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Danny Riviera - Subjective Data Collection

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Subjective Data Collection: 16 of 20 (80.0%) 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  Finding: Reports cough (Found) Pro Tip: Asking about the characteristics of your patient's cough and voice quality should guide your assessment. Example Question: Do you have a cough? History of Present Illness  Finding: Asked about onset of cough  Finding: Reports cough started 5 days ago (Found) Pro Tip: Whenever you are assessing a symptom or a health condition, inquiring about onset assesses the severity and the progression of the problem. Example Question: How long have you had a cough?  Finding: Asked about frequency and duration of cough  Finding: Reports coughing every couple minutes (Available) Pro Tip: Establishing a timeline for Danny's coughing will illustrate how long he has been suffering these particular symptoms and might indicate possible triggers. Example Question: How frequently have you been coughing?  Finding: Asked about character of cough  Finding: Reports cough is wet (Available) Pro Tip: Asking about the characteristics of your patient's cough and voice quality should guide your assessment. Example Question: Is your cough a wet cough?  Finding: Reports clear sputum with cough (Found) Pro Tip: Asking if your patient's cough is productive should guide your assessment. Example Question: Do you produce any phlegm or sputum with your cough?  Finding: Asked about aggravating factors for cough  Finding: Reports cough is worse at night (Found) Pro Tip: Establishing a timeline for Danny's coughing will illustrate how long he has been suffering these particular symptoms and might indicate possible triggers. Example Question: Is your cough worse at night?  Finding: Reports exposure to secondhand smoke

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danny riviera




Subjective Data Collection: 16 of 20 (80.0%)

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

 Finding:

Reports cough

(Found)

, Pro Tip: Asking about the characteristics of your patient's cough and voice quality should
guide your assessment.

Example Question:

Do you have a cough?

History of Present Illness

 Finding:

Asked about onset of cough

 Finding:

Reports cough started 5 days ago

(Found)

Pro Tip: Whenever you are assessing a symptom or a health condition, inquiring about
onset assesses the severity and the progression of the problem.

Example Question:

How long have you had a cough?

 Finding:

Asked about frequency and duration of cough

 Finding:

Reports coughing every couple minutes

(Available)

Pro Tip: Establishing a timeline for Danny's coughing will illustrate how long he has
been suffering these particular symptoms and might indicate possible triggers.

Example Question:

How frequently have you been coughing?

 Finding:

Asked about character of cough

,  Finding:

Reports cough is wet

(Available)

Pro Tip: Asking about the characteristics of your patient's cough and voice quality should
guide your assessment.

Example Question:

Is your cough a wet cough?

 Finding:

Reports clear sputum with cough

(Found)

Pro Tip: Asking if your patient's cough is productive should guide your assessment.

Example Question:

Do you produce any phlegm or sputum with your cough?

 Finding:

Asked about aggravating factors for cough

 Finding:

Reports cough is worse at night

(Found)

Pro Tip: Establishing a timeline for Danny's coughing will illustrate how long he has
been suffering these particular symptoms and might indicate possible triggers.

Example Question:

Is your cough worse at night?

 Finding:

Reports exposure to secondhand smoke

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Written in
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