Subjective Data Collection: 25 of 28 (89.3%)
Chief Complaint
Finding:
Established chief complaint
Finding:
Reports sore throat
(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:
Is your throat sore?
Finding:
Reports itchy throat
(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:
Is your throat itchy?
Finding:
Reports itchy eyes
(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:
, Are your eyes itchy?
Finding:
Reports runny nose
(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:
Do you have a runny nose?
History of Present Illness
Finding:
Asked about onset of symptoms
Finding:
Reports sore throat began "about a week ago"
(Found)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her
condition, experience, or symptoms. Establishing a timeline for how long Tina's throat
has been sore will also aid in treating her sore throat.
Example Question:
How long has your throat been sore?
Finding:
Reports runny nose began "about a week ago"
(Found)
Pro Tip: Establishing a timeline for how long Tina's nose has been running will illustrate
how long she has been suffering these particular symptoms and might indicate possible
triggers.
Example Question:
, When did your nose start running?
Finding:
Reports itchy eyes began "about a week ago"
(Found)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her
condition, experience, or symptoms. Establishing a timeline for how long Tina's eyes
have been itching will also aid in treating her itchy eyes.
Example Question:
When did your eyes start itching?
Finding:
Asked about aggravating factors for throat symptoms
Finding:
Reports throat pain is constant
(Found)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her
condition, experience, or symptoms. Establishing a timeline for how long Tina's throat
has been sore will also aid in treating her sore throat.
Example Question:
Is the throat pain constant?
Finding:
Reports throat pain is worse in the morning
(Found)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her
condition, experience, or symptoms. Establishing a timeline for how long Tina's throat
has been sore will also aid in treating her sore throat.
Example Question:
, When does your sore throat feel the worst?
Finding:
Reports some soreness with swallowing
(Found)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her
condition, experience, or symptoms.
Example Question:
Does it hurt when you swallow?
Finding:
Asked severity of throat discomfort
Finding:
Describes sore throat as mild to moderate
(Found)
Pro Tip: Pain severity might change for a variety of reasons. Asking Tina to rate the
severity of her pain on a scale of 1-10 will provide a quantified and relative measurement
of her condition.
Example Question:
Can you rate your sore throat on a scale of 0 to 10?
Finding:
Asked about frequency and duration of runny nose
Finding:
Reports nose is runny "pretty much all day"
(Available)
Pro Tip: Establishing a timeline for how long Tina's nose has been running will illustrate
how long she has been suffering these particular symptoms, when the symptoms are
worst, and possible triggers.
Chief Complaint
Finding:
Established chief complaint
Finding:
Reports sore throat
(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:
Is your throat sore?
Finding:
Reports itchy throat
(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:
Is your throat itchy?
Finding:
Reports itchy eyes
(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:
, Are your eyes itchy?
Finding:
Reports runny nose
(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:
Do you have a runny nose?
History of Present Illness
Finding:
Asked about onset of symptoms
Finding:
Reports sore throat began "about a week ago"
(Found)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her
condition, experience, or symptoms. Establishing a timeline for how long Tina's throat
has been sore will also aid in treating her sore throat.
Example Question:
How long has your throat been sore?
Finding:
Reports runny nose began "about a week ago"
(Found)
Pro Tip: Establishing a timeline for how long Tina's nose has been running will illustrate
how long she has been suffering these particular symptoms and might indicate possible
triggers.
Example Question:
, When did your nose start running?
Finding:
Reports itchy eyes began "about a week ago"
(Found)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her
condition, experience, or symptoms. Establishing a timeline for how long Tina's eyes
have been itching will also aid in treating her itchy eyes.
Example Question:
When did your eyes start itching?
Finding:
Asked about aggravating factors for throat symptoms
Finding:
Reports throat pain is constant
(Found)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her
condition, experience, or symptoms. Establishing a timeline for how long Tina's throat
has been sore will also aid in treating her sore throat.
Example Question:
Is the throat pain constant?
Finding:
Reports throat pain is worse in the morning
(Found)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her
condition, experience, or symptoms. Establishing a timeline for how long Tina's throat
has been sore will also aid in treating her sore throat.
Example Question:
, When does your sore throat feel the worst?
Finding:
Reports some soreness with swallowing
(Found)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her
condition, experience, or symptoms.
Example Question:
Does it hurt when you swallow?
Finding:
Asked severity of throat discomfort
Finding:
Describes sore throat as mild to moderate
(Found)
Pro Tip: Pain severity might change for a variety of reasons. Asking Tina to rate the
severity of her pain on a scale of 1-10 will provide a quantified and relative measurement
of her condition.
Example Question:
Can you rate your sore throat on a scale of 0 to 10?
Finding:
Asked about frequency and duration of runny nose
Finding:
Reports nose is runny "pretty much all day"
(Available)
Pro Tip: Establishing a timeline for how long Tina's nose has been running will illustrate
how long she has been suffering these particular symptoms, when the symptoms are
worst, and possible triggers.
