COPD Debbie O’Connor shadow health Subjective Data

COPD Debbie O’Connor shadow health Subjective Data
Subjective Data Collection: 32 of 32 (100.0%)

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Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.

Found:
Indicates an item that you found.

Available:
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.

Chief Complaint

Finding:
Established chief complaint and reason for admittance

&nbspSubjective Action&nbspPro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.&nbspExample Question: "When did your symptoms start?"” data-html=”true” data-title=”Reports a bronchospasm three days ago (Found)” data-original-title=””>
Finding:
Reports a bronchospasm three days ago
(Found)
Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.
Example Question:
When did your symptoms start?

&nbspSubjective Action&nbspPro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.&nbspExample Question: "What are your symptoms?"” data-html=”true” data-title=”Reports increased difficulty breathing (Found)” data-original-title=””>
Finding:
Reports increased difficulty breathing
(Found)
Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.
Example Question:
What are your symptoms?

&nbspSubjective Action&nbspPro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.&nbspExample Question: "What can I do for you?"” data-html=”true” data-title=”Reports desire for smoking cessation aids (Found)” data-original-title=””>
Finding:
Reports desire for smoking cessation aids
(Found)
Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.
Example Question:
What can I do for you?

History of Present Illness

Finding:
Asked about additional symptoms

&nbspSubjective Action&nbspPro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.&nbspExample Question: "Do you feel fatigued?"” data-html=”true” data-title=”Reports fatigue and weakness (Found)” data-original-title=””>
Finding:
Reports fatigue and weakness
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Do you feel fatigued?

&nbspSubjective Action&nbspPro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.&nbspExample Question: "Do you have purulent sputum?"” data-html=”true” data-title=”Reports purulent sputum (Found)” data-original-title=””>
Finding:
Reports purulent sputum
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Do you have purulent sputum?

&nbspSubjective Action&nbspPro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.&nbspExample Question: "Do you have a cough?"” data-html=”true” data-title=”Reports cough (Found)” data-original-title=””>
Finding:
Reports cough
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Do you have a cough?

&nbspSubjective Action&nbspPro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.&nbspExample Question: "How do you feel about your symptoms?"” data-html=”true” data-title=”Reports feeling anxious about symptoms and worsening health issues (Found)” data-original-title=””>
Finding:
Reports feeling anxious about symptoms and worsening health issues
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
How do you feel about your symptoms?

Finding:
Asked about onset and duration of symptoms

&nbspSubjective Action&nbspPro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.&nbspExample Question: "When did your fatigue begin?"” data-html=”true” data-title=”Reports most severe fatigue and difficulty breathing began three days ago (Available)” data-original-title=””>
Finding:
Reports most severe fatigue and difficulty breathing began three days ago
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
When did your fatigue begin?

&nbspSubjective Action&nbspPro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.&nbspExample Question: "When did your productive cough begin?"” data-html=”true” data-title=”Reports purulent sputum production started two weeks ago (Found)” data-original-title=””>
Finding:
Reports purulent sputum production started two weeks ago
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
When did your productive cough begin?

&nbspSubjective Action&nbspPro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.&nbspExample Question: "How long have you had your symptoms?"” data-html=”true” data-title=”Reports respiratory symptoms increased in the last four months (Available)” data-original-title=””>
Finding:
Reports respiratory symptoms increased in the last four months
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
How long have you had your symptoms?

Finding:
Followed up on characteristics of respiratory distress

&nbspSubjective Action&nbspPro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.&nbspExample Question: "What does your sputum look like?"” data-html=”true” data-title=”Reports sputum is mostly clear with occasional yellow, gray, or dark color (Found)” data-original-title=””>
Finding:
Reports sputum is mostly clear with occasional yellow, gray, or dark color
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
What does your sputum look like?

&nbspSubjective Action&nbspPro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.&nbspExample Question: "Are you wheezing?"” data-html=”true” data-title=”Reports wheezing (Available)” data-original-title=””>
Finding:
Reports wheezing
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Are you wheezing?

&nbspSubjective Action&nbspPro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.&nbspExample Question: "What does your cough sound like?"” data-html=”true” data-title=”Reports cough sounds like crackling (Available)” data-original-title=””>
Finding:
Reports cough sounds like crackling
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
What does your cough sound like?

Finding:
Asked about aggravating factors

&nbspSubjective Action&nbspPro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.&nbspExample Question: "Does exertion make your symptoms worse?"” data-html=”true” data-title=”Reports exertion worsens symptoms (Available)” data-original-title=””>
Finding:
Reports exertion worsens symptoms
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Does exertion make your symptoms worse?

&nbspSubjective Action&nbspPro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.&nbspExample Question: "When do you have coughing fits?"” data-html=”true” data-title=”Reports coughing fits after smoking (Found)” data-original-title=””>
Finding:
Reports coughing fits after smoking
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
When do you have coughing fits?

Finding:
Asked about treatment and relieving factors of respiratory symptoms

&nbspSubjective Action&nbspPro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.&nbspExample Question: "How long do you wait between cigarettes?"” data-html=”true” data-title=”Reports trying to hold off on smoking cigarettes as long as possible (Found)” data-original-title=””>
Finding:
Reports trying to hold off on smoking cigarettes as long as possible
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
How long do you wait between cigarettes?

Finding:
Asked about severity of respiratory distress

&nbspSubjective Action&nbspPro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.&nbspExample Question: "Can you rate your symptoms on a scale of 1 to 10?"” data-html=”true” data-title=”Reports breathing difficulty and associated discomfort is a 6/10 (Found)” data-original-title=””>
Finding:
Reports breathing difficulty and associated discomfort is a 6/10
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Can you rate your symptoms on a scale of 1 to 10?

Finding:
Asked about effects of health on social activity

&nbspSubjective Action&nbspPro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.&nbspExample Question: "How do your symptoms prevent you from social activities?"” data-html=”true” data-title=”Reports low social activity – doesn’t feel up to getting out and about (Found)” data-original-title=””>
Finding:
Reports low social activity – doesn’t feel up to getting out and about
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
How do your symptoms prevent you from social activities?

Past Medical History

Finding:
Asked about existing health conditions

&nbspSubjective Action&nbspPro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.&nbspExample Question: "Do you have chronic bronchitis?"” data-html=”true” data-title=”Reports chronic bronchitis related to COPD (Found)” data-original-title=””>
Finding:
Reports chronic bronchitis related to COPD
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Do you have chronic bronchitis?

Finding:
Followed up on chronic bronchitis COPD diagnosis

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