Clinical Interview

Clinical Interview. Identify a friend, peer, or family member you can interview to collect subjective data, as though they were a new pati…

Clinical Interview

Instructions

Identify a friend, peer, or family member you can interview to collect subjective data, as though they were a new patient in your office. 

Conduct an interview.

Document the subjective findings in a word document and submit to Canvas.  This will be evaluated by the clinical faculty. 

Estimated time to complete: 1 hour

Rubric

NU610 Unit 2 Assignment – Case Studies Rubric

NU610 Unit 2 Assignment – Case Studies Rubric

Criteria

Ratings

Pts

This criterion is linked to a Learning OutcomeSubjective Data

40 pts

Highly Proficient

Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are adeptly documented and demonstrate consistent information across all aspects represented

32 pts

Proficient

Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are appropriately documented and demonstrate consistent information across all aspects represented

24 pts

Marginally Proficient

Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are satisfactorily documented but do not demonstrate consistent information across all aspects represented

16 pts

Approaching Proficiency

Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are either not satisfactorily documented or do not demonstrate consistent information across all aspects represented

8 pts

Not Proficient

Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are not satisfactorily documented and do not demonstrate consistent information across all aspects represented

0 pts

Not Evident

There are elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) that are not provided in assignment.

40 pts

Total Points: 40

Clinical Interview

Solution

An interview is a crucial tool used by physicians and psychologists to obtain data from a patient presenting clinical concern in a healthcare facility (Shankman et al., 2018). Obtained data are crucial in making diagnosis and appropriate treatment intervention (Tolentino, & Schmidt, 2018). In this paper, subjective data from an interview with a friend presenting clinical concerns.

Patient Information: TX Age: 21 Sex: Male Race: African American

S.

CC: Crumping pain on the lower abdomen.

HPI: The patient is a 21-year-old male. The patient present pain in the lower abdomen, which began over a week ago. He reports that he has been feeling generally ill since then. He occasionally feels he nauseate but does not vomit. He reports fever and pain or burning with urination. The patient rates severity as 8/10 but eases with Acetaminophen 4g medication.

Current Medications:

Acetaminophen 4g to manage pain.

Allergies: NKDFA

PMHx: Immunization status is up to date. The last tetanus immunization was three months ago. No history of significant sickness or hospitalization. No history of surgery. Denies abusing illicit drugs. Consumes alcohol every weekend.

Soc Hx: The patient is a third-year university student pursuing a Bachelor of Education. The patient is outgoing and joins friends for night parties every weekend.While off-campus, the patient lives together with the parents on their ranch. The neighbourhood is well guarded with essential social and health amenities.

Fam Hx: The patient is the firstborn in a family of three. Younger sisters are aged 17 and 13. The sisters are well are healthy. The father, 43, is diagnosed with diabetes – managed through medication. The mother, 42, is well and healthy.

ROS:

GENERAL: No weight loss. He has a fever and is fatigued

HEENT: Uses eyeglasses since childhood. Vision and hearing are intact. Sense of smell intact. No sore throat or runny nose.   

SKIN: Normal skin turgor. No itching or skin rash.

CARDIOVASCULAR:  No chest discomfort, pain, or pressure.

RESPIRATORY:  Normal breath. No cough or sputum.

GASTROINTESTINAL: Report nausea. No vomiting or diarrhoea. Reports abdominal pain.  

NEUROLOGICAL:  Occasional headache. No dizziness or numbness. Bowel and bladder movement is intact.

MUSCULOSKELETAL:  No muscle pain, stiffness, or joint pain.

LYMPHATICS:  Normal joint/node symmetry.

PSYCHIATRIC:  No history of depression or anxiety.

ENDOCRINOLOGIC:  No heat, sweat or cold intolerance.

ALLERGIES:  NKDFA

References

Shankman, S. A., Funkhouser, C. J., Klein, D. N., Davila, J., Lerner, D., & Hee, D. (2018). Reliability and validity of severity dimensions of psychopathology assessed using the Structured Clinical Interview for DSM‐5 (SCID). International journal of methods in psychiatric research, 27(1), e1590.

Tolentino, J. C., & Schmidt, S. L. (2018). DSM-5 criteria and depression severity: implications for clinical practice. Frontiers in psychiatry, 9, 450.