Advanced Health Assessment and Diagnostic Reasoning - NP - August 2024, nurs6512-laureate_higher_education_group-202510
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Overview
Subjective Data Collection: 50 of 50 (100.0%)
Transcript
Subjective Data Collection
Hover To Reveal... Indicates an item that you
Objective Data Collection found.
Hover over the Patient Data items Indicates an item that is
Documentation below to reveal important available to be found.
information, including Pro Tips and
Program Competency Progress
Example Questions.
Category Scored Items Patient Data
Not Scored
Experts selected these topics as essential components A combination of open and closed questions will y
of a strong, thorough interview with this patient. better patient data. The following details are facts
patient's case.
Current Health Status
Confirmed reason for visit Reports needing a pre-employment physical
Reports no current acute health problems
Asked about last visit to a healthcare provider Last visit to a healthcare provider was 4 month
ago
Reason for last visit was annual gynecological
exam
Last general physical examination was 5 month
ago when she was prescribed metformin and dai
inhaler
Asked about current prescription medications Reports taking diabetes medication
Reports using a daily inhaler
Reports taking prescription birth control pills
Followed up about diabetes medication Medication is metformin
Started taking metformin 5 months ago
Reports that eating probiotic yogurt helps with
side effects and they have abated over time
, Followed up on metformin frequency and dose Reports taking metformin twice daily
Metformin dose is 850 mg
Asked about asthma medication Reports using Flovent inhaler twice daily
Has a Proventil rescue inhaler
Last use of Proventil inhaler was three months
ago
Has used Proventil inhaler twice in the last yea
Followed up about birth control prescription Started taking birth control 4 months ago
Reason for birth control was to manage PCOS
symptoms
Birth control type is Yaz (drospirenone and
ethinyl estradiol)
Takes birth control pill daily
Takes birth control pill at the same time every
day
Reports no skipped days
Asked about current non-prescription Reports rare Advil use for cramps
medications Reports no OTC herbal products
Reports no OTC vitamins
Reports no OTC supplements
Asked about allergies Confirms allergies
Reports no new allergies
Followed up on seasonal allergies Reports no recent seasonal allergy symptoms
Reports no current medication for allergies
Asked about diabetes Reports managing diabetes with diet and
exercise in addition to medication
Asked about blood glucose monitoring Reports checking blood sugar once a day
Checks sugar in the morning
Blood sugar number is usually around 90
Reports having adequate supplies
Asked about asthma symptoms Reports no current asthma symptoms
Reports no recent asthma exacerbations
Reports last asthma exacerbation was three
months ago
Asked about headache symptoms Reports no recent headache
Asked about vision Reports optometrist visit
Optometrist visit 3 months ago
Reports prescription eyeglasses
Reports that glasses improve overall vision
Reports reduction in blurry vision
Asked about palpitations Reports no current palpitations
Reports no recent palpitations