronic.
Example Question:
How long have you had breathing problems?
Finding:
Asked about frequency and duration of SOB episodes
Finding:
Reports exacerbations lasting several minutes
(Found)
Pro Tip: Knowing the duration of an asthma or shortness of breath episode
will give you insight into how effective the patient's interventions are, and
how severe the episode is.
Example Question:
How long do your asthma episodes last?
Finding:
Reports exacerbated breathing about every 4 hours since original episode
(Found)
Pro Tip: The frequency of asthma episodes or shortness of breath might vary
over time. Asking Tina about her recent experience will expound upon her
current condition.
Example Question:
How many times have you had breathing problems in the past two days?
,
Finding:
Reports waking up twice a night with asthma the past 2 nights
(Found)
Pro Tip: Many patients with asthma report trouble sleeping. Asking Tina if she
has trouble sleeping can indicate the severity of her asthma.
Example Question:
How many times in the past two nights did asthma wake you up?
Finding:
Asked about severity of symptoms
Finding:
Describes asthma severity as "not full attack," but worse than usual
(Found)
Pro Tip: Asthma severity might change over time for a variety of reasons.
Asking Tina about the severity of her asthma will allow her to assess her
condition.
Example Question:
How severe is your asthma?
Finding:
Reports asthma has been interfering with activities of daily life
(Found)
Pro Tip: Severe asthma can interfere with daily life. Asking Tina the degree to
which asthma impacts her daily life can be illustrative of the relative severity
of her asthma.
Example Question:
, Is there anything you can't do because of your asthma?
Finding:
Asked about character of symptoms
Finding:
Reports recent wheezing
(Found)
Pro Tip: Some people who experience chronic asthma may be accustomed to
wheezing and, as a result, might not volunteer this information. Asking Tina if
she's been wheezing illustrates how her asthma is presenting.
Example Question:
Do you wheeze during an asthma exacerbation?
Finding:
Reports chest tightness
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina to describe
what happens when her asthma acts up will indicate how her individual
symptoms manifest.
Example Question:
What happens when your asthma acts up?
Finding:
Denies chest pain
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina whether
she experiences chest pain during an attack will indicate how her individual
symptoms manifest.
