Noah Caputo school age sick visit dermatology shadow health Subjective data Collection
Category: Scored Items
Experts selected the following topics as essential components for a comprehensive interview during Noah Caputo’s dermatology visit in a school-age sick visit.
A combination of open and closed questions will help provide a thorough understanding of the patient’s case.
Patient Data (Not Scored)
A mix of open and closed-ended questions will yield comprehensive insights about the patient’s situation. Below are key details about the patient’s background and condition.
Caretaker’s Relationship
- Finding: Asked about relationship to patient
- Caretaker reports being patient’s uncle and godfather (Found)
- Pro Tip: Confirming the patient’s relationship with their guardian ensures that you’re observing legal and ethical protections for patient privacy and that you’re speaking with someone who has access to their information.
- Example Question: What is your relationship to the patient?
- Finding: Patient reports being caretaker’s nephew and godson (Found)
- Pro Tip: Confirming the patient’s relationship with their guardian ensures that you’re observing legal and ethical protections for patient privacy.
- Example Question: Who brought you in today?
- Caretaker reports being patient’s uncle and godfather (Found)
Chief Complaint
- Finding: Asked about the chief complaint
- Caretaker reports babysitting nephew over the weekend (Found)
- Pro Tip: The chief complaint helps establish the patient’s concerns and informs next steps for evaluation.
- Example Question: What brings you in today?
- Finding: Caretaker noticed a rash on nephew (Found)
- Pro Tip: Establishing the chief complaint helps clarify symptoms and direct questioning.
- Example Question: What brings you in today?
- Finding: Patient reports feeling itchy (Found)
- Pro Tip: Understanding the primary concern allows you to better direct further assessment.
- Example Question: What brings you in today?
- Caretaker reports babysitting nephew over the weekend (Found)
History of Present Illness (HPI)
Onset of Rash
- Finding: Caretaker reports noticing the rash yesterday (Found)
- Pro Tip: A clear understanding of the onset of symptoms can help narrow down potential diagnoses.
- Example Question: When did you notice your nephew’s rash?
- Finding: Patient reports being itchy since last weekend (Found)
- Pro Tip: Asking about the duration of symptoms helps provide context for treatment options.
- Example Question: How long have you had this rash?
Location of Rash
- Finding: Caretaker denies knowing when rash started (Available)
- Pro Tip: Understanding when the rash started is important for developing an appropriate timeline for diagnosis and management.
- Example Question: When did your nephew’s rash start?
- Finding: Caretaker reports concern that patient’s parents did not notice the rash (Found)
- Pro Tip: Exploring the caretaker’s perspective on whether the rash was previously noticed can offer insight into the progression of the condition.
- Example Question: Did your nephew’s parents know he had a rash?
- Finding: Patient reports rash on feet and ankles (Found)
- Pro Tip: Asking about the location of the rash can help with differential diagnosis.
- Example Question: Where is the rash?
Characteristics of Rash
- Finding: Patient reports red bumps (Found)
- Pro Tip: Describing the characteristics of the rash can be key to identifying the underlying condition.
- Example Question: How does the rash look?
- Finding: Patient denies painful rash (Found)
- Pro Tip: It’s essential to ask about pain associated with the rash, as it can provide insights into the severity or type of rash.
- Example Question: Does the rash hurt?
- Finding: Patient denies drainage (Found)
- Pro Tip: Drainage can suggest infection or other issues that require immediate attention.
- Example Question: Does your rash have drainage?
- Finding: Patient denies bleeding (Found)
- Pro Tip: Inquiring about bleeding can rule out conditions like skin injury or certain infectious rashes.
- Example Question: Is the rash bleeding?
- Finding: Patient denies blisters (Available)
- Pro Tip: The presence or absence of blisters can help differentiate between different dermatologic conditions.
- Example Question: Does the rash have blisters?
Bathing and Hygiene History
Bathing Routine
- Finding: Patient reports showering once a week or less (Found)
- Pro Tip: Understanding bathing habits is crucial in assessing whether poor hygiene may contribute to the rash.
- Example Question: What is your bathing routine?
- Finding: Patient reports using hot water (Available)
- Pro Tip: Hot water can exacerbate skin irritation, especially in sensitive or inflamed skin areas.
- Example Question: Do you use hot water?
- Finding: Patient denies anyone helping him shower (Available)
- Pro Tip: It’s helpful to assess whether the patient needs assistance with bathing, especially in younger children.
- Example Question: Does anyone help you bathe?
- Finding: Patient denies being told to bathe (Available)
- Pro Tip: Ensuring that the patient follows proper hygiene practices is key for preventing skin conditions.
- Example Question: Do you need to be reminded to bathe?
- Finding: Patient denies using soap regularly (Available)
- Pro Tip: The use of soap is an important factor in maintaining skin health.
- Example Question: Do you use soap?
Animal Exposure
Pets and Animals
- Finding: Patient denies pets at home (Found)
- Pro Tip: Understanding potential exposure to pets can help rule out conditions like flea allergies or infections.
- Example Question: Do you have pets at home?
- Finding: Patient reports spending a lot of time with a neighbor’s dog (Found)
- Pro Tip: Exposure to animals can lead to conditions like pet-related rashes or infections.
- Example Question: Do you come into contact with animals?
- Finding: Patient denies knowing if the dog has fleas (Available)
- Pro Tip: Knowing whether the dog has fleas can help assess if the rash may be flea-related.
- Example Question: Does the dog have fleas?
Aggravating and Relieving Factors
Aggravating Factors
- Finding: Patient reports scratching makes the itching worse (Found)
- Pro Tip: Scratching can often worsen itching and inflammation, making the condition harder to treat.
- Example Question: What aggravates your rash?
- Finding: Patient reports showering makes the itching worse (Found)
- Pro Tip: Identifying aggravating factors like showering helps tailor treatment options.
- Example Question: What aggravates your rash?
Relieving Factors
- Finding: Caretaker denies using topical treatments (Found)
- Pro Tip: Topical treatments can be key in treating certain types of rashes. It’s important to understand what has been tried.
- Example Question: Did you put anything on the rash?
- Finding: Caretaker reports giving patient cold compresses to put on ankles last night (Found)
- Pro Tip: Cold compresses can provide temporary relief for itchy rashes.
- Example Question: Did you put anything on the rash?
- Finding: Patient reports cold compress relieved itching temporarily (Found)
- Pro Tip: Cold compresses can help soothe irritation, although the effect is usually short-term.
- Example Question: Does anything make the itching better?
Pharmacological Interventions
Medication History
- Finding: Caretaker reports giving the patient children’s diphenhydramine last night (Found)
- Pro Tip: It’s important to track any medications used to manage symptoms, including over-the-counter options.
- Example Question: Did you give your nephew any medication for the rash?
- Finding: Caretaker reports giving the recommended dosage on the package (Found)
- Pro Tip: Ensure the correct dosage is administered to avoid complications.
- Example Question: Did you give your nephew any medication for the rash?
- Finding: Caretaker reports diphenhydramine relieved itching (Found)
- Pro Tip: Antihistamines like diphenhydramine can help alleviate itching, but may cause side effects.
- Example Question: Did you give your nephew anything for the itching?
- Finding: Patient reports diphenhydramine made him sleepy (Found)
- Pro Tip: Diphenhydramine may cause drowsiness, which is important to monitor, especially in children.
- Example Question: Did you give your nephew anything for the itching?
Family and Social History
Family Members with Rash
- Finding: Patient reports not knowing whether or not his neighbors have a rash (Available)
- Pro Tip: Understanding whether others in the household or social circle have similar symptoms can help assess whether the rash is contagious.
- Example Question: Does anyone you know have a rash?
- Finding: Caretaker reports that other family members do not have rash (Available)
- Pro Tip: A lack of similar symptoms in family members can help rule out contagious conditions.
- Example Question: Does anyone in the household have a rash?
Past Medical History
- Finding: Patient denies past medical issues (Available)
- Pro Tip: A clean medical history can rule out underlying chronic conditions that may be contributing to the rash.
- Example Question: Has your nephew had any medical problems?
Home Medications
- Finding: Patient denies taking medications (Noah Caputo school age sick visit dermatology shadow health Subjective data)
Hover To Reveal…
Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
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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 Noah Caputo school age sick visit dermatology shadow health Subjective data.
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.
Caretaker’s Relationship
Finding:
Asked about relationship to patient
- Finding:Caretaker reports being patient’s uncle and godfather
(Found)
Pro Tip: Confirming the patient’s relationship with their guardian ensures that you’re observing legal and ethical protections for patient privacy and that you’re speaking with someone who has access to their information.Example Question:
What is your relationship to the patient? - Finding:Patient reports being caretaker’s nephew and godson
(Found)
Pro Tip: Confirming the patient’s relationship with their guardian ensures that you’re observing legal and ethical protections for patient privacy and that you’re speaking with someone who has access to their information.Example Question:
Who brought you in today?
Chief Complaint
- Finding:Asked about chief complaint
- Finding:Caretaker reports babysitting nephew over the weekend
(Found)
Pro Tip: A patient’s chief complaint establishes any illnesses or concerns that they are presenting with. In the case of a pediatric patient, an approved guardian may provide this information Noah Caputo school age sick visit dermatology shadow health Subjective data. Understanding the chief complaint will help you ask relevant questions, rule out potential diagnoses, and ultimately inform your recommendations for next steps.Example Question:
What brings you in today? - Finding:Caretaker reports noticing a rash on nephew
(Found)
Pro Tip: A patient’s chief complaint establishes any illnesses or concerns that they are presenting with. In the case of a pediatric patient, an approved guardian may provide this information. Understanding the chief complaint will help you ask relevant questions, rule out potential diagnoses, and ultimately inform your recommendations for next steps.Example Question:
What brings you in today?
Finding:
Patient reports being itchy
(Found)
Pro Tip: A patient’s chief complaint establishes any illnesses or concerns that they are presenting with. In the case of a pediatric patient, an approved guardian may provide this information. Noah Caputo school age sick visit dermatology shadow health Subjective data Understanding the chief complaint will help you ask relevant questions, rule out potential diagnoses, and ultimately inform your recommendations for next steps.Example Question:
What brings you in today?
History of Present Illness
- Finding:Asked about onset of rash
- Finding:Caretaker reports noticing the rash yesterday
(Found)
Pro Tip: Asking about the history of presenting illness will allow you to better understand the patient’s condition and symptoms. The subjective data you gather around this line of questioning will help you identify appropriate interventions.Example Question:
When did you notice your nephew’s rash?
- Finding:Patient reports being itchy since last weekend
(Found)
Pro Tip: Asking about the history of presenting illness will allow you to better understand the patient’s condition and symptoms. The subjective data you gather around this line of questioning will help you identify appropriate interventions Noah Caputo school age sick visit dermatology shadow health Subjective data.Example Question:
How long have you had this rash?
Finding:
Caretaker denies knowing when rash started
(Available)
Pro Tip: Asking about the history of presenting illness will allow you to better understand the patient’s condition and symptoms. The subjective data you gather around this line of questioning will help you identify appropriate interventions.Example Question:
When did your nephew’s rash start?
Finding:
Caretaker reports concern that patient’s parents did not notice the rash
(Found)
Pro Tip: Asking about the history of presenting illness will allow you to better understand the patient’s condition and symptoms. The subjective data you gather around this line of questioning will help you identify appropriate interventions.Example Question:
Did your nephew’s parents know he had a rash?
- Finding:Asked about location of rash
- Finding:Patient reports rash on feet and ankles
(Found)
Pro Tip: Asking about the history of presenting illness will allow you to better understand the patient’s condition and symptoms. The subjective data you gather around this line of questioning will help you identify appropriate interventions.Example Question:
Where is the rash?
Finding:
Patient reports rash on lower legs
(Found)
Pro Tip: Asking about the history of presenting illness will allow you to better understand the patient’s condition and symptoms. The subjective data you gather around this line of questioning will help you identify appropriate interventions.Example Question:
Where is the rash?
-
Finding:
Asked about duration
-
Finding:
Caretaker reports Noah scratching consistently this weekend
(Found)
Pro Tip: Asking about the history of presenting illness will allow you to better understand the patient’s condition and symptoms. The subjective data you gather around this line of questioning will help you identify appropriate interventions.Example Question:
How long has your nephew been scratching for?
- Finding:Asked about characteristics of rash
- Finding:Patient reports red bumps
(Found)
Pro Tip: Asking about the history of presenting illness will allow you to better understand the patient’s condition and symptoms Noah Caputo school age sick visit dermatology shadow health Subjective data. The subjective data you gather around this line of questioning will help you identify appropriate interventions.Example Question:
How does the rash look? -
Finding:
Patient denies painful rash
(Found)
Pro Tip: Asking about the history of presenting illness will allow you to better understand the patient’s condition and symptoms. The subjective data you gather around this line of questioning will help you identify appropriate interventions.Example Question:
Does the rash hurt? -
Finding:
Patient denies drainage
(Found)
Pro Tip: Asking about the history of presenting illness will allow you to better understand the patient’s condition and symptoms. The subjective data you gather around this line of questioning will help you identify appropriate interventions.Example Question:
Does your rash have drainage? -
Finding:
Patient denies bleeding
(Found)
Pro Tip: Asking about the history of presenting illness will allow you to better understand the patient’s condition and symptoms. The subjective data you gather around this line of questioning will help you identify appropriate interventions.Example Question:
Is the rash bleeding? - Finding:Patient denies blisters
(Available)
Pro Tip: Asking about the history of presenting illness will allow you to better understand the patient’s condition and symptoms. The subjective data you gather around this line of questioning will help you identify appropriate interventions.Example Question:
Does the rash have blisters?
- Finding:Asked about typical bathing routine
- Finding:Patient reports showering once a week or less
(Found)
Pro Tip: Asking about the history of presenting illness will allow you to better understand the patient’s condition and symptoms. The subjective data you gather around this line of questioning will help you identify appropriate interventions.Example Question:
What is your bathing routine?
Finding:
Patient reports using hot water
(Available)
Pro Tip: Asking about the history of presenting illness will allow you to better understand the patient’s condition and symptoms. The subjective data you gather around this line of questioning will help you identify appropriate interventions.Example Question:
Do you use hot water?
Finding:
Patient denies anyone helping him shower
(Available)
Pro Tip: Asking about the history of presenting illness will allow you to better understand the patient’s condition and symptoms. The subjective data you gather around this line of questioning will help you identify appropriate interventions.Example Question:
Does anyone help you bathe?
Finding:
Patient denies being told to bathe
(Available)
Pro Tip: Asking about the history of presenting illness will allow you to better understand the patient’s condition and symptoms. The subjective data you gather around this line of questioning will help you identify appropriate interventions.Example Question:
Do you need to be reminded to bathe?- Finding:Patient denies using soap regularly
(Available)
Pro Tip: Asking about the history of presenting illness will allow you to better understand the patient’s condition and symptoms. The subjective data you gather around this line of questioning will help you identify appropriate interventions.Example Question:
Do you use soap?
- Finding:Asked about exposure to animals
- Finding:Patient denies pets at home
(Found)
Pro Tip: Asking about the history of presenting illness will allow you to better understand the patient’s condition and symptoms. The subjective data you gather around this line of questioning will help you identify appropriate interventions.Example Question:
Do you have pets at home? - Finding:Patient reports spending a lot of time with neighbors’ dog
(Found)
Pro Tip: Asking about the history of presenting illness will allow you to better understand the patient’s condition and symptoms Noah Caputo school age sick visit dermatology shadow health Subjective data. The subjective data you gather around this line of questioning will help you identify appropriate interventions.Example Question:
Do you come into contact with animals?
Finding:
Patient denies knowing if dog has fleas
(Available)
Pro Tip: Asking about the history of presenting illness will allow you to better understand the patient’s condition and symptoms. The subjective data you gather around this line of questioning will help you identify appropriate interventions.Example Question:
Does the dog have fleas?
- Finding:Asked about aggravating factors
- Finding:Patient reports scratching makes the itching worse
(Found)
Pro Tip: Asking about the history of presenting illness will allow you to better understand the patient’s condition and symptoms. The subjective data you gather around this line of questioning will help you identify appropriate interventions.Example Question:
What aggravates your rash? - Finding:Patient reports showering makes the itching worse
(Found)
Pro Tip: Asking about the history of presenting illness will allow you to better understand the patient’s condition and symptoms. The subjective data you gather around this line of questioning will help you identify appropriate interventions.Example Question:
What aggravates your rash?
- Finding:Asked about relieving factors
- Finding:Caretaker denies using topical treatments
(Found)
Pro Tip: Asking about the history of presenting illness will allow you to better understand the patient’s condition and symptoms. The subjective data you gather around this line of questioning will help you identify appropriate interventions.Example Question:
Did you put anything on the rash? -
Finding:
Caretaker reports giving patient cold compresses to put on ankles last night
(Found)
Pro Tip: Asking about the history of presenting illness will allow you to better understand the patient’s condition and symptoms. The subjective data you gather around this line of questioning will help you identify appropriate interventions.Example Question:
Did you put anything on the rash?
Finding:
Patient reports cold compress relieved itching temporarily
(Found)
Pro Tip: Asking about the history of presenting illness will allow you to better understand the patient’s condition and symptoms. The subjective data you gather around this line of questioning will help you identify appropriate interventions.Example Question:
Does anything make the itching better?
- Finding:Asked about pharmacological relieving factors
- Finding:Caretaker reports giving patient children’s diphenhydramine last night
(Found)
Pro Tip: Asking about the history of presenting illness will allow you to better understand the patient’s condition and symptoms. The subjective data you gather around this line of questioning will help you identify appropriate interventions.Example Question:
Did you give your nephew any medication for the rash?
Finding:
Caretaker reports giving recommended dosage on package
(Found)
Pro Tip: Asking about the history of presenting illness will allow you to better understand the patient’s condition and symptoms. The subjective data you gather around this line of questioning will help you identify appropriate interventions.Example Question:
Did you give your nephew any medication for the rash?-
Finding:
Caretaker reports diphenhydramine relieved itching
(Found)
Pro Tip: Asking about the history of presenting illness will allow you to better understand the patient’s condition and symptoms. The subjective data you gather around this line of questioning will help you identify appropriate interventions.Example Question:
Did you give your nephew anything for the itching? - Finding:Patient reports diphenhydramine made him sleepy
(Found)
Pro Tip: Asking about the history of presenting illness will allow you to better understand the patient’s condition and symptoms. The subjective data you gather around this line of questioning will help you identify appropriate interventions.Example Question:
Did you give your nephew anything for the itching?
- Finding:Asked about family and friends having rash
- Finding:Patient reports not knowing whether or not his neighbors have rash
(Available)
Pro Tip: Asking about the history of presenting illness will allow you to better understand the patient’s condition and symptoms. The subjective data you gather around this line of questioning will help you identify appropriate interventions.Example Question:
Does anyone you know have a rash? - Finding:Caretaker reports that other family members do not have rash
(Available)
Pro Tip: Asking about the history of presenting illness will allow you to better understand the patient’s condition and symptoms. The subjective data you gather around this line of questioning will help you identify appropriate interventions.Example Question:
Does anyone in the household have a rash?
- Finding:Asked about past medical history
-
Finding:
Patient denies past medical issues
(Available)
Pro Tip: Asking about the history of presenting illness will allow you to better understand the patient’s condition and symptoms. The subjective data you gather around this line of questioning will help you identify appropriate interventions.Example Question:
Has your nephew had any medical problems?
Home Medications
- Finding:Asked about medications
- Finding:Patient denies taking medications
- Noah Caputo school age sick visit dermatology shadow health Subjective data
Subjective Information for Noah Caputo’s Dermatology Visit
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