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NR 509 Conversation Concept Lab

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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............................... [Show More]

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