SUBJECTIVE
Subjective Data Collection: 32 of 32
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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 following details are facts
of the patient's case.
Relevant Medical History
Finding: Asked about history of headache
Finding: Reports occasional headaches (Found)Pro Tip: Sinus problems can result in increased pressure
buildup and headaches. Asking Tina if she gets headaches is soliciting information about possible
symptoms that she experiences.Example Question:Do you get headaches?
Finding: Asked about frequency and/or duration of headaches
Finding: Headaches occur once a week (Found)Pro Tip: Establishing a timeline for how often Tina gets
headaches will illustrate how long she has been suffering these particular symptoms and might indicate
possible triggers.Example Question:How frequently do your headaches occur?
Finding: Headaches last "a few hours" (Found)Pro Tip: Establishing a timeline for how long Tina's
headaches last will illustrate how long she has been suffering these particular symptoms and might
indicate possible triggers.Example Question:For how long do your headaches last?
Finding: Asked about character and location of headaches
, Finding: Describes headaches as tight and throbbing (Found)Pro Tip: Follow-up questions will enable
Tina to more fully and specifically describe her condition, experience, or symptoms.Example
Question:What do your headaches feel like?
Finding: Describes headache location as behind her eyes (Found)Pro Tip: Specifying the location of
pain can narrow and define where Tina's pain is occurring. Soliciting this information allows you to
more accurately treat her symptoms.Example Question:Where do you feel your headaches?
Finding: Asked to rate headache pain on a scale
Finding: Rates headaches as a 2 or 3 (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:On a scale of 1 to 10, how bad are your
headaches?
Finding: Asked about headache treatment
Finding: Reports treating headaches with Tylenol (Found)Pro Tip: Tina's response to a question about
managing her headaches will reveal the severity of her symptoms, her health literacy, and the way she's
complied with previous treatment plans.Example Question:Do you take anything to treat your
headaches?
Finding: Reports Tylenol and rest usually resolve symptoms (Found)Pro Tip: Tina's response to a
question about managing her headaches will reveal the severity of her symptoms, her health literacy,
and the way she's complied with previous treatment plans.Example Question:Does the Tylenol help
with your headaches?
Finding: Asked about headache triggers
Finding: Reports headaches only happen when reading or studying (Found)Pro Tip: Follow-up
questions will enable Tina to more fully and specifically describe her condition, experience, or
symptoms.Example Question:When do you get headaches?
Finding: Reports that blurry vision and headaches often coincide (Available)Pro Tip: Follow-up questions
will enable Tina to more fully and specifically describe her condition, experience, or symptoms.Example
Question:Do your headaches coincide with your blurry vision?
Finding: Asked about vision problems
Finding: Reports occasional blurry vision (Found)Pro Tip: Broad, open questions will allow Tina to
describe, in her own words, the specific pain and discomfort that she is experiencing.Example
Question:Have you been having problems with your vision?
Finding: Asked about character of blurry vision
Finding: Describes blurry vision as "fuzzy letters" (Found)Pro Tip: Broad, open questions will allow Tina
to describe, in her own words, the specific pain and discomfort that she is experiencing.Example
Question:What's your blurry vision like?
Finding: Asked about onset and frequency of blurry vision