Focused Exam: Community-Acquired Pneumonia Results | Completed
Advanced Pharmacotherapeutics I & II - July 2024, msnjan2024_nurs_505__advanced_pharmacotherpeutics_i
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Overview
Subjective Data Collection: 29 of 29 (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.
Debrief
Medication Selection
Category Scored Items Patient Data
Patient Teaching Not Scored
Prescription Writing Experts selected these topics as essential A combination of open and closed questions
components of a strong, thorough interview with yield better patient data. The following details
this patient. are facts of the patient's case.
Chief Complaint
Established chief complaint and reason Reports fever
for admittance Reports chest pain
Reports cough
History of Present Illness
Asked about additional symptoms Reports fatigue
Reports coughing up sputum
Reports sinus congestion
Reports muscle soreness
Asked about onset and duration of Reports fatigue began 3 days ago
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symptoms 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 symptoms Reports fatigue is constant
Reports fever is constant
Reports congestion is consta
Reports less severe chest pa
Reports more severe chest p
Reports coughing every few m
Followed up on location of pain Reports pain in lower right sid
Followed up on characteristics of pain Reports chest pain is dull
Followed up on characteristics of discharge Reports coughing up rust-colo
Reports nasal mucus varies f
Asked about aggravating factors Reports deep breathing aggra
Reports speaking aggravates
Reports physical exertion agg
fatigue
Asked about non-medicational relieving factors Reports resting provides relie
Reports tea provides relief
Reports humidifier steam prov
Asked about severity of pain Reports chest pain when not
Reports chest pain during nor
Past Medical History
Asked about pre-existing health conditions Reports chronic kidney disea
Reports hypertension
Asked about onset and duration of pre-existing health Reports chronic kidney disea
conditions ago
Reports hypertension was dia
Asked about hospitalizations Denies recent hospitalizations
Asked about allergies Denies allergies
Asked about vaccines Reports receiving pneumococ
Reports receiving flu vaccine
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, 9/5/24, 12:12 PM | Shadow Health® │ Digital Clinical Experiences™ from Elsevier
Home Medications
Asked about home medications Reports taking trandolapril/ve
Reports taking chlorothiazide
Reports taking aspirin
Followed up on trandolapril/verapamil Reports taking trandolapril/ve
and chronic kidney disease
Reports pill contains 2 milligra
milligrams of verapamil
Reports taking trandolapril/ve
Reports having taken trandola
Reports last dose of trandolap
morning
Denies adverse effects from t
Followed up on chlorothiazide Reports taking chlorothiazide
Reports chlorothiazide pill is 5
Reports taking chlorothiazide
Reports having taken chloroth
Reports last dose of chlorothi
Reports chlorothiazide increa
Followed up on aspirin Reports taking aspirin for pain
Reports aspirin pill is 325 mill
Reports taking 2 aspirin pills e
day
Reports having taken aspirin
Reports last dose of aspirin w
Denies adverse effects from a
Asked about vitamins and supplements Reports taking calcium supple
Reports taking vitamin D supp
Followed up on calcium supplement Reports taking calcium supple
disease
Reports calcium supplement
Reports taking calcium supple
Reports having taken calcium
Reports last dose of calcium
morning
Denies adverse effects from c
Followed up on vitamin D supplement Reports taking vitamin D supp
disease
Reports vitamin D supplemen
Reports taking vitamin D supp
Reports having taken vitamin
Reports last dose of vitamin D
Denies
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