Tina jones respiratory assessment Subjective Data

Subjective Data Collection: 21 of 21 (100.0%)

  • 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 increased breathing problems and shortness of breath

    (Found)

    Pro Tip: Foundational questions about general well-being are important in assessing how a patient feels at the current moment. This creates a space for Tina to contextualize her current feeling in relation to a chief complaint.

    Example Question:

    What brings you in today?

  • Finding:

    Reports decreased effectiveness of inhaler

    (Found)

    Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.

    Example Question:

    Why did you decide to seek treatment?

History of Presenting Illness


  • Finding:

    Asked about onset of symptoms


  • Finding:

    Reports symptoms began two days ago

    (Found)

    Pro Tip: Determining the onset of a health problem is the first step to understanding if the underlying condition is acute or chronic.

    Example Question:

    How long have you had breathing problems?

  • Finding:

    Asked about frequency and duration of SOB episodes


  • Finding:

    Reports exacerbations lasting several minutes

    (Available)

    Pro Tip: Knowing the duration of an asthma or shortness of breath episode will give you insight into how effective the patient’s interventions are, and how severe the episode is.

    Example Question:

    How long do your asthma episodes last?

  • Finding:

    Reports exacerbated breathing about every 4 hours since original episode

    (Found)

    Pro Tip: The frequency of asthma episodes or shortness of breath might vary over time. Asking Tina about her recent experience will expound upon her current condition.

    Example Question:

    How many times have you had breathing problems in the past two days?

  • Finding:

    Reports waking up twice a night with asthma the past 2 nights

    (Available)

    Pro Tip: Many patients with asthma report trouble sleeping. Asking Tina if she has trouble sleeping can indicate the severity of her asthma.

    Example Question:

    How many times in the past two nights did asthma wake you up?

  • Finding:

    Asked about severity of symptoms


  • Finding:

    Describes asthma severity as “not full attack,” but worse than usual

    (Found)

    Pro Tip: Asthma severity might change over time for a variety of reasons. Asking Tina about the severity of her asthma will allow her to assess her condition.

    Example Question:

    How severe is your asthma?

  • Finding:

    Reports asthma has been interfering with activities of daily life

    (Found)

    Pro Tip: Severe asthma can interfere with daily life. Asking Tina the degree to which asthma impacts her daily life can be illustrative of the relative severity of her asthma.

    Example Question:

    Is there anything you can’t do because of your asthma?

  • Finding:

    Asked about character of symptoms


  • Finding:

    Reports recent wheezing

    (Found)

    Pro Tip: Some people who experience chronic asthma may be accustomed to wheezing and, as a result, might not volunteer this information. Asking Tina if she’s been wheezing illustrates how her asthma is presenting.

    Example Question:

    Do you wheeze during an asthma exacerbation?

  • Finding:

    Reports chest tightness

    (Found)

    Pro Tip: Symptoms often vary from patient to patient. Asking Tina to describe what happens when her asthma acts up will indicate how her individual symptoms manifest.

    Example Question:

    What happens when your asthma acts up?

  • Finding:

    Denies chest pain

    (Found)

    Pro Tip: Symptoms often vary from patient to patient. Asking Tina whether she experiences chest pain during an attack will indicate how her individual symptoms manifest.

    Example Question:

    Are the shortness of breath episodes associated with chest pain?

  • Finding:

    Asked about cough


  • Finding:

    Reports cough

    (Found)

    Pro Tip: A shallow history of a patient’s condition can provide a comparative baseline for juxtaposing an attack, exacerbation, and more regular breathing. Soliciting this information from Tina allows her to explain any recent developments with her asthma.

    Example Question:

    Have you been coughing?

  • Finding:

    Cough has persisted since original asthma exacerbation 2 days ago

    (Found)

    Pro Tip: Some people who experience chronic asthma may be accustomed to coughing and thus might not volunteer this information. Asking Tina how long she has been coughing illustrates how her asthma is presenting.

    Example Question:

    How long have you had a cough?

  • Finding:

    Describes cough as “dry”

    (Found)

    Pro Tip: Symptoms often vary from patient to patient. Asking Tina to describe her cough specifies the way her individual symptoms manifest.

    Example Question:

    How would you describe your cough?

  • Finding:

    Describes cough as “small” and not severe

    (Found)

    Pro Tip: Symptoms often vary from patient to patient. Asking Tina to describe her cough specifies the way her individual symptoms manifest.

    Example Question:

    How severe is your cough?

  • Finding:

    Reports cough slightly relieved by drinking water

    (Found)

    Pro Tip: Coughing can be a symptom of a constricted airway. Assessing what relieves Tina’s cough can open up a conversation about asthma management.

    Example Question:

    What makes your cough better?

  • Finding:

    Has not treated cough with medication or home remedies

    (Found)

    Pro Tip: Some people who experience chronic asthma may be accustomed to coughing and thus might not treat this symptom. Asking Tina how she is treating her cough might reveal her current symptom management and health literacy.

    Example Question:

    Have you tried to treat your cough?

  • Finding:

    Asked about aggravating factors


  • Finding:

    Reports symptoms worse at night

    (Found)

    Pro Tip: Sometimes a condition will fluctuate during the course of the day. By asking Tina how her asthma differentially impacts her both during the day and at night, you are assessing an important change over time.

    Example Question:

    Is your asthma worse at night?

  • Finding:

    Reports symptoms increase when lying flat on back

    (Found)

    Pro Tip: Asthma can be aggravated by movements that constrict the respiratory airways. By asking Tina if lying down causes shortness of breath, you’re assessing which positions might cause exacerbation.

    Example Question:

    Does lying down make your asthma worse?

  • Finding:

    Reports symptoms aggravated by movement

    (Found)

    Pro Tip: Asthma can be aggravated by movements that constrict the respiratory airways. Inquiring into what activities make Tina short of breath can indicate possible triggers.

    Example Question:

    Is there anything you can’t do because of your asthma?

Medical History


  • Finding:

    Confirmed use of medications


  • Finding:

    Confirms medications (no new medications reported)

    (Found)

    Pro Tip: Determining what, if any, medications a patient is taking is a crucial element of a thorough health history and will help you avoid unwanted drug interactions.

    Example Question:

    What medications do you take?

  • Finding:

    Followed up about inhaler use


  • Finding:

    Uses an inhaler to treat asthma symptoms

    (Found)

    Pro Tip: It’s essential to ask specifically what medications a patient is using to treat her current complaint or any ongoing medical conditions.

    Example Question:

    Do you use an inhaler for your asthma?

  • Finding:

    Inhaler is Proventil

    (Found)

    Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina what medication she takes for her asthma will indicate her treatment plan and the degree to which she complies with it.

    Example Question:

    What is the name of the inhaler you are currently using?

  • Finding:

    Reports most recent inhaler use was this morning

    (Available)

    Pro Tip: Soliciting a shallow history of a patient’s medication history can reveal recent exacerbation. Asking Tina when she last used her inhaler will indicate when her symptoms most recently required medical treatment.

    Example Question:

    When did you last use your inhaler?

  • Finding:

    Reports using inhaler every 4 hours or so since exacerbation

    (Found)

    Pro Tip: After an asthma exacerbation, patients often will become more reliant on medical tools like inhalers. Asking Tina how many times she’s used her inhaler in the past two days will point to the severity of her recent exacerbation.

    Example Question:

    How many times have you used your inhaler in the past two days?

  • Finding:

    Prescribed usage is 2 puffs

    (Found)

    Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina how many puffs of her inhaler she’s prescribed will indicate her treatment plan and the degree to which she complies with it.

    Example Question:

    How many puffs of your inhaler are you prescribed?

  • Finding:

    Reports needing more than 2 puffs to resolve asthma symptoms

    (Found)

    Pro Tip: Inhaler effectiveness can vary over time for a variety of reasons. Asking Tina about the number on inhaler puffs she needs to resolve symptoms can indicate whether her asthma has worsened or point to potential problems like poor inhaler technique.

    Example Question:

    How many inhaler puffs do you need?

  • Finding:

    Confirmed allergies


  • Finding:

    Confirms allergies (no new allergies reported)

    (Found)

    Pro Tip: It’s best practice to ask a patient about her allergies each visit, even with an established patient, to uncover any new allergy triggers or symptoms.

    Example Question:

    Do you have any new allergies?

  • Finding:

    Followed up on exposure to allergy and asthma triggers


  • Finding:

    Reports cat allergy triggered recent episodes

    (Found)

    Pro Tip: Questions about what factors might have caused an illness can point to a patient’s environmental stressors, habits, and general wellbeing. Asking Tina what caused her asthma might indicate her health literacy and understanding of what factors impact her breathing.

    Example Question:

    What started your recent asthma problems?

  • Finding:

    Reports dust as a known trigger

    (Found)

    Pro Tip: Environmental factors can often be primary allergy triggers. Asking whether Tina has a dust allergy can reveal one such trigger.

    Example Question:

    Does being around dust trigger your asthma?

  • Finding:

    Reports activity such as walking up stairs as a known trigger

    (Available)

    Pro Tip: Shortness of breath or asthma can be exercise-induced. Asking whether climbing stairs can be a trigger for Tina might reveal a possible provocation.

    Example Question:

    Does climbing stairs trigger your asthma?

  • Finding:

    Denies seasonal pattern

    (Found)

    Pro Tip: Discerning what’s making Tina’s asthma worse can point to possible triggers like environmental factors, bodily positions, or movement that may have a bearing on Tina’s breathing. Asking Tina whether she has seasonal triggers will indicate, in part, Tina’s health literacy.

    Example Question:

    Do you have seasonal asthma triggers?

  • Finding:

    Denies changes in weather as a trigger

    (Available)

    Pro Tip: For some patients, weather changes can be asthma irritants. Asking Tina if the weather impacts her asthma will indicate if weather is an irritant for Tina’s condition.

    Example Question:

    Do changes in weather make your asthma worse?

  • Finding:

    Reports minimal exposure to asthma triggers at work

    (Available)

    Pro Tip: Environmental factors at home or work can often be primary allergy triggers. Asking Tina about possible allergens at work might indicate a relevant factor in her recent exacerbation.

    Example Question:

    Does anything at work make your asthma worse?

  • Finding:

    Asked detailed questions about asthma history


  • Finding:

    No current asthma doctor

    (Found)

    Pro Tip: Seeing a specialist, like an asthma doctor, can help patients to manage symptoms. Asking whether Tina is seeing an asthma doctor will allow you to assess her current treatment plan and healthcare access.

    Example Question:

    Do you have an asthma doctor?

  • Finding:

    Diagnosed with asthma in childhood

    (Found)

    Pro Tip: By determining the onset of asthma you can get a sense for Tina’s asthma history, instance, and frequency of exacerbation.

    Example Question:

    How long have you had asthma?

  • Finding:

    Age of diagnosis was 2 1/2 years old

    (Found)

    Pro Tip: By determining the onset of asthma you can get a sense for Tina’s asthma history, instance, and frequency of exacerbation.

    Example Question:

    How old were you when you were diagnosed with asthma?

  • Finding:

    Asked about hospitalizations for asthma


  • Finding:

    Reports prior hospitalizations for asthma

    (Found)

    Pro Tip: Hospitalization for a condition, like asthma, can reveal its severity. By asking Tina if she’s been hospitalized, you are soliciting information about the history and severity of her condition.

    Example Question:

    Have you ever been hospitalized for asthma?

  • Finding:

    Reports last hospitalization was age 16

    (Found)

    Pro Tip: Hospitalization for a condition, like asthma, can reveal its severity. By asking Tina when she was last hospitalized, you are soliciting information about the history and severity of her condition.

    Example Question:

    When was your last hospitalization for asthma?

  • Finding:

    Estimates 5 total hospitalizations for asthma

    (Available)

    Pro Tip: Hospitalization for a condition, like asthma, can reveal its severity. By asking Tina the number of times she’s been hospitalized, you are soliciting information about the history and severity of her condition.

    Example Question:

    How many times have you been to the hospital?

  • Finding:

    Reports she has never been intubated

    (Found)

    Pro Tip: Intubation for a condition, like asthma, can reveal its severity. By asking Tina if she’s been intubated, you are soliciting information about the history and severity of her condition.

    Example Question:

    Have you ever been put on a breathing tube?

  • Finding:

    Followed up about non-medication forms of asthma management


  • Finding:

    Denies record keeping of asthma exacerbation or shortness of breath episodes

    (Found)

    Pro Tip: For some patients, keeping records of asthma exacerbation allows them to monitor their conditions. Soliciting this information from Tina will show health literacy.

    Example Question:

    Do you use a chart to monitor your asthma?

  • Finding:

    Denies using peak flow meter

    (Found)

    Pro Tip: A peak flow meter measures how well a patient’s lungs can expel air. By asking whether Tina uses a peak flow meter, you are asking about her health literacy and what kind of medical tools she uses to manage her asthma.

    Example Question:

    Do you check your peak flow regularly?

  • Finding:

    Denies nebulizer use

    (Found)

    Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina if she uses a nebulizer for her asthma will indicate her treatment plan and the degree to which she complies with it.

    Example Question:

    Do you use a nebulizer?

Social History


  • Finding:

    Asked about exercise and activity level


  • Finding:

    Reports general low activity level

    (Found)

    Pro Tip: Learning about a patient’s typical exercise habits helps

    Example Question:

    Do you exercise?

  • Finding:

    Reports diminished activity due to asthma

    (Found)

    Pro Tip: Asking a patient if her current complaint affects her exercise level or (vice version) helps you understand if there is a causal relationship in symptoms.

    Example Question:

    Have you been able to exercise?

  • Finding:

    Asked about environmental control


  • Finding:

    Reports living situation is tidy and free of dust

    (Available)

    Pro Tip: Environmental factors at home or work can often be primary allergy triggers. Asking Tina about possible allergens at home might indicate a relevant factor in her recent exacerbation.

    Example Question:

    Have you noticed anything at home that aggravates your asthma?

  • Finding:

    Reports hypoallergenic bedding hygiene

    (Available)

    Pro Tip: Bedding provides the perfect environment for dust mites and other allergens. By asking Tina if she regularly changes her bedding, you’re soliciting information about environmental factors that might exacerbate her condition. Hypoallergenic bedding can provide relief to those who suffer from sensitivity to dust mites, allergies, or asthma. Discovering that Tina uses hypoallergenic bedding can indicate a reason why she might feel asthma relief at night.

    Example Question:

    Do you change your bedding regularly?

  • Finding:

    Avoids animals and has no pets at home

    (Found)

    Pro Tip: Environmental factors can often be primary allergy triggers. Asking whether Tina has any pets can reveal one such trigger.

    Example Question:

    Do you have pets at home?

  • Finding:

    Avoids exposure to secondhand smoke

    (Found)

    Pro Tip: Secondhand smoke can be particularly triggering for asthmatics. Asking whether anyone in Tina’s household smokes might indicate a proximate environmental trigger.

    Example Question:

    Does anyone in your house smoke?

  • Finding:

    Asked about possible contributing factors in health history


  • Finding:

    Denies history of eczema

    (Available)

    Pro Tip: Children with eczema are often at a higher risk of developing asthma. In soliciting a medical history from Tina, you are getting a sense for the history of Tina’s asthma and related conditions.

    Example Question:

    Have you had eczema?

  • Finding:

    Denies history of sinus problems

    (Found)

    Pro Tip: People with asthma are likely to also experience sinus problems. It is important to determine whether Tina has sinus problems as they can cause complicating symptoms in patients who also experience asthma.

    Example Question:

    Do you have a history of sinus problems?

  • Finding:

    Denies history of GERD, heartburn, or indigestion

    (Found)

    Pro Tip: People with asthma are almost twice as likely to also experience GERD. It is important to determine whether Tina has GERD as GERD can cause shortness of breath in patients who also experience asthma.

    Example Question:

    Do you have gastroesophageal reflux disease?

  • Finding:

    Denies history of COPD or emphysema

    (Found)

    Pro Tip: For a patient with a known history of COPD or emphesyma, the symptoms of cough or shortness of breath could be caused by that disease.

    Example Question:

    Have you ever been diagnosed with COPD?

  • Finding:

    Asked about smoking, inhalants, or tobacco


  • Finding:

    Denies history of tobacco use, including cigarettes

    (Found)

    Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Asking Tina is she ever smoked cigarettes can help you to discern whether smoking was an exacerbating factor for Tina’s asthma.

    Example Question:

    Have you ever smoked cigarettes?

  • Finding:

    Reports past history of marijuana use

    (Found)

    Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Asking Tina is she ever smoked marijuana can help you to discern whether smoking was an exacerbating factor for Tina’s asthma.

    Example Question:

    Have you ever smoked marijuana?

  • Finding:

    Last use of marijuana was age 20 or 21

    (Found)

    Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Asking Tina is she ever smoked marijuana can help you to discern whether smoking was an exacerbating factor for Tina’s asthma.

    Example Question:

    When was the last time you smoked marijuana?

  • Finding:

    Denies inhaling substances

    (Found)

    Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Asking Tina when she quit smoking marijuana can help you to discern whether smoking recently exacerbated Tina’s asthma.

    Example Question:

    Have you ever experimented with inhaling substances?

Review of Systems


  • Finding:

    Asked about general symptoms


  • Finding:

    Denies recent respiratory or other illness

    (Found)

    Pro Tip: Broad, open questions will allow Tina to describe, in her own words, the specific pain and discomfort that she is experiencing.

    Example Question:

    Have you been sick recently?

  • Finding:

    Denies fever

    (Found)

    Pro Tip: The presence or absence of fever can indicate if an infection is approaching sepsis, a life-threatening condition.

    Example Question:

    Have you had any fever symptoms?

  • Finding:

    Denies nausea or vomiting

    (Found)

    Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like nausea, details the way her individual symptoms and pain manifest.

    Example Question:

    Have you had nausea or vomiting?

  • Finding:

    Denies chills

    (Found)

    Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like getting chills, details the way her individual symptoms and pain manifest.

    Example Question:

    Have you had chills?

  • Finding:

    Reports low energy level

    (Available)

    Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like fatigue, details the way her individual symptoms and pain manifest.

    Example Question:

    Are you fatigued?

  • Finding:

    Denies night sweats

    (Found)

    Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her injury, like night sweats, details the way her individual symptoms and pain manifest.

    Example Question:

    Have you had night sweats?

  • Finding:

    Asked review of systems for respiratory


  • Finding:

    Denies phlegm or sputum

    (Found)

    Pro Tip: A productive asthma cough can expel sputum from the lungs. By asking whether Tina has been coughing up phlegm or sputum you are discovering the nature of Tina’s cough since exacerbation.

    Example Question:

    Have you been coughing anything up?

  • Finding:

    Denies sore throat, swelling, or difficulty swallowing

    (Found)

    Pro Tip: Difficulty swallowing could indicate a more severe allergic reaction, or a physical problem with the throat.

    Example Question:

    Do you have any problems swallowing?

  • Finding:

    Denies nasal drainage

    (Found)

    Pro Tip: Nasal drainage could suggest that the patient’s symptoms are caused by a viral or bacterial infection, or an allergy attack.

    Example Question:

    Do you have any nasal drainage?

Family History


  • Finding:

    Asked about relevant family history


  • Finding:

    Reports no recent illnesses with family members at home

    (Available)

    Pro Tip: For people with asthma, getting sick can increase their risk for exacerbation. If Tina’s had any family members recently sick, that might have caused her recent exacerbation.

    Example Question:

    Has anyone at home been sick?

  • Finding:

    Reports younger sister as only family with asthma

    (Found)

    Pro Tip: Soliciting a family history helps you to determine which, if any, conditions are inherited. In asking Tina whether anyone in her family has asthma, you’re ascertaining whether Tina’s condition is inherited.

    Example Question:

    Does anyone in your family have asthma?

  • Finding:

    Reports younger sister as only family member with allergies

    (Available)

    Pro Tip: A family history of allergies is an important factor to determine whether a patient is at risk for developing allergies.

    Example Question:

    Does anyone in your family have allergies?

  • Finding:

    Reports no family history of eczema

    (Found)

    Pro Tip: People with a family history of eczema are often at a higher risk of developing asthma.

    Example Question:

    Does anyone in your family have eczema?

  • Finding:

    Reports no family history of chronic nasal or sinus problems

    (Available)

    Pro Tip: People with a family history of sinus problems are often at a higher risk for asthma. If Tina has a family history of sinus problems, this could suggest inherited sensitivity.

    Example Question:

    Do you have a family history of sinus problems?

  • Finding:

    Reports no family history of COPD or emphysema

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