Gabriel Martinez Focused Exam: Asthma Exacerbation shadow health Subjective Data

Subjective Data Collection: 31 of 31 (100.0%)

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Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.

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Gabriel Martinez Focused Exam: Asthma Exacerbation shadow health Subjective Data

Scored Items

Experts selected these topics as essential components of a strong, thorough interview with this patient.

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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 Patient

Finding:

Asked about patient’s status

Finding:

Reports breathing is better

(Found)
Pro Tip: Assessing a pediatric patient’s status involves asking about their current comfort, needs, and chief complaint. It’s important to check in with a patient’s status, because it may reveal insight into their current condition.
- Gabriel Martinez Focused Exam: Asthma Exacerbation shadow health Subjective Data
Example Question:

How are you?
Finding:

Reports chest soreness

(Found)

Pro Tip: Assessing a pediatric patient’s status involves asking about their current comfort, needs, and chief complaint. It’s important to check in with a patient’s status, because it may reveal insight into their current condition.

Example Question:

How are you?

Finding:

Followed up on symptoms

Finding:

Reports wheezing

(Found)
Pro Tip: Assessing a pediatric patient’s status involves asking about their current comfort, needs, and chief complaint. It’s important to check in with a patient’s status, because it may reveal insight into their current condition.
- Gabriel Martinez Focused Exam: Asthma Exacerbation shadow health Subjective Data
Example Question:

What is your chief complaint?
Finding:

Reports coughing is less frequent

(Found)

Pro Tip: Assessing a pediatric patient’s status involves asking about their current comfort, needs, and chief complaint. It’s important to check in with a patient’s status, because it may reveal insight into their current condition.

Example Question:

What is your chief complaint?
Finding:

Reports chest does not feel as tight

(Found)
Pro Tip: Assessing a pediatric patient’s status involves asking about their current comfort, needs, and chief complaint. It’s important to check in with a patient’s status, because it may reveal insight into their current condition.
- Gabriel Martinez Focused Exam: Asthma Exacerbation shadow health Subjective Data
Example Question:

What is your chief complaint?

Gabriel Martinez Asthma Exacerbation Interview – Subjective Data

History of Present Illness Patient

Finding:Followed up on onset of symptoms

Finding:Reports symptoms started after playing kickball

(Found)

Pro Tip: Asking a pediatric patient about the duration and onset 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 brings you to the hospital?
Finding:

Reports full-on asthma attack began when he got home

(Found)
Pro Tip: Asking a pediatric patient about the duration and onset of their current health issues solicits information relevant to the history of their present illness.
- Gabriel Martinez Focused Exam: Asthma Exacerbation shadow health Subjective Data
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 brings you to the hospital?

Finding:

Followed up on aggravating factors

Finding:

Reports secondhand smoke exposure

(Found)
Pro Tip: Asking a pediatric patient about the duration and onset of their current health issues solicits information relevant to the history of their present illness
- Gabriel Martinez Focused Exam: Asthma Exacerbation shadow health Subjective Data
. 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 triggers your asthma?
Finding:

Denies being around secondhand smoke normally

(Found)
Pro Tip: Asking a pediatric patient about the duration and onset of their current health issues solicits information relevant to the history of their present illness.
- Gabriel Martinez Focused Exam: Asthma Exacerbation shadow health Subjective Data
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 triggers your asthma?

Home Medications Patient

Finding:

Followed up on rescue inhaler adherence

Finding:

Reports carrying rescue inhaler with him in the past

(Found)

Pro Tip: A pediatric 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 is the name of the rescue inhaler you are currently using?
Finding:

Reports throwing away the rescue inhaler a few weeks ago

(Found)
Pro Tip: A pediatric patient’s home medications can provide insight into the patient’s current treatment and its efficacy.
- Gabriel Martinez Focused Exam: Asthma Exacerbation shadow health Subjective Data
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 is the name of the rescue inhaler you are currently using?
Finding:

Reports disliking rescue inhaler because of side effects

(Found)

Pro Tip: A pediatric 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 do you take for your asthma?

Finding:

Asked about side effects of rescue inhaler

Finding:

Reports rescue inhaler made him feel shaky

(Found)

Pro Tip: A pediatric 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:

Have you experienced medication side effects before?
Finding:

Reports rescue inhaler made his heart beat fast

(Found)
Pro Tip:
- Gabriel Martinez Focused Exam: Asthma Exacerbation shadow health Subjective Data
A pediatric 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:

Have you experienced medication side effects before?

Social History Patient

Finding:Asked about exercise

Finding:Reports being mostly sedentary

(Found)

Pro Tip: A pediatric patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet and exercise. Even though you are working with pediatric patients, it is important to ask about sexual activity and substance use. These factors can influence their current health and wellness. Asking about a pediatric patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

Do you exercise?

Finding:

Asked about living situation

Finding:

Reports living with mother in an apartment

(Found)
Pro Tip: A pediatric patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet and exercise. Even though you are working with pediatric patients, it is important to ask about sexual activity and substance use. These factors can influence their current health and wellness.
- Gabriel Martinez Focused Exam: Asthma Exacerbation shadow health Subjective Data
Asking about a pediatric patient’s social history can also unveil the influence of their present illnesses in their social lives.
Example Question:

Where do you live?

Finding:

Asked about patient’s substance use

Finding:

Denies alcohol use

(Found)

Pro Tip: A pediatric patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet and exercise. Even though you are working with pediatric patients, it is important to ask about sexual activity and substance use. These factors can influence their current health and wellness. Asking about a pediatric patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

Do you drink alcohol?
Finding:

Denies using tobacco products

(Found)
Pro Tip: A pediatric patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet and exercise. Even though you are working with pediatric patients, it is important to ask about sexual activity and substance use. These factors can influence their current health and wellness.
- Gabriel Martinez Focused Exam: Asthma Exacerbation shadow health Subjective Data
Asking about a pediatric patient’s social history can also unveil the influence of their present illnesses in their social lives.
Example Question:

Do you smoke cigarettes?

Finding:Asked about education

Finding:Reports being in 3rd grade

(Found)

Pro Tip: A pediatric patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet and exercise. Even though you are working with pediatric patients, it is important to ask about sexual activity and substance use. These factors can influence their current health and wellness. Asking about a pediatric patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

What education do you have?

Review of Relevant Systems Patient

Finding:

Asked about cardiovascular system

Finding:

Reports heart is racing

(Found)
Pro Tip: Understanding a pediatric patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
- Gabriel Martinez Focused Exam: Asthma Exacerbation shadow health Subjective Data
Example Question:

Is your heartbeat normal?

Finding:

Asked about integumentary system

Finding:

Denies current skin problems

(Found)

Pro Tip: Understanding a pediatric patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Do you have skin problems? Gabriel Martinez Focused Exam: Asthma Exacerbation shadow health Subjective Data
Finding:

Reports using prescription cream to treat skin

(Found)

Pro Tip: Understanding a pediatric patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Do you have skin problems?

Finding:

Asked about mental health

Finding:

Reports frustration with diagnosis

(Found)

Pro Tip: Understanding a pediatric patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Gabriel Martinez Focused Exam: Asthma Exacerbation shadow health Subjective Data

Example Question:

Are you depressed?

History of Present Illness Guardian

Finding:

Followed up on patient’s asthma diagnosis

Finding:

Reports patient has mild asthma

(Found)

Pro Tip: Asking a pediatric patient’s guardian about the duration and onset of the patient’s 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. Gabriel Martinez Focused Exam: Asthma Exacerbation shadow health Subjective Data

Example Question:

What are your son’s symptoms
Finding:

Reports patient was diagnosed at age 5

(Found)

Pro Tip: Asking a pediatric patient’s guardian about the duration and onset of the patient’s 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 your child have any health issues?

Finding:Asked guardian to elaborate on severity of symptoms

Finding:Reports peak flow meter readings at home were 55%, 59%, and 60%

(Found)

Pro Tip: Asking a pediatric patient’s guardian about the duration and onset of the patient’s 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 peak flow meter?

Finding:Asked guardian about pharmacological relieving factors for current exacerbation

Finding:Reports giving patient an extra dose of daily maintenance inhaler

(Found)

Pro Tip: Asking a pediatric patient’s guardian about the duration and onset of the patient’s 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 Gabriel Martinez Focused Exam: Asthma Exacerbation shadow health Subjective Data.

Example Question:

Have you tried treatments at home?

Home Medications Guardian

Finding:Confirms home medications with guardian

Finding:Confirms patient is prescribed a rescue inhaler

(Found)

Pro Tip: A pediatric patient’s home medications can provide insight into their current treatment and its efficacy. Asking their guardian about medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Does your son have an inhaler for exacerbations?
Finding:

Confirms patient is prescribed a maintenance inhaler

(Found)

Pro Tip: A pediatric patient’s home medications can provide insight into their current treatment and its efficacy. Asking their guardian about medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

What is the prescription for your son’s daily inhaler?

Finding:Followed up on rescue inhaler

Finding:Reports rescue inhaler is albuterol

(Found)

Pro Tip: A pediatric patient’s home medications can provide insight into their current treatment and its efficacy. Asking their guardian about medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation. Gabriel Martinez Focused Exam: Asthma Exacerbation shadow health Subjective Data

Example Question:

What is the name of your son’s rescue inhaler?
Finding:

Reports rescue inhaler dose is two puffs as needed

(Found)

Pro Tip: A pediatric patient’s home medications can provide insight into their current treatment and its efficacy. Asking their guardian about medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

what dose is your son’s rescue inhaler

Finding:Followed up on maintenance inhaler

Finding:Reports maintenance inhaler is fluticasone propionate

(Found)

Pro Tip: A pediatric patient’s home medications can provide insight into their current treatment and its efficacy. Asking their guardian about medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

What is your son’s maintenance inhaler called?
Finding:Reports patient takes 2 puffs twice a day

(Found)

Pro Tip: A pediatric patient’s home medications can provide insight into their current treatment and its efficacy. Asking their guardian about medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

What is the dosage for your son’s maintenance inhaler?

Finding:

Asked about medication adherence

Finding:

Reports patient takes maintenance inhaler as directed

(Found)

Pro Tip: A pediatric patient’s home medications can provide insight into their current treatment and its efficacy. Asking their guardian about medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation. Gabriel Martinez Focused Exam: Asthma Exacerbation shadow health Subjective Data

Example Question:

How is your son’s medication adherence?
Finding:

Reports patient has not needed rescue inhaler in the past year

(Found)

Pro Tip: A pediatric patient’s home medications can provide insight into their current treatment and its efficacy. Asking their guardian about 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 the last time your son used the rescue inhaler?

Finding:

Asked about over the counter medications

Finding:

Reports occasional antihistamine use for allergy symptom treatment

(Found)

Pro Tip: A pediatric patient’s home medications can provide insight into their current treatment and its efficacy. Asking their guardian about medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

What over the counter medications has your son had?

Past Medical History Guardian

Finding:

Asked about patient’s general allergies

Finding:

Denies patient has food allergies

(Found)

Pro Tip: Asking a guardian about the pediatric patient’s relevant medical 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. Gabriel Martinez Focused Exam: Asthma Exacerbation shadow health Subjective Data

Example Question:

What allergies does your son have?
Finding:

Denies patient has a latex allergy

(Found)

Pro Tip: Asking a guardian about the pediatric patient’s relevant medical 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:

What allergies does your son have?
Finding:

Denies patient has medication allergies

(Found)

Pro Tip: Asking a guardian about the pediatric patient’s relevant medical 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:

What allergies does your son have?
Finding:

Reports environmental allergies

(Found)

Pro Tip: Asking a guardian about the pediatric patient’s relevant medical 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:

What allergies does your son have?

Finding:Followed up on environmental allergies

Finding:Reports patient has allergies to tree pollen, pet dander, and dust mites

(Found)

Pro Tip: Asking a guardian about the pediatric patient’s relevant medical 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. Gabriel Martinez Focused Exam: Asthma Exacerbation shadow health Subjective Data

Example Question:

What environmental allergies does your son have?

Finding:

Followed up on impact of allergies on asthma

Finding:

Reports allergies have caused previous exacerbations

(Found)

Pro Tip: Asking a guardian about the pediatric patient’s relevant medical 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:

How do your son’s environmental allergies impact his asthma?
Finding:

Reports high pollen count traditionally worsens asthma symptoms

(Found)

Pro Tip: Asking a guardian about the pediatric patient’s relevant medical 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:

How do your son’s environmental allergies impact his asthma?

Finding:Asked about previous hospitalizations

Finding:Reports one previous hospitalization for moderate asthma exacerbation

(Found)

Pro Tip: Asking a guardian about the pediatric patient’s relevant medical 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:

Has your son been hospitalized before?
Finding:

Reports hospitalization was one year ago

(Found)

Pro Tip: Asking a guardian about the pediatric patient’s relevant medical 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. Gabriel Martinez Focused Exam: Asthma Exacerbation shadow health Subjective Data

Example Question:

Has your son been hospitalized before?

Finding:Followed up on factors leading to prior hospitalization

Finding:Reports patient had been exposed to smoke the night before hospitalization

(Found)

Pro Tip: Asking a guardian about the pediatric patient’s relevant medical 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:

Why was your son last hospitalized?
Finding:

Reports rescue inhaler was not effective in managing symptoms

(Found)

Pro Tip: Asking a guardian about the pediatric patient’s relevant medical 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:

Why was your son last hospitalized?

Social History Guardian

Finding:Asked about patient’s activity level

Finding:Reports preventing patient from performing aerobic exercise

(Found)

Pro Tip: A patient’s and their guardian’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, and substance use. These factors can influence their current health and wellness. Asking a guardian about a pediatric patient’s social history can also unveil the influence of their present illnesses on their social lives.

Example Question:

How does exercise impact your son’s asthma?

Finding:

Asked about patient’s exposure to secondhand smoke

Finding:

Denies using tobacco products
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(Found)

Pro Tip: A patient’s and their guardian’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, and substance use. These factors can influence their current health and wellness. Asking a guardian about a pediatric patient’s social history can also unveil the influence of their present illnesses on their social lives. Gabriel Martinez Focused Exam: Asthma Exacerbation shadow health Subjective Data

Example Question:

Does anyone in your family use tobacco?

Finding:Asked about childcare

Finding:Reports working around 55 hours per week

(Found)

Pro Tip: A patient’s and their guardian’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, and substance use. These factors can influence their current health and wellness. Asking a guardian about a pediatric patient’s social history can also unveil the influence of their present illnesses on their social lives.

Example Question:

What is your childcare situation?
Finding:Reports utilizing after-school programs during the school year

(Found)

Pro Tip: A patient’s and their guardian’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, and substance use. These factors can influence their current health and wellness. Asking a guardian about a pediatric patient’s social history can also unveil the influence of their present illnesses on their social lives.

Example Question:

What is your childcare situation?
Finding:Reports patient’s maternal grandparents care for him once a weekend

(Found)

Pro Tip: A patient’s and their guardian’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, and substance use. These factors can influence their current health and wellness. Asking a guardian about a pediatric patient’s social history can also unveil the influence of their present illnesses on their social lives.

Example Question:

What is your childcare situation?

Family Medical History Guardian

Finding:Asked about relevant family medical history

Finding:Denies family history of respiratory illness

(Found)

Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information from a guardian can contextualize a pediatric patient’s current complaint and how their family’s health history might be influencing it. Gabriel Martinez Focused Exam: Asthma Exacerbation shadow health Subjective Data

Example Question:

What health problems run in your family?

Review of Relevant Systems Guardian

Finding:Followed up on patient’s integumentary system

Finding:Reports patient is diagnosed with eczema Gabriel Martinez Focused Exam: Asthma Exacerbation shadow health Subjective Data

Gabriel Martinez Focused Exam: Asthma Exacerbation shadow health Subjective Data