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NAOMI ADEBAYO- ACUTE VISIT: FATIGUE Subjective Data Collection

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Written in
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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. Patient Identity • Finding: • Asked about patient identity • Finding: • Reports name is Naomi (Found) • Pro Tip: A patient's preferred name, gender identity, and pronouns may not match the electronic health record. Asking a patient to state how they would like to be addressed during the interview can establish rapport and provide a comfortable and welcoming environment. • Example Question: • What name would you like to be referred to by? • • Finding: • Reports pronouns are she and her (Available) • Pro Tip: A patient's preferred name, gender identity, and pronouns may not match the electronic health record. Asking a patient to state how they would like to be addressed during the interview can establish rapport and provide a comfortable and welcoming environment. • Example Question:

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Institution
NAOMI ADEBAYO- ACUTE VISIT: FATIGUE Subjective Dat
Course
NAOMI ADEBAYO- ACUTE VISIT: FATIGUE Subjective Dat

Content preview

NAOMI ADEBAYO- ACUTE VISIT: FATIGUE
Subjective Data Collection: 70 of 70 (100%)

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.


Patient Identity

Finding:
 Asked about patient identity






Finding:


 Reports name is Naomi

,(Found)





Pro Tip: A patient's preferred name, gender identity, and pronouns may not match the
electronic health record. Asking a patient to state how they would like to be addressed
during the interview can establish rapport and provide a comfortable and welcoming
environment.







Example Question:





What name would you like to be referred to by?








Finding:


 Reports pronouns are she and her


(Available)





Pro Tip: A patient's preferred name, gender identity, and pronouns may not match the
electronic health record. Asking a patient to state how they would like to be addressed
during the interview can establish rapport and provide a comfortable and welcoming
environment.







Example Question:





, What are your pronouns?








Chief Complaint

Finding:
 Asked about chief complaint






Finding:


 Reports continuous fatigue


(Found)





Pro Tip: Asking your patient in open terms about the reason for their visit allows them to
explain their concerns in their own words, providing a foundation for your interview.







Example Question:





What brings you in today?








History of Present Illness


, Finding:
 Asked about onset






Finding:


 Reports fatigue began 2 weeks after
birth of twins


(Found)






Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to
ask a wide variety of follow-up questions about the history of the present illness. This can
help providers better understand the nature of the disorder, especially through questions
about timing, severity, and types of symptoms.







Example Question:






When did your fatigue start?








Finding:
 Asked about characteristics






Finding:

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Institution
NAOMI ADEBAYO- ACUTE VISIT: FATIGUE Subjective Dat
Course
NAOMI ADEBAYO- ACUTE VISIT: FATIGUE Subjective Dat

Document information

Uploaded on
September 10, 2024
Number of pages
79
Written in
2024/2025
Type
CASE
Professor(s)
None
Grade
A

Subjects

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