Rachel Adler Subjective Data Collection
Introduction and Medical History
1. Established reason for visit: Rachel Adler reported needing an annual physical.
– Pro Tip: Asking the patient’s reason for their visit is a practical way to establish a chief complaint.
– Example Question: What brings you in today?
2. Asked about past medical history: Rachel Adler denies any medical conditions.
– Pro Tip: A broad question about the patient’s past medical history may prompt a more comprehensive answer.
– Example Question: What medical conditions do you have?
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Medications
3. Asked about general medication use: Rachel Adler reports taking occasional ibuprofen.
– Pro Tip: Asking a patient what medications they take may prompt a broader response.
– Example Question: What medications do you take?
4. Denies taking prescription medication: Rachel Adler denies taking any prescription medications.
– Pro Tip: Asking the patient what medications are prescribed to him or her may prompt a more detailed response.
– Example Question: Do you take any prescription medications?
5. Followed up about reason for ibuprofen use: Rachel Adler takes ibuprofen to relieve menstrual cramps.
– Pro Tip: When a patient reports taking any medication, it is important to gather information about the reasons for its use.
– Example Question: For what reason do you take ibuprofen?
6. Followed up on frequency and dosage of ibuprofen use: Rachel Adler takes ibuprofen monthly, 2 at a time, typically on the first day of her period. She is unsure of the dosage but reports they are “regular strength,” and the last dose was 2 weeks ago.
– Pro Tip: Gathering information about the frequency and dosage of medication use provides a comprehensive understanding of the patient’s habits.
– Example Questions:
– How often do you take ibuprofen?
– How many ibuprofen do you take at a time?
– What dosage of ibuprofen do you take?
– When did you last take Advil?
7. Asked about supplements: Rachel Adler denies taking any vitamins or herbal supplements.
– Pro Tip: Asking specific questions about supplement use will prompt definitive answers.
– Example Questions:
– Do you take any vitamins?
– Do you take any herbal supplements?
Allergies
8. Asked about general allergies: Rachel Adler reports being allergic to peanuts.
– Pro Tip: Starting with a broad question can be a good entry into the topic.
– Example Question: What allergies do you have?
9. Followed up on peanut allergy symptoms: Rachel Adler discovered her peanut allergy at the age of 4 and experiences itchy mouth and throat symptoms.
– Pro Tip: When a patient reports an allergy, it is important to establish its onset and understand the type and extent of the allergic reaction.
– Example Questions:
– How old were you when you had your first reaction to peanuts?
– What are the symptoms of your peanut allergy?
10. Followed up on peanut allergy severity: Rachel Adler describes her peanut allergy as not severe and denies breathing problems or hospitalization due to exposure.
– Pro Tip: Assessing the severity and specific reactions associated with allergies provides a comprehensive picture.
– Example Questions:
– How severe do you think your peanut allergy is?
– Do you experience breathing problems when you eat peanuts?
– Have you ever been hospitalized for a reaction to peanuts?
11. Followed up on peanut allergy treatment: Rachel Adler treats her peanut allergy with Benadryl and avoids peanuts and peanut oil. She denies the use of an epi-pen.
– Pro Tip: Inquiring about treatment methods and resource availability is crucial when discussing allergies.
– Example Questions:
– How do you treat your peanut allergy?
– Do you have an epi-pen?
12. Asked about medication allergies: Rachel Adler denies known medication allergies.
– Pro Tip: Specific questions about medication allergies ensure comprehensive information is gathered.
– Example Question: Are you allergic to any medications?
13. Asked about other allergies: Rachel Adler denies latex allergy, food allergies (other than peanuts), and environmental allergies.
– Pro Tip: Specific questions about various allergies are necessary for a complete understanding.
– Example Questions:
– Are you allergic to latex?
– Do you have any food allergies?
– Do you have any environmental allergies?
Rachel Adler Subjective Data Collection
Substance Use
14. Asked about tobacco and nicotine use: Rachel Adler reports “some” tobacco use and smoking cigarettes.
– Pro Tip: Inquiring about tobacco use is essential for assessing associated health risks.
– Example Questions:
– What tobacco products have you used?
– What do you smoke?
15. Followed up on type of tobacco or nicotine: Rachel Adler denies other forms of smoking tobacco, chew, or e-cigarettes.
– Pro Tip: Different forms of tobacco use may carry specific health risks, necessitating specific questions.
– Example Questions:
– Do you smoke cigars?
– Have you ever tried chewing tobacco?
– Have you ever tried an electronic cigarette?
16. Followed up on patterns of tobacco use: Rachel Adler reports smoking “really not very many” cigarettes and having smoked three times.
– Pro Tip: Determining the quantity, frequency, and duration of tobacco use is crucial for assessing risks and dependence.
– Example Questions:
– How much do you smoke?
– How many times have you smoked?
17. Explored patient’s perception of tobacco use: Rachel Adler reports understanding the health impacts of smoking and negative experiences with smoking.
– Pro Tip: Assessing the patient’s knowledge and attitude toward tobacco use is important for relevant education.
– Example Questions:
– Can you tell me what you know about the health impacts of smoking?
– How do you feel about smoking?
18. Explored reasons that patient experimented with smoking: Rachel Adler describes peer pressure related to smoking and states she will avoid smoking in the future.
– Pro Tip: Understanding the motives behind smoking experimentation is crucial for patient education.
– Example Questions:
– Do your friends encourage you to smoke?
– What will you say if your friends ask you to smoke again?
19. Asked about alcohol use: Rachel Adler denies alcohol use and being around friends who consume alcohol. She reports alcohol consumed by parents at home.
– Pro Tip: Directly asking about alcohol consumption is likely to prompt a definitive response.
– Example Questions:
– Have you ever tried alcohol?
– Do your friends ever drink alcohol?
– Does anyone at home drink alcohol?
– How much alcohol do your parents drink at home?
20. Asked about drug use: Rachel Adler denies previous drug use and being around friends who use drugs.
– Pro Tip: Asking direct questions about drug use ensures clear responses.
– Example Question: Have you ever experimented with drugs?
Rachel Adler conversation concept lab
Subjective Data Collection:
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. Rachel Adler conversation concept lab
Introduction and Medical History
Finding:
Established reason for visit
Finding:
Reports needing an annual physical
(Found)
Pro Tip: Asking the patient’s reason for their visit is a practical way to establish a chief complaint.Example Question:
What brings you in today?
Finding:
Asked about past medical history
Finding:
Denies medical conditions
(Found)
Pro Tip: A broad question about the patient’s past medical history may prompt a more comprehensive answer.Example Question:
What medical conditions do you have?
Medications
Finding:
Asked about general medication use
Finding:
Reports taking occasional ibuprofen
(Found)
Pro Tip: Asking a patient what medications they take may prompt a broader response that does not capture a complete picture of their medication use. Rachel Adler conversation concept labExample Question:
What medications do you take?
Finding:
Denies taking prescription medication
(Available)
Pro Tip: Asking the patient what medications are prescribed to him or her may prompt the patient to report medications taken daily or on an as-needed basis.Example Question:
Do you take any prescription medications?
Finding:
Only OTC medication is ibuprofen (no others reported)
(Found)
Pro Tip: Asking specifically about a patient’s use of the over-the-counter medications may prompt a more definitive response and yield greater insight into their medication use.Example Question:
Do you take any other over the counter medications?
Finding:
Followed up about reason for ibuprofen use
Finding:
Takes ibuprofen to relieve menstrual cramps
(Found)
Pro Tip: When a patient reports taking any type of medication, it is important to gather information about the reasons it is used.Example Question:
For what reason do you take ibuprofen?
Finding:
Followed up on frequency and dosage of ibuprofen use
Finding:
Takes ibuprofen monthly
(Available)
Pro Tip: When a patient reports taking any type of medication, it is important to gather information about the frequency of its use. A broader question may prompt a broader response from the patient.Example Question:
How often do you take ibuprofen?
Finding:
Takes 2 at a time
(Available)
Pro Tip: When a patient reports taking any type of medication, it is important to gather information about the quantity of its use.Example Question:
How many ibuprofen do you take at a time?
Finding:
Typically takes 2 doses on first day of period
(Available)
Pro Tip: When a patient reports taking any type of medication, it is important to gather information about the frequency of its use.Example Question:
How many days do you take ibuprofen?
Finding:
Unsure of the dosage, but reports they are “regular strength”
(Found)
Pro Tip: When a patient reports taking any type of medication, it is important to gather information about the quantity of its use.Example Question:
What dosage of ibuprofen do you take?
Finding:
Last dose was 2 weeks ago
(Available)
Pro Tip: When a patient reports taking any type of medication, it is important to gather information about the frequency of its use. Asking specifically about the last time the patient took the medication may prompt a response that speaks to the medications day to day use.Example Question:
When did you last take Advil?
Finding:
Asked about supplements
- Rachel Adler conversation concept lab
Finding:
Denies vitamins
(Found)
Pro Tip: Asking a patient a specific question about their use of vitamins will prompt a definitive answer and provide insight into their supplement use.Example Question:
Do you take any vitamins?
Finding:
Denies herbal supplements
(Found)
Pro Tip: Asking a patient a specific question about their use of herbal supplements will prompt a definitive answer and provide insight into their supplement use.Example Question:
Do you take any herbal supplements?
Allergies
Finding:
Asked about general allergies
Finding:
Reports allergy to peanuts
(Found)
Pro Tip: Beginning an interview with a broad question is a good entry into the topic.Example Question:
What allergies do you have?
Finding:
Followed up on peanut allergy symptoms
Finding:
Discovered at age 4
(Available)
Pro Tip: When a patient reports an allergy, it is important to establish its onset.Example Question:
How old were you when had your first reaction to peanuts?
Finding:
Symptoms are itchy mouth and throat
(Found)
Pro Tip: When a patient reports an allergy, it’s necessary to determine the type and extent of his or her allergic reaction. For example, if a patient reports a bee-sting allergy, the provider must determine whether the patient has experienced localized allergic reactions or anaphylaxis.Example Question:
What are the symptoms of your peanut allergy?
Finding:
Followed up on peanut allergy severity
Finding:
Describes allergy as not severe
(Found)
Pro Tip: When a patient reports an allergy, it is important ascertain the severity of their reaction to the allergen. A broad question about this topic, while a good starting point, may prompt a broad response that lacks the specifics of the reaction type.Example Question:
How severe do you think your peanut allergy is?
Finding:
Denies breathing problems after exposure
(Available)
Pro Tip: Asking a patient about specific life-threatening reactions to their allergy, such as breathing problems, will prompt a response that characterizes the severity of the allergy.Example Question:
Do you experience breathing problems when you eat peanuts?
Finding:
Denies hospitalization for reaction to peanuts
(Available)
Pro Tip: Asking a patient about past, allergy-related hospitalizations will prompt a response that characterizes the severity of the allergy.Example Question:
Have you ever been hospitalized for a reaction to peanuts?
Finding:
Followed up on peanut allergy treatment
Finding:
Treated with Benadryl
(Available)
Pro Tip: When a patient reports an allergy, it is important to ask about the patient’s ability and willingness to treat allergic reactions. The patient’s response may provide insight into their health literacy and impact the allergy has had on their daily life.Example Question:
How do you treat your peanut allergy?
Finding:
Reports avoiding peanuts and peanut oil
(Available)
Pro Tip: When a patient reports an allergy, it is important to ask about the patient’s ability and willingness to avoid the allergen. The patient’s response may provide insight into their health literacy and impact the allergy has had on their daily life.Example Question:
How do you avoid eating peanuts?- Rachel Adler conversation concept lab
Finding:
Denies use of epi-pen
(Available)
Pro Tip: When a patient reports an allergy, it is important to ask about access to specific resources that may treat an allergic reaction in the event of an emergency.Example Question:
Do you have an epi pen?
Finding:
Asked about medication allergies
Finding:
Denies known medication allergies
(Available)
Pro Tip: While general questions about allergies may elicit important information, the patient may not spontaneously report all allergies. For example, medication allergies may be overlooked by the patient because he or she considers adverse reactions to medications separate from more common allergies, such as hay fever or allergic reactions to animal dander. In addition, if the patient experienced an allergic reaction to medication long ago, he or she may not immediately recall it. Therefore, it is important to ask specifically about medication allergies.Example Question:
Are you allergic to any medications?
Finding:
Asked about other allergies
Finding:
Denies latex allergy
(Available)
Pro Tip: While general questions about allergies may elicit important information, the patient may not spontaneously report all allergies. For example, a latex allergy may be overlooked by a patient who rarely comes into contact with latex, or who has only experienced a mild allergic reaction. Therefore, it is important to ask specifically about latex allergy.Example Question:
Are you allergic to latex?
Finding:
Denies food allergies or sensitivities (other than peanuts)
(Available)
Pro Tip: While general questions about allergies may elicit important information, the patient may not spontaneously report all allergies. For example, a food allergy may be overlooked by a patient who hasn’t experienced an allergy to things they eat, or to a patient who has already reported known food allergies. To form a more complete picture, it is important to ask specifically about food allergies.Example Question:
Do you have any food allergies?
Finding:
Denies known environmental allergies
(Found)
Pro Tip: While general questions about allergies may elicit important information, the patient may not spontaneously report all allergies. For example, seasonal allergies may be overlooked by the patient because he or she considers them to be very common or harmless. In addition, if the patient is not currently experiencing an allergic reaction, this information may slip his or her mind. Therefore, it is important to ask specifically about environmental allergies.Example Question:
Do you have any environmental allergies?
Substance Use
Finding:
Asked about tobacco and nicotine use
Finding:
Reports “some” tobacco use
(Found)
Pro Tip: Tobacco use in all its forms carries risk of adverse health consequences, so it is critical to ask your patient about tobacco use during a health history interview.Example Question:
What tobacco products have you used?
Finding:
Followed up on type of tobacco or nicotine
Finding:
Reports smoking cigarettes
(Found)
Pro Tip: Smoking is a significant risk factor for many diseases and conditions including lung cancer, emphysema, and heart disease. Therefore, it is essential to ask patients about smoking and other tobacco use during a health history interview.Example Question:
What do you smoke?
Finding:
Denies other forms of smoking tobacco such as cigars and pipes
(Available)
Pro Tip: Smoking is a significant risk factor for many diseases and conditions including lung cancer, emphysema, and heart disease. Furthermore, different forms of smoked tobacco may carry specific health risks; it is important to ask about other types of smoking tobacco to form a full picture of the patient’s smoking patterns. Rachel Adler conversation concept lab.Example Question:
Do you smoke cigars?
Finding:
Denies using chew or smokeless forms of tobacco
(Available)
Pro Tip: Smokeless tobacco also carries the risk of adverse health consequences for users, therefore it is important to ask a patient specifically about these products.Example Question:
Have you ever tried chewing tobacco?
Finding:
Denies vaping or e-cigarettes
(Available)
Pro Tip: While less is known about the specific health consequences of e-cigarettes and personal vaporizers for tobacco use, it is important to to ask a patient about these products to form a more complete picture of their tobacco use patterns.Example Question:
Have you ever tried an electronic cigarette?
Finding:
Followed up on patterns of tobacco use
Finding:
Reports smoking “really not very many” cigarettes
(Available)
Pro Tip: When a patient reports smoking, it is important to determine the quantity of the patient’s tobacco use in order to assess the patient’s risk level for associated health problems, and also to gauge the degree of the patient’s dependence.Example Question:
How much do you smoke?
Finding:
Has smoked 3 times (one cigarette each time)
(Found)
Pro Tip: When a patient reports smoking, it is important to determine the frequency and duration of the patient’s tobacco use in order to assess the patient’s risk level for associated health problems, and also to gauge the degree of the patient’s dependence.Example Question:
How many times have you smoked?
Finding:
Explored patient’s perception of tobacco use
Finding:
Reports understanding of health impacts of smoking
(Available)
Pro Tip: When a patient reports smoking, assessing their knowledge about tobacco use can enable providers to engage in relevant conversation with the patient, and to offer helpful education.Example Question:
Can you tell me what you know about the health impacts of smoking?
Finding:
Reports negative experiences with smoking
(Available)
Pro Tip: In an adolescent patient, evaluating his or her attitude towards smoking can enable the provider to offer relevant support and education. For example, if the patient communicates that he or she views smoking as a means of relaxing, a provider can offer education and strategies for achieving relaxation in healthy ways.Example Question:
How do you feel about smoking?
Finding:
Explored reasons that patient experimented with smoking
Finding:
Describes peer pressure related to smoking
(Found)
Pro Tip: When an adolescent patient reports smoking, evaluating the circumstances and social pressure involved may help the provider understand the patient’s motive for smoking. Addressing these motives directly, and exploring their origins, can be essential components of patient education regarding smoking.Example Question:
Do your friends encourage you to smoke?
Finding:
Reports that she will avoid smoking in the future
(Available)
Pro Tip: When an adolescent patient reports smoking, evaluating the circumstances and social pressure involved may help the provider understand the patient’s motive for smoking. Addressing these motives directly, and exploring their origins, can be essential components of patient education regarding smoking.Example Question:
What will you say if your friends asked you to smoke again? Rachel Adler conversation concept lab
Finding:
Asked about alcohol use
Finding:
Denies alcohol use
(Found)
Pro Tip: Asking direct opening questions about alcohol consumption is more likely to prompt a definitive response from a patient.Example Question:
Have you ever tried alcohol?
Finding:
Denies being around friends who consume alcohol
(Available)
Pro Tip: When asking an adolescent patient about alcohol consumption, it is important to evaluate the circumstances and social pressure involved. Addressing these motives directly, and exploring their origins, can be essential components of patient education regarding drinking.Example Question:
Do your friends ever drink alcohol?
Finding:
Reports alcohol consumed by parents at home
(Available)
Pro Tip: When asking an adolescent patient about alcohol consumption, it is important to evaluate the circumstances and social pressure involved. Since parents serve as direct models of adult alcohol consumption, asking about drinking patterns in the home may prove insightful.Example Question:
Does anyone at home drink alcohol?
Finding:
Reports that parents drink “a glass of wine at dinner”
(Available)
Pro Tip: When asking an adolescent patient about alcohol consumption, it is important to evaluate the circumstances and social pressure involved. Since parents serve as direct models of adult alcohol consumption, asking about drinking patterns in the home may prove insightful. A broad question about the quantity of alcohol use in the home is a good starting point.Example Question:
How much alcohol do your parents drink at home?
Finding:
Asked about drug use
Finding:
Denies previous drug use
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(Found)
Pro Tip: Asking direct opening questions about drug use is more likely to prompt a definitive response from a patient.Example Question:
Have you ever experimented with drugs?
Finding:
Denies being around friends who use drugs
- Rachel Adler conversation concept lab