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Case uitwerking

NSG 410 Samantha Monroe Shadow Health Subjective Data

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29-05-2025
Geschreven in
2024/2025

Chief Complaint Finding: Asked about reason for visit Finding: Reports needing sports physical for soccer (Found) Pro Tip: Confirming the purpose of a patient’s visit is important for determining the scope of the exam. Knowing that a patient is seeking a pre-participation evaluation will guide your conversation and inform the physical exam actions that you take, all with the goal of determining if a patient is healthy enough to participate in sports. It is also important to know which sport(s) the patient plays. Some sports have a higher risk of concussions, while other may require participants to maintain a certain weight. Individual considerations must be made for each type of activity Samantha Monroe shadow Health Subjective data. Example Question: What brings you into the clinic?

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Instelling
NSG 410
Vak
NSG 410

Voorbeeld van de inhoud

Samantha Monroe shadow Health Subjective data

Samantha Monroe shadow Health Subjective data
Subjective Data Collection: 26 of 27 (96.3%)
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 Samantha Monroe shadow Health Subjective data.

Confirmed Guardian’s Relationship


Finding:

Asked about relationship with patient



Finding:

Reports being Samantha’s mother

(Found)

Pro Tip: Confirming the patient’s relationship with their guardian ensures that you are observing legal and ethical
protections for patient privacy, and that you are speaking with someone who has access to the patient’s information.

Example Question:

What is your relationship to the patient?

Chief Complaint


Finding:

Asked about reason for visit

, Finding:

Reports needing sports physical for soccer

(Found)

Pro Tip: Confirming the purpose of a patient’s visit is important for determining the scope of the exam. Knowing that
a patient is seeking a pre-participation evaluation will guide your conversation and inform the physical exam actions
that you take, all with the goal of determining if a patient is healthy enough to participate in sports. It is also important
to know which sport(s) the patient plays. Some sports have a higher risk of concussions, while other may require
participants to maintain a certain weight. Individual considerations must be made for each type of activity Samantha
Monroe shadow Health Subjective data.

Example Question:

What brings you into the clinic?

Past Medical History


Finding:

Asked about medical conditions



Finding:

Denies having any medical conditions

(Found)

Pro Tip: Discussing the patient’s past medical history will alert you to any past or present medical conditions that
may restrict a patient from participating in sports. Keep in mind the particular sport the patient wishes to participate
in, as a contact sport like football has different risks than a sport like golf.

Example Question:

Do you have any medical conditions?



Finding:

Asked about history of surgery



Finding:

Reports only having a tonsillectomy

(Found)

Pro Tip: Discussing the patient’s past medical history will alert you to any past or present medical conditions that
may restrict a patient from participating in sports. Keep in mind the particular sport the patient wishes to participate
in, as a contact sport like football has different risks than a sport like golf.

Example Question:

Have you ever had surgery? Samantha Monroe shadow Health Subjective data

, Finding:

Asked about missing organs



Finding:

Denies missing organs

(Found)

Pro Tip: Discussing the patient’s past medical history will alert you to any past or present medical conditions that
may restrict a patient from participating in sports. Keep in mind the particular sport the patient wishes to participate
in, as a contact sport like football has different risks than a sport like golf.

Example Question:

Are you missing any organs?



Finding:

Asked about allergies



Finding:

Denies being allergic to insects

(Available)

Pro Tip: Discussing the patient’s past medical history will alert you to any past or present medical conditions that
may restrict a patient from participating in sports. Keep in mind the particular sport the patient wishes to participate
in, as a contact sport like football has different risks than a sport like golf.

Example Question:

Are you allergic to insects?


Finding:

Denies environmental allergies

(Available)

Pro Tip: Discussing the patient’s past medical history will alert you to any past or present medical conditions that
may restrict a patient from participating in sports. Keep in mind the particular sport the patient wishes to participate
in, as a contact sport like football has different risks than a sport like golf.

Example Question:

Are you allergic to pollen?


Finding:

Denies food allergies

(Available)

Geschreven voor

Instelling
NSG 410
Vak
NSG 410

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29 mei 2025
Aantal pagina's
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Geschreven in
2024/2025
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