Subjective Data Collection: 19 of 19 (100.0%)
Indicates an item that you found.
Indicates an item that is available to be found.
Category Scored Items
Experts selected these topics as essential compone
...
Subjective Data Collection: 19 of 19 (100.0%)
Indicates an item that you found.
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.
Introduction and Medical History
Established reason for visit Reports needing an annual physical
Followed up on frequency and dosage of ibuprofen use Takes ibuprofen monthly
Takes 2 at a time
Typically takes 2 doses on first day of period Unsure of the dosage, but reports they are "regular
strength"
Last dose was 2 weeks ago
Asked about supplements Denies vitamins
Denies herbal supplements
Allergies
Asked about general allergies Reports allergy to peanuts
Followed up on peanut allergy symptoms Discovered at age 4
Symptoms are itchy mouth and throat
Followed up on peanut allergy severity Describes allergy as not severe
Denies breathing problems after exposure Denies hospitalization for reaction to peanuts
Followed up on peanut allergy treatment Treated with Benadryl
Reports avoiding peanuts and peanut oil Denies use of epi-pen
Asked about medication allergies Denies known medication allergies
Asked about other allergies Denies latex allergy
Denies food allergies or sensitivities (other than peanuts)
Denies known environmental allergies
Substance Use
Asked about tobacco and nicotine use Reports "some" tobacco use
Followed up on type of tobacco or nicotine Reports smoking cigarettes
....................................Continued...............................
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