Unit 2 Case Studies. Conducting interview for comprehensive subjective data.
1000w. due 3-17-23. Help write my thesis – APA format. 4 references.
Instructions
Identify a friend, peer, or family member you can interview as a possible patient.
Collect information to construct a complete and comprehensive subjective data set consistent with documentation requirements for a new patient scheduled for an annual wellness exam.
Conduct an interview.
Document your findings in a Word file. Structure the subjective data set in the format provided in your lecture materials.
Submit the Word file containing your subjective data set to this assignment.
This assignment should look similar to unit 1 case study 1 completed the previous week.
!
Introduction
Comprehensive subjective data is vital in healthcare as it enables healthcare providers to identify patients’ health problems and come up with a proper diagnosis and treatment plan. The subjective data set should be comprehensive and consistent with documentation requirements for a new patient scheduled for an annual wellness exam. In this paper, I will interview my friend John as a potential patient to collect the necessary information and structure a comprehensive subjective data set.
Identifying Information
John is a 32-year-old male who works as a software developer in a tech company. He resides in San Francisco, California, and is of Caucasian descent. He is single and has no children.
Chief Complaint
John has no specific health concerns or complaints at the moment. He, however, notes that he has been feeling fatigued and tired lately.
History of Present Illness
John reports no significant illness or injuries. However, he states that he has been feeling more exhausted than usual and has been experiencing mild headaches.
Past Medical History
John reports that he has had no significant medical history. He has never been hospitalized or undergone any surgeries. He has never been diagnosed with any chronic illness or disease.
Family History
John’s family history is significant for hypertension on his father’s side, and his maternal grandfather had a history of heart disease. His mother has been diagnosed with diabetes, and his uncle has been diagnosed with colon cancer.
Social History
John is a non-smoker and does not consume alcohol or any recreational drugs. He works as a software developer in a tech company, and he spends most of his time sitting at his desk. He reports that he tries to exercise at least three times a week by jogging around his neighborhood.
Review of Systems
General: Reports feeling tired and fatigued lately.
Skin: No skin rashes, itching or lesions.
HEENT: Reports mild headaches but no visual changes, blurred vision, or eye pain. No hearing loss, tinnitus, or ear pain.
Respiratory: No cough, shortness of breath, or wheezing.
Cardiovascular: No chest pain, palpitations, or edema.
Gastrointestinal: No nausea, vomiting, or abdominal pain.
Genitourinary: No dysuria or hematuria.
Musculoskeletal: No joint pain or stiffness.
Neurological: No weakness, numbness, or tingling in the extremities.
Psychiatric: No anxiety, depression, or suicidal ideation.
Conclusion
In conclusion, a comprehensive subjective data set is essential in healthcare as it enables healthcare providers to identify patients’ health problems and come up with a proper diagnosis and treatment plan. Through the interview with John, it was established that he has no significant medical history, although he has been feeling fatigued and experiencing mild headaches. He has no family history of chronic diseases, but his mother has been diagnosed with diabetes, and his uncle has been diagnosed with colon cancer. John’s review of systems was negative for any significant findings. Healthcare providers can use this information to develop an appropriate care plan
