Unit 2B.1: Collecting Subjective Data | Chief Complaints

1. Fever

2. Pain

3. Cough

4. Vomiting

5. Diarrhea/LBM

6. Masses

7. Injury

7 Common Chief Complaints

1. Duration

2. Severity

3. Accompanying Symptoms

Generally, what must be assessed for Fever?

1. Remittent

2. Intermittent

3. Relapsing

4. Undulant

5. Constant

Types of Duration for Fever

Remittent

One of the Types of Duration for Fever

Over the course of 24 hours, the client has fluctuating temperatures above normal temperature

Intermittent

One of the Types of Duration for Fever

Over the course of 24 hours, the client’s temperature fluctuates from above normal then below normal (On-Off Fever)

Relapsing

One of the Types of Duration for Fever

Over the course of a week, a client experiences a normal temperature for a few days then a temperature above normal for other days

Constant

One of the Types of Duration for Fever

Over the course of 24 hours, the client’s temperature consistently stays above normal at around the same temperature

1. Mild

2. Moderate

3. High

Types of Severity for Fever

37.5-38.4 degrees Celsius

What does the Mild Severity for Fever measure?

38.5-39.4 degrees Celsius

What does the Moderate Severity for Fever measure?

>39.5 degrees Celsius

What does the High Severity for Fever measure?

1. Chills

2. Fatigue/Body Malaise

3. Weakness

4. Pain

5. Cough

6. Rashes

What are some typical Accompanying Symptoms for Fever?

1. Manner of Occurrence

2. Severity

3. Character

4. Duration

5. Location

Generally, what must be assessed for Pain?

1. Sudden or Abrupt

2. Gradual or Progressive

Types of Manner of Occurrence for Pain

1. Mild

2. Discomforting

3. Distressing

4. Horrible

5. Excruciating

Types of Severity for Pain

Mild

One of the types of Severity for Pain

Tolerable

Discomforting

One of the types of Severity for Pain

“Not at ease”

Distressing

One of the types of Severity for Pain

4-5 on pain scale, asks for pain medications

Horrible

One of the types of Severity for Pain

Severe, concentration of patient difficult

Patient can still converse

Excruciating

One of the types of Severity for Pain

Patient is immobilized from the pain

1. Dull

2. Sharp

3. Stabbing

4. Burning

5. Gnawing

6. Cramping

7. Throbbing

Types of Character for Pain

1. Continuous/Steady/Constant

2. Rhythmic/Periodic/Intermittent

3. Brief/Momentary/Transient

Types of Duration for Pain

• Specific body part

• Quadrant or region

• (If Applicable) Where pain is radiating to

What should Location for Pain include?

1. Character

2. Sputum Amount

3. Sputum Odor

4. Sputum Color

5. Sputum Consistency

6. Other Respiratory Problems

Generally, what should be assessed for in Cough?

1. Productive

2. Non-Productive

Types of Character in Cough

Productive

One of the types of Character in Cough

With phlegm

Non-Productive

One of the types of Character in Cough

Dry

1. Scant (little)

2. Moderate

3. Copious (abundant)

Types of Sputum Amount in Cough

1. Blood-Tinged

2. Whitish

3. Greenish

4. Yellowish

5. Rust-Tinged

Types of Sputum Color in Cough

Bacterial/Viral Infection

What do the colors white, green, and yellow as sputum colors indicate?

1. Tenacious or thick

2. Thin/watery/mucoid

3. Frothy

Types of Sputum Consistency in Cough

Tenacious or thick

One of the Types of Sputum Consistency in Cough

Viscose, sticky

Frothy

One of the Types of Sputum Consistency in Cough

Foamy

Dyspnea (Difficulty breathing)

What is the main accompanying symptom of Cough

1. Character

2. Characteristic of Vomitus

3. Quantity

4. Accompanying Symptoms

Generally, what must be assessed for in Vomiting?

Projectile

What is the main type of character assessed for in vomiting?

1. Bile-Stained/Green

2. Bloody

3. Brown with Fecal Odor

4. Coffee Ground

5. Undigested Food

Types of Characteristic of Vomitus

Bile-Stained/Greenish

One of the types of Characteristic of Vomitus

Indicates a gallbladder problem

Bloody

One of the types of Characteristic of Vomitus

Hematemesis

Brown with Fecal odor

One of the types of Characteristic of Vomitus

Obstruction in ileum

Coffee Ground

One of the types of Characteristic of Vomitus

Coagulation of blood; bleeding

1. 1 Glass = 240 mL

2. 1 Cup = 180 mL

3. 1 oz = 30 mL

Measures of Quantity (including for Quantity of Vomitus and Diarrhea)

1. Nausea

2. Abdominal Pain

3. Anorexia

4. Weight Loss

5. Change in Bowel Habits

6. Excessive Belching/Flatus

7. Bloating/Fullness

8. Dizziness

9. Vertigo

What are the typical accompanying symptoms for vomiting?

1. Characteristic

2. Odor

3. Quantity

4. Accompanying Symptoms

Generally, what must be assessed for Diarrhrea/LBM?

1. Loose & Watery

2. Grossly Bloody

3. Black & Tarry

4. With Pus

5. Copious mucus

6. Blood

Types of Characteristics for Diarrhea/LBM

Grossly Bloody

One of the types of Characteristics for Diarrhea/LBM

Indicates lower GI bleeding

Black & Tarry

One of the types of Characteristics for Diarrhea/LBM

A medical emergency, especially if pediatric client

Sign of upper GI bleeding

1. Foul-smelling

2. Fishy

Types of Odor for Diarrhea/LBM

Foul-smelling

One of the types of Odor for Diarrhea/LBM

Indicates malabsorption

Fishy

One of the types of Odor for Diarrhea/LBM

Likely patient with hemorrhoids

1. Nausea & Vomiting

2. Abdominal Pain

3. Fever

4. Abdominal Distention

5. Bloating/Fullness

What are the typical accompanying symptoms for diarrhea/LBM?

1. Character

2. Size

3. Location

Generally, what are assessed for Masses?

1. Tender

2. Pulsating

3. Mobility: Fixed or Mobile

4. Consistency: Soft, Hard, Firm

5. Shape: Well-Defined or Irregular

Types of Character for Masses

Either…

• Exact diameter (in cm)

• About the size of ___ (ex: 25 centavo)

What is used to describe Size for Masses?

1. Exact body landmark

2. Quadrant

3. Region

What is used to describe Location for Masses?

1. Quantity

2. Usual Injuries

3. Location

4. Accompanying Symptoms

5. Mechanism

Generally, what is used to assess Injuries?

1. Single

2. Multiple

Quantity of Injuries

1. Gunshot Wound

2. Stab

3. Laceration

4. Fractures

5. Burns

What are Usual Injuries?

Exact body landmark

What is used to describe the Location for Injuries?

1. Severe bleeding

2. Low level of consciousness

3. (If Applicable) If there’s pain, must include the pain score

What are typical accompanying symptoms for Injuries?

1. Motor vehicle Accident

2. Falls

3. Occupational/Industrial Accident

4. House Fire

What are common mechanisms for Injuries?