Sick Visit: Management of Endocrine Conditions Shadow health Subjective Data Collection
Subjective Data Collection Summary: The subjective data collection process for managing endocrine conditions during a sick visit comprises 40 out of 43 items (93.0%). Below are key findings and relevant pro tips to enhance the interview process.
Chief Complaint:
- Patient reports hair loss and fatigue.
- Pro Tip: Use open-ended questions to allow patients to express their concerns in their own words.
- Example Question: “What brings you in today?”
Orientation:
- Patient is oriented to person, time, place, and situation.
- Pro Tip: Assessing orientation helps evaluate cognitive function.
- Example Question: “Can you tell me where you are right now?”
History of Present Illness:
- Fatigue onset reported one month ago, lasting all day.
- Various questions about timing, aggravating and relieving factors, and impact on daily activities.
- Pro Tip: Explore details to understand the nature of the disorder.
- Example Question: “When did your fatigue start?”
Past Medical History:
- Patient reports hypothyroidism and osteopenia diagnoses.
- In-depth inquiries about onset, symptoms, and impact on daily life.
- Pro Tip: Understanding existing health conditions aids in proper assessment.
- Example Question: “Do you have any existing health conditions?”
Allergies and Surgeries:
- Patient denies food, medication, latex, and environmental allergies.
- No history of previous surgeries reported.
- Pro Tip: Collecting information on allergies and surgeries is essential for context.
- Example Question: “Do you have any food allergies?”
Home Medications:
- Patient reports taking a supplement.
- Pro Tip: Inquire about vitamins and supplements to complete the medication profile.
- Example Question: “Are you currently taking any vitamins or supplements?”
This comprehensive subjective data collection will contribute to a thorough assessment of the patient’s health status, facilitating effective management of endocrine conditions during the sick visit.
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