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SHADOWHEALTH HEENT SUBJECTIVE

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SHADOWHEALTH HEENT SUBJECTIVE Subjective Data Collection: 32 of 32 (100.0%) Hover To Reveal... 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

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