Shadow Health Focused Exam: Community-Acquired Pneumonia Results (Summer 2020) Subjective Data Collection: 28 of 29 (96.6%)

Document Content and Description Below

Focused Exam: Community-Acquired Pneumonia Results | Turned In Advanced Pharmacology - Summer 2019, NURS 5304 Return to Assignment Your Results Lab Pass Subjective Data Collection: 28 of 29 (9... 6.6%) Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions. Category Scored Items Experts selected these topics as essential components of a strong, thorough interview with this patient. Chief Complaint Indicates an item that you found. Indicates an item that is available to be found. 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. Established chief complaint and reason for admittance Reports fever Reports chest pain Reports cough History of Present Illness Asked about additional symptoms Reports fatigue Reports coughing up sputum Reports sinus congestion Reports muscle soreness Asked about onset and duration of symptoms Reports fatigue began 3 days ago Reports chest pain began 3 days ago If you are using Safari and have issues with audio in your assignment, please click here for assistance. Click here for more information Overview Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Debrief Medication Selection Patient Teaching Prescription Writing / Reports productive cough began 3 days ago Reports sinus congestion began 3 days ago Reports fever began 1 day ago Asked about frequency of symptoms Reports fatigue is constant Reports fever is constant Reports congestion is constant Reports less severe chest pain is constant Reports more severe chest pain occurs with coughing Reports coughing every few minutes Followed up on location of pain Reports pain in lower right side of chest Followed up on characteristics of pain Reports chest pain is dull Followed up on characteristics of discharge Reports coughing up rust-colored sputum Reports nasal mucus varies from yellow to green in color Asked about aggravating factors Reports deep breathing aggravates chest pain Reports speaking aggravates chest pain Reports physical exertion aggravates chest pain and fatigue Asked about non-medicational relieving factors Reports resting provides relief Reports tea provides relief Reports humidifier steam provides slight relief Asked about severity of pain Reports chest pain when not coughing is 2 out of 10 Reports chest pain during normal coughing is 5 out of 10 Past Medical History Asked about pre-existing health conditions Reports chronic kidney disease stage 2 Reports hypertension Asked about onset and duration of pre- existing health conditions Reports chronic kidney disease was diagnosed 9 years ago Reports hypertension was diagnosed 14 years ago Asked about hospitalizations Denies recent hospitalizations Asked about allergies Denies allergies Asked about vaccines Reports receiving pneumococcal vaccine 12 years ago Reports receiving flu vaccine 3 months ago Home Medications Asked about home medications Reports taking trandolapril/verapamil combination drug Reports taking chlorothiazide Reports taking aspirin Followed up on trandolapril/verapamil Reports taking trandolapril/verapamil for hypertension and chronic kidney disease Reports pill contains 2 milligrams of trandolapril and 180 milligrams of verapamil Reports taking trandolapril/verapamil pill once a day Reports having taken trandolapril/verapamil for 9 years Reports last dose of trandolapril/verapamil was this morning Denies adverse effects from trandolapril/verapamil Followed up on chlorothiazide Reports taking chlorothiazide for hypertension Reports chlorothiazide pill is 500 milligrams Reports taking chlorothiazide pill twice a day Reports having taken chlorothiazide for 14 years Reports last dose of chlorothiazide was this morning Reports chlorothiazide increases frequency of urination Followed up on aspirin Reports taking aspirin for pain and fever Reports aspirin pill is 325 milligrams Reports taking 2 aspirin pills every 6 hours, 3 times a day Reports having taken aspirin pills for [Show More]

Last updated: 1 year ago

Preview 1 out of 5 pages