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Case uitwerking

Patient damien brooks.

Beoordeling
-
Verkocht
-
Pagina's
45
Cijfer
A+
Geüpload op
06-07-2022
Geschreven in
2021/2022

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 Patient  Finding: Established chief complaint  Finding: Reports hitting head (Found) Pro Tip: A pediatric 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 remember details of the accident?  Finding: Reports falling off skateboard (Found) Pro Tip: A pediatric 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 made you come here today?  Finding: Reports scalp hematoma (Found) Pro Tip: A pediatric 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: Where did you hurt when you fell?  Finding: Reports headache (Found) Pro Tip: A pediatric 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 confusion (Found) Pro Tip: A pediatric 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: Were you confused when you woke up?  Finding: Reports dizziness (Found) Pro Tip: A pediatric 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: Have you felt lightheaded or dizzy?  Finding: Reports light sensitivity (Found) Pro Tip: A pediatric 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: Have you been sensitive to light? History of Present Illness Patient  Finding: Asked patient about additional symptoms  Finding: Reports also vomiting (Found) Pro Tip: Asking a pediatric patient about the duration and onset 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: Have you noticed other symptoms?  Finding: Reports also losing consciousness (Found) Pro Tip: Asking a pediatric patient about the duration and onset 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 other health concerns?  Finding: Denies noticing other injuries (Available) Pro Tip: Asking a pediatric patient about the duration and onset 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 does it hurt besides your head?  Finding: Asked patient onset and duration  Finding: Reports headache started when he fell (Found) Pro Tip: Asking a pediatric patient about the duration and onset 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 has your head been hurting?  Finding: Reports confusion started when he fell (Available) Pro Tip: Asking a pediatric patient about the duration and onset 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 the confusion begin?  Finding: Reports dizziness started when he fell (Found) Pro Tip: Asking a pediatric patient about the duration and onset 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 dizziness for me?  Finding: Reports light sensitivity since he fell (Available) Pro Tip: Asking a pediatric patient about the duration and onset 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 eyes sensitive to light?  Finding: Reports vomiting once after getting home (Available) Pro Tip: Asking a pediatric patient about the duration and onset 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 much did you vomit after falling?  Finding: Denies knowing duration of loss of consciousness (Available) Pro Tip: Asking a pediatric patient about the duration and onset 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 can you remember about losing consciousness?  Finding: Asked patient about mechanism of injury  Finding: Denies wearing helmet (Found) Pro Tip: Asking a pediatric patient about the duration and onset 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 tell me if you have a helmet?  Finding: Denies knowing how he fell (Found) Pro Tip: Asking a pediatric patient about the duration and onset 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 remember details of the accident?  Finding: Denies knowing how far he fell (Found) Pro Tip: Asking a pediatric patient about the duration and onset 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 far did you fall?  Finding: Asked patient about history of present illness  Finding: Reports going to skate park after school (Found) Pro Tip: Asking a pediatric patient about the duration and onset 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: Was anyone with you when you fell?  Finding: Reports being with his friend when he fell (Available) Pro Tip: Asking a pediatric patient about the duration and onset 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: Was anyone with you when you fell?  Finding: Reports walking home with his friend after he fell (Available) Pro Tip: Asking a pediatric patient about the duration and onset 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 much do you remember about getting home?  Finding: Reports being driven to emergency room by his stepfather (Available) Pro Tip: Asking a pediatric patient about the duration and onset 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 did you get to the ER?  Finding: Asked patient about characteristics of pain  Finding: Reports dull pain from headache (Found) Pro Tip: Asking a pediatric patient about the duration and onset 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.

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Voorbeeld van de inhoud

case stud




Patient: Damien Brooks




Subjective Data Collection: 28 of 28 (100.0%)

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 Patient


Finding:

Established chief complaint



Finding:

Reports hitting head

(Found)

Pro Tip: A pediatric 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 remember details of the accident?



Finding:

Reports falling off skateboard

(Found)

Pro Tip: A pediatric 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 made you come here today?

,

Finding:

Reports scalp hematoma

(Found)

Pro Tip: A pediatric 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:

Where did you hurt when you fell?



Finding:

Reports headache

(Found)

Pro Tip: A pediatric 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 confusion

(Found)

Pro Tip: A pediatric 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:

Were you confused when you woke up?

, 

Finding:

Reports dizziness

(Found)

Pro Tip: A pediatric 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:

Have you felt lightheaded or dizzy?



Finding:

Reports light sensitivity

(Found)

Pro Tip: A pediatric 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:

Have you been sensitive to light?


History of Present Illness Patient


Finding:

Asked patient about additional symptoms



Finding:

Reports also vomiting

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Documentinformatie

Geüpload op
6 juli 2022
Aantal pagina's
45
Geschreven in
2021/2022
Type
Case uitwerking
Docent(en)
Prof
Cijfer
A+

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