Subjective Data Collection: 26 of 26 (100.0%)
Chief Complaint
History of Present Illness
Your Results Turn In (/assignment_attempts/7379321/choos
Reopen (/assignment_attempts/7379321/reopen
Lab Pass (/assignment_a
...
Subjective Data Collection: 26 of 26 (100.0%)
Chief Complaint
History of Present Illness
Your Results Turn In (/assignment_attempts/7379321/choos
Reopen (/assignment_attempts/7379321/reopen
Lab Pass (/assignment_attempts/7379321/lab_pass.p
Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Debrief
Medication Selection
Patient Teaching
Prescription Writing
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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 t
patient's case.
Established chief complaint Reports burning during urination
Reports frequent need to urinate
Reports changes in urine characteristics
Asked about onset and duration of symptoms Reports increased urinary frequency, burning
during urination, and change in urine characteristics
started three days ago
Asked about history of intercourse related to UTI Reports last intercourse was four days ago
Reports did not urinate after intercourse
Asked about additional symptoms of UTI Denies incontinence
Denies holding in urine unnecessarily
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This study source was downloaded by 100000852290574 from CourseHero.com on 01-23-2023 14:28:02 GMT -06:00
https://www.coursehero.com/file/65679061/Focused-Exam-UTI-with-Antibiotic-Sensitivity-Subjective-Checklistpdf/
7/25/2020 Focused Exam: UTI with Antibiotic Sensitivity | Completed | Shadow Health
https://app.shadowhealth.com/assignment_attempts/7379321 2/4
Past Medical History
Home Medications
Asked about location of pain Reports pain is in urethra, urinary tract
Asked about characteristics of urine Reports urine as foul-smelling
Reports urine has been dark and cloudy
Asked about characteristics of pain Reports pain during urination as stinging
Reports pain during urination as burning
Asked about non-medication relieving factors of
pain
Reports drinking less water so she doesn't have
burning
Asked about aggravating factors of pain Reports urination makes the pain worse
Asked about severity of pain Reports pain on urination as 7/10
Asked about relevant past medical history Reports no existing relevant health conditions
Asked about general allergies Reports seasonal environmental allergy
Reports itchy eyes, scratchy throat, and stuffy
nose as rhinitis symptoms
Asked about home medications Reports taking antihistamine for environmental
allergies (seasonal allergic rhinitis)
Reports oral birth control (contraceptive)
Reports cranberry pills (supplement)
Asked about medication regimen adherence Reports taking medications first thing in the
morning
Denies missing doses
Followed up on daily environmental allergy pill Reports taking loratadine
Reports taking one 10 mg pill once a day
Reports no adverse effects
Reports taking daily as a preventative measure
Reports started taking allergy medication three
months ago when her allergies started "acting up"
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