Community Acquired Pneumonia Shadow Health (Anita Douglas)-Subjective Data Collection

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Focused Exam: Community-Acquired Pneumonia Results | Turned In
Advanced Pharmacology - March 2020
Return to Assignment (https://app.shadowhealth.com/ass ignments/293294/)
Your ResultsLab Pass (https://app.shadowhealth.com/assignment_attempts/6604366/lab_p
Overview (https://app.shadowhealth.com/ass ignment_ attempts/6604366#experience-overview- pane)Subjective Data Collection: 29 of 29 (100.0%)
Transcript (https://app.shadowhealth.com/ass ignment_ attempts/6604366#transcript-pane4953 )
Subjective Data Collection (https://app.shadowhealth.com/ass ignme nt_attempts/6604366#subjective _data_coll
ection-pane4953)
Objective Data Collection (https://app.shadowhealth.com/ass ignment_ attempts/6604366#objective_data_collection
-pane4953)Hover To Reveal...
Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
CategoryScored Items
Experts selected these topics as essentialIndicates an item that you found.
Indicates an item that is available to be found.
Patient Data
Not Scored
A combination of open and closed questions will
Education & Empathy (https://app.shadowhealth.com/ass ignment_ attempts/6604366#education _and_empathy- pane4953)
Documentation (https://app.shadowhealth.com/ass ignment_ attempts/6604366#documentation-pane )
Debrief (https://app.shadowhealth.com/ass ignment_ attempts/6604366#sbar-pane4953 )Chief Complaintcomponents of a strong, thorough interview with this patient.
Established chief complaint and reason for admittanceyield better patient data. The following details are facts of the patient's case.
Reports fever Reports chest pain
Reports cough
Medication Selection (https://app.shadowhealth.com/ass ignment_ attempts/6604366#show_medication_selecti
on-pane4953)
Patient Teaching (https://app.shadowhealth.com/ass ignment_ attempts/6604366#show_patient_teaching- pane4953)History of Present Illness
Asked about additional symptomsReports fatigue
Reports coughing up sputum Reports sinus congestion Reports muscle soreness
Prescription Writing (https://app.shadowhealth.com/ass ignment_ attempts/6604366#show_prescription_writin g-pane4953)Asked about onset and duration of symptomsReports fatigue began 3 days ago Reports chest pain began 3 days ago Reports productive cough began 3 days
ago
Reports sinus congestion began 3 days ago
Reports fever began 1 day ago Asked about frequency of symptomsReports fatigue is constant
Reports fever is constant Reports congestion is constant
Reports less severe chest pain is constant Reports more severe chest pain occurs
with coughing
Reports coughing every few minutes Followed up on location of painReports pain in lower right side of chest
Followed up on characteristics of painReports chest pain is dull Followed up on characteristics of dischargeReports coughing up rust-colored sputum Reports nasal mucus varies from yellow to
green in color Asked about aggravating factorsReports deep breathing aggravates chest
pain
Reports speaking aggravates chest pain Reports physical exertion aggravates chest
pain and fatigue Asked about non-medicational relieving factorsReports resting provides relief
Reports tea provides relief
Reports humidifier steam provides slight relief Asked about severity of painReports chest pain when not coughing is 2 out of 10
Reports chest pain during normal coughing is 5 out of 10
Past Medical History Asked about pre-existing health
conditionsReports chronic kidney disease stage 2 Reports hypertension Asked about onset and duration of pre- existing health conditionsReports chronic kidney disease was diagnosed 9 years ago
Reports hypertension was diagnosed 14 years ago Asked about hospitalizations Denies recent hospitalizations Asked about allergies Denies allergies Asked about vaccines Reports receiving pneumococcal vaccine 12 years ago
Reports receiving flu vaccine 3 months ago