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NAOMI ADEBAYO- ACUTE VISIT: FATIGUE
Subjective Data Collection: 7 0 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:
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:
Reports difficulty falling asleep
(Available)
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:
How has the fatigue impacted your sleep?
Finding:
Reports not having much of an appetite
(Found)
Pro Tip: Conducting a review of a patient's bodily systems is important to determine a patient's general health and the impact of their conditions. Many diseases can cause symptoms in a wide range of bodily systems, so conduct a system by system interview to better understand a patient's current health.
Finding:
Denies aggravating factors
(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:
What makes your fatigue worse?
Finding:
Asked about relieving factors
Finding:
Reports family members babysit so she can sleep
(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:
What makes your fatigue better?
Finding:
Reports still having fatigue after getting enough sleep
(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:
Can you tell me more about what makes your fatigue better?
Finding:
Reports fatigue at an 8 out of 10
(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:
How would you rate the severity of your fatigue on a scale from one to ten? Past Medical History
Finding:
Asked about existing conditions
Finding:
Reports preeclampsia diagnosis at 32 weeks
(Found)
Pro Tip: A patient's past medical history includes their health conditions, what preventative and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient's medical history helps you contextualize their current health for proper assessment.
Example Question:
What are your existing health issues?
Finding:
Reports twins spent time in NICU
(Found)
Pro Tip: A patient's past medical history includes their health conditions, what preventative and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient's medical history helps you contextualize their current health for proper assessment.
Example Question:
Finding:
Reports hospitalization for birth of twins
(Found)
Pro Tip: A patient's past medical history includes their health conditions, what preventative and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient's medical history helps you contextualize their current health for proper assessment.
Example Question:
Do you have any previous hospitalizations?
Finding:
Asked about surgical history
Finding:
Reports uncomplicated cesarean delivery for twins 4 months ago
(Found)
Pro Tip: A patient's past medical history includes their health conditions, what preventative and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient's medical history helps you contextualize their current health for proper assessment.
Example Question:
Have you ever had surgery?
Finding:
Reports surgical site is healing fine
(Found)
Pro Tip: A patient's past medical history includes their health conditions, what preventative and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient's medical history helps you contextualize their current health for proper assessment.
Example Question:
How is your cesarean scar healing?
Pro Tip: A patient's past medical history includes their health conditions, what preventative and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient's medical history helps you contextualize their current health for proper assessment.
Example Question:
Are you allergic to anything in your environment?
Finding:
Denies food allergies
(Available)
Pro Tip: A patient's past medical history includes their health conditions, what preventative and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient's medical history helps you contextualize their current health for proper assessment.
Example Question:
Do you have any food allergies?
Finding:
Denies latex allergies
(Available)
Pro Tip: A patient's past medical history includes their health conditions, what preventative and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient's medical history helps you contextualize their current health for proper assessment.
Example Question:
Do you have any allergies to latex? Maternal Health
Finding:
Asked about health of twins
Finding:
Pro Tip: If a patient has recently given birth, asking maternal health questions can provide insight into the patient's physical, emotional, and mental health. Asking questions related to a patient's maternal health helps you contextualize what challenges they are facing, how their body is recovering, and how the new baby is doing at home.
Example Question:
Are you having any issues with breastfeeding?
Finding:
Asked about twins' sleep
Finding:
Reports frustration with current sleep situation
(Available)
Pro Tip: If a patient has recently given birth, asking maternal health questions can provide insight into the patient's physical, emotional, and mental health. Asking questions related to a patient's maternal health helps you contextualize what challenges they are facing, how their body is recovering, and how the new baby is doing at home.
Example Question:
How are the twins sleeping?
Finding:
Reports "being the main one on the night shift"
(Available)
Pro Tip: If a patient has recently given birth, asking maternal health questions can provide insight into the patient's physical, emotional, and mental health. Asking questions related to a patient's maternal health helps you contextualize what challenges they are facing, how their body is recovering, and how the new baby is doing at home.
Example Question:
Can you tell me more about the twins' sleep habits?
Finding:
Asked about contraception use
