Subjective Data Collection Summary: The subjective data collection for Community-Acquired Pneumonia is complete, with 29 out of 29 items (100.0%) addressed. The following highlights key findings, pro tips, and example questions to enhance the patient interview.
Chief Complaint
- Patient presents with fever, chest pain, and cough.
- Pro Tip: Chief complaints provide insight into the patient’s primary concerns.
- Example Question: “Do you have a fever?”
History of Present Illness
- Additional symptoms reported include fatigue, coughing up sputum, sinus congestion, and muscle soreness.
- Pro Tip: Inquire about the onset, duration, and frequency of symptoms.
- Example Question: “Are you feeling congested?”
Onset and Duration of Symptoms
- Symptoms began three days ago, with variations in severity.
- Pro Tip: Understanding the timeline helps in assessing the progression of the illness.
- Example Question: “When did your fatigue start?”
Frequency of Symptoms
- Fatigue and fever reported as constant.
- Pro Tip: Determine the consistency of symptoms for a comprehensive assessment.
- Example Question: “How often are you fatigued?”
Location and Characteristics
- Chest pain located in the lower right side, described as dull.
- Pro Tip: Detailing the characteristics of pain aids in understanding the nature of discomfort.
- Example Question: “Where is your pain located?”
Characteristics of Discharge
- Rust-colored sputum reported in cough, varying nasal mucus color.
- Pro Tip: Explore the characteristics of discharge for diagnostic insights.
- Example Question: “Can you describe your mucus?”
Aggravating Factors
- Deep breathing, speaking, and physical exertion aggravate chest pain and fatigue.
- Pro Tip: Identify factors worsening symptoms to inform the management plan.
- Example Question: “Does speaking hurt your chest?”
Non-Medicational Relieving Factors
- Resting, tea, and humidifier steam provide relief.
- Pro Tip: Understand non-medicational relieving factors to support patient comfort.
- Example Question: “Does resting help your symptoms?”
Severity of Pain
- Chest pain intensity during different activities, ranging from 2 to 5 out of 10.
- Pro Tip: Assessing pain severity provides a comprehensive view of symptom impact.
- Example Question: “How severe is your chest pain when you’re not coughing?”
This comprehensive subjective data collection contributes to a thorough understanding of Anita Douglas’s symptoms and aids in formulating an effective care plan for Community-Acquired Pneumonia.
Community-Acquired Pneumonia Anita Douglas shadow health Subjective Data
Past Medical History
Finding: Inquired about pre-existing health conditions
Finding: Patient reports chronic kidney disease stage 2
(Found)Pro Tip: Delving into the patient’s pertinent history can uncover previous diagnoses and ongoing health concerns. Information about the patient’s existing health conditions, including the timeline of diagnoses, symptoms, and allergies, guides further inquiry for comprehensive care and treatment.Example Question: Do you have any existing health conditions?
Finding: Patient reports hypertension
(Found)Pro Tip: Delving into the patient’s pertinent history can uncover previous diagnoses and ongoing health concerns. Information about the patient’s existing health conditions, including the timeline of diagnoses, symptoms, and allergies, guides further inquiry for comprehensive care and treatment.Example Question: Do you have any existing health conditions?
Finding: Inquired about onset and duration of pre-existing health conditions
Finding: Patient reports chronic kidney disease diagnosis nine years ago
(Found)Pro Tip: Delving into the patient’s pertinent history can uncover previous diagnoses and ongoing health concerns. Information about the patient’s existing health conditions, including the timeline of diagnoses, symptoms, and allergies, guides further inquiry for comprehensive care and treatment.Example Question: When were you diagnosed with chronic kidney disease?
Finding: Patient reports hypertension diagnosis 14 years ago
(Found)Pro Tip: Delving into the patient’s pertinent history can uncover previous diagnoses and ongoing health concerns. Information about the patient’s existing health conditions, including the timeline of diagnoses, symptoms, and allergies, guides further inquiry for comprehensive care and treatment.Example Question: When were you diagnosed with hypertension?
Finding: Inquired about hospitalizations
Finding: Patient denies recent hospitalizations
(Found)Pro Tip: Delving into the patient’s pertinent history can uncover previous diagnoses and ongoing health concerns. Information about the patient’s existing health conditions, including the timeline of diagnoses, symptoms, and allergies, guides further inquiry for comprehensive care and treatment.Example Question: Have you been hospitalized recently?
Finding: Inquired about allergies
Finding: Patient denies allergies
(Found)Pro Tip: Delving into the patient’s pertinent history can uncover previous diagnoses and ongoing health concerns. Information about the patient’s existing health conditions, including the timeline of diagnoses, symptoms, and allergies, guides further inquiry for comprehensive care and treatment.Example Question: Do you have any allergies?
Finding: Inquired about vaccines
Finding: Patient reports receiving pneumococcal vaccine 12 years ago
(Found)Pro Tip: Delving into the patient’s pertinent history can uncover previous diagnoses and ongoing health concerns. Information about the patient’s existing health conditions, including the timeline of diagnoses, symptoms, and allergies, guides further inquiry for comprehensive care and treatment.Example Question: Have you had the pneumococcal vaccine?
Finding: Patient reports receiving flu vaccine 3 months ago
(Found)Pro Tip: Delving into the patient’s pertinent history can uncover previous diagnoses and ongoing health concerns. Information about the patient’s existing health conditions, including the timeline of diagnoses, symptoms, and allergies, guides further inquiry for comprehensive care and treatment.Example Question: Have you had the flu shot this year?
Home Medications
Finding: Inquired about home medications
Finding: Patient reports taking trandolapril/verapamil combination drug
(Found)Pro Tip: A patient’s home medications offer insights into their current treatment and its effectiveness. Exploring medication history, dosage, and frequency aids in understanding the patient’s background and its impact on their present situation.Example Question: Are you currently taking medications?
Finding: Patient reports taking chlorothiazide
(Found)Pro Tip: A patient’s home medications offer insights into their current treatment and its effectiveness. Exploring medication history, dosage, and frequency aids in understanding the patient’s background and its impact on their present situation.Example Question: Are you currently taking medications?
Finding: Patient reports taking aspirin
(Found)Pro Tip: A patient’s home medications offer insights into their current treatment and its effectiveness. Exploring medication history, dosage, and frequency aids in understanding the patient’s background and its impact on their present situation.Example Question: Are you currently taking medications?
Finding: Followed up on trandolapril/verapamil
Finding: Patient reports taking trandolapril/verapamil for hypertension and chronic kidney disease
(Found)Pro Tip: A patient’s home medications offer insights into their current treatment and its effectiveness. Exploring medication history, dosage, and frequency aids in understanding the patient’s background and its impact on their present situation.Example Question: Why do you take trandolapril/verapamil?
Finding: Patient reports pill contains 2 milligrams of trandolapril and 180 milligrams of verapamil
(Found)Pro Tip: A patient’s home medications offer insights into their current treatment and its effectiveness. Exploring medication history, dosage, and frequency aids in understanding the patient’s background and its impact on their present situation.Example Question: What dosage is the trandolapril/verapamil?
Finding: Patient reports taking trandolapril/verapamil pill once a day
(Found)Pro Tip: A patient’s home medications offer insights into their current treatment and its effectiveness. Exploring medication history, dosage, and frequency aids in understanding the patient’s background and its impact on their present situation.Example Question: How often do you take trandolapril/verapamil?
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