Debbie O’Co nn o r
Shadow Health COPD Debbie
O’Connor
Subjective Data Collection: 32 of 32
(100.0%)
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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 follow ing
details are facts of the patient's case.
Chief Complaint
•
Finding:
Established chief complaint and reason for admittance
Debbie O’Co nn o r
,Solved
Debbie O’Co nn o r
•
Finding:
Report s 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 sympto ms the patient may have.
Example Question:
When did your sympto ms start?
•
Finding:
Reports increased difficult y 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 sympto ms the patient may have.
Example Question:
What are your sympt o ms?
•
Finding:
Report s desire for smoking cessatio n 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 sympto ms the patient may have.
Example Question:
What can I do for you?
Debbie O’Co nn o r
,Solved
Debbie O’Co nn o r
History of Present Illness
•
Finding:
Asked about additio nal sympto ms
•
Finding:
Report s fatigue and weakness
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits
informatio n relevant to the history of their present illness. Details of their current
complaint will help you follow -up on any present conditions or sympto ms, 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
informatio n relevant to the history of their present illness. Details of their current
complaint will help you follow -up on any present conditions or sympto ms, such as
the location of their pain or the amount of pain they may be experiencing.
Example Question:
Do you have purulent sputum?
•
Finding:
Report s cough
Debbie O’Co nn o r
, Solved
Debbie O’Co nn o r
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits
informatio n relevant to the history of their present illness. Details of their current
complaint will help you follow -up on any present conditions or sympto ms, such as
the location of their pain or the amount of pain they may be experiencing.
Example Question:
Do you have a cough?
•
Finding:
Report s feeling anxious about sympto ms and worsening healt h issues
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits
informatio n relevant to the history of their present illness. Details of their current
complaint will help you follow -up on any present conditions or sympto ms, such as
the location of their pain or the amount of pain they may be experiencing.
Example Question:
How do you feel about your sympt o ms?
•
Finding:
Asked about onset and durat io n of sympto ms
•
Finding:
Reports most severe fatigue and difficult y breathing began three days ago
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits
informatio n relevant to the history of their present illness. Details of their current
complaint will help you follow -up on any present conditions or sympto ms, such as
the location of their pain or the amount of pain they may be experiencing.
Example Question:
Debbie O’Co nn o r