Category: Nursing

Subjective Data Collection: 32 of 32 (100.0%)

Hover To Reveal…

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

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?

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?

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

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?

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?

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?

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

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?

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?

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

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?

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?

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

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?

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

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

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

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

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

Finding:

Reports diagnosed with “Class B” 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:

What class of COPD were you diagnosed with?

Finding:

Reports diagnosed after respiratory distress episode

(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:

What was your respiratory episode?

Finding:

Asked about ER visits or hospitalizations

Finding:

Reports hospitalization after miscarriage at age 24

(Available)

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:

When were you hospitalized?

Finding:

Reports most recent hospitalization was two years ago

(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:

When was your most recent hospitalization?

Finding:

Reports most recent hospitalization was for respiratory distress episode

(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:

What was your recent hospitalization for?

Home Medications

Finding:

Asked about home medications

Finding:

Reports taking a long-acting beta-agonist (LABA)

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Do you take a LABA?

Finding:

Followed up on LABA

Finding:

Reports the LABA is formoterol inhaler

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Do you use a LABA inhaler?

Finding:

Reports formoterol dose of 12 micrograms

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

What is the dosage of your inhaler?

Finding:

Reports only using once every 12 hours, once in the morning and once at night

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

How often do you take your inhaler?

Finding:

Reports using LABA this morning

(Available)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

When is the last time you used your inhaler?

Finding:

Reports the LABA is not very effective

(Available)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Is the inhaler effective?

Finding:

Denies medication side effects

(Available)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Do you have any side effects from your inhaler?

Finding:

Asked about supplements and vitamins

Finding:

Denies use of supplements or vitamins

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Do you take vitamins?

Finding:

Asked about medication regimen adherence

Finding:

Denies missing doses

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Do you miss doses of your medication?

Finding:

Asked about spirometry

Finding:

Reports sporadic spirometry readings at home

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Do you take spirometry readings at home?

Finding:

Reports most recent FEV1 reading was 1.37 L, 49% of her predicted FEV1

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

What is your most recent spirometry reading?

Finding:

Asked about oxygen use

Finding:

Denies oxygen therapy due to cigarette smoking

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Do you use oxygen even though you smoke?

Finding:

Asked about allergies

Finding:

Denies allergies

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Do you have any allergies?

Finding:

Asked about vaccines

Finding:

Denies recent influenza vaccine

(Available)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Have you had a flu shot?

Finding:

Denies recent pneumococcal vaccines

(Available)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Have you had a pneumonia vaccine?

Social History

Finding:

Asked about living environment

Finding:

Reports she lives with her daughter

(Found)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

Who do you live with?

Finding:

Reports recently moving in with her daughter because of her declining health

(Found)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

When did you move in with your daughter?

Finding:

Reports stress from arguments with daughter over smoking

(Available)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

Is your home stressful?

Finding:

Asked about substance use

Finding:

Reports cigarette smoking

(Found)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

Do you smoke cigarettes?

Finding:

Denies drinking alcohol

(Found)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

Do you drink alcohol?

Finding:

Denies using illegal substances

(Found)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

Do you use illegal drugs?

Finding:

Followed up on current cigarette smoking

Finding:

Reports three to five cigarettes a day for the past four months

(Found)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

How many cigarettes do you smoke a day?

Finding:

Reports stressful situations trigger her smoking

(Available)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

What triggers your smoking?

Finding:

Reports daughter convinced her to quit smoking because of declining health issues

(Available)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

Why do you want to quit smoking?

Finding:

Reports husband’s death of lung cancer makes her want to quit

(Available)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

What was your husband’s cause of death?

Finding:

Followed up on history of cigarette smoking

Finding:

Reports started smoking at age 15

(Found)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

When did you start smoking?

Finding:

Reports quit smoking when her daughter was young but started smoking again in her 30s

(Found)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

Have you ever quit smoking?

Finding:

Reports 37 pack years according to an online calculator her daughter used

(Available)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

How many pack years do you have?

Finding:

Followed up on smoking cessation

Finding:

Reports trying to quit several times unsuccessfully with nicotine replacement therapy

(Available)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

Have you ever quit smoking using nicotine replacement therapy?

Finding:

Reports having tried nicotine gum, lozenges, and patches

(Available)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

What kind of nicotine replacement therapy have you tried?

Finding:

Reports nicotine replacement therapy failed because she did not want to deal with the required compliance

(Available)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

Why didn’t nicotine replacement therapy work?

Finding:

Reports her longest period without smoking was 10 years

(Found)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

What is the longest amount of time you quit smoking?

Finding:

Asked about exercise

Finding:

Denies exercise due to fatigue, exhaustion, exacerbated symptoms upon exertion

(Found)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

Why don’t you exercise?

Finding:

Asked about diet

Finding:

Reports eating mostly frozen meals when daughter is at work

(Found)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

What do you eat at home?

Finding:

Reports her daughter cooks healthy meals for her

(Found)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

Do you cook?

Family Medical History

Finding:

Asked about relevant family history

Finding:

Reports father, smoker, died of a heart attack

(Found)

Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.

Example Question:

Did your father smoke?

Finding:

Reports mother died of smoking-related pneumonia

(Found)

Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.

Example Question:

Did your mother smoke?

Finding:

Reports husband smoked and died of lung cancer

(Available)

Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.

Example Question:

Did your husband smoke?

Finding:

Reports daughter is a “health nut” non-smoker

(Available)

Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.

Example Question:

Does your daughter smoke?

Review of Systems

Finding:

Asked about weight changes

Finding:

Reports weight gain of 30 pounds in the last two years

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

How much weight have you gained?

Finding:

Asked about review of systems for HEENT

Finding:

Reports vision is nearsighted

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Are you nearsighted?

Finding:

Reports wearing glasses

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Do you wear glasses?

Finding:

Asked about review of systems for integumentary

Finding:

Reports yellowing of skin, nails, and teeth

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Have you noticed changes in your skin color?

Finding:

Denies cyanosis

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Are your fingernails blue?

Finding:

Asked about review of systems for genitourinary

Finding:

Reports being postmenopausal

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Are you postmenopausal?

Finding:

Reports not sexually active

(Available)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Are you sexually active?

Activities of Daily Living

Finding:

Asked about ADLs

Finding:

Reports difficulty moving around home

(Found)

Pro Tip: Information about a patient’s activities of daily living will help you determine if their wellbeing is at risk. Questions about your patient’s ability to bathe themselves, feed themselves, or walk without assistance will help you determine whether the patient can care for themselves at home.

Example Question:

Do you have trouble moving around your home?

Finding:

Reports difficulty with activities like dressing or cooking due to exhaustion

APA Scavenger Hunt Template

Student Name:
                                                         
Date:
January 25, 2014

Directions:

Carefully read the APA Scavenger Hunt Guidelines found in Doc Sharing. This provides specific details on how to complete this assignment.

Rename this document by clicking “Save As.” Change the file name so it reads
Your Last Name APA Scavenger Hunt.docx
. For example, if your last name is Smith, type “Smith APA Scavenger Hunt.docx”.

Save the document in a file format compatible with Microsoft Word 2010 or later.

Type your name and date at the top of this template.

Type your answers directly on the template. Follow all instructions. Save frequently to prevent loss of your work.

Submit to the Dropbox by the end of Week 3, Sunday at 11:59 p.m. MT.

Post questions about this assignment to the Q & A Forum so your classmates can read the advice, too. You may also e-mail questions to your instructor.

 

APA Element/Rule

Answer

APA Manual
Location

(Page Number and Reference Point)

Points Earned

 

Title Page

1.    Running head: Using correct capitalization, alignment, and punctuation, type a running head used for a
title page
in the Answer box for this item.

On the line below that, using correct capitalization, alignment, and punctuation, demonstrate a running head used for
subsequent pages.

 

(10 points answer)

 

APA SCAVENGER HUNT ASSIGNMENT              1

APA SCAVENDER HUNT ASSIGNMENT              2

 

 

 

 

 

 

p. 229–230, 8.03

p. 41, Fig. 2.1.

 

2.    Byline and institutional affiliation: Using correct alignment, capitalization, and line spacing, type your byline and institutional affiliation in the box to the right.

(6 points answer, 4 points location)

 

Kevin Corner

Chamberlain: College of Nursing

 

p. 23-24, 2.02 Table 2.1

 

 

 

Body of Paper and General Formatting Rules

3.    Margins: What setting is prescribed for margins in the body of the paper and reference page?

 

(10 points answer)

 

Margins should be uniformly set at 1 inch on the top, bottom, left, and right of every page.

p. 229, 8.03.

 

4.    Line spacing and typeface: What line spacing should be used for the title, body of the paper, and references?

What is the preferred typeface and size?

 

(6 points answer, 4 points location)

 

The appropriate line spacing that should be used in the title, body, and references of your paper is double space.  The preffered typeface and size is Times New Roman, with a 12 point font size.

p. 228-229, 8.03.

 

5.    Headings: What are headings and how are they formatted?

 

(6 points answer, 4 points location)

 

Headings helps to organize your ideas and highlight important items within the section.  Headings also help the reader  identify key points within a manuscript.

p.  62, 3.02.

 

6.    Commas: Where are commas used in separating the following words in a series within a sentence? After explaining the rule, demonstrate correct comma use by retyping the words below in the answer block.

height width or depth

 

(6 points answer, 4 points location)

 

Commas are used to separate elements including before
and
and or in a series of three or more items. Commas are also used to separate two independent clauses, setting of the year in exact dates, and to separate groups of three digits in most numbers.

height, width, or depth

 

p. 88-89, 4.03,

p. 94, 4.10, p89, 114.

 

 

Citations, Quotations, and Reference List

7.    Citations: What is a citation? How is it formatted?  When do you use “and” to join the authors and when do you use “&” to join the authors in a citation?

 

(10 points answer)

 

Citations are key elements that gives background information, supports your thesis and offers critical definitions and data.  In text citations are formatted with the author’s last name and the year of the publication.  A page number is also required for direct quotations. When citing multiple authors’  Use the word “and” between author’s names within the body of the text and use “&” in parentheses.

p. 169,

p. 174, 6.11,

p. 175, 6.12.

 

8.    Quotations: How are quotations formatted? How are quotations cited?

 

(6 points answer, 4 points location)

 

When formatting a direct quote, you must include the author, year of the publication, and page number.  If the quote contains fewer than 40 words, incorporate it into the text and use double quotation marks. Ensure that you use open quotation at the beginning of  the quoted material and close quotation at the end of a quoted material. If the quotation comprises of more than 40 words, display in freestanding block text and do not include quotation marks  Block quotations must be started on a new line and indented.  Also, the sentence should be grammatically correct.

p. 15, 1.10,

p. 170-171, 6.03,

p. 92, 4.08.

 

 

9.    Secondary source citation: You read an article by John Brown (published in 2013) who credited an idea to Susan Johnson (published in 2010). How do you cite Susan Johnson’s idea in your paper? HINT: This is known as a secondary source citation.

 

(6 points answer, 4 points location)

 

In this example, you should list the secondary source (Susan Johnson) in the reference list.  In text, name the original work (John Brown) but give citation for the secondary source (Susan Johnson), for example:

In Browns article (as cited in Johnson, 2010).

p. 178, 6.17.

 

10. Citation and reference: Explain the relationship between what is cited and what is on the References page.

 

(10 points answer)

 

The citation briefly describes the source for readers, usually bibliographic information.  The reference is what guides the reader to the source you have selected.  Each citation in your text must have a reference source to avoid plagiarism.

p. 174, 6.10.

 

11. Reference italics: What portions of a reference for a book are
italicized
? What portions of a reference for a journal article are
italicized
?

 

(6 points answer, 4 points location)

 

For a book reference, Italicize the entire title of the book excluding information within parenthesis.  For an article, do not italicize anything within the reference.  Lastly, for a journal reference, italicize the the name of the periodicals.

p. 185, 6.29.

 

12. Author information on the reference page: You have read one article by C. William Howard, Lu L. Kim, and Samuel L. Colton. Demonstrate the correct author information in the correct order that should be placed on the reference page.

 

(10 points answer)

 

Colton, L. S.

Howard, C. W.

Kim, L. L.

p. 184, 6.27,

p. 181, 6.25.

 

13. Letter case in article titles on reference page: When typing the title of the article on the reference page, when do you use UPPERCASE letters and when do you use lowercase letters?

 

(6 points answer, 4 points location)

 

When typing the title of an article on the reference page, capitalize the first word of the title, sub title, and periodical only.  All other letters should be lowercase.

p. 185, 6.29.

 

14. Reference page format for periodical: Type the general reference form shown in the
APA Manual
as the basic formula for periodical.

Use correct line spacing, spacing between elements, capitalization, indentation, and italics as you would on the Reference page of a paper.

 

(6 points answer, 4 points location)

 

Author, A. A., Author, B. B., & Author, C. C. (year). Title of article. Titile of Periodical, xx, pp-pp. doi:xx.xxxxxxxxxx

p. 198, 7.01.

 

15. Reference examples by type: In the
APA Manual
, on what page do the “examples  by type” of reference begin?

How will you use this section as you create references?

 

(6 points answer, 4 points location)

 

Examples of references begins on page 198 in the APA Manual.  This section is priceless.  It is a step by step go by of how to reference books, journals, magazines, etc.  I can use this section as a quick reference for my advanced English class as well as my other nursing courses to help me with properly formatting references from different sources.

p. 198, 7.01.

 

16. Entire paper location: The
APA Manual
contains a miniaturized picture of an entire paper with title page, body of the paper, and a reference list.

On what page does this miniature paper begin? How will you use this section when you need to write a paper?

 

(6 points answer, 4 points  location)

 

The sample papers within the APA Manual starts on page 41.  I can use these papers as outlines and go-bys to properly format my writing assignments and ensure that I am abiding by the APA rules.

p. 41, figure 2.1.

 

17. DOI numbers: What does DOI stand for? Explain its use. When you are writing a paper, where will you include the DOI for articles you used?

 

(6 points answer, 4 points location)

 

DOI stands for digital object identifiers.  The DOI is a unique alphanumeric string assigned by a registration agency to identify content and provide a persistent link to its location on the internet.  The DOI is included in the reference list.

P 189, 6.31.

 

 

Grammar and Sentence Structure

18. Referring to author tense: If you are referring to a statement made by an author, do you write “Smith claims” or “Smith claimed”?

 

(6 points answer, 4 points location)

 

Referring to author tense and even the example, you would write, “Smith claimed.”

p. 78, 3.18.

 

19. Gender-biased language: What are some ways to avoid gender-biased language?

 

(10 points answer)

 

You can avoid gender-biased language by choosing nouns, pronouns, and adjectives that specially describe the participants.  You should also be clear about whether you are referring

p. 73, 3.12.

 

20. Abbreviations: What are the rules for properly using abbreviations the first time and subsequent times in the body of the paper?

 

(10 points answer)

 

An abbreviation must be written out on it’s first appearance of your paper followed immediately by it’s abbreviation in parenthesis.  You may use the abbreviated version thereafter, keeping in mind not to constantly switch from the abbreviated version to the complete version.

p. 107, 4.23.

 

TOTAL Points Possible: 200

TOTAL Points Earned:

Transcript

Started:
Mar 30, 2020 |
Total Time:
125 min

Hello Debbie O’Connor, My name is Danielle Scott. I will be your provider today.

Greet

03/30/20 3:44 PM CDT

Hello.

Can you verify your Name and birthday?

Question

03/30/20 3:44 PM CDT

I was born on October 5 . . . [Ms. O’Connor reports the correct birth year.]

What brings you in today?

Question

03/30/20 3:44 PM CDT

I’m having so much trouble just trying to breathe. And I’ve had these terrible coughing fits. A few days ago, a bronchospasm. My health is going downhill fast . . . I know it has to do with my smoking habit. It’s so hard to kick. I was hoping I could get something to help me.

I’m sorry to hear that you are experiencing anxiety over your current health conditions. Not being able to breathe is a scary condition. With the right therapy, and if you quit smoking, you’ll begin to feel better.

Empathize

03/30/20 3:47 PM CDT

That’s very kind.

Are you experiencing any other symptoms?

Question

03/30/20 3:48 PM CDT

I feel exhausted. I’m just so weak now, that even walking up the stairs feels exhausting. I had this awful coughing fit three days ago. But I’ve had trouble breathing for several months now. I’ve also been coughing up some nasty phlegm.

When did you start coughing up the phlegm

Question

03/30/20 3:50 PM CDT

I cough up sputum all the time. It’s been like this for a couple of weeks. It’s this dark gray — or sometimes yellow color.

Any aggravating factors?

Question

03/30/20 3:51 PM CDT

Honestly, smoking makes my breathing worse. I have these terrible coughing fits afterwards. Kind of a no-brainer, but I can’t help myself. I can’t handle the withdrawal, so I just try to hold out between cigarettes as long as I can.

Is there anything that relieves the symptoms?

Question

03/30/20 3:52 PM CDT

Nothing seems to make my symptoms feel better — not even my inhaler. I know for sure that smoking makes it worse. I try to hold off as long as I can between cigs. But still . . . I think if I quit I’d feel better.

How bad is you breathing? (Clarified to How severe are your breathing problems?.)

Question

03/30/20 3:52 PM CDT

Breathing is so hard, all the time. I guess I’d put it at a 6 out of 10. (Clarified to how severe my breathing problems are.)

How does your health affect your social life?

Question

03/30/20 3:53 PM CDT

My breathing problems sure aren’t helping my social life any. I was never exactly a social butterfly, but now I’m not up to going out. Even normal things–shopping, picking up my meds.

Do you have any other existing health conditions?

Question

03/30/20 3:54 PM CDT

I’ve only got Group B COPD. The chronic bronchitis kind. [AUDIO COMING SOON]

Any recent hospitalizations?

Question

03/30/20 3:55 PM CDT

I haven’t been to the hospital in about two years. I had a bad breathing episode and they said I had COPD.

What medications are you currently taking?

Question

03/30/20 3:57 PM CDT

I have an inhaler that I use for my COPD — a formoterol inhaler.

How often you do you use your inhaler?

Question

03/30/20 3:58 PM CDT

I use it twice a day, morning and night. Every 12 hours.

Whats the dosage of the inhaler?

Question

03/30/20 3:58 PM CDT

I take 12 micrograms of formoterol.

Do you take any supplements or vitamins?

Question

03/30/20 3:59 PM CDT

I don’t take any vitamins or supplements or any of that stuff.

Are you complaint with your medicine? (No matching questions found.)

Question

03/30/20 3:59 PM CDT

Do you miss doses of medications? (Clarified to Do you miss doses of your medication?.)

Question

03/30/20 4:00 PM CDT

No, I never miss doses. I use my inhaler once in the morning and once at night. I find that easy enough to remember. (Clarified to if I miss doses of my medication.)

Do you use a spirometer?

Question

03/30/20 4:00 PM CDT

I have a spirometer, yes. Only use it sometimes. Got an FEV1 reading of 1.37 L the other day. That’s 49%.

Do you have any allergies?

Question

03/30/20 4:01 PM CDT

I don’t have any allergies, never had an allergic reaction . . . nothing like that.

Do you use home oxygen?

Question

03/30/20 4:01 PM CDT

I don’t use oxygen . . . it could probably help me. But I’d blow myself up, smoking near it.

Oxygen therapy could help alleviate some of your symptoms of breathlessness and fatigue. Unfortunately, you cannot use oxygen therapy if you smoke. It’s too dangerous. Once you quit smoking, you can seek this treatment.

Educate

03/30/20 4:04 PM CDT

You certainly know your stuff.

Have you had any vaccines?

Question

03/30/20 4:05 PM CDT

I’ve had vaccines before, but . . . it’s been a long time.

At your age, and with your health conditions, it’s vital that you get an annual flu shot, and that you receive a pneumococcal vaccine every ten years. These two infections could have terrible effects on your health because your respiratory system is already compromised.

Educate

03/30/20 4:08 PM CDT

That’s good to know.

Do you live at home alone?

Question

03/30/20 4:11 PM CDT

I live with my daughter, Ava. I moved in when my health started getting worse. She takes care of me.

do you drink alcohol?

Question

03/30/20 4:11 PM CDT

I don’t touch the stuff. My daddy was a drinker, and I saw what it did to him.

Any substance abuse?

Question

03/30/20 4:12 PM CDT

No, that never appealed to me.

how long have you been a smoker

Question

03/30/20 4:12 PM CDT

I started smoking when I was 15. I’ve smoked for a long time. Had a little success quitting. I stopped for ten years when my daughter was born. But, I picked up the habit again. I’ve tried quitting since my husband died, but . . . it’s hard.

I’m sorry that you lost your husband. That sounds like it must have been very difficult for you.

Empathize

03/30/20 4:15 PM CDT

Thanks.

how many cigarettes do you smoke per day

Question

03/30/20 4:15 PM CDT

Typically I smoke between three and five cigarettes a day. It’s been that way for the last four months. Ever since I relapsed. Smoking makes my breathing worse, so . . . I try to hold off as long as I can between cigarettes.

It’s vital that you quit smoking as soon as possible in order to get some relief from you COPD symptoms. Smoking is putting your life in danger and making your symptoms worse. I can point you towards community or national smoking cessation programs that can help support you while you are quiting

Educate

03/30/20 4:20 PM CDT

I’ll be sure to keep that in mind.

Do you exercise?

Question

03/30/20 4:20 PM CDT

I can’t exercise. I can’t even move around the house without feeling fatigued and out of breath. Exerting myself in any way makes me feel worse.

Tell me about your diet?

Question

03/30/20 4:21 PM CDT

Well, I’m too weak to cook. I eat microwavable meals if I’m alone. Pasta, pizza, rice, all that. My daughter cooks nice food . . . quinoa, salads, salmon.

When you COPD symptoms have been alleviated it is important that you try to eat well and get some light exercise. Not exercising can exacerbate your symptoms, and some exercise will help you breathe easier and build lung capacity

Educate

03/30/20 4:23 PM CDT

Oh! That makes sense.

Any family history of illness?

Question

03/30/20 4:24 PM CDT

My parents died from smoking their whole lives. It was a different time . . . my father had a heart attack at 42. My mother edged him out, but she eventually got pneumonia.

Changes in your weight? (Clarified to Has your weight changed recently?.)

Question

03/30/20 4:24 PM CDT

I’ve gained 30 pounds these past two years. (Clarified to if I have had weight changes recently.)

Do you have any problems with your vision

Question

03/30/20 4:26 PM CDT

I’m nearsighted, but my glasses work fine.

have you noticed any shin issues (No matching questions found.)

Question

03/30/20 4:26 PM CDT

Any skin changes?

Question

03/30/20 4:27 PM CDT

Skin’s been turning yellow around my mouth and fingers. From cigarettes, I’m sure. At least I haven’t turned blue.

Any issues with your menses (No matching questions found.)

Question

03/30/20 4:28 PM CDT

WHen was you last period

Question

03/30/20 4:28 PM CDT

I haven’t had a period since I went through menopause.

Do you work?

Question

03/30/20 4:28 PM CDT

I’m retired. Used to be an office manager.

Hello, I have written some prescriptions

Question

03/30/20 5:02 PM CDT

Sure thing, honey.

For the tiotropium inhaler, take missed dose as soon as possible.

Question

03/30/20 5:03 PM CDT

Ok. I understand.

use the rescue inhaler for acute symptoms

Question

03/30/20 5:03 PM CDT

I’ll be sure to do just that.

do not swallow the capsules, they should be inhaled with the inhaler

Question

03/30/20 5:04 PM CDT

I understand.

Inhale the capsule twice to get the full dose

Question

03/30/20 5:04 PM CDT

Alright.

stop the medication and contact the doctor if you experience bronchospasm immediately after a treatment

Question

03/30/20 5:06 PM CDT

Isn’t this inhaler supposed to keep that from happening?

yes, youre right. thats why it is important to contact us

Question

03/30/20 5:06 PM CDT

Alright. I think I understand.

common side effects will be dry mouth

Question

03/30/20 5:07 PM CDT

Alright.

keep the capsules inside the packaging

Question

03/30/20 5:07 PM CDT

Understood.

be sure to use the medication as recommended

Question

03/30/20 5:08 PM CDT

Okay.

prep the inhaler before use

Question

03/30/20 5:08 PM CDT

I’ll be sure to keep that in mind.

seek help if you can not control your breathing

Question

03/30/20 5:09 PM CDT

I sure hope that doesn’t happen.

you might feel nervous

Question

03/30/20 5:09 PM CDT

Thank you for letting me know. I’ll keep an eye out for that.

for the varenicline take missed dose as soon as possible

Question

03/30/20 5:10 PM CDT

I’ll be sure to do just that.

begin smoking cessation counseling immediately

Question

03/30/20 5:11 PM CDT

I won’t stop trying to quit, no matter what. I have to make it happen this time.

it will cause dry mouth

Question

03/30/20 5:11 PM CDT

I can try to deal with that if it happens.

stop medication if you experience an allergic reaction

Question

03/30/20 5:12 PM CDT

I’ll keep an eye out for those side effects.

contact provider if you have thoughts of hurting yourself or depression

Question

03/30/20 5:13 PM CDT

That’s awful scary. Are you sure I should be taking this medicine?

Its rare, we just want to be safe

Question

03/30/20 5:13 PM CDT

Alright. As long as you think it will work.

anything else?

Question

03/30/20 5:13 PM CDT

Ok. See you later.

Title of the Paper in Full

 

Student Name

Program Name or Degree Name (e.g., Master of Science in Nursing), xx University

COURSE XX: Title of Course

Instructor Name

Month XX, 202X

 

Abstract

This is the abstract, which is typed in block format with no indentation. Abstracts are not required for all course papers. Please ask your instructor if you have questions regarding whether an abstract is required for a particular assignment. The abstract briefly summarizes your paper in 250 words or less. Through your abstract, your readers should be able to fully understand the content and the implications of the paper. Also, note that writing this section after the paper itself may be helpful. See section 2.9 of APA 7 and the Writing Center’s
Abstracts webpage
for tips and more information on writing abstracts.

 

 

 

Title of the Paper in Full

This template’s margins, page numbers, and page breaks are set for you, and you do not need to change them. Do not add any extra spaces between the heading and the text (tip: check Spacing under Format, Paragraph in your word processor, and make sure that it is set to 0”). Instead, just use a standard double space, indent a full ½ inch (preferably using the tab button), and start typing. While APA allows writers to choose a font that is “accessible to readers” (American Psychological Society, 2020, p. 44), and offers a few recommended types and sizes (see Section 2.19), this template uses Times New Roman size 12. The introduction should receive no specific heading because readers assume that the first section functions as your paper’s introduction.

After considering these formatting issues, you will need to construct a
thesis statement
, which lets readers know how you synthesized the literature into a treatise that is capable of advancing a new point of view. This statement provides readers with a lens for understanding the
evidence
you will present in the body of your essay (each
paragraph
and thus evidence within those paragraphs you include should support and apply to this thesis statement).

Once you have established your thesis, begin constructing the
introduction
. An easy template for writing an introduction follows:

Start with what has been said or done regarding the topic.

Explain the problem with what has been said or done.

Offer a solution in a concise thesis statement that can be supported by the evidence.

Level 1 Heading

This text will be the beginning of the body of the essay. Even though this section has a new heading, make sure to connect this section to the previous one so readers follow your ideas and evidence. The first sentence in each paragraph should start with a
topic sentence
, which summarizes the main point in the current paragraph. Make sure each paragraph contains only one topic, which helps establish a
clear scope for your paragraph
. When you see yourself drifting to another idea, make sure you break into a new paragraph. You can use the
MEAL plan
as a way to conceptualize and organize your paragraphs. In short, think about our paragraphs in this way: new idea, new paragraph.

Another Level 1 Heading

Here is another Level 1 heading. Note that, when you add additional headings, you should use the APA levels available in the Styles area of your toolbar. If you enter them manually instead, you may need to delete the automatic indent that appears because Word thinks you are beginning a new paragraph. Again, the
topic sentence
of this section should explain how this paragraph is related or a result of what you discussed in the previous section. Consider using
transitions
between sentences to help readers see the connections between ideas.

Level 2 Heading

The Level 2 heading designates a subsection of the previous section. Using headings is a great way to organize a paper and increase its readability, so see Section 2.27 of APA 7 and the Writing Center’s
Heading Levels webpage
for details on heading formatting (APA 7 also has a chart detailing heading formatting in the inside front cover). For shorter papers, using one or two levels is all that is needed. You would use Level 1 (centered, bold font with title case) and Level 2 (left aligned, bold, title case). This template provides examples of APA’s four heading levels, but remember to use headings judiciously to indicate your paper’s organization. Too many headings (e.g., headings for each paragraph) can be distracting, while too little headings can make your paper’s organization unclear.

 

Level 3 Heading

Level 3 and 4 headings introduce some new formatting. Level 3 headings are in italics, and Level 4 headings are indented. All headings are in title case. The number of heading levels needed in a particular paper is not set, but longer papers may benefit from another heading level, such as this Level 3 heading (which is left-aligned, bold, italicized, and title case), in order to clearly organize and identify the nesting development of ideas.

Level 4 Heading.
One crucial area in APA is learning how to cite. Make sure to
cite source information throughout your paper
to avoid plagiarism. This practice is critical: you need to give credit to your sources and avoid copying others’ work. Look at Chapter 8 of APA 7 and the Writing Center’s
Plagiarism Prevention Resource Kit
for guidelines on citing source information in your writing.

Level 1 Heading

APA can seem difficult to master, but following the general rules becomes easier with use. The Writing Center also offers numerous resources on its website and by email to help. Email or visit our
Live Chat Hours
for questions, and peruse the
APA Style section
of our website for in-depth information. The Writing Center’s
Crash Course in APA Style
video
can help you identify the APA rules you may need to learn more about.

Level 1 Heading

The
conclusion
section should recap the major points of your paper. A conclusion can be one paragraph, but it can also be a few paragraphs, depending on the length of your paper. However, perhaps more importantly, the conclusion should also interpret what you have written and what it means in the bigger picture. To help write your conclusion, consider asking yourself these questions: What do you want to happen with the information you have provided? What do you want to change? What is your ultimate goal in using this information? What would it mean if the reader of your paper took and used the suggestions in your paper?

Course_Paper_Template_With_Abstract_APA_7

 

References

(Note that the following references are intended as examples only. These entries illustrate different types of references but are not cited in the body of this template. In your paper, be sure every reference entry matches a citation, and every citation refers to an item in the reference list.

For additional information, examples, and help with reference entries, see Chapter 9 of APA 7 and the Writing Center’s
References section of the website
, particularly the
Common Reference List Examples page
.)

American Counseling Association. (n.d.).
About us.

https://www.counseling.org/about-us/about-aca

Anderson, M. (2018). Getting consistent with consequences.
Educational Leadership, 76
(1), 26-33.

Bach, D., & Blake, D. J. (2016). Frame or get framed: The critical role of issue framing in nonmarket management.
California Management Review, 58
(3), 66-87.
https://doi.org/10.1525/cmr.2016.58.3.66

Burgess, R. (2019).
Rethinking global health: Frameworks of Power.
Routledge.

Herbst-Damm, K. L., & Kulik, J. A. (2005). Volunteer support, marital status, and the survival times of terminally ill patients.
Health Psychology, 24
(2), 225–229.
https://doi.org/10.1037/0278-6133.24.2.225

Johnson, P. (2003).
Art: A new history.
HarperCollins.
https://doi.org/10.1037.0000136-000
​

Lindley, L. C., & Slayter, E. M. (2018). Prior trauma exposure and serious illness at end of life: A national study of children in the U.S. foster care system from 2005 to 2015.
Journal of Pain and Symptom Management, 56
(3), 309–317.
https://doi.org/10.1016/j.jpainsymman.2018.06.001

Osman, M. A. (2016, December 15).
5 do’s and don’ts for staying motivated.
Mayo Clinic.
https://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/5-dos-and-donts-for-staying-motivated/art-20270835

Sue, D. W., & Sue, D. (2016).
Counseling the culturally diverse: Theory and practice
(7th ed.). Wiley.

Walden University Library. (n.d.).
Anatomy of a research article
[Video].
https://academicguides.waldenu.edu/library/instructionalmedia/tutorials#s-lg-box-7955524

Walden University Writing Center. (n.d.).
Writing literature reviews in your graduate coursework
[Webinar].
https://academicguides.waldenu.edu/writingcenter/webinars/graduate#s-lg-box-18447417

World Health Organization. (2018, March).
Questions and answers on immunization and vaccine safety.

https://www.who.int/features/qa/84/en/

Subjective Data Collection: 29 of 29 (100.0%)

Hover To Reveal…

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

Finding:

Reports fever

(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:

Do you have a fever?

Finding:

Reports chest pain

(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:

Do you have chest pain?

Finding:

Reports cough

(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:

Do you have a cough?

History of Present Illness

Finding:

Asked about additional symptoms

Finding:

Reports fatigue

(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:

Are you fatigued?

Finding:

Reports coughing up 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 cough anything up?

Finding:

Reports sinus congestion

(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:

Are you feeling congested?

Finding:

Reports muscle soreness

(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:

Are your muscles sore?

Finding:

Asked about onset and duration of symptoms

Finding:

Reports fatigue began 3 days 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 fatigue start?

Finding:

Reports chest pain began 3 days 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 chest pain start?

Finding:

Reports productive cough began 3 days 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 cough start?

Finding:

Reports sinus congestion began 3 days 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 congestion start?

Finding:

Reports fever began 1 day 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 fever start?

Finding:

Asked about frequency of symptoms

Finding:

Reports fatigue is constant

(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 often are you fatigued?

Finding:

Reports fever is constant

(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:

Is the fever constant?

Finding:

Reports congestion is constant

(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 often are you congested?

Finding:

Reports less severe chest pain is constant

(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 often do you have less severe chest pain?

Finding:

Reports more severe chest pain occurs with coughing

(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 often do you have more severe chest pain?

Finding:

Reports coughing every few minutes

(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 often do you cough?

Finding:

Followed up on location of pain

Finding:

Reports pain in lower right side of chest

(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:

Where is your pain located?

Finding:

Followed up on characteristics of pain

Finding:

Reports chest pain is dull

(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 is the pain like?

Finding:

Followed up on characteristics of discharge

Finding:

Reports coughing up rust-colored 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:

Can you describe your mucus?

Finding:

Reports nasal mucus varies from yellow to green in color

(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:

Can you describe your mucus?

Finding:

Asked about aggravating factors

Finding:

Reports deep breathing aggravates chest pain

(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:

Does deep breathing hurt your chest?

Finding:

Reports speaking aggravates chest pain

(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:

Does speaking hurt your chest?

Finding:

Reports physical exertion aggravates chest pain and fatigue

(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:

Does exertion make your symptoms worse?

Finding:

Asked about non-medicational relieving factors

Finding:

Reports resting provides relief

(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:

Does resting help your symptoms?

Finding:

Reports tea provides relief

(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 drink tea?

Finding:

Reports humidifier steam provides slight relief

(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 use a humidifier?

Finding:

Asked about severity of pain

Finding:

Reports chest pain when not coughing is 2 out of 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:

How severe is your chest pain when you’re not coughing?

Finding:

Reports chest pain during normal coughing is 5 out of 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:

How severe is your chest pain when coughing?

Past Medical History

Finding:

Asked about pre-existing health conditions

Finding:

Reports chronic kidney disease stage 2

(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 any existing health conditions?

Finding:

Reports hypertension

(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 any existing health conditions?

Finding:

Asked about onset and duration of pre-existing health conditions

Finding:

Reports chronic kidney disease was diagnosed 9 years ago

(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:

When were you diagnosed with chronic kidney disease?

Finding:

Reports hypertension was diagnosed 14 years ago

(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:

When were you diagnosed with hypertension?

Finding:

Asked about hospitalizations

Finding:

Denies recent hospitalizations

(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:

Have you been hospitalized recently?

Finding:

Asked about allergies

Finding:

Denies allergies

(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 any allergies?

Finding:

Asked about vaccines

Finding:

Reports receiving pneumococcal vaccine 12 years ago

(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:

Have you had the pneumococcal vaccine?

Finding:

Reports receiving flu vaccine 3 months ago

(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:

Have you had the flu shot this year?

Home Medications

Finding:

Asked about home medications

Finding:

Reports taking trandolapril/verapamil combination drug

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Are you currently taking medications?

Finding:

Reports taking chlorothiazide

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Are you currently taking medications?

Finding:

Reports taking aspirin

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Are you currently taking medications?

Finding:

Followed up on trandolapril/verapamil

Finding:

Reports taking trandolapril/verapamil for hypertension and chronic kidney disease

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Why do you take trandolapril/verapamil?

Finding:

Reports pill contains 2 milligrams of trandolapril and 180 milligrams of verapamil

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

What dosage is the trandolapril/verapamil?

Finding:

Reports taking trandolapril/verapamil pill once a day

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

How often do you take trandolapril/verapamil?

Finding:

Reports having taken trandolapril/verapamil for 9 years

(Available)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

How long have you taken trandolapril/verapamil?

Finding:

Reports last dose of trandolapril/verapamil was this morning

(Available)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

When was your last dose of trandolapril/verapamil?

Finding:

Denies adverse effects from trandolapril/verapamil

(Available)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Do you have adverse effects from trandolapril/verapamil?

Finding:

Followed up on chlorothiazide

Finding:

Reports taking chlorothiazide for hypertension

(Available)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Why do you take chlorothiazide?

Finding:

Reports chlorothiazide pill is 500 milligrams

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

What dosage is the chlorothiazide?

Finding:

Reports taking chlorothiazide pill twice a day

(Available)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

How often do you take chlorothiazide?

Finding:

Reports having taken chlorothiazide for 14 years

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

How long have you taken chlorothiazide?

Finding:

Reports last dose of chlorothiazide was this morning

(Available)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

When was your last dose of chlorothiazide?

Finding:

Reports chlorothiazide increases frequency of urination

(Available)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Do you have adverse effects from chlorothiazide?

Finding:

Followed up on aspirin

Finding:

Reports taking aspirin for pain and fever

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Why do you take aspirin?

Finding:

Reports aspirin pill is 325 milligrams

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

What dosage is the aspirin?

Finding:

Reports taking 2 aspirin pills every 6 hours, 3 times a day

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

How often do you take aspirin?

Finding:

Reports having taken aspirin pills for 3 days

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

How long have you taken aspirin?

Finding:

Reports last dose of aspirin was this morning

(Available)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

When was your last dose of aspirin?

Finding:

Denies adverse effects from aspirin

(Available)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Do you have adverse effects from aspirin?

Finding:

Asked about vitamins and supplements

Finding:

Reports taking calcium supplement

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Do you take vitamins or supplements?

Finding:

Reports taking vitamin D supplement

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Do you take vitamins or supplements?

Finding:

Followed up on calcium supplement

Finding:

Reports taking calcium supplement for chronic kidney disease

(Available)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Why do you take calcium supplements?

Finding:

Reports calcium supplement is 1200 milligrams

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

What dosage are your calcium supplements?

Finding:

Reports taking calcium supplement once a day

(Available)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

How often do you take calcium supplements?

Finding:

Reports having taken calcium supplement for 9 years

(Available)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

How long have you been taking calcium supplements?

Finding:

Reports last dose of calcium supplement was this morning

(Available)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

When did you last take a calcium supplement?

Finding:

Denies adverse effects from calcium supplement

(Available)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Do you have adverse effects from calcium supplements?

Finding:

Followed up on vitamin D supplement

Finding:

Reports taking vitamin D supplement for chronic kidney disease

(Available)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Why do you take vitamin D supplements?

Finding:

Reports vitamin D supplement is 15 micrograms

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

What dosage are your vitamin D supplements?

Finding:

Reports taking vitamin D supplement once a day

(Available)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

How often do you take vitamin D supplements?

Finding:

Reports having taken vitamin D supplement for 9 years

(Available)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

How long have you been taking vitamin D supplements?

Finding:

Reports last dose of vitamin D was this morning

(Available)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

When did you last take a vitamin D supplement?

Finding:

Denies adverse effects from vitamin D

(Available)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Do you have adverse effects from vitamin D supplements?

Finding:

Asked about medication regimen adherence

Finding:

Denies missing medication doses

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Do you miss doses of your medication?

Finding:

Reports being able to afford medication

(Available)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Are you able to afford your medication?

Finding:

Reports using pillbox

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Do you use a pillbox for your medication?

Finding:

Asked about history of antibiotic use

Finding:

Denies recent antibiotic regimen

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Have you taken antibiotics recently?

Social History

Finding:

Asked about substance use

Finding:

Reports drinking 1-2 glasses of wine per week

(Available)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

Do you drink alcohol?

Finding:

Denies tobacco use

(Available)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

Do you use tobacco products?

Finding:

Denies illicit drug use

(Found)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

Do you use illicit drugs?

Finding:

Asked about exercise

Finding:

Reports taking 10 minute walks 2-3 times per week

(Found)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

What type of exercise do you do?

Finding:

Asked about diet

Finding:

Reports being a lacto-ovo-vegetarian

(Found)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

Do you have any dietary restrictions?

Finding:

Reports usually eating pasta or salad

(Found)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

What do you eat on a typical day?

Finding:

Asked about activities of daily living

Finding:

Reports no difficulties with activities of daily living

(Found)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

Are you able to complete activities of daily living?

Family Medical History

Finding:

Asked about relevant family medical history

Finding:

Reports father had hypertension

(Found)

Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.

Example Question:

What health problems run in your family?

Document your clinical practice hours using the Lopes Activity Tracker (LAT) in your student portal. Once you have opened the app, click on the link for your class to record your hours. Clinical practice hours should be documented and submitted within 48 hours of the clinical experience. After the hours have been submitted, the preceptor will verify the hours, which are then reviewed by the faculty.

Download the electronic summary of your practicum experience from the Lopes Activity Tracker. Save the file and submit it though the assignment dropbox for faculty approval.

This report is to be submitted in every topic.

Transcript

Started:
Mar 25, 2020 |
Total Time:
59 min

Hi Dr. Douglas, My name is Danielle. I will be your provider today

Greet

03/25/20 12:48 AM CDT

Hello.

What is the reason for you visit today?

Question

03/25/20 12:48 AM CDT

I’m here because I’ve got an awful cough, a fever, and my chest feels like I’ve been kicked by a horse. I’m sure this is some kind of upper respiratory infection. I was hoping it would go away on its own, but it hasn’t, so my husband Jeffrey convinced me to come in. As amusing as it is for Jeffrey to serve me my meals, this has gone on long enough. I need to feel better.

I’m sorry to hear that you are so uncomfortable from your symptoms. Your frequent cough sounds like it’s aggravating your already uncomfortable chest pain. You have done a great job toughing it out so far, and we’ll find a treatment plan to help you feel better.

Empathize

03/25/20 12:52 AM CDT

Thank you.

When did your symptoms start?

Question

03/25/20 12:53 AM CDT

Most of my symptoms started three days ago. I developed this nasty cough, and my nose has been all stuffed up. That’s also when the chest pain started, and when I began to feel exhausted. The fever set in last night. That was the last straw, so Jeffrey brought me in.

How often do the symptoms occur?

Question

03/25/20 12:54 AM CDT

Most of my symptoms — the hacking cough, chest pain, fatigue, achiness, stuffy nose — started three days ago. The fever started yesterday. None of it has let up since.

Where is your pain?

Question

03/25/20 12:54 AM CDT

Most of the chest pain is located in the lower right part of my chest. Aside from that, I have some general aches and muscle soreness; this is mostly a deep, dull sort of ache, but it feels more severe when I cough.

I’m sorry to hear that you’re in constant pain, and that your cough makes your pain worse. I will work on finding a therapy that will give you some relief.

Empathize

03/25/20 12:56 AM CDT

I appreciate your saying that.

Are you coughing up any mucous?

Question

03/25/20 12:58 AM CDT

I’m coughing up rust-colored sputum.

Are there any factors that make your symptoms worse? (Clarified to Does anything make your symptoms worse?.)

Question

03/25/20 12:59 AM CDT

Coughing makes this chest pain much worse. Deep breathing also seems to aggravate it, or talking too much. I also can’t move around too much . . . I’ve been staying in bed because any kind of activity makes my pain worse and leaves me exhausted. (Clarified to if anything makes my symptoms worse.)

What helps relieve your symptoms

Question

03/25/20 1:00 AM CDT

Rest has helped me feel a little better. Exerting myself in any way just makes me feel worse. Jeffrey has also been bringing me hot tea and soup. We’ve also kept my humidifier going. Other than that, I tried taking aspirin to help with my fever and chest pain, but that didn’t give me much relief.

how bad is the pain?

Question

03/25/20 1:00 AM CDT

I think that this cough is pretty severe. It brings my chest pain up from a 2 out of 10 to a 5 out of 10.

sorry to hear that

Empathize

03/25/20 1:01 AM CDT

Well, that’s very nice.

Lets talk about your past medical history (Clarified to What is your past medical history?.)

Question

03/25/20 1:01 AM CDT

I have hypertension and chronic kidney disease. stage 2. (Clarified to what health problems I have had.)

how long have you had the conditions? (Clarified to How long have you had your preexisting health problems?.)

Question

03/25/20 1:02 AM CDT

I was diagnosed with stage 2 chronic kidney disease 9 years ago, when I had some blood work done for my hypertension. I don’t know how long I had it before that, but I was diagnosed with hypertension 14 years ago, so it could have been a long time. (Clarified to how long I have had my preexisting health problems.)

any recent hospitalizations?

Question

03/25/20 1:03 AM CDT

I have not been hospitalized recently.

do you have any allergies

Question

03/25/20 1:03 AM CDT

No, I don’t have allergies.

Are you up to date on vaccines?

Question

03/25/20 1:04 AM CDT

Let me think . . . I had a flu shot about three months ago. Other than that, it’s been quite a while since I’ve needed any vaccines. I had a pneumococcal vaccine 12 years ago.

You are due for a pneumococcal vaccine, which you should receive again in your adulthood five to ten years after your first shot. These vaccines protect against the bacteria that most commonly cause pneumonia.

Educate

03/25/20 1:07 AM CDT

Alright.

What medications do you take?

Question

03/25/20 1:09 AM CDT

I take two prescription medications; a trandolapril/verapamil combo and chlorothiazide. I also take two supplements, vitamin D and calcium. And for the last three days I’ve been taking aspirin.

tell me about the trandolapril/verapamil

Question

03/25/20 1:10 AM CDT

I take my trandolapril/verapamil once a day for my stage 2 chronic kidney disease and hypertension.

how long have you taken the chlorothiazide?

Question

03/25/20 1:11 AM CDT

I have taken chlorothiazide for 14 years.

whats is the dosage of your medications?

Question

03/25/20 1:11 AM CDT

The trandolapril/verapamil combination is 2 milligrams of trandolapril and 180 milligrams of verapamil. The chlorothiazide pill is 500 milligrams. The aspirin is 325 milligrams each pill. As for the supplements: the calcium is 1200 milligrams and the vitamin D is 15 micrograms.

are you compliant with all of your medications? (Clarified to Are you compliant with your medications?.)

Question

03/25/20 1:12 AM CDT

I never miss doses of my medication. Jeffrey and I are very diligent, and the pillbox keeps track for us. (Clarified to if I am compliant with medication.)

That is great

Empathize

03/25/20 1:13 AM CDT

Thank you. I appreciate that.

what you taken any antibiotics? (Clarified to Have you taken antibiotics recently?.)

Question

03/25/20 1:13 AM CDT

I haven’t taken any antibiotics in some time . . . I honestly can’t remember when that would’ve been. (Clarified to if I have taken antibiotics recently.)

Do you drink, smoke, or use illicit substances?

Question

03/25/20 1:14 AM CDT

I’ve never used any illicit drugs.

do you exercise?

Question

03/25/20 1:15 AM CDT

I try to stay active by taking a few short walks a week. Jeffrey and I will walk around our neighborhood for about ten minutes. We try to do this two or three times a week. Unfortunately, right now all I can do is rest.

any difficulties with activities of daily living? (Clarified to Do you have trouble performing daily activities?.)

Question

03/25/20 1:16 AM CDT

I’ve been struggling a little with everything of late, but I am quite capable in general, thank you. [AUDIO COMING SOON] (Clarified to if I have trouble performing daily activities.)

tell me about your diet?

Question

03/25/20 1:16 AM CDT

In the morning, Jeffrey and I will have a piece of toast with some eggs, or maybe a fresh croissant that he picks up from the bakery around the corner. We normally eat a very light lunch — a sandwich, or some homemade soup — and for dinner we like to go out to eat a few times a week. Normally we get pasta, or a salad.

For people with hypertension and with chronic kidney disease, some foods are healthier and safer than others. It’s important to consider how your health will be affected when making everyday meal choices.

Empathize

03/25/20 1:18 AM CDT

That’s kind of you to say.

whats your family medical history

Question

03/25/20 1:20 AM CDT

My parents have both passed away. My mother was fairly healthy, but my father had hypertension. [AUDIO COMING SOON]

just want to follow up on the aspirin (No matching questions found.)

Question

03/25/20 1:20 AM CDT

How often do you take the aspirin

Question

03/25/20 1:20 AM CDT

Not normally, but since I got sick three days ago, I have been taking two aspirins three times a day. That’s a 325 milligram pill.

does it help with pain?

Educate

03/25/20 1:21 AM CDT

I’ll keep that in mind.

does it help with pain (No matching questions found.)

Question

03/25/20 1:21 AM CDT

does the aspirin relieve your pain

Question

03/25/20 1:22 AM CDT

It has done a little good, I suppose, both for my chest pain and my fever . . . I suppose it’s hard to tell, though, because I’ve been taking it since my symptoms started, so I haven’t really felt how bad my symptoms are sans aspirin. [AUDIO COMING SOON]

While it’s great that the aspirin has relieved your symptoms, it is not approved for older adults nor for people taking some of your medications. Always ask a healthcare provider before starting a new medication.

Educate

03/25/20 1:24 AM CDT

I’ll remember that.

Hi, i will educate you on the new prescription

Question

03/25/20 1:38 AM CDT

I appreciate it.

Take the medication with a full glass of water

Question

03/25/20 1:38 AM CDT

Shouldn’t be a problem.

Take the full course of medications

Question

03/25/20 1:39 AM CDT

I’ll be sure to take the whole course.

Be sure to avoid the sun

Question

03/25/20 1:39 AM CDT

I won’t be leaving my bed much anyway.

Contact your doctor if you experience rapid weight gain

Question

03/25/20 1:40 AM CDT

Alright then.

call 911 if you show signs of a severe allergic reaction

Question

03/25/20 1:40 AM CDT

I’ll have Jeffrey call 911 if that happens.

take tylenol for pain and fever

Question

03/25/20 1:41 AM CDT

Thanks for that.

guaifenesin will help with your cough

Question

03/25/20 1:41 AM CDT

Good to know.

you should start feeling better in a few days

Question

03/25/20 1:42 AM CDT

Hmm. Okay.

drink plenty of fluids

Question

03/25/20 1:42 AM CDT

I can do that. Does tea work?

yes Mrs Douglas

Question

03/25/20 1:42 AM CDT

That works for me.

THank you

Question

03/25/20 1:42 AM CDT

Alright. Thank you for all of your help today.

Education & Empathy
: 5 of 6 (83.3%)

During the patient interview, there are a number of opportunities to provide patient education and empathy. The opportunities listed below are those identified by nursing experts to be of particular importance to this patient. A
Model Statement
is provided as an example of an appropriate response to each opportunity.

Opportunities marked as
Not Encountered
are opportunities that were not elicited in the interview

Opportunities marked as
Not Followed Up
are missed opportunities that were present in the interview, but where no statements were made

Opportunities marked as
Followed Up
were followed up by students, and include the dialogue between student and patient

1 Urinary Pain and UTI Symptoms

Followed Up

Description:
Ms. Henderson reports discomfort with her associated urinary symptoms such as pain, cramping, burning, and feelings of increased urgency to urinate.

What brings you in today?

Question

09:47 PM CDT

I’ve had to pee a lot lately. It burns when I pee, and it looks weird. I thought it would go away on its own, but it hasn’t. So I was like, fine, I need to see someone. [AUDIO COMING SOON]

I’m sorry that you’re experiencing pain and burning during urination. I’ll try to find a medication that will help alleviate these symptoms.

Empathize

09:49 PM CDT

Thanks.

How long have you had these symptoms?

Question

09:50 PM CDT

Three days ago, I started feeling pretty bad. I kept having to pee, and each time I did, it burned. It was gross, too. The pee looked different. [AUDIO COMING SOON]

any other symptoms?

Question

09:51 PM CDT

Other than the pain and burning, I have a little bit of cramping in my lower abdomen. [AUDIO COMING SOON]

where is the pain?

Question

09:52 PM CDT

It hurts the most when I pee, right where it comes out. It’s this burning, stinging feeling.

do the urine have an odor?

Question

09:52 PM CDT

It smells really strong. It’s basically rank. It’s also, like, dark . . . cloudy.

how bad does it hurt (Clarified to: How painful is urinating?)

Question

09:53 PM CDT

It burns every time I pee and I am really not OK with how much pain I’m in. I’d call it a 7 out of 10. (Clarified to: how painful urinating is)

any factors that make it worse? (Clarified to: What aggravates the pain?)

Question

09:54 PM CDT

Well, it burns every time I pee, so peeing makes the pain worse, I guess. (Clarified to: what makes my pain worse)

what do you do to relieve the pain?

Question

09:54 PM CDT

Since it only burns and stings when I pee, I thought maybe it would hurt less if I didn’t pee so much. I tried drinking less water, but I’m not sure how much good it’s doing.

I know that you tried to alleviate your symptoms by not drinking fluids; you should try to stay hydrated by drinking more water and avoiding drinks that irritate the bladder such as soda coffee or alcohol

Educate

09:59 PM CDT

Yeah, OK.

Model Statement:
“I’m sorry that you’re experiencing pain and burning during urination and an increased sense of urgency. I’ll try to find a medication that will help alleviate these symptoms.”

2 Breast Cancer

Followed Up

Description:
Ms. Henderson discloses that her mother is a breast cancer survivor.

any family history of illness

Question

10:20 PM CDT

My dad’s really healthy. My mom’s a breast cancer survivor. She’s fine now, though. Totally cancer free. My Nana — that’s my Mom’s mom — died of it, though.

I’m sorry that your mother had breast cancer. That must have been a difficult thing for your family to go through. I’m glad that she is OK and that you and your sister are are not at risk

Empathize

10:23 PM CDT

OK.

Model Statement:
“I’m sorry that your mother had breast cancer. That must have been a difficult thing for your family to go through. I’m glad that she is OK and that you and your sister are not at risk.”

3 Hydration

Not Followed Up

Description:
Ms. Henderson reports that she avoided drinking fluids in order to alleviate her pain, burning, and increased urinary urgency.

do you drink

Question

10:15 PM CDT

I usually drink one or two nights a week, depending on if there’s good parties or not. But I never have more than a drink or two. Gotta keep my brain right so I can take over the world.

do you practice safe sex

Question

10:16 PM CDT

Model Statement:
“I know that you tried to alleviate your symptoms by not drinking fluids; you should try to stay hydrated by drinking more water and avoiding drinks that irritate the bladder such as soda, coffee, or alcoholic beverages.”

4 Urinating After Intercourse

Followed Up

Description:
Ms. Henderson reports that she does not have any post-intercourse habits, such as urinating after intercourse.

do you urinate after sex?

Question

10:03 PM CDT

Oh . . . I guess I didn’t know you were supposed to.

Urinating after sex helps lower the risk of UTIs by clearing the urinary tract of any bacteria. Making this a regular habit might decrease your chances of getting a UTI again in the future

Educate

10:05 PM CDT

Hm. Alright.

Model Statement:
“Urinating after intercourse helps lower the risk of UTIs by clearing the urinary tract of any bacteria. Making this a regular habit might decrease your chances of getting a UTI again in the future.”

5 Safe Sex

Followed Up

Description:
Ms. Henderson reports that she is sexually active.

do you practice safe sex

Question

10:16 PM CDT

Uh, I always use protection. I take birth control and I use those spermicidal condoms.

good, practice sex safe with partners of all genders in order to minimize the risk of STIs

Educate

10:17 PM CDT

Thanks for the info.

Model Statement:
“Practice safe sex with partners of all genders in order to minimize the risk of STIs.”

6 Cranberry Pills

Followed Up

Description:
Ms. Henderson reports she took cranberry pills to treat her UTI.

do you take any other medications

Question

10:10 PM CDT

I don’t know if it qualifies as medication, but I took some cranberry supplements cause apparently they help with UTIs, which I figured I had when my pee started burning.

do you cranberry pills help (Clarified to: Are the cranberry pills effective?)

Question

10:10 PM CDT

I don’t know . . . I’ve heard you’re supposed to take them for UTIs, but it’s been three days and nothing’s gotten better. And I even took two at a time. I don’t know the dosage, but regardless, you’d think they’d be doing something. (Clarified to: if the cranberry pills are effective)

Cranberry pills aren’t an effective treatment against UTIs. In the future when you notice these symptoms contact a healthcare provider sooner so that you can receive medication that will be more effective treatment

Educate

10:13 PM CDT

Thank you. That makes sense.

Model Statement:
“Cranberry pills aren’t an effective treatment against UTIs. In the future when you notice these symptoms contact a healthcare provider sooner so that you can receive medication that will be more effective treatment.”

Transcript

Started:
Mar 30, 2020 |
Total Time:
66 min

Hi Miss Henderson, My name is danielle, I will be your provider today

Greet

03/30/20 9:47 PM CDT

Hey.

What brings you in today?

Question

03/30/20 9:47 PM CDT

I’ve had to pee a lot lately. It burns when I pee, and it looks weird. I thought it would go away on its own, but it hasn’t. So I was like, fine, I need to see someone. [AUDIO COMING SOON]

I’m sorry that you’re experiencing pain and burning during urination. I’ll try to find a medication that will help alleviate these symptoms.

Empathize

03/30/20 9:49 PM CDT

Thanks.

How long have you had these symptoms?

Question

03/30/20 9:50 PM CDT

Three days ago, I started feeling pretty bad. I kept having to pee, and each time I did, it burned. It was gross, too. The pee looked different. [AUDIO COMING SOON]

any other symptoms?

Question

03/30/20 9:51 PM CDT

Other than the pain and burning, I have a little bit of cramping in my lower abdomen. [AUDIO COMING SOON]

where is the pain?

Question

03/30/20 9:52 PM CDT

It hurts the most when I pee, right where it comes out. It’s this burning, stinging feeling.

do the urine have an odor?

Question

03/30/20 9:52 PM CDT

It smells really strong. It’s basically rank. It’s also, like, dark . . . cloudy.

how bad does it hurt (Clarified to How painful is urinating?.)

Question

03/30/20 9:53 PM CDT

It burns every time I pee and I am really not OK with how much pain I’m in. I’d call it a 7 out of 10. (Clarified to how painful urinating is.)

any factors that make it worse? (Clarified to What aggravates the pain?.)

Question

03/30/20 9:54 PM CDT

Well, it burns every time I pee, so peeing makes the pain worse, I guess. (Clarified to what makes my pain worse.)

what do you do to relieve the pain?

Question

03/30/20 9:54 PM CDT

Since it only burns and stings when I pee, I thought maybe it would hurt less if I didn’t pee so much. I tried drinking less water, but I’m not sure how much good it’s doing.

I know that you tried to alleviate your symptoms by not drinking fluids; you should try to stay hydrated by drinking more water and avoiding drinks that irritate the bladder such as soda coffee or alcohol

Educate

03/30/20 9:59 PM CDT

Yeah, OK.

When was the last date of intercourse (Clarified to When did you last have sex?.)

Question

03/30/20 10:03 PM CDT

I had sex with this guy like four days ago. We’ve had a pretty regular thing for a couple of months. (Clarified to when my last sexual encounter was.)

do you urinate after sex?

Question

03/30/20 10:03 PM CDT

Oh . . . I guess I didn’t know you were supposed to.

Urinating after sex helps lower the risk of UTIs by clearing the urinary tract of any bacteria. Making this a regular habit might decrease your chances of getting a UTI again in the future

Educate

03/30/20 10:05 PM CDT

Hm. Alright.

Any past medical condition?

Question

03/30/20 10:07 PM CDT

Besides what I’m here for now, I’m pretty healthy, honestly.

do you have any allergies?

Question

03/30/20 10:08 PM CDT

I have seasonal allergies in spring and summer. I don’t know to what exactly, but my eyes itch, my throat gets scratchy, I get a stuffy nose, and all that fun stuff.

do you take any for you allergies?

Question

03/30/20 10:08 PM CDT

I just take these antihistamines ahead of time so I don’t get symptoms. It’s loratadine.

what dosage do you take? (Clarified to How much loratadine do you use at once?.)

Question

03/30/20 10:09 PM CDT

It’s a pill that’s 10 milligrams a day. (Clarified to what dosage the loratadine is.)

do you miss doses

Question

03/30/20 10:09 PM CDT

I never miss doses. I just take all my pills in the morning together, and they’re all once a day, so it’s easy. And with my birth control, I can track it with the click pack.

do you take any other medications

Question

03/30/20 10:10 PM CDT

I don’t know if it qualifies as medication, but I took some cranberry supplements cause apparently they help with UTIs, which I figured I had when my pee started burning.

do you cranberry pills help (Clarified to Are the cranberry pills effective?.)

Question

03/30/20 10:10 PM CDT

I don’t know . . . I’ve heard you’re supposed to take them for UTIs, but it’s been three days and nothing’s gotten better. And I even took two at a time. I don’t know the dosage, but regardless, you’d think they’d be doing something. (Clarified to if the cranberry pills are effective.)

Cranberry pills aren’t an effective treatment against UTIs. In the future when you notice these symptoms contact a healthcare provider sooner so that you can receive medication that will be more effective treatment

Educate

03/30/20 10:13 PM CDT

Thank you. That makes sense.

any medication allergies?

Question

03/30/20 10:13 PM CDT

Actually, now that you mention it, I’m hypersensitive to penicillin.

what is you reaction to penicillin (Clarified to What type of reaction do you have to penicillin?.)

Question

03/30/20 10:14 PM CDT

My penicillin reaction is pretty bad. I get a red, itchy rash, and I get all sick to my stomach and throw up a lot. (Clarified to what my reaction to penicillin is.)

do you use any illicit substances

Question

03/30/20 10:14 PM CDT

I tried weed at a party at my first semester here, but I just didn’t like it. I never bothered with it again after that. But before you say anything, no, I’ve never touched tobacco.

do you drink

Question

03/30/20 10:15 PM CDT

I usually drink one or two nights a week, depending on if there’s good parties or not. But I never have more than a drink or two. Gotta keep my brain right so I can take over the world.

do you practice safe sex

Question

03/30/20 10:16 PM CDT

Uh, I always use protection. I take birth control and I use those spermicidal condoms.

good, practice sex safe with partners of all genders in order to minimize the risk of STIs

Educate

03/30/20 10:17 PM CDT

Thanks for the info.

any family history of illness

Question

03/30/20 10:20 PM CDT

My dad’s really healthy. My mom’s a breast cancer survivor. She’s fine now, though. Totally cancer free. My Nana — that’s my Mom’s mom — died of it, though.

I’m sorry that your mother had breast cancer. That must have been a difficult thing for your family to go through. I’m glad that she is OK and that you and your sister are are not at risk

Empathize

03/30/20 10:23 PM CDT

OK.

when was your last period

Question

03/30/20 10:23 PM CDT

My last period started two and a half weeks ago, so the last day was two weeks ago. [AUDIO COMING SOON]

Hi

Question

03/30/20 10:32 PM CDT

Hey, sure thing. [AUDIO COMING SOON]

take the full course of medications

Question

03/30/20 10:32 PM CDT

Ok – but what if I start feeling better?

even if you start feeling better

Question

03/30/20 10:32 PM CDT

Oh, ok. That makes sense.

take with meal

Question

03/30/20 10:33 PM CDT

Ok. Can do.

use backup contraceptives to prevent unwanted pregnancy

Question

03/30/20 10:33 PM CDT

Ok. Got it.

contact provider for reactions

Question

03/30/20 10:34 PM CDT

I’ll look out for that.

take to relieve pain

Question

03/30/20 10:34 PM CDT

Ok. Yeah, that’s pretty important. Will do.

continue this while on the antibiotic

Question

03/30/20 10:34 PM CDT

Ok, I will.

urine will appear orange

Question

03/30/20 10:35 PM CDT

Weird! Thanks for letting me know.

contact provider is you notice and rashes

Question

03/30/20 10:35 PM CDT

Got it.

pee before and after sex

Question

03/30/20 10:35 PM CDT

Oh, I didn’t know. I’ll be sure to do that. [AUDIO COMING SOON]

wear loose fitting cotton clothes

Question

03/30/20 10:36 PM CDT

I’ll be sure they’re made from cotton. [AUDIO COMING SOON]

wipe front to back

Question

03/30/20 10:36 PM CDT

Oookay. Gotcha. [AUDIO COMING SOON]

thank you

Question

03/30/20 10:36 PM CDT

Ok. See you later.

Patient Teaching Score: 9 out of 10

Greet the patient’s guardian

Topics priorized for patient teaching

Education Items

Greet the patient’s guardian and explain why you need to educate them.

Greet the patient’s guardian and explain why you need to educate them.

Sophia’s test came back positive.

Statement

10/3/2020 7:17:20 AM

Alright. Thank you.

Model Statement:
Hi, Omar. We’re going to be going over how to safely give Sophia her medication.

amoxicillin

6.5 out of 7

Model Plan

(1 point) Only use the dosing instrument that comes with medication

(1 point) Shake medication well before use

(1 point) Check to make sure you are administering the correct dose

(1 point) Give your child rewards and incentives for taking medication

(1 point) Take the full course of antibiotics

(1 point) Contact a health provider if symptoms do not improve

(1 point) Discontinue if you see signs of amoxicillin allergy

Topics priorized for patient teaching

Education Items

(1 point) Only use the dosing instrument that comes with medication

(1 point) Keep medication in a safe pace, out of reach of the child

(1 point) Check to make sure you are administering the correct dose

(1 point) Symptoms should improve in a few days

(1 point) Take the full course of antibiotics

(0.5 points) Look for signs of thrush

(1 point) Discontinue if you see signs of amoxicillin allergy

Only use the dosing instrument that comes with medication

Follow the instructions on the medication

Statement

10/3/2020 7:17:48 AM

I’ll be sure to do that.

Model Statement:
It’s important to give Sophia the precise dose prescribed to her. Only use the dosing instrument that came with medication and never use a kitchen utensil like a spoon.

Keep medication in a safe pace, out of reach of the child

Keep medication in safe place, out of children reach

Statement

10/3/2020 7:18:11 AM

Good call. I don’t think she’d pour it out or something, but—oh, you mean she might drink it. Right, that too.

Model Statement:
Keep medication in a safe pace, where Sophia can’t reach it.

Check to make sure you are administering the correct dose

Check to be sure the dose is correct

Statement

10/3/2020 7:18:35 AM

I bet it’s really dangerous to give a kid too much medicine. Better be careful.

Model Statement:
Check carefully to make sure you are administering the correct dose of medication using age-appropriate weight-based calculations.

Symptoms should improve in a few days

Symptoms should improve in a couple of days

Statement

10/3/2020 7:19:05 AM

That’s really good to hear. I hate to see her like this.

Model Statement:
Sophia’s symptoms should begin to improve in a few days.

Take the full course of antibiotics

Sophia will be able to return to school in 3 days

Statement

10/3/2020 7:19:24 AM

Yeah, I can do that. Make sure Sophia takes all of her medicine. No matter how much she doesn’t want to. Make her do the thing she doesn’t want to do. I got it.

Model Statement:
If Sophia doesn’t take the full course of antibiotics, she could get sick again. Make sure she takes all of her medicine just like the instructions say.

Look for signs of thrush

Looks for a rash in here mouth

Statement

10/3/2020 7:19:47 AM

Oh, thrush is terrible. I’ll let you know right away if I see any signs of it.

Model Statement:
Contact your clinician if you see signs of thrush in Sophia’s mouth and throat.

Discontinue if you see signs of amoxicillin allergy

Stop the medication of you see any signs of an allergic reaction, like difficulty breathing

Statement

10/3/2020 7:20:34 AM

Sophia already has some of those things because of the strep. How do I know if she’s also having a reaction to the amoxicillin?

Hives and if your daughter cant breathe

Statement

10/3/2020 7:21:04 AM

Understood.

Model Statement:
Discontinue if you see signs of an allergic reaction to amoxicillin, which includes swelling, rash, and queasiness.

Symptoms and Care

2.5 out of 3

Model Plan

(1 point) Throw away toothbrush after 48 hours

(1 point) Give child ibuprofen or acetaminophen to treat fever

(1 point) Give Sophia a lot of liquids to keep her hydrated

Topics priorized for patient teaching

Education Items

(1 point) Throw away toothbrush after 48 hours

(0.5 points) When she can return to school

(1 point) Give Sophia a lot of liquids to keep her hydrated

Throw away toothbrush after 48 hours

change the toothbrush

Statement

10/3/2020 7:21:15 AM

She’s pretty attached to her butterfly toothbrush, but I’m sure we can find another one . . . probably . . .

Model Statement:
Throw away Sophia’s toothbrush after 48 hours. Strep can linger on the toothbrush, and potentially reinfect her.

When she can return to school

she can return to school in 3 days

Statement

10/3/2020 7:21:49 AM

That’s good to know. Thanks.

Model Statement:
Sophia can return to school after 48 hours, if her symptoms have improved.

Give Sophia a lot of liquids to keep her hydrated

She can drink plenty of water

Statement

10/3/2020 7:22:19 AM

Sophia’s pretty good about drinking water. Normally I’d go for tea, but I don’t think I need a caffeinated Sophia stuck at home from school. Bad times for everybody.

Model Statement:
Make sure that Sophia drinks plenty of liquids so she stays hydrated.

Say Goodbye

Topics priorized for patient teaching

Education Items

Educate the patient’s guardian on anything else and say goodbye

Educate the patient’s guardian on anything else and say goodbye

Have a good day

Statement

10/3/2020 7:22:43 AM

Ok. See you later.