Subjective Data Collection: 21 of 21

(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.

Guardian Discovery

Finding:

Asked about relationship to patient

 

Finding:

Reports being Maya's father

(Found)

Pro Tip: Confirming the patient's relationship with their guardian

ensures that you are observing legal and ethical protections for patient
privacy, and that you are speaking with someone who has access to
the patient's information.

Example Question:

What is your relationship to the patient?

Chief Complaint

Finding:

Asked about chief complaint

Finding:

Reports Maya has ear pain

(Found)

Pro Tip: Determining the reason for a visit in the patient's own words
ensures that you understand what the patient wants from the visit. It
also allows you to correctly document the visit's purpose.

Example Question:

What brings your daughter in today?


 Finding:

Reports Maya cranky

(Found)

Pro Tip: Determining the reason for a visit in the patient's own words
ensures that you understand what the patient wants from the visit. It
also allows you to correctly document the visit's purpose.

Example Question:

What brings your daughter in today?

Finding:

Reports Maya pulling at ear

(Found)

Pro Tip: Determining the reason for a visit in the patient's own words
ensures that you understand what the patient wants from the visit. It
also allows you to correctly document the visit's purpose.

Example Question:

What brings your daughter in today?

History of Present Illness

Finding:

Asked about onset of illness

Finding:
 Reports pain started yesterday

(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:

How long ago did your daughter get sick?

Finding:

Asked location

Finding:

Reports right ear

(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:

Which ear is hurting your daughter?

Finding:
 Asked about duration of symptoms

Finding:

Reports Maya's pain appears to be constant since yesterday

(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:

Is your daughter's ear pain constant?

Finding:

Asked about relieving factors

Finding:

Denies treatment or medications

(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:
 How did you treat your daughter's symptoms?

Finding:

Asked about risk factors

Finding:

Denies exposure to secondhand smoke

(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:

Is your daughter exposed to secondhand smoke?

Finding:

Reports Maya recently started swim lessons

(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:
 Has your daughter been swimming lately?

Finding:

Denies cold symptoms

(Available)

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 daughter have cold symptoms?

Finding:

Followed up on risk factors

Finding:

Reports not knowing if ears and hair are dried

(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 dry your daughters ears after swimming?

Finding:

Reports wife takes Maya to and from swim lessons

(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 dry your daughters ears after swimming?

Finding:

Reports last swim lesson was 2 days ago

(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:

When was your daughters last swim lesson?

Past Medical History


 Finding:

Asked about allergies

Finding:

Denies allergies to food

(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:

Does your daughter have allergies?

Finding:

Denies allergies to latex

(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:

Does your daughter have allergies?

Finding:
 Denies allergies to medication

(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:

Does your daughter have allergies?

Finding:

Reports mild seasonal nasal congestion

(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:

Does your daughter have allergies?

Finding:

Asked about pre-existing medical conditions

Finding:

Reports Autism Spectrum Disorder

 (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:

Does your daughter have any pre existing medical conditions?

Finding:

Reports ASD diagnosis at age 3

(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:

When was your daughter diagnosed with ASD?

Finding:

Followed up on ASD

Finding:

Reports Maya is verbal

(Available)
 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:

Is your daughter verbal?

Finding:

Reports aversion to big crowds

(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:

Does anything trigger your daughter?

Finding:

Reports aversion to loud noises

(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:
 Does anything trigger your daughter?

Finding:

Denies aversion to touch

(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:

Is your daughter touch averse?

Finding:

Reports Maya sees a behavioral specialist

(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:

Does your daughter see a behavioral specialist?

Finding:

Asked about previous surgeries or hospitalizations

 

Finding:

Denies previous surgeries or hospitalizations

(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 daughter had any surgeries?

Finding:

Denies ear tube surgery

(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 daughter had any surgeries?

Health Promotion

Finding:
 Asked about health promotion

Finding:

Reports Maya is up to date on vaccinations

(Found)

Pro Tip: Asking a guardian about their health promotion habits and
behaviors can uncover opportunities to educate them and the patient.
Promoting wellness and a healthy lifestyle is a key aspect of primary
care.

Example Question:

Is your daughter vaccinated?

Finding:

Reports Maya's last visit was a year ago

(Available)

Pro Tip: Asking a guardian about their health promotion habits and
behaviors can uncover opportunities to educate them and the patient.
Promoting wellness and a healthy lifestyle is a key aspect of primary
care.

Example Question:

When was your daughters last well visit?

Social History

Finding:
 Asked about socialization

Finding:

Reports Maya is in Pre-K

(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 daughter's social life like?

Finding:

Reports Maya has swim lessons

(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 daughter's social life like?

Finding:
 Reports social group with children on the spectrum

(Available)

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:

Does yur daughter have friends?

Finding:

Reports frequent playdates

(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 daughter's social life like?

Finding:

Asked about exposure to illness

Finding:
 Denies exposure to illness

(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:

Has your daughter been exposed to illness lately?

Finding:

Asked about living situation

Finding:

Reports Maya lives with parents

(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:

Who does your daughter live with?

Review of Relevant Systems


 Finding:

Asked about general symptoms

Finding:

Denies chills

(Available)

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:

Does your daughter get chills?

Finding:

Denies fever

(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:

Does your daughter have a fever?

Finding:

Reports mild fatigue

 (Available)

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:

Is your daughter fatigued?

Finding:

Asked about HEENT system

Finding:

Denies itching, discharge, or redness of the eyes

(Available)

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:

How are your daughter's eyes?

Finding:

Denies change in hearing

(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:

Can your daughter hear normally?

Finding:

Denies discharge from ears

(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:

What ear problems has your daughter had?

Finding:

Denies nose symptoms

(Available)

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:

How is your daughter's nose?

Finding:
 Denies throat symptoms

(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:

Does yur daughter have a sore throat?

Finding:

Asked about respiratory

Finding:

Denies respiratory problems other than sneezing

(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:

How is your daughter's respiratory system?

Finding:

Asked about gastrointestinal system


 Finding:

Denies nausea and vomiting

(Available)

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:

How is your daughter's gastrointestinal system

Finding:

Denies constipation

(Available)

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:

Is your daughter constipated?

Finding:

Reports eating and drinking normally

(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:

Has your daughter been eating and drinking?

Finding:

Asked about sleeping

Finding:

Reports more tired than usual

(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:

How is your daughter sleeping?

Finding:

Reports fitful sleeping