Advanced Diagnostics Spring 2025, NURS
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Overview
Subjective Data Collection: 22 of 22 (100.0%)
Transcript
Subjective Data Collection
Hover To Reveal... Indicates an item that
Objective Data Collection you found.
Hover over the Patient Data items Indicates an item that
Education & Empathy below to reveal important
is available to be found.
information, including Pro Tips and
Documentation Example Questions.
Differential Selection
Test Selection
Category Scored Items Patient Data
Test Linking Not Scored
Test Review Experts selected these topics as essential A combination of open and closed questions
Final Diagnosis components of a strong, thorough interview will yield better patient data. The following
with this patient. details are facts of the patient's case.
Self-Reflection
Confirmed Guardian's Relationship
Establish Relationship Ned reports he is Chelsea's guardian
Chelsea reports Ned is her guardian
Chief Complaint
Established Chief Complaint Patient reports left knee pain after a fall
Guardian reports patient has been
complaining of knee pain for "a few weeks"
History of Present Illness
Asked about previous injuries Patient denies previous injury
Guardian denies previous injury
,Asked about mechanism of injury Patient denies landing on head
Patient denies losing consciousness
Patient reports falling two or three feet
Patient reports horse was standing still
Patient reports blood glucose level was normal after fall
Asked about onset Patient reports mild pain on
ago
Patient reports severe pain s
fall
Guardian reports noticing pa
the fall two days ago
Asked about location Patient reports pain located
Asked about duration Patient reports mild pain end
stops
Patient reports severe pain a
after
Asked about characteristics Patient reports mild pain on
Patient reports severe pain a
Asked about aggravating factors Patient reports walking up st
Patient reports kneeling aggr
Patient reports mounting and
aggravates pain
Guardian confirms noticing t
physical activity
Asked about relieving factors Patient reports rest relieves p
Patient denies using ice pack
Guardian reports patient refu
Guardian reports acetaminop
Asked about timing Patient denies the pain being
times of the day
Guardian confirms the pain d
better at certain times of the d
Asked about severity Patient reports mild pain on
Patient reports severe pain a
bad"
Asked about activities of daily living Patient reports discomfort pu
Guardian reports patient's di
boots
, Asked about social history Patient reports all her friends are girls
Patient reports having a close group of friends
Patient reports being afraid of having her horse taken
away
Guardian reports that patient is well socialized
Asked about sports safety Denies wearing a helmet bec
Review of Systems
Asked about musculoskeletal Reports pain with ambulation
Denies pain with ambulation
Reports full range of motion
Reports pain within certain ra
Reports being able to bear fu
Asked about neurological Patient denies abnormal gait
Guardian denies noticing abn
Patient denies numbness an
Patient denies weakness
Guardian denies noticing we
Asked about cardiovascular Patient denies swelling in low
Patient denies ecchymosis in
Patient denies palpitations
Asked about hematologic Patient denies recurrent or e
Guardian denies noticing rec
Asked about integumentary Patient denies itching, rash,
Guardian denies noticing itch
Family History
Asked about family history Guardian denies family histor
disease
Guardian denies family histor
Past Medical History
Asked about type 1 diabetes Patient reports full treatment
Patient denies diabetes sym
Guardian confirms patient is
Guardian denies noticing dia