Community-Acquired Pneumonia Anita Douglas shadow health Subjective Data

May 30, | nursing, med, NURS, Paper

Community-Acquired Pneumonia Anita Douglas shadow health Subjective Data

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 Q

Kaylee Hales I-HUMAN CASE STUDY SOAP NOTE: EVALUATING AND MANAGING INTEGUMENTARY CONDITIONS

May 30, | nursing, med, NURS, Paper

Kaylee Hales I-HUMAN CASE STUDY SOAP NOTE: EVALUATING AND MANAGING INTEGUMENTARY CONDITIONS
Kaylee Hales i-human case study soap note: evaluating and managing integumentary conditions
PATIENT INFORMATION
Name: Kaylee Hales
Age: 25 years
Gender Identity: Male
Sources: Patient
Allergies: NKA
Current Medication: Contraceptive Pills
PMA: N/A
IMMUNIZATION: Up to Date
PREVENTIVE CARE: N/A
Surgical HISTORY: None
FAMILY HISTORY: The patient is single with one boyfriend. Both parents are healthy and alive.
SOCIAL HISTORY: In a relationship, drink alcohol occasionally. Denies smoking tobacco.
SEXUAL ORIENTATION: Straight, sexually active
NUTRITION HISTORY: Balanced Diet
SUBJECTIVE DATA:
Chief Complaint: Itchy, tender rash at the inner thigh and inner forearm.
Symptoms analysis/HPI: Kaylee Hales, a 25-year-old woman in otherwise good condition, appeared with an extremely itchy, erythematous rash over her inner thighs and left forearm that had been present for two days. Physical examination reveals a 10×12 cm scattered contiguous erythematous papular rash with surrounding superficial excoriation on the inner thighs, along with erythematous blisters on the left inner forearm and a 6 cm pair of linear circumscribes Kaylee Hales i-human case study soap note: evaluating and managing integumentary conditions. Recent exposures include using a hot tub, a new lotion, and scallops for the first time in her life. She has also gone on a nature hike and used a hot tub.
CONSTITUTIONAL: She denied weight gain or loss.
ORDER iHUMAN CLASS HELP HERE
NEUROLOGIC: No memory loss or seizures, or tremors experience.
HEENT: No headache or head injuries. No vision problem. He denied hearing lost. PT denied nose bleeding and changes in smelling senses. No presence of sore hoarseness or throat. Denies difficulty with swallowing. She denied mouth sore and bleeding gums.
RESPIRATORY: Denied wheezing or cough.
CARDIOVASCULAR: Pt denied palpitation, edema, and chest pain. She also denied difficulty breathing and rapid heart rate.
GASTROINTESTINAL: Denied having constipation and diarrhea symptoms.
GENITOURINARY: Denied polyuria and dysuria.
MUSCULOSKELETAL: Denied joint swelling, myalgia, and back pain.
SKIN: Has skin rash at inner thigh and inner forearm.
OBJECTIVE DATA:
VITAL SIGNS: BP 116/62, HR 70, Temp. 98.3, Spo2 95% room air, RR 20.
GENERAL APPEARANCE: Pt is health, neatly dressed and alert
NEUROLOGIC: Pt is focused and denied memory loss history.
MAIN DIAGNOSIS:

Contact Dermatitis (ICD-10 Code- 9)

Skin inflammation known as contact dermatitis is brought on by coming into proximity to an allergen or irritant. The two subtypes of CD are allergy and irritating dermatitis. Pruritus, an erythematous rash, vesicular and linear, rough, redden patches, weepy lesions with numerous small vesicles on an erythematous base, and a burning or stinging sensation are all common cardinal symptoms of CD (Bains & Fonacier, 2019). According to the patient’s activity history, she recently went hiking; she was wearing shorts and a tank top, and it’s probable that she came into contact with hazardous plants on her extremities and upper arms. Contact with poison ivy, oak, or sumac causes the skin condition known as poison ivy (Toxicodendron) dermatitis (TD) Kaylee Hales i-human case study soap note: evaluating and managing integumentary conditions. Millions of Americans suffer from this frequent type of allergic contact dermatitis (ACD) each year (Buttaro et al., 2019). Blisters, intense itching, and discomfort are possible symptoms of toxicodendron dermatitis (Shenoy et al., 2021). The patient’s inner arms and thighs are covered in an itchy, blistering, and erythematous papular rash. The main diagnosis is contact dermatitis based on these symptoms.
DIFFERENT DIAGNOSIS

Folliculitis

An infection of the hair follicles known as folliculitis causes yellow-white papules and pustules to form on the erythematous base (Buttaro et al., 2019). The folliculitis patient has non-pruritic pustules on the erythematous base of the body-wide hair rash. Folliculitis, an infection of the hair follicles, can appear as a red papule (which may be sensitive) or a pustule can have a number of different causes (Shenoy et al., 2021). The patient may suffer from hot tub folliculitis in this situation. Hot tub folliculitis, on the other hand, must cause the rash to spread to every part of the body that has been submerged in the hot tub, not only the upper thighs and left upper arms.

Urticaria

A sudden, widespread eruption of pale, transient wheals or papules accompanied by excruciating itching is known as urticaria (Buttaro et al., 2019). Drugs, food, food preservatives, insect bites, and bacterial, fungal, viral, or parasitic diseases are some of the things that might cause urticaria. Hives or wheals that occur at a specific time of day, disappear, and then return the following day are its primary symptoms (Shenoy et al., 2021). Due to a potential allergy to scallops, the patient may develop urticaria. The patient’s rash started two days ago, but instead of wheals and papules, there are vesicles on the erythematous base.

Pruritus

The condition known as pruritus is characterized by itching and a desire to scratch (Bains & Fonacier, 2019). With or without a rash, pruritus can be present. Internal illnesses such renal, liver, the illusion of parasitosis, hyperparathyroidism, Hodgkin’s lymphoma, and polycythemia vera do not create a rash or pruritus. External skin conditions, bug bites, fungus, topical medications, scabies, dry skin, or drug reactions can all induce pruritus with a rash. The patient also has other symptoms in addition to pruritis, including vesicles with an erythematous base and a rash that extends from her thighs to her left arm, and she is able to pinpoint the causes. As a result, the diagnosis of pruritus is insufficient for this patient.
PLAN
Labs and Diagnostic Tests:

Patch Testing

Patch testing will assist discover allergens not detected by blood testing or skin prick testing and helps determine which compounds may be causing a delayed-type allergic reaction in a patient Kaylee Hales i-human case study soap note: evaluating and managing integumentary conditions
Case: Management Plan
Pharmacological Care

Apply Clobetasol propionate 0.05% cream topical 2X daily to the afflicted region for two weeks, avoid applying to your face and the groin area.
Cetirizine 10mg tablet PO daily as needed for itching

Supportive Care

Bathe in oatmeal
To treat the region, use cool, moist compresses.
Apply aluminum acetate or topical calamine lotion to the afflicted area
Aloe vera gel should be applied at the region with rash

Patient Education

Apply the betamethasone cream as prescribed
If a rash develops on the face, avoid applying clobetasol cream.
Return to the office if a face rash appears.
Adequate hand washing
Throw away any exposed clothing, trim your fingernails to avoid infection and itching.
When hiking or gardening, protect yourself from further exposure by dressing in long pants and long sleeve t-shirts, socks, and closed-toe shoes.
If blisters appear, leave the skin there because it can shield the open wound below and ward off infection.
After washing, gently pat the skin dry with a soft cloth rather than rubbing it.
Wear breathable clothing

 
Follow Up/Disposition

Follow up with your PCP if not improve in two weeks.
No restriction, may return to work at tolerated

 
References
Bains, S. N., & Fonacier, L. (2019). Irritant contact dermatitis. Clinical Reviews in Allergy &            Immunology, 56(1), 99-109.
Buttaro, T. M., Trybulski, J., Polgar-Bailey, P., & Sandberg-Cook, J. (2021). Primary care:             Interprofessional collaborative practice (6th ed.). Elsevier.
Shenoy, E. S., Macy, E., Rowe, T., & Blumenthal, K. G. (2019). Evaluation and management of          penicillin allergy: a review. Jama, 321(2), 188-199. Kaylee Hales i-human case study soap note: evaluating and managing integumentary conditions