Unit 5 Differentiating Components of Health Assessment Please review the following data and differentiate subjective, objective, assessment, and plan data. Place the data under the appropriate component of the assessment. Submit the completed chart to the discussion forum
- Bilateral breath sounds clear to auscultation
- Consumes 75% of meals
- Pneumonia
- Fine needle aspiration of thyroid gland
- Refer to pulmonology
- Chronic bronchitis
- “My throat is sore and I’m hoarse”
- Hemoglobin 25
- Sister with breast cancer
- Relieve of chest pain with Tylenol
- Back pain score 8/10 with radiation to legs
- Skin warm and dry
- “My head hurts”
- Potassium 3.8
- Refer to oncology
- COPD
- Left mastitis
- Lateral curvature of thoracic spine
- Productive cough x 10 days of green yellow sputum
- Chest pain associated with activity
Subjective Data | Objective Data | Assessment (medical diagnosis) | Plan (orders) |
Expert Solution Preview
Introduction:
The following chart requires the differentiation of subjective, objective, assessment, and plan data. The purpose of this exercise is to hone your skills in identifying and categorizing different components of health assessment to prepare you for your future medical practice.
Answer:
| Subjective Data | Objective Data | Assessment (medical diagnosis) | Plan (orders) |
| Consumes 75% of meals | Hemoglobin 25 | Anemia | Order iron supplementation |
| “My throat is sore and I’m hoarse” | Pharyngitis | Order throat culture and prescribe antibiotics if positive | |
| “My head hurts” | Headache | Order further investigation and/or prescribe pain medication as needed | |
| Back pain score 8/10 with radiation to legs | Lateral curvature of thoracic spine | Herniated disc | Refer to physical therapy for conservative management, order MRI if symptoms worsen |
| “Relieve chest pain with Tylenol” | Non-cardiac chest pain | Reassure patient, discontinue further cardiac workup if negative | |
| Productive cough x 10 days of green yellow sputum | Bilateral breath sounds clear to auscultation | Acute bronchitis | Prescribe broad-spectrum antibiotics, cough suppressants as needed, follow-up in 7-10 days |
| “Sister with breast cancer” | Increased risk of breast cancer | Order genetic testing and mammography screening starting at an earlier age if appropriate | |
| Skin warm and dry | N/A | N/A | |
| Potassium 3.8 | Hypokalemia | Order potassium supplementation, recheck levels in 24 hours | |
| COPD | Chronic obstructive pulmonary disease | Refer to pulmonary specialist, prescribe bronchodilators and/or corticosteroids as needed | |
| Left mastitis | Breast infection | Prescribe antibiotics, encourage continued breastfeeding to promote drainage | |
| Chest pain associated with activity | Cardiac chest pain | Order further cardiac workup, possibly including stress testing and/or cardiac catheterization | |
| Pneumonia | Community-acquired pneumonia | Prescribe antibiotics, provide supportive care, follow up in 48 hours, consider hospitalization if severe symptoms or risk factors for complications | |
| Fine needle aspiration of thyroid gland | Thyroid nodule | Refer to endocrinology for evaluation, possible biopsy or further imaging | |
| Refer to pulmonology | N/A | N/A | |
| Chronic bronchitis | Chronic obstructive pulmonary disease | Continue bronchodilators and/or corticosteroids as prescribed, consider pulmonary rehabilitation, educate on smoking cessation | |
| Chest x-ray shows new infiltrate | Pneumonia | Admit to hospital, start antibiotics, monitor oxygenation and respiratory status |
