Assignment 2: Digital Clinical Experience (DCE): Health History Assessment NURS 6512N
Shadow Health Digital Clinical Experience Health History Documentation SUBJECTIVE DATA: Patient states she tripped on stairs two weeks ago and scraped her foot.
Chief Complaint (CC): Infected wound on right plantar foot
History of Present Illness (HPI):Tina Jones is a 28 year old female with chief complaints of an infected wound on right foot. Making it very difficult to walk. Patient reports she tripped while walking upstairs outside, twisting her right ankle and scraping the ball of her foot about a week ago . She also states it’s been draining white purulent, with no foul smells. She visited the emergency room where she got an X Ray , which showed no broken bones .Received Tramadol 50mg for the pain. Ms. Jones reports no relief from the tramadol. She reports cleaning the wound twice a day with hydrogen peroxide and applies bacitracin, neomycin and polymyxin B (Neosporin). She complains of a throbbing sharp pain of 7 on a scale of 1-10.
Medications: Inhaler Proventil ,Tramadol 50 mg
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Past Medical History (PMH): Asthma, type 2 diabetes (diagnosed at 24)
Past Surgical History (PSH): Pt reports no past surgical procedure
Sexual/Reproductive History: Not sexually active. No STIs. last pap smear was 4 years ago. Irregular menstrual cycle
Personal/Social History: The Patient lives with her mom and sister. States she’s usually independent with ADL’s until she acquired the wound on her foot. She has never used tobacco . Used to smoke marijuana . Drinks 1 – 2 glasses once or twice a week.
Immunization History: Patient hasn’t received her flu shots for the season. However, up to date with most of her shots.
Health Maintenance: She has not seen her PCP in more than 2 years. Had a pap smear four years ago.She stopped taking her Metformin 3 years ago. She reports that she does not exercise nor do she follow a diabetic diet.
Significant Family History Mother has HTN, and High cholesterol
Father had HTN, DM and high cholesterol. Sister has asthma. Brother has no known diagnoses.
Grandfather died of colon cancer.
Assignment 2: Digital Clinical Experience (DCE): Health History Assessment NURS 6512N
Assignment 2 Digital Clinical Experience (DCE) Health History Assessment NURS 6512N
SUBJECTIVE DATA:
The patient is Tina Jones 28 years of age who came to the facility in regards to a scrape on her foot that is not healing as expected that she got due to an accident. She does not live alone but together with her sister and her mother. She is a student who is studying bachelor in accounting. Furthermore, she is working at company known as Mid- American Copy & Ship as a supervisor.
In terms of a relationship she does not have a boyfriend and reports she has not been sexually active for about 2 years. Apart from those she lives with her family further consists of a brother, a maternal grandmother and paternal grandparents. She lost her father due to a road accident and reports that her maternal grandfather also passed away.
Chief Complaint (CC): Pain on her foot due to a scrape that has persisted and won’t heal on its despite wound care.
History of Present Illness (HPI):
Patient has come into the facility due to a scrape on her foot that isn’t healing normally despite appropriate interventions and is also giving her pain. She ranks the pain at 7 out of a scale of 1-10 and reports the pain is aggravated by when she attempts to stand while her pain medication tramadol provides partial relief. The wound was a result of scrapping it on a cement step the previous week.
After that she did go to the emergency room and has been taking tramadol pills as part of pain management. Her wound care consists of using bandages together with neosprin. She is not able to engage in activities of daily living as before as her ability to walk has been impaired thus limiting her in tasks she could perform.
Medications:
90 micrograms inhaler taking 2 puffs per required need for asthma treatment
50 mgs tramadol taken orally two pills three times daily
Patient was prescribed metformin but is no longer compliant with that medication
Allergies:
Patient reports she is allergic to cats that causes wheezing, sneezing and itchy eyes
Patient reports she is allergic to dust that causes wheezing, sneezing and itchy eyes
Patient reports she is allergic to penicillin that in her childhood caused hives.
Past Medical History (PMH):
Patient reports she has been previously diagnosed with asthma
Patient reports she has been previously diagnosed with diabetes type 2
Patient reports she is not compliant with her diabetes medication that she last took 3 years ago and her management involves not taking sweets and diet soda.
Patient reports she does not regularly monitor her glucose levels.
Patient reports her last asthma attack was in high school.
Patient reports exacerbation 3 days ago
Patient reports she uses an inhaler for her asthma per required need.
Patient reports dust, cats and running up the stairs can trigger her asthma.
Past Surgical History (PSH):
Patient has not had a surgical procedure before.
Sexual/Reproductive History:
Patient reports her last sexual activity was about 2 years ago, she is not currently in a relationship and has had 3 previous sexual partners.
Patient reports not to be under any current form of contraception.
Patient reports previous condom and oral birth control use.
Personal/Social History:
Patient reports to take alcohol though when her friends are around.
Patient reports previous marijuana use that she no longer takes.
Patient reports an increase in appetite.
Patient reports not to have stress
Patient denies to take tobacco.
Patient denies caffeine consumption.
Immunization History:
Patient reports to have had all her childhood vaccines and is up to date with current vaccines she is supposed to take.
Health Maintenance:
Patient reports that she is no longer compliant with her diabetes medication and her management from the condition involves not taking sweets and drinking diet soda instead of regular.
Patient reports to manage her pain due to the scrape in her foot she takes
Assignment 2 Digital Clinical Experience (DCE) Health History Assessment NURS 6512N
tramadol pain pills and wound care that involves bandages applied with neosprin.
Patient reports asthma management that involves use of an inhaler per required need and staying away from her asthma triggers.
Significant Family History (Include history of parents, maternal/paternal Grandparents, siblings, and children):
Patient reports a family history of high cholesterol and high blood pressure from her parents, maternal as well as paternal grandparents.
Patient reports a family high history of diabetes that her father had.
Patient reports that her sister had been diagnosed with asthma
Review of Systems
General: Patient reports an occurrence of weight loss, fever and fatigue.
HEENT: Patient reports occasional headaches, blurry vision but reports no ear pain, nosebleeds or sore throat
Neck: Patient reports no neck problems
Breasts: Patients reports having regular breast exams with no problems noted.
Respiratory: Patient reports at the time no wheezing, chest tightness or pain while breathing.
Cardiovascular/Peripheral Vascular: Patient reports no palpitations or edema.
Gastrointestinal: Patient reports no nausea or vomiting.
Genitourinary: Patient reports increased urine frequency though no blood in the urine
Reproductive: Patient reports irregular periods.
Musculoskeletal: Patient reports no swelling of joints, no back pain and no pain in the joints
Psychiatric: Patient denies having suicidal ideations.
Neurological: Patient denies having seizures, tingling or feeling dizzy.
Skin: Patient reports having acne, dry skin at times, excessive hair in the body and moles.
Hematologic: Patient reports not having excessive bleeding.
Endocrine: Patient reports not having issues in her thyroid.
Initials: T.J.
Age: 22 years
Sex: female
Race: African American
Height: 170 cm.
Weight: 90 kg.
BMI: 31
Blood Pressure: 142/82 mmHg.
Random Blood Glucose: 238
Temperature: 101.1 F
Pulse: 86
Respiratory rate: 19
Saturation: 99% on room air.
SUBJECTIVE DATA:
Chief Complaint (CC): “ I got this scrape on my foot a while ago, and I thought it would heal up on its own, but now it’s looking pretty nasty. And the pain is killing me!”
History of Present Illness (HPI): T.J. is a 22-year-old African American female who presents to the clinic with complaints of pain for 1 week following a scrape on her foot. The pain is on the right foot as a result of a wound on the planter surface with a severity of 7/10. The pain is throbbing but becomes sharp on standing. It radiates to the ankle and has worsened over the past 2 days.
The pain has also prevented weight bearing on her right foot. T.J. scrapped her foot (barefooted) on a cement step a week ago sustaining the injury on her foot as well as a mild ankle injury. The wound bled a little. She went to the ER and an X-ray was done which showed no broken bones after which she was prescribed pain medications. However, she noticed pus draining from the wound 2 days ago.
The pus was yellow in color but no odor was noted from the wound. She reports cleaning the wound at home twice daily with hydrogen peroxide before applying topical bacitracin, neomycin, and polymyxin B (Neosporin). Currently, the pain is so severe that has affected her ability to walk, stand at work, and walk to class. Finally, she reports swelling, warmth, and redness around the wound.
Medications:
Tramadol PO 50 mg 3 times daily for 2 days ( last use this morning)
Albuterol inhaler 1-3 puffs as needed (last use 3 days ago)
Tylenol occasionally for headaches
Ibuprofen for cramps
Allergies: She is allergic to dust, cats, penicillin, and dust which triggers and exacerbates her asthma symptoms. Denies seasonal allergies, latex, and food allergies.
Past Medical History (PMH): She was diagnosed with type 2 diabetes at age of 24 years. She was prescribed metformin which she last took 3 years ago. She cites demands of medication compliance and side effects of metformin as central to her diabetes treatment noncompliance. Currently attempts lifestyle changes such as eating less sugary foods. Reports less frequent blood sugar monitoring. Her last glucose check was a week ago but does not recall the value.
She was diagnosed with asthma at the age of 2.5 years. She uses an albuterol inhaler for her asthma symptoms. Has had a total of five hospitalizations due to asthma during childhood and teenage years. Her last hospitalization was at the age of 16 years while her last asthmatic exacerbation was 3 days ago. She highlights cats, dust, and climbing stairs as triggers of her asthma symptoms. Denies past diagnosis of hypertension. Her last blood pressure reading was approximately 140/80 mmHg.
Past Surgical History (PSH): Denies previous surgeries or blood transfusion.
Sexual/Reproductive History: Her last menstrual period was 3 weeks ago. Her periods are irregular,
Assignment 2 Digital Clinical Experience (DCE) Health History Assessment NURS 6512N
appearing after every 6 weeks to 2 months. Her typical period lasts for 9 days. Reports heavy menstrual flow for up to 5 days during which she uses super absorbency tampons that she changes every 2 to 3 hours. She also reports heavy cramping during the initial days of her period for which she uses heat pads and ibuprofen for relief.
Heterosexual. Sexual debut at 18 years. Denies recent sexual activity although she was sexually active in the past 2 years. Has had 3 partners. Denies current use of contraceptives. However, she reports using oral contraceptives as well as condoms in the past. Denies current and past pregnancies.
Personal/Social History: She is currently in college and working towards obtaining an undergraduate degree in accounting. She stays with her mother and sister who help her with activities. She is currently under high stress. her last meal was dinner time the previous night and consisted of baked chicken and mashed potatoes.
Her typical breakfast is a muffin or pumpkin bread while her lunch is typically a sandwich. On the other hand, dinner is usually a home-cooked meat dish and vegetables. Finally, she takes pretzels or French fries for snacks. She reports habitual diet soda drinking (up to 4 per day) but denies caffeine intake or adding salt to food.
Reports a history of recreational marijuana smoking, last use at the age of 21 but stopped due to waning interest and health reasons. She takes alcohol although not more than 2 nights per week and no more than 3 alcoholic drinks per sitting. Her last alcohol use was 3 weeks ago. Denies vaping, smoking tobacco, or exposure to secondhand smoke.
Immunization History: Reports having received all her childhood vaccinations. Has not yet received her annual flu vaccine. The last tetanus vaccination was a year ago.
Health Maintenance: Denies finances and transportation as barriers to her access to healthcare services. Her last eye exam was in childhood. The last dental visit was several years ago. The last STI testing and pap smear test was 4 years ago. Denies STI symptoms or abnormal pap smear tests. However, she is uncertain about past partners and their STI testing.
Significant Family History: Her mother has hypertension and high cholesterol. Father died at the age of 58 years following a road traffic accident although he had hypertension, type 2 diabetes, and high cholesterol. Her paternal grandfather died of colon cancer although he had type 2 diabetes, high blood pressure, and high cholesterol. The Paternal grandmother has hypertension and high cholesterol.
Similarly, her maternal grandfather was diagnosed with hypertension and high cholesterol. Her maternal grandmother also has hypertension and high cholesterol. Her sister has asthma while her brother has not been diagnosed with any medical condition. However, all her family members are overweight. Her uncle has an alcohol use disorder. Finally, there is no family history of thyroid disorders and headaches.
Review of Systems
General: Reports fever, chills, occasional tiredness, and ordinary sleep patterns. Also, reports increased appetite and unintentional weight loss (10 lbs. over the past month). Denies night sweats
HEENT: Reports occasional headaches. Denies head injury, change in hearing, tinnitus, ringing, ear pain, or ear discharge. Reports episodes of blurry vision and infrequent itchy eyes. Denies use of corrective lenses, double vision, watery eyes, eye discharge, eye redness, eye pain, or dry eyes.
Reports infrequent runny nose. Denies nose bleeds, sinus pain, or alteration in smell sensation. Denies dental problems, gum bleeds, mouth pain, mouth sores, dry mouth, changes in taste sensation, tongue problems, or jaw concerns. Denies sore throat, swollen glands, lymph node problems, or voice changes.
Neck: Denies neck pain and general neck problems.
Breasts: Reports occasional breast exams. Denies nipple changes, nipple discharge, breast lumps, breast pain, and general breast conditions. Has not had a mammogram before.
Respiratory: Denies difficulty in breathing, wheezing, chest tightness, pain while breathing, or frequent coughing.
Gastrointestinal: Denies nausea, vomiting, abdominal pain, changes in bowel movements, heartburn, GERD, or indigestion. No diarrhea, constipation, blood in stool, flatulence, or bloating.
Genitourinary: Reports frequency, nocturia, and polyuria. Denies hematuria, flank pain, dysuria, incontinence, or bladder infection. Denies abnormal vaginal discharge.
Musculoskeletal: Denies muscle pain, joint pain, muscle weakness, joint swelling, back pain, or history of fractures.
Psychiatric: Denies anxiety, depression, hallucinations, delusions, suicidal thoughts, or mania.
Neurological: Denies vertigo, syncope, loss of consciousness, dizziness, lightheadedness, visual disturbances, tingling, loss of sensation, loss of coordination, memory loss, seizures, or balance issues.
Skin: Reports skin discoloration to the skin around the neck, moles, occasional dryness of skin, acne, and excessive facial and body hair. Denies dandruff, nail abnormalities, body sores, or skin rashes. Reports rarely using sunscreens.
Hematologic: Denies anemia, easing bruising or bleeding.
Endocrine: Reports polyuria, polyphagia, and polydipsia. Denies heat or cold intolerance.
A comprehensive health history is essential to providing quality care for patients across the lifespan, as it helps to properly identify health risks, diagnose patients, and develop individualized treatment plans. To effectively collect these heath histories, you must not only have strong communication skills, but also the ability to quickly establish trust and confidence with your patients. For this DCE Assignment, you begin building your communication and assessment skills as you collect a health history from a volunteer "patient." Photo Credit: Sam Edwards / Caiaimage / Getty Images
To Prepare
Review this week’s Learning Resources as well as the Taking a Health History media
program, and consider how you might incorporate these strategies. Download and review the Student Checklist: Health History Guide and the History Subjective Data Checklist, provided in this week's Learning Resources, to guide you through the necessary components of the assessment.
Access and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom. Review the Shadow Health Student Orientation media program and the Useful Tips and Tricks document provided in the week’s Learning Resources to guide you through Shadow Health. Review the Week 4 DCE Health History Assessment Rubric, provided in the Assignment submission area, for details on completing the Assignment. DCE Health History Assessment: Complete the following in Shadow Health: Orientation DCE Orientation (15 minutes) Conversation Concept Lab (50 minutes) Health History Health History of Tina Jones (180 minutes) Note: Each Shadow Health Assessment may be attempted and reopened as many times as necessary prior to the due date to achieve 80% or better, but you must take all attempts by the Week 4 Day 7 deadline. Submission and Grading Information No Assignment submission due this week but will be due Day 7, Week 4. Grading Criteria To access your rubric:
Assignment 2: Digital Clinical Experience (DCE): Health History Assessment NURS 6512N Week 4 Assignment 2 DCE Rubric
What's Coming Up in Module 3?
Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images In Module 3, you will examine advanced health assessments using a system focused approach. Next week, you will specifically explore how to assess the skin, hair, and nails, as well as how to evaluate abnormal skin findings while conducting health assessments. You will also complete your first Lab Assignment: Differential Diagnosis for Skin Conditions as well as complete your DCE: Health History Assessment in the simulation tool,
Shadow Health. Week 4 Required Media
Photo Credit: [fergregory]/[iStock / Getty Images Plus]/Getty Images Next week, you will need to view several videos and animations in Seidel’s Guide to Physical Examination as well as other media, as required, prior to completing your Lab Assignment. There are several videos in varied lengths. Please plan ahead to ensure you have time to view these media programs to complete your Assignment on time. Next Module
To go to the next module: Module 3
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Learning Resources
Required Readings (click to expand/reduce) Note: To access this week's required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus. Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel's guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby. Chapter 3, “Examination Techniques and Equipment” This chapter explains the physical examination techniques of inspection, palpation, percussion, and auscultation. This chapter also explores special issues and equipment relevant to the physical exam process.
Chapter 8, “Growth and Nutrition” In this chapter, the authors explain examinations for growth, gestational age, and pubertal development. The authors also differentiate growth among the organ systems.
Chapter 5, “Recording Information” (Previously read in Week 1) This chapter provides rationale and methods for maintaining clear and accurate records. The text also explores the legal aspects of patient records. Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Student checklist: Health history guide. In Seidel's guide to physical examination (9th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Seidel's Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center. Centers for Disease Control and Prevention. (2018). Childhood overweight and obesity. Retrieved from http://www.cdc.gov/obesity/childhood
This website provides information about overweight and obese children. Additionally, the website provides basic facts about obesity and strategies to counteracting obesity.
Chaudhry, M. A. I., & Nisar, A. (2017). Escalating health care cost due to unnecessary diagnostic testing. Mehran University Research Journal of Engineering and Technology, (3), 569.
This study explores the escalating healthcare cost due the unnecessary use of diagnostic testing. Consider the impact of health insurance coverage in each state and how nursing professionals must be cognizant when ordering diagnostics for different individuals.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.
Chapter 1, “Clinical Reasoning, Evidence-Based Practice, and Symptom Analysis”
This chapter introduces the diagnostic process, which includes performing an analysis of the symptoms and then formulating and testing a hypothesis. The authors discuss how becoming an expert clinician takes time and practice in developing clinical judgment.
Gibbs , H., & Chapman-Novakofski, K. (2012). Exploring nutrition literacy: Attention to assessment and the skills clients need. Health, 4(3), 120–124. This study explores nutrition literacy. The authors examine the level of attention paid to health literacy among nutrition professionals and the skills and knowledge needed to understand nutrition education.
Martin, B. C., Dalton, W. T., Williams, S. L., Slawson, D. L., Dunn, M. S., & Johns-Wommack, R. (2014). Weight status misperception as related to selected health risk behaviors among middle school students. Journal of School Health, 84(2), 116–123. doi:10.1111/josh.12128 Credit Line: Weight status misperception as related to selected health risk behaviors among middle school students by Martin, B. C., Dalton, W. T., Williams, S. L., Slawson, D. L., Dunn, M. S., & Johns-Wommack, R., in Journal of School Health, Vol. 84/Issue 2. Copyright 2014 by Blackwell Publishing. Reprinted by permission of Blackwell Publishing via the Copyright Clearance Center.
Noble, H., & Smith, J. (2015) Issues of validity and reliability in qualitative research . Evidence Based Nursing, 18(2), pp. 34–35.
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). History subjective data checklist. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Mosby’s Guide to Physical Examination, 7th Edition by Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2011 by Elsevier. Reprinted by permission of Elsevier via the Copyright Clearance Center.
This History Subjective Data Checklist was published as a companion to Seidel’s Guide to Physical Examination (8th ed.) by Ball, J. W., Dains, J. E., & Flynn, J.A. Copyright Elsevier (2015). From https://evolve.elsevier.com Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis. Chapter 2, "The Comprehensive History and Physical Exam" (Previously read in Week 1) Chapter 5, "Pediatric Preventative Care Visits" (pp. 91 101) Shadow Health Support and Orientation Resources Use the following resources to guide you through your Shadow Health orientation as well as other support resources: Frey, C. [Chris Frey]. (2015, September 4). Student orientation [Video file]. Retrieved from https://www.youtube.com/watch?v=Rfd_8pTJBkY Shadow Health. (n.d.). Shadow Health help desk. Retrieved from https://support.shadowhealth.com/hc/en-us Document: Shadow Health. (2014). Useful tips and tricks (Version 2) (PDF) Document: Shadow Health Nursing Documentation Tutorial (Word document) Document: Student Acknowledgement Form (Word document) Note: You will sign and date this form each time you complete your DCE Assignment in Shadow Health to acknowledge your commitment to Walden University’s Code of Conduct. Optional Resource LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.
Chapter 17, "Principles of Diagnostic Testing" Chapter 18, "Common Laboratory Tests" Required Media (click to expand/reduce)
Taking a Health History
How do nurses gather information and assess a patient’s health? Consider the importance of conducting an in-depth health assessment interview and the strategies you might use as you watch. (16m) Accessible player
SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
Chief Complaint (CC): A painful wound on the right foot.
History of Present Illness (HPI): An African American woman named Tina, 28, alleges that a week ago while walking, she stumbled over a concrete step and twisted her right ankle, scraping the ball of her foot in the process. She went to a neighboring emergency unit, where an X-ray was ordered and found to be negative. Tramadol was nonetheless provided to her to help with the discomfort.
She says she cleans the wound twice daily, applies antibiotic cream, and wraps it in a bandage. Even though the pain and swelling at the location of the injury have fully subsided, she claims that the bottom of her foot is still quite uncomfortable. She describes the discomfort as being weight-bearing, throbbing, and intense. But, the discomfort in her ankle has already subsided.
She continues to rate the pain as 7/10 even after a recent dose of tramadol. She gives the pain when bearing weight, a 9 out of 10. She describes a swollen football that has become redder over the last two days. A day before the current appointment, the wound was already dripping with an odorless discharge. She claims that recently, her shoes have been uncomfortable, so she has started wearing slippers instead.
Her fever was 1020F last night. She, though, denies having been unwell recently. She reports an increase in hunger and an unintentional 10-pound weight reduction over the past month. She asserts that her diet and energy levels have not changed.
Medications:
Ibuprofen 600mg orally three times each day for menstrual cramps.
Acetaminophen 500-100 mg orally, as needed for headaches.
Tramadol 50 mg orally twice a day if foot pain persists.
Albuterol 90mcg/spray multiple-dose inhalation up to two puffs every 6 hours for wheeze caused by cat allergies. She had last used the medication around three days before the current appointment.
Allergies:
There are no documented latex or food sensitivities.
Penicillin hypersensitivity
Establishes dust and cat allergies
Allergic reaction: runny nose, puffy and itchy eyes, and worsening asthma symptoms.
Past Medical History (PMH): At the age of two and a half years, was given an asthma diagnosis. Two to three times each week, she utilizes an Albuterol inhaler to control her symptoms when she is exposed to dust or cats. She was exposed to cats three days ago, and she used an inhaler, which was quite efficient in controlling the symptoms. She was hospitalized for asthma the last time she was in high school. She, on the other hand, denies ever being intubated.
When she was 24, she was diagnosed with diabetes mellitus. She had been taking metformin but had discontinued roughly three years ago because of flatulence adverse effects. She also reports that taking the tablets and checking her blood glucose simultaneously has been exhausting. She denies that she has been monitoring her blood glucose levels since then. She claims that the last time her levels of sugar in her blood soared was a week ago at the emergency department.
Past Surgical History (PSH): None
Sexual/Reproductive History: At the age of 11, she had her first menstrual cycle. heterosexual; first sexual experience occurred at the age of 18. denies ever becoming a mother. Menstrual cycles have been heavy and irregular in the last year, lasting 9 to 10 days every 4 to 8 weeks, with the most recent period starting around 3 weeks before the current appointment.
She acknowledges using oral contraceptives mostly in past, but she is now single. denies wearing condoms when engaging in sexual activity. No reported history of STIs. The patient claims to have never had an HIV/AIDS test before. Her previous pap smear exam was roughly four years ago, according to her.
Personal/Social History: The patient enjoys going to clubs and drinking alcohol on occasion. Her bachelor’s degree is in accountancy. She has a loving family and friends. There will be no cigarette or marijuana use. He goes to a Baptist church.
Immunization History: She had a tetanus booster last year. Her influenza vaccination is out of date. Her human papillomavirus vaccination was not given to her. She received her meningococcal vaccine when she was still attending college and believes she was immunized as a teenager.
Health Maintenance: No physical activity. She recalls her nutrition over the previous 24 hours. The day before the current visit, he claims to have skipped breakfast and had a lunch of a sandwich and chicken or steak for dinner. She brings mostly French fries or pretzels as snacks.
Smoke detectors have been put in her home. She admits to wearing a seatbelt in the automobile but denies riding a bike. He denies wearing sunblock. Her father’s firearms are still in the house, but they are locked up in their parents’ room.
Significant Family: The mother, who is 50, has high cholesterol. Her Father died in an automobile accident when he was 58 years old. Diabetes and hypertension were present. Her sister suffers from asthma. Brother has no medical issues. At the age of 73, her maternal granny passed away after a stroke.
At the age of 78, her maternal grandfather passed away after a stroke. At the age of 65, her paternal grandfather passed away from colon cancer. Her paternal grandmother is still living. There is no history of addiction, mental health problems, headaches, malignancies, or thyroid problems.
Review of Systems:
General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.
General: Tina is polite, friendly, and well-organized in general. She is also well-groomed, responds well to queries, and is not depressed.
HEENT: The patient complains of headaches when studying. He has impaired eyesight but does not use glasses. There is no runny nose or ear discharge. There is no swelling or painful throat.
Neck: There are no lymphatic problems or inflammation around the neck.
Breasts: There is no nipple discharge or soreness in the breasts.
Respiratory: No breathlessness, chest pain, or tightness.
Cardiovascular/peripheral: There are no blood clots in the cardiovascular or peripheral systems.
Gastrointestinal: No constipation, bowel disturbances, or watery stools. The patient feels thirsty and has an increased appetite.
Gastrointestinal: No bowel changes, constipation, or watery stool. The patient has an increased appetite and is thirsty.
Genitourinary: The patient’s periods are irregular.
Musculoskeletal: No back or muscular discomfort. Psychiatric: There are no signs of depression or hallucinations.
Neurological: There is no tingling or dizziness.
Skin: Acne-free skin with no chin hair.
Hematologic: There is no history of significant bleeding in the patient. There is no sweating, shivers, or fever.
Endocrine: Denies heat or cold intolerance.
Assignment 2: Digital Clinical Experience (DCE): Health History Assessment NURS 6512N Rubric
Description: Note: To complete the Shadow Health assignments it is helpful to use the text and follow along with each chapter correlating to the area of assessment to assist in covering all the subjective questions. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Week 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to assist with narrative documentation of the assessments. Do not copy any sample documentation as this is plagiarism. Shadow Health exams may be added to or repeated as many times as necessary prior to the due date to assist in achieving the desired score. You must pass this assignment with a total cumulative score of 79.5% or greater in order to pass this course.
I totally agree with you that there has been a lot of changes in the healthcare field resulting from patients becoming more involved in their care and not just being receivers of care. It is true that many healthcare providers are not 100% competent in cultural assessment due to new cultures as well as the rapid changes among different cultures.
The important thing for the providers is to acknowledge and respect all the cultures and try to understand them. Providers can genuinely ask their patient to clarify to them about their culture which to a patient can make a lot of difference knowing that their provider is willing to understand more about them and their culture. Your patient being a transgender as well as being HIV positive according to (Erickson, et al 2022) have been reported to experience a range of social inequities and barriers to optimal health which is heightened by gender-based violence and trauma in the society.
These experiences have been known to lead into PTSD and other mental health conditions. These patients have been known to not comply with their antiretroviral drugs which is detrimental to them. Other areas that have been studied recently have shown front line staff continues to lack knowledge regarding transgender patients in terms of using the right pronouns. According to (Toman,2019) many staff at different facilities have been witnessed making derogatory comments towards patients of the LGBTQ community instead of trying to understand and respect them of their choices. Great pos
CASE STUDY 1
John Green, a 33-year-old Caucasian male, presents to the office to establish himself as a new patient. John’s natal sex is female, but he identifies as a male. He transitioned from female to male 2 years ago. He has made a full transition with family and socially last year. He just moved back home and is unemployed at this time. He has been obtaining testosterone from the internet to give to himself.
He has not had any health care since he decided to change other than getting his suppression medications through Telehealth 3 months ago. His past medical history includes smoking 2 packages of cigarettes per day for the last 10 years, smoking 3-6 marijuana joints every weekend (he has an active green card), and does suffer from depressive episodes. He has been HIV positive for the last 3 years but remains virally suppressed at his last blood draw 6 months ago. He has been feeling very weak over the last few weeks, which prompted him to move back home with his parents.
He takes Biktarvy once daily, which comes in the mail for free, tolerates it well, and 100 mg Testosterone IM every 7 days. His PMH is non-contributory. No past medical history. He has never been married. No significant family history. He is worried since moving back home and unemployed, he will be a burden on his family, and he thinks his health may be declining.
Cultural competence enables nurses to care for patients from diverse backgrounds. Culturally competent nurses respond to unique patient needs from various spiritual and cultural settings (Centers for Disease Control and Prevention, 2020). To demonstrate cultural competence, this assessment will examine the social-economic and cultural factors to consider when examining the patient John Green, a 33-year old Caucasian male who presents to the office as a new client.
Socio-economic factors
The specific socioeconomic factors for the patient include; gender identity and lack of employment. Gender is a critical factor that can occasionally be misunderstood in healthcare delivery. In this case, the healthcare providers must understand and respect the patient’s gender identity. The fact that the patient transitioned his gender identity with family and socially indicated some acceptance levels and a reason why the healthcare providers should not interfere with such an identity (Centers for Disease Control and Prevention, 2020).
Additionally, a lack of employment could limit the patient’s ability to access healthcare services. John moved back home and is unemployed, but he still needs to obtain testosterone from the internet to give himself. Unemployment could be associated with financial constraints and high dependence on other people. The patient is worried that he will become a burden to the family. Also, John has not had health care since changing their identity.
The lifestyle factors include smoking, which could expose him to other health issues. Spiritually, John is depressed, and this could be associated with a limited social circle and spiritual nourishment. People with queer gender are most likely to be isolated from the rest of the communities due to their unique sexual orientation or identity.
Furthermore, the cultural factors include the unique cultural patterns linked with LGBTQ (Centers for Disease Control and Prevention, 2020). Healthcare providers must understand the unique cultural attributes associated with the LGBTQ communities and how they impact their health decisions, willingness to seek healthcare services and lifestyle.
Issues to be Sensitive about when Interacting with the Patient
The key issue to be sensitive about when interacting with the patient is sexual identity. In this case, it may not be appropriate to recognize the patient based on their biological sexual identities. Instead, it will be recommended to ask them about their preferred sexual identity or salutation. In addition, healthcare providers should be sensitive when discussing HIV/AIDs status with patients.
Some patients are likely to be stigmatized and unwilling to discuss their status. Especially the LGBTQ populations are likely to be sensitive to such discussion, considering that they may be seen as immoral and promiscuous. The areas are sensitive because of the possible conflicts due to the misunderstanding and drastically diverging values between the patient and the healthcare providers.
Effective interaction between the patient and the healthcare providers requires situational awareness and understanding of the patient’s needs. In this case, healthcare providers should be open to understanding patients’ needs and responding to them without prejudice or discrimination. The following questions will be important and appropriate for the interview session.
Five Targeted Questions
Would you tell me more about your gender identity?
What is your experience now having changed your gender identity, and how has this impacted your interactions with other people?
Have you ever encountered any challenges seeking healthcare services?
Do you think smoking cigarettes and marijuana affects your health status in any way?
Could you be willing to help me understand when you started feeling depressed moods?
The questions will help understand the patient’s health risks and medical history for effective management (Ball et al., 2019). The language and tone framing the interview questions are friendly and encourage the patient to open up and present his views without fear.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Tinea barbae is an infection of the superficial dermatophyte that occurs on the bearded areas of the face and neck. It occurs almost solely in older adolescents and adult males (Kuruvella & Pandey, 2021). It most often affects farmers due to contact with an infected animal since a zoophilic organism causes it. Tinea barbae presents with a characteristic lesion, an inflammatory red nodule with pustules, and draining sinuses on the surface (Kuruvella & Pandey, 2021). The beard hairs are usually loose or broken, and removing the hair is easy and painless.
The pus-filled white masses affect the hair root and follicle (Singh et al., 2017). Tinea barbae is a priority differential diagnosis based on the patient’s findings of inflamed and red lumpy areas on the lower beards and red pustules with crusting around the beard hairs. Besides, the patient’s beard hairs are broken and easily plucked. The patient could have contracted the infection from an infected animal at the ranch. A direct microscopy culture will help in confirming the diagnosis.
Bacterial Folliculitis
Bacterial folliculitis is an inflammation of the hair follicle caused by infection, physical injury, or chemical irritation. It is primarily caused by Staphylococcus aureus (Jappa & Sameer, 2018). Bacterial folliculitis mostly occurs in skin areas exposed to occlusion, rubbing, and sweating, including the face, neck, axillae, and buttocks (Lin et al., 2018). Persons with superficial folliculitis usually have an acute onset that occurs with pruritus or mild discomfort.
Deep folliculitis typically has longer-standing lesions, and patients frequently report pain and, at times, suppurative drainage. Recurrent lesions can cause scarring and permanent hair loss. Superficial folliculitis presents with many small papules and pustules on an erythematous base pierced by a central hair, although the hair is not always visualized (Jappa & Sameer, 2018). Folliculitis is a differential diagnosis based on patient symptoms of pruritus and mild pain on the beard and pustules and crusting on an erythematous base.
Pseudofolliculitis Barbae:
Pseudofolliculitis barbae is a form of folliculitis involving the beard area. It is caused by infection with Staphylococcus aureus. It is a chronic inflammatory condition of follicular and perifollicular skin (Ogunbiyi, 2019). I presents with pustules, papules, and post-inflammatory hyperpigmentation. It occurs mostly in males of African and Asian descent. Patients report experiencing a painful eruption of acne after shaving (Ogunbiyi, 2019). It presents with an erythematous papule having a hair shaft in its center. The patient’s symptoms consistent with pseudofolliculitis barbae include pustules and erythematous at the beard area.
Reflection
The clinical experience has enlightened me on dermatological conditions affecting the beard area. I have learned that various bacteria or fungal infections can cause the conditions. Besides, I learned that the clinician should be keen during the examination to differentiate if a patient has papules (pimples with no visible pus) or pustules (pus-filled pimples), which helps differentiate the dermatological condition. If I were to repeat the assessment, I would perform a culture to identify the specific causative microbe.
References
Jappa, L. S., & Sameer, R. K. (2018). A clinical and bacteriological study of bacterial folliculitis. Panacea Journal of Medical Sciences, 8(2), 54-58. https://doi.org/10.18231/2348-7682.2018.0014
Kuruvella, T., & Pandey, S. (2021). Tinea Barbae. StatPearls [Internet].
Lin, H. S., Lin, P. T., Tsai, Y. S., Wang, S. H., & Chi, C. C. (2018). Interventions for bacterial folliculitis and boils (furuncles and carbuncles). The Cochrane Database of Systematic Reviews, 2018(8), CD013099. https://doi.org/10.1002/14651858.CD013099
Ogunbiyi, A. (2019). Pseudofolliculitis barbae; current treatment options. Clinical, cosmetic and investigational dermatology, 12, 241–247. https://doi.org/10.2147/CCID.S149250
Singh, S., Sondhi, P., Yadav, S., & Ali, F. (2017). Tinea barbae presenting as kerion. Indian journal of dermatology, venereology, and leprology, 83(6). https://doi.org/10.4103/ijdvl.IJDVL_1104_16
Review of Systems
General: Patient reports an occurrence of weight loss, fever and fatigue.
HEENT: Patient reports occasional headaches, blurry vision but reports no ear pain, nosebleeds or sore throat
Neck: Patient reports no neck problems
Breasts: Patients reports having regular breast exams with no problems noted.
Respiratory: Patient reports at the time no wheezing, chest tightness or pain while breathing.
Cardiovascular/Peripheral Vascular: Patient reports no palpitations or edema.
Gastrointestinal: Patient reports no nausea or vomiting.
Genitourinary: Patient reports increased urine frequency though no blood in the urine
Reproductive: Patient reports irregular periods.
Musculoskeletal: Patient reports no swelling of joints, no back pain and no pain in the joints
Psychiatric: Patient denies having suicidal ideations.
Neurological: Patient denies having seizures, tingling or feeling dizzy.
Skin: Patient reports having acne, dry skin at times, excessive hair in the body and moles.
Hematologic: Patient reports not having excessive bleeding.
Endocrine: Patient reports not having issues in her thyroid.
Digital Clinical Experience (DCE): Health History Assessment
In Week 3, you began your DCE: Health History Assessment. For this week, you will complete this Health History Assessment in your simulation tool, Shadow Health and finalize for submission.
Resources
Be sure to review the Learning Resources before completing this activity. Click the weekly resources link to access the resources.
Review this week’s Learning Resources as well as the Taking a Health History media program in Week 3, and consider how you might incorporate these strategies. Download and review the Student Checklist: Health History Guide and the History Subjective Data Checklist, provided in this week’s Learning Resources, to guide you through the necessary components of the assessment.
Review the DCE (Shadow Health) Documentation Template for Health History found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
Access and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom.
Review the Shadow Health Student Orientation media program and the Useful Tips and Tricks document provided in the week’s Learning Resources to guide you through Shadow Health.
Review the Week 4 DCE Health History Assessment Rubric, provided in the Assignment submission area, for details on completing the Assignment.
Note: There are 2 parts to this assignment – the lab pass and the documentation. You must achieve a total score of 80% in order to pass this assignment. Carefully review the rubric and video presentation in order to fully understand the requirements of this assignment.
DCE Health History Assessment:
Complete the following in Shadow Health:
Orientation
DCE Orientation (15 minutes)
Conversation Concept Lab (50 minutes, Required)
Health History
Health History of Tina Jones (180 minutes)
Note: Each Shadow Health Assessment may be attempted and reopened as many times as necessary prior to the due date to achieve a total of 80% or better (this includes your DCE and your Documentation Notes), but you must take all attempts by the Week 4 Day 7 deadline.
submission information
Complete your Health Assessment DCE assignments in Shadow Health via the Shadow Health link in Canvas.
Once you complete your assignment in Shadow Health, you will need to download your lab pass and upload it to the corresponding assignment in Canvas for your faculty review.
Complete your documentation using the documentation template in your resources and submit it into your Assignment submission link below.
To submit your completed assignment, save your Assignment as WK4Assgn2+last name+first initial.
Then, click on Start Assignment near the top of the page.
Next, click on Upload File and select both files and then Submit Assignment for review.
Note: You must pass this assignment with a minimum score of 80% in order to pass the class. Once submitted, there are not any opportunities to revise or repeat this assignment.
By submitting this assignment, you confirm that you have complied with Walden University’s Code of Conduct including the expectations for academic integrity while completing the Shadow Health Assessment.
Student DCE score(DCE percentages will be calculated automatically by Shadow Health after the assignment is completed.)Note: DCE Score – Do not round up on the DCE score.
Points Range: 56 (56%) – 60 (60%)
DCE score>93
Points Range: 51 (51%) – 55 (55%)
DCE Score 86-92
Points Range: 46 (46%) – 50 (50%)
DCE Score 80-85
Points Range: 0 (0%) – 45 (45%)
DCE Score <79
No DCE completed.
Subjective Documentation in Provider NotesSubjective narrative documentation in Provider Notes is detailed and organized and includes:Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS)ROS: covers all body systems that may help you formulate a list of differential diagnoses. You should list each system as follows: General: Head: EENT: etc.You should list these in bullet format and document the systems in order from head to toe.
Points Range: 36 (36%) – 40 (40%)
Documentation is detailed and organized with all pertinent information noted in professional language.
Documentation includes all pertinent documentation to include Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).
Points Range: 31 (31%) – 35 (35%)
Documentation with sufficient details, some organization and some pertinent information noted in professional language.
Documentation provides some of the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).
Points Range: 26 (26%) – 30 (30%)
Documentation with inadequate details and/or organization; and inadequate pertinent information noted in professional language.
Limited or/minimum documentation provided to analyze students critical thinking abilities for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).
Points Range: 0 (0%) – 25 (25%)
Documentation lacks any details and/or organization; and does not provide pertinent information noted in professional language.
No information is provided for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).
or
No documentation provided.
Total Points: 100
Assignment 2: Digital Clinical Experience (DCE): Health History Assessment NURS 6512N Rubric
Description: Note: To complete the Shadow Health assignments it is helpful to use the text and follow along with each chapter correlating to the area of assessment to assist in covering all the subjective questions. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Week 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to assist with narrative documentation of the assessments. Do not copy any sample documentation as this is plagiarism. Shadow Health exams may be added to or repeated as many times as necessary prior to the due date to assist in achieving the desired score. You must pass this assignment with a total cumulative score of 79.5% or greater in order to pass this course.
SUBJECTIVE DATA:
Chief Complaint (CC): ‘My right foot hurts’
History of Present Illness (HPI): The patient in the case study comes to the clinic with complains of a painful, swollen, red, warm scrape on her right foot for the last two days. The patient thought it would heal on its own but has been worsening over time. The patient reports that the pain worsened over the last two days. The patient sustained the injury a week ago while going down the back steps when she tripped and twisted her ankle. She also scrapped her foot on the edge of the step. The patient went to the ER an hour after falling because of the strained ankle. The x-ray performed was normal. She was prescribed pain medications. The patient rates the pain 7/10 in the pain rating scale. She reports that the scrape is infected and worsening. The patient describes the pain as throbbing. It is associated with sharp pain when weight is applied.
The pain radiates to the ankle. The patient reports that the affected foot is non-weight bearing. The patient reports that the wound drains pus, white in color, for the last two days. She has been treating the wound at home by cleaning twice daily and bandaging it. She has been cleaning it with soap, water, and some peroxide if irritated. She has also been applying Neosporin ointment twice daily. The problem has affected her functioning ability since she has missed her work because of the pain. She has also missed her class two days ago. Besides the current problem, she reports losing 10 pounds unintentionally, being thirsty, experiencing oliguria and polyphagia for the past month.
Medications: She currently uses Proventil inhaler if symptoms of asthma persist. She last used her inhaler three days ago. She is prescribed two puffs of inhaler, but at times needs three puffs for symptom management.
Allergies: She develops asthma symptoms when she is near cats. She is also allergic to dust and develops asthma symptoms with intensive physical activity. She is also allergic to penicillin.
Past Medical History (PMH): The patient was diagnosed with diabetes type 2 at the age of 24 years. She is also asthmatic since the age of two and half years. Her last asthmatic attack was when she was in high school. She developed breathing problems three days ago at her cousin’s place. She has a history of using Metformin, which she took it three years ago. The patient has history of five hospitalizations when she was 16 years because of asthma.
She has a history of using nebulizer. She manages asthma by avoiding triggers but uses Proventil inhaler if symptoms persist. She last used her inhaler three days ago. She is prescribed two puffs of inhaler, but at times needs three puffs for symptom management. She has also been using tramadol 100 mg three times a day for pain for the last two days. She takes Advil when her cramps het bad and Tylenol for headache.
Past Surgical History (PSH): The patient denies any history of surgeries
Sexual/Reproductive History: The patient denies history of sexually transmitted infections
Personal/Social History: The patient is a student currently finishing her bachelor’s degree in accounting. She lives with her mother and her sister. She is worried about her right foot. The patient denies barriers in accessing healthcare. Her family and church are her social support systems.
Immunization History: The patient believes that she received her childhood immunizations. She did not get her flu shot this year. Her tetanus booster was a year ago.
Health Maintenance: The patient reports that she started watching her sugar and avoiding regular soda after she found out that she is diabetic. She only drinks diet coke. She rarely checks her sugars, with the last time being a month ago. She does not understand the meaning of blood glucose numbers. She rarely checks her blood pressure. She stopped taking Metformin because of its side effects and feeling overwhelmed remembering to take the pills and checking her blood sugar. Her typical breakfast comprises muffin or pumpkin bread obtained from a nearby café. Her typical lunch is a meal she usually picks from a nearby campus or subway to get turkey sandwich.
Her typical dinner is meatloaf, pasta, casseroles, and chicken. Her typical snacks include pretzels and French fries. She does not pay attention to the amount of salt she eats. She drinks about four-diet coke daily. She last took alcohol three weeks ago. She drinks alcohol once or twice a week during night outs. She is exposed to second-hand smoke from her friends. Her last eye and dental examination was when she was a child. She reports doing self-breast examination a couple times. She has never undergone mammography.
Significant Family History: Her mother has high cholesterol and diabetes. Her deceased father had type 2 diabetes, high cholesterol, and hypertension. Grandfather had colon cancer, diabetes, and hypertension. Paternal grandmother has high cholesterol and hypertension. Her sister is asthmatic. Her brother and father are overweight. Her uncle has alcohol addiction problem.
Review of Systems:
Vital signs: Height 170 cm, weight 90kg, BMI 31, Random blood glucose 238, Temperature 101.1F, O2 saturation 99%
General: The patient reports fatigue, fever and chills last night. She denies night sweat or suicidal thoughts.
HEENT: She denies headache, head injuries, changes in hearing, ringing ears, ear pain, and ear discharge. She denies changes in vision, double vision, itchy eyes, watery eyes, and dry eyes. She reports eye pain when she reads for too long. She reports occasional rhinorrhea. She denies sinus pain, changes in sense of smell, nosebleeds, or dental problems. She denies changes in sense of taste, dry mouth, mouth pain, mouth sores, or tongue problems.
Neck: She denies dysphagia, sore throat, lymphadenopathy, voice changes, or neck pain.
Breasts: She denies breast problems, such as pain, lumps, nipple changes, or nipple discharge.
Respiratory: The patient denies wheezing, chest tightness, dyspnea, cough, or chest pain.
Cardiovascular/Peripheral Vascular: The patient denies palpitations, easy bruising, edema, circulation problems, or vascular diseases.
Gastrointestinal: The patient denies nausea, vomiting, stomach pain, changes in bowel movements, heartburn, constipation or diarrhea.
Genitourinary: The patient denies dysuria, urgency, frequency, or history of sexually transmitted infections.
Musculoskeletal: The patient reports right ankle sprain, which is non-weight bearing. She denies fractures.
Psychiatric: The patient denies depression, anxiety, or stress.
Neurological: The patient denies ataxia, numbness, tingling, loss of balance, and difficulties in coordinating movement.
Skin: The patient denies rash. She reports swollen right foot with a wound draining pus.
Hematologic: The patient denies easy bruising or prolonged bleeding
Endocrine: The patient denies heat or cold intolerance. She reports unintentional weight loss, polydipsia, polyphagia, and polyuria.
Subjective Data Collection: 100 of 100 (100.0%)
Hover To Reveal…
Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
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.
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.
Chief Complaint
Finding:
Established chief complaint
Finding:
Reports pain
(Found)
Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.
Example Question:
How severe is the pain?
Finding:
Reports foot wound
(Found)
Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.
Example Question:
What’s causing your pain?
History of Present Illness
Finding:
Asked to rate current pain level on a scale
Finding:
Reports current pain is 7/10
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Can you rate the pain on a scale of 0 to 10?
Finding:
Asked for details about the pain
Finding:
Reports pain is throbbing
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Can you please describe the pain?
Finding:
Reports pain is sharp when she attempts to stand
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
What is the pain like when you stand on your foot?
Finding:
Reports pain has increased in the past 2 days
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
How has the pain changed over time?
Finding:
Reports feeling pain radiating into ankle
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Does the pain radiate anywhere else?
Finding:
Reports pain prevents bearing weight on foot
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Can you bear weight on your foot?
Finding:
Asked location of wound
Finding:
Reports right foot is injured
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Which foot is in pain?
Finding:
Reports wound is on the plantar surface of her foot
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Where is the wound?
Finding:
Asked details of the injury
Finding:
Reports she scraped foot on a cement step
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
How did your injury happen?
Finding:
Reports initial injury occurred 1 week ago
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
When did the pain start?
Finding:
Reports mild ankle injury
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Did you injure anything besides your foot?
Finding:
Reports being barefoot at the time of injury
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Were you wearing shoes when you fell?
Finding:
Asked about the assessment of the injury at the ER
Finding:
Reports going to the ER after sustaining the injury
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
When did you go to the ER?
Finding:
Reports going to the ER because she suspected an ankle sprain
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Why did you go to the ER?
Finding:
Reports receiving an X-ray at the ER
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Did they xray your foot at the ER?
Finding:
Reports X-ray showed no broken bones
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
What did the x-ray show?
Finding:
Reports receiving a prescription for pain pills
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Did you receive any pain medications at the ER?
Finding:
Asked about drainage from the foot wound
Finding:
Reports that the wound bled a little after sustaining the injury
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Did your foot bleed?
Finding:
Reports seeing pus draining from wound
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Did you notice any discharge from the wound?
Finding:
Reports noticing pus 2 days ago
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
When did you first notice the pus?
Finding:
Followed up on drainage
Finding:
Reports pus as white or yellow
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
What color is the drainage from your wound?
Finding:
Denies odor from the wound
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Does the wound have an odor?
Finding:
Asked about home treatment of foot wound
Finding:
Reports wound care regimen of bandaging
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
How did you treat your foot at home?
Finding:
Reports cleaning wound twice a day
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
How often did you clean the wound?
Finding:
Reports cleaning wound with hydrogen peroxide
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
What did you use to clean the wound?
Finding:
Reports applying bacitracin, neomycin and polymyxin B (Neosporin)
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Did you use any ointment on the wound?
Finding:
Asked about other foot wound symptoms
Finding:
Reports swelling around foot wound
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Is there swelling around the wound?
Finding:
Reports swelling worsened in the past 2 days
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
How long have you noticed swelling around the wound?
Finding:
Reports redness around the wound
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Did you notice any redness around the wound?
Finding:
Reports that the wound feels warm
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Does the wound feel warm?
Finding:
Explored impact of patient’s foot injury on activities of daily living
Finding:
Reports pain affects ability to walk
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Does your injury impact your ability to walk?
Finding:
Reports pain affects ability to stand at work for long periods of time
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Does your foot pain affect your work?
Finding:
Reports pain prevented her from being able to walk to class
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Has your injury prevented you from going to class?
Past Medical History
Finding:
Asked about preexisting medical conditions
Finding:
Reports diabetes
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Do you have diabetes?
Finding:
Reports asthma
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Do you have asthma?
Finding:
Followed up on diabetes diagnosis
Finding:
Reports specific age of diagnosis was 24
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
At what age were you diagnosed with diabetes?
Finding:
Reports that her diabetes is Type 2
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Do you know what type of diabetes you have?
Finding:
Asked about diabetes management through lifestyle changes
Finding:
Reports staying away from sweets
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Tell me more about any sugars you consume.
Finding:
Reports drinking diet soda instead of regular
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Do you drink sugary drinks?
Finding:
Asked about current diabetes medication use
Finding:
Reports that she does not currently take medication for diabetes
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Do you take prescribed medication for your diabetes?
Finding:
Asked about past diabetes medication use
Finding:
Reports that she used to take diabetes medication
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Have you ever taken medication for your diabetes?
Finding:
Reports previous medication was prescription metformin
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Do you remember what you were prescribed for diabetes?
Finding:
Reports last use of medication was 3 years ago
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
When was the last time you took your diabetes medication on a regular basis?
Finding:
Asked about blood glucose monitoring
Finding:
Reports infrequent blood glucose monitoring
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Tell me about your blood sugar monitoring.
Finding:
Reports last glucose check was a week ago at the ER
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
How often do you check your blood sugar?
Finding:
Reports confusion about what the numbers mean
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
What are your usual blood sugar levels?
Finding:
Asked about thirst
Finding:
Reports increased thirst
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Have you been more thirsty lately?
Finding:
Reports increased water intake
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Are you drinking more water than normal?
Finding:
Asked about frequency of urination
Finding:
Reports more frequent urination
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Have you been urinating more often than usual?
Finding:
Reports urinating every hour or two during the day
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
How often do you urinate during the day?
Finding:
Reports urinating 2 to 3 times during the night
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
How often do you wake up at night to urinate?
Finding:
Asked about change in appetite
Finding:
Reports increased appetite
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Have you noticed an increase in appetite?
Finding:
Reports change in appetite began a month ago
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
When did you notice the increase in your appetite?
Finding:
Asked about weight change
Finding:
Reports recent loss of 10 lbs
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
How much weight have you lost?
Finding:
Reports weight loss occurred over the past month
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
How long did it take you to lose 10 pounds?
Finding:
Followed up on reason for weight change
Finding:
Reports weight loss was unintentional
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Was your weight loss intentional?
Finding:
Asked about history of asthma exacerbations
Finding:
Reports last asthma attack was in high school
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
When was your last asthma attack?
Finding:
Reports last exacerbation was three days ago
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
When did you last have issues with asthma?
Finding:
Asked about asthma symptoms
Finding:
Reports chest tightness during exacerbation
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
What do your asthma symptoms feel like?
Finding:
Reports difficulty breathing during exacerbation
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Do you have trouble breathing?
Finding:
Reports wheezing during exacerbation
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Do you ever wheeze?
Finding:
Asked about prior hospitalizations
Finding:
Reports past hospitalizations
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Have you been hospitalized in the past?
Finding:
Reports last hospitalization was for asthma
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Why were you hospitalized last time?
Finding:
Reports last hospitalization was age 16
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
When was your last hospitalization?
Finding:
Reports about 5 total hospitalizations for asthma as a child and teen
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
How many times have you been hospitalized?
Finding:
Reports past nebulizer use
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Have you ever used a nebulizer?
Finding:
Asked about asthma diagnosis
Finding:
Reports specific age of diagnosis is 2.5 years old
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
At what age were you diagnosed with asthma?
Finding:
Asked about asthma management
Finding:
Reports using an inhaler
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
How do you manage your asthma?
Finding:
Reports inhaler is albuterol (Proventil)
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
What is the name of the inhaler prescription?
Finding:
Reports last use of inhaler was 3 days ago
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
When did you last use your inhaler?
Finding:
Reports using inhaler no more than 2 times per week
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
How often do you use your inhaler?
Finding:
Asked about number of puffs when using asthma inhaler
Finding:
Reports recommended dose is 1-3 puffs as needed
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
How many puffs of your inhaler are you prescribed?
Finding:
Reports typically taking 2 puffs
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Does your inhaler effectively relieve your symptoms?
Finding:
Reports sometimes needing 3 puffs to control symptoms
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
What’s the most puffs you ever take?
Finding:
Asked about asthma triggers
Finding:
Reports asthma triggered by cats
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
What triggers your asthma problems?
Finding:
Reports asthma triggered by dust
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Does dust trigger your asthma?
Finding:
Reports asthma triggered by running up stairs
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Does physical activity trigger your asthma?
Finding:
Denies seasonal triggers
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Do you have seasonal asthma triggers?
Finding:
Asked about general allergies
Finding:
Reports allergy to cats
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
What allergies do you have?
Finding:
Followed up on cat allergy symptoms
Finding:
Reports sneezing, itchy eyes, and wheezing
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
What is your reaction to cats?
Finding:
Asked about latex allergy
Finding:
Denies latex allergy
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Are you allergic to latex?
Finding:
Asked about medication allergies
Finding:
Reports penicillin allergy
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
What medication allergies do you have?
Finding:
Asked about penicillin reaction
Finding:
Reports that penicillin resulted in hives in childhood
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
What is your reaction to penicillin?
Finding:
Asked about food allergies
Finding:
Denies food allergies
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Do you have any food allergies?
Finding:
Asked if the patient has allergies to dust, mold, or pollen
Finding:
Reports reaction to dust
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Do you have any reaction to dust?
Finding:
Reports dust causes sneezing, itchy eyes, and wheezing
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Do you have any environmental allergies?
Finding:
Denies seasonal allergies
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Do you have any seasonal allergies?
Finding:
Asked about general immunizations received
Finding:
Reports being up to date on shots
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Are your immunizations current?
Finding:
Asked about childhood immunizations
Finding:
Reports receiving all necessary childhood immunizations
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Did you receive childhood vaccinations?
Finding:
Asked if the patient has received a flu vaccine
Finding:
Denies receiving annual flu vaccine
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Did you get a flu shot this year?
Finding:
Asked if the patient received a tetanus immunization
Finding:
Reports last tetanus vaccination was in the past year
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
When was your last tetanus booster?
Finding:
Asked about hypertension
Finding:
Denies past diagnosis of hypertension
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Have you ever been diagnosed with hypertension?
Finding:
Reports that last BP reading was 140 over 80 or 90
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
What is your usual blood pressure?
Finding:
Denies checking BP regularly
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
How often do you check your blood pressure?
Home Medications
Finding:
Asked about use of pain medication
Finding:
Reports taking prescription pain medication
(Available)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
Have you taken any prescription pain medications?
Finding:
Reports medication is tramadol
(Available)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
What is the name of the pain medication?
Finding:
Followed up on pain medication frequency
Finding:
Reports taking pain medication for 2 days
(Available)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
How many days have you needed pain medication?
Finding:
Reports taking tramadol 3 times a day
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
How many times a day do you take pain medication?
Finding:
Reports last dose was this morning
(Available)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
When was your last dose of pain medication?
Finding:
Followed up on pain medication dose
Finding:
Reports dosage is 50 mg
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
What is the dose of the pain medication?
Finding:
Reports taking 2 pills each time
(Available)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
How many pain pills do you take at a time?
Finding:
Followed up on efficacy of pain medication
Finding:
Reports that pain pills provide partial relief
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
How effective is the pain medication?
Finding:
Reports pain returns in full every few hours
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
How long does the pain medication last?
Finding:
Asked about other prescription medications
Finding:
Reports a prescription inhaler
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
What prescription medications do you take?
Finding:
Asked about use of OTC medication
Finding:
Reports occasionally taking Advil (ibuprofen) for cramps
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
Do you take any over the counter medications?
Finding:
Reports occasionally taking Tylenol (acetaminophen) for headaches
(Available)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
Do you take any over the counter medications?
Finding:
Denies vitamin supplements
(Available)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
Do you take any vitamins?
Finding:
Denies herbal supplements
(Available)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
Do you take any herbal supplements?
Social Determinants of Health
Finding:
Asked about access to healthcare
Finding:
Denies finances are a barrier to healthcare
(Found)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.
Example Question:
Do you have trouble affording healthcare?
Finding:
Denies transportation is a barrier to healthcare
(Available)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.
Example Question:
Is transportation a barrier to your healthcare?
Finding:
Followed up on diabetes noncompliance
Finding:
Reports that she got sick of the demands of medication compliance
(Found)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.
Example Question:
Why aren’t you taking your diabetes medication?
Finding:
Reports disliking metformin side effects
(Available)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.
Example Question:
Did the metformin cause any side effects?
Finding:
Reports disliking checking blood glucose
(Found)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.
Example Question:
What’s preventing you from taking your diabetes medication?
Finding:
Denies that cost of metformin was reason for discontinuing medication
(Available)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.
Example Question:
Did you have problems affording the diabetes medication?
Finding:
Denies that glucometer-related costs are reason for not checking blood glucose
(Available)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.
Example Question:
Do you have problems affording the glucometer?
Finding:
Asked about patient’s level of education
Finding:
Reports currently working toward undergraduate degree
(Found)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.
Example Question:
What is your highest level of education?
Finding:
Reports her major is accounting
(Available)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.
Example Question:
What do you study?
Finding:
Asked about patient’s living situation
Finding:
Reports living with mother and sister
(Found)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.
Example Question:
Does anyone live at home with you?
Finding:
Reports family members will be able to help with activities
(Available)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.
Example Question:
Tell me more about living at home.
Social History
Finding:
Asked about stressors
Finding:
Reports she is currently under high stress
(Found)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.
Example Question:
Can you tell me about your stress level?
Finding:
Asked about food intake
Finding:
Reports last meal was dinner time the previous night
(Available)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.
Example Question:
When was your last meal?
Finding:
Reports last meal consisted of baked chicken and mashed potatoes
(Available)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.
Example Question:
What did you eat for your last meal?
Finding:
Reports breakfast is usually a muffin or pumpkin bread
(Available)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.
Example Question:
What is your typical breakfast?
Finding:
Reports lunch is usually a sandwich
(Available)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.
Example Question:
What is your typical lunch?
Finding:
Reports dinner is usually a home-cooked meat dish and side of vegetables
(Available)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.
Example Question:
What is your typical dinner?
Finding:
Reports snacks are pretzels or French fries
(Available)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.
Example Question:
What do you typically eat for snacks?
Finding:
Asked about salt intake
Finding:
Denies adding salt to food
(Found)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.
Example Question:
Do you add a lot of salt to your food?
Finding:
Asked about caffeine intake
Finding:
Denies drinking coffee
(Found)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.
Example Question:
Do you drink coffee?
Finding:
Reports habitual diet soda drinking
(Available)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.
Example Question:
Do you drink soda?
Finding:
Reports drinking up to 4 diet sodas per day
(Available)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.
Example Question:
How many diet sodas do you drink in a day?
Finding:
Asked about illicit drug use
Finding:
Reports history of recreational marijuana smoking
(Found)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.
Example Question:
Have you ever experimented with drugs?
Finding:
Followed up on drug use
Finding:
Reports last use was at age 20 or 21
(Found)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.
Example Question:
When did you last smoke marijuana?
Finding:
Reports she stopped because of health reasons and waning interest
(Available)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.
Example Question:
What happened to cause you to stop smoking pot?
Finding:
Asked about alcohol intake
Finding:
Reports last alcoholic drink was 3 weeks ago
(Available)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.
Example Question:
When was your last alcoholic drink?
Finding:
Reports no more than 2 or 3 alcoholic drinks in one sitting
(Available)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.
Example Question:
How many alcoholic drinks do you have in one sitting?
Finding:
Reports no more than 1 or 2 nights a week drinking alcohol
(Found)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.
Example Question:
How many nights a week do you drink alcohol?
Finding:
Asked about tobacco use
Finding:
Denies smoking tobacco
(Found)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.
Example Question:
Have you ever smoked cigarettes?
Finding:
Denies vaping
(Available)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.
Example Question:
Do you vape?
Finding:
Asked about secondhand smoke
Finding:
Denies exposure to secondhand smoke
(Found)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.
Example Question:
Are you ever exposed to secondhand smoke?
Family Medical History
Finding:
Asked about mother’s health
Finding:
Reports mother diagnosed with high blood pressure
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.
Example Question:
Does your mother have health conditions?
Finding:
Reports mother diagnosed with high cholesterol
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.
Example Question:
Does your mother have health conditions?
Finding:
Asked about father’s health
Finding:
Reports father was diagnosed with Type 2 diabetes
(Available)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.
Example Question:
Does your father have health conditions?
Finding:
Reports father was diagnosed with high blood pressure
(Available)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.
Example Question:
Does your father have health conditions?
Finding:
Reports father was diagnosed with high cholesterol
(Available)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.
Example Question:
Does your father have health conditions?
Finding:
Followed up on father’s death
Finding:
Reports father died at age 58
(Available)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.
Example Question:
How old was your father when he died?
Finding:
Reports cause of death was a car accident
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.
Example Question:
What caused your father’s death?
Finding:
Followed up on coping with father’s death
Finding:
Reports past grief
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.
Example Question:
How are you coping with your father’s death?
Finding:
Reports feeling at peace now
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.
Example Question:
How are you coping now?
Finding:
Asked about paternal grandfather’s health
Finding:
Reports paternal grandfather diagnosed with Type 2 diabetes
(Available)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.
Example Question:
Does your paternal grandfather have health conditions?
Finding:
Reports paternal grandfather diagnosed with high blood pressure
(Available)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.
Example Question:
Does your paternal grandfather have health conditions?
Finding:
Reports paternal grandfather diagnosed with high cholesterol
(Available)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.
Example Question:
Does your paternal grandfather have health conditions?
Finding:
Reports paternal grandfather died of colon cancer
(Available)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.
Example Question:
Have you had any family members with cancer?
Finding:
Asked about paternal grandmother’s health
Finding:
Reports paternal grandmother diagnosed with high blood pressure
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.
Example Question:
Does your paternal grandmother have health conditions?
Finding:
Reports paternal grandmother diagnosed with high cholesterol
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.
Example Question:
Does your paternal grandmother have health conditions?
Finding:
Asked about maternal grandfather’s health
Finding:
Reports maternal grandfather diagnosed with high blood pressure
(Available)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.
Example Question:
Does your maternal grandfather have health conditions?
Finding:
Reports maternal grandfather diagnosed with high cholesterol
(Available)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.
Example Question:
Does your maternal grandfather have health conditions?
Finding:
Asked about maternal grandmother’s health
Finding:
Reports maternal grandmother diagnosed with high blood pressure
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.
Example Question:
Does your maternal grandmother have health conditions?
Finding:
Reports maternal grandmother diagnosed with high cholesterol
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.
Example Question:
Does your maternal grandmother have health conditions?
Finding:
Asked about brother’s health
Finding:
Denies brother having diagnosed health problems
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.
Example Question:
Does your brother have health conditions?
Finding:
Asked about sister’s health
Finding:
Reports sister diagnosed with asthma
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.
Example Question:
Does your sister have health conditions?
Finding:
Asked about family history of obesity
Finding:
Reports that family members are overweight
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.
Example Question:
Does obesity run in your family?
Finding:
Asked about family history of thyroid issues
Finding:
Denies family history of thyroid issues
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.
Example Question:
Do you have a family history of thyroid problems?
Finding:
Asked about family history of substance abuse
Finding:
Reports 1 uncle has alcoholism
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.
Example Question:
Do you have relatives with addiction problems?
Finding:
Asked about family history of headaches
Finding:
Denies family history of headaches
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.
Example Question:
Do you have a family history of headaches?
Review of Systems
Finding:
Asked about constitutional health
Finding:
Reports occasional tiredness or fatigue
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Are you fatigued?
Finding:
Reports typical sleep pattern
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you noticed changes in your sleep?
Finding:
Reports fever
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Are you feeling feverish right now?
Finding:
Reports chills
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you had chills?
Finding:
Denies night sweats
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you had night sweats?
Finding:
Asked about review of systems for mental health
Finding:
Denies depression
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you have a history of depression?
Finding:
Denies suicidal ideation or attempts
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you have a history of suicidal thinking?
Finding:
Asked about review of systems for head
Finding:
Reports occasional headaches
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you ever get headaches?
Finding:
Denies current headache
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you have a headache?
Finding:
Denies head injury
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you had any head injuries?
Finding:
Asked about review of systems for ears
Finding:
Denies change in hearing
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Has your hearing changed?
Finding:
Denies ringing or tinnitus
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you ever have ringing in your ears?
Finding:
Denies ear pain
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you had ear pain?
Finding:
Denies ear discharge
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you had ear discharge?
Finding:
Asked about review of systems for eyes and vision
Finding:
Reports periods of blurry vision
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you noticed any changes in your vision?
Finding:
Denies corrective lenses
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you wear glasses or contact?
Finding:
Denies double vision
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you ever get double vision?
Finding:
Reports infrequent itchy eyes
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you had itchy eyes?
Finding:
Denies eye redness
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you had red eyes?
Finding:
Denies discharge, crusting or wateriness
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you had watery eyes?
Finding:
Denies eye pain
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you had eye pain?
Finding:
Denies dry eyes
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you had dry eyes?
Finding:
Reports last eye exam was in childhood
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
When was your last eye exam?
Finding:
Asked about review of systems for nose
Finding:
Reports infrequent nose problems
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you had nose problems?
Finding:
Reports infrequent runny nose
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you had a runny nose?
Finding:
Denies frequent sinus problems
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you had sinus pain?
Finding:
Denies change in sense of smell
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Has your sense of smell changed?
Finding:
Denies nosebleeds
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you had nosebleeds?
Finding:
Asked about review of systems for mouth and jaw
Finding:
Denies dental problems
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you had any recent dental problems?
Finding:
Reports last dental visit was several years ago
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
When did you last see a dentist?
Finding:
Denies change in sense of taste
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Has your sense of taste changed?
Finding:
Denies dry mouth
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you had dry mouth?
Finding:
Denies mouth pain
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you had mouth pain?
Finding:
Denies mouth sores
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you had mouth sores?
Finding:
Denies gum problems
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you had gum problems?
Finding:
Denies tongue problems
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you had tongue problems?
Finding:
Denies jaw problems
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you had jaw problems?
Finding:
Asked about review of systems for neck, throat, and glands
Finding:
Denies difficulty swallowing
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you had difficulty swallowing?
Finding:
Denies sore throat
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you had a sore throat?
Finding:
Denies lymph node problems
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
How are your lymph nodes?
Finding:
Denies frequent sore throat
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you have a history of throat problems?
Finding:
Denies swollen glands
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you have any swollen glands?
Finding:
Denies voice changes
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you had voice changes?
Finding:
Denies general neck problems
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you had neck pain?
Finding:
Asked about breast health
Finding:
Reports doing occasional breast exams
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you do regular breast exams?
Finding:
Denies general breast problems
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you have any problems with your breasts?
Finding:
Denies breast lumps
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you noticed any lumps in your breasts?
Finding:
Denies breast pain
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you felt pain in your breasts?
Finding:
Denies nipple changes
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you noticed changes in your nipples?
Finding:
Denies nipple discharge
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you noticed any nipple discharge?
Finding:
Denies ever having a mammogram
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you ever had a mammogram?
Finding:
Asked about review of systems for respiratory
Finding:
Denies current breathing problems
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you had breathing problems?
Finding:
Denies current wheezing
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you been wheezing?
Finding:
Denies current chest tightness
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you had chest tightness?
Finding:
Denies pain while breathing
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Does it hurt when you breathe?
Finding:
Denies frequent coughing
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you been coughing?
Finding:
Asked about review of systems for cardiovascular
Finding:
Denies chest pain or discomfort
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you ever have chest pain?
Finding:
Denies palpitations
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you had palpitations?
Finding:
Denies irregular heartbeat
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Has your heartbeat been irregular?
Finding:
Denies easy bruising
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you noticed bruising more than usual?
Finding:
Denies edema
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you noticed any swelling in your legs?
Finding:
Denies circulation problems
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you have circulation problems?
Finding:
Denies vascular diseases
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you have any vascular diseases?
Finding:
Asked review of systems for gastrointestinal
Finding:
Denies nausea
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you had nausea?
Finding:
Denies vomiting
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you been vomiting?
Finding:
Denies stomach pain
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you have stomach pain?
Finding:
Denies change in bowel movements
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you had changes in your bowel movements?
Finding:
Denies heartburn, GERD, or indigestion
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you ever get heartburn?
Finding:
Denies constipation
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you have constipation?
Finding:
Denies diarrhea or loose stool
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you have diarrhea?
Finding:
Denies flatulence or bloating
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you have flatulence?
Finding:
Denies bloody or tarry stool
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you have tarry stools?
Finding:
Asked review of systems for genitourinary
Finding:
Denies painful or difficult urination
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Does it hurt when you urinate?
Finding:
Reports waking up to urinate during the night
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you wake up at night to urinate?
Finding:
Reports large amount of urine
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you urinate frequently?
Finding:
Denies blood in urine
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you ever notice blood in your urine?
Finding:
Denies flank pain
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you have flank pain?
Finding:
Denies incontinence
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Are you able to hold your urine?
Finding:
Denies history of urinary tract or bladder infection
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you ever had a urinary infection?
Finding:
Reports normal vaginal discharge
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
What is your vaginal discharge like?
Finding:
Asked review of systems for reproductive
Finding:
Reports last menstrual period was 3 weeks ago
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
When was your last menstrual period?
Finding:
Reports that periods are irregular
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Are your periods regular?
Finding:
Reports menstruating every 6 weeks to 2 months
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
How often do you get your period?
Finding:
Reports typical period lasts 9 days
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
How many days does your period last?
Finding:
Followed up on menstrual flow
Finding:
Reports heavy periods
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you have heavy periods?
Finding:
Reports heavy flow for 4 to 5 days
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
How many days is your period heavy?
Finding:
Reports changing tampon every 2 to 3 hours
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
How often do you change your tampon or pad?
Finding:
Reports using super absorbency tampons
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
What absorbency are your tampons?
Finding:
Denies anemia
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you ever been diagnosed with low iron?
Finding:
Followed up on menstrual symptoms
Finding:
Reports heavy cramping
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you get menstrual cramps?
Finding:
Reports cramps for the first 2 days of period
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
How many days do your cramps last?
Finding:
Asked about treatment of menstrual symptoms
Finding:
Reports using a heating pad at home to treat cramps
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you use a heating pad?
Finding:
Reports taking ibuprofen for first 3 days of period
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
How many days do you need Advil for your cramps?
Finding:
Reports ibuprofen effectively reduces pain from cramps
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Does the Advil reduce your cramps?
Finding:
Asked about sexual activity
Finding:
Denies recent sexual activity
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Are you sexually active?
Finding:
Reports past sexual activity
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you ever been sexually active?
Finding:
Reports that she prefers to sleep with men
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you prefer to sleep with men, women, or both?
Finding:
Reports first sexual activity was at age 18
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
When were you first sexually active?
Finding:
Reports last sexual activity was 2 years ago
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
When was your last sexual encounter?
Finding:
Reports total number of partners is 3
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
How many sexual partners have you had?
Finding:
Asked about contraception
Finding:
Reports no current use of any oral or hormonal birth control
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Are you currently taking oral contraception?
Finding:
Reports past use of oral contraception
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you ever taken oral contraception?
Finding:
Reports last taking oral contraception a couple of years ago
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
When did you last take oral contraception?
Finding:
Reports she didn’t see the point in taking contraception while single
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Why did you stop taking birth control?
Finding:
Asked about condom use
Finding:
Reports past condom use
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you ever used a condom?
Finding:
Reports past sexual encounters without condoms
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you ever had sex without using a condom?
Finding:
Reports oral contraceptive use while sexually active
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Were you on oral contraception when you did not use a condom?
Finding:
Asked about STI testing
Finding:
Reports last STI testing was 4 years ago
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
When were you last tested for STIs?
Finding:
Denies STI symptoms
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you have STI symptoms?
Finding:
Reports uncertainty about past partners and STI testing
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have your previous partners been tested for STIs?
Finding:
Asked about history of pap smears
Finding:
Reports last pap smear was 4 years ago
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
When was your last pap smear?
Finding:
Reports no abnormal pap smears
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you ever had an abnormal pap smear?
Finding:
Asked about history of pregnancy
Finding:
Denies current pregnancy
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you think you are pregnant?
Finding:
Denies past pregnancies
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you ever tested positive for pregnancy?
Finding:
Asked review of systems for musculoskeletal
Finding:
Denies muscle pain
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you have muscle pain?
Finding:
Denies joint pain
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you have joint pain?
Finding:
Denies muscle weakness
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you have muscle weakness?
Finding:
Denies joint swelling
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you ever have swelling in your joints?
Finding:
Denies back pain
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you ever have back pain?
Finding:
Denies history of fractures or breaks
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you ever broken a bone?
Finding:
Asked review of systems for neurological
Finding:
Denies recent loss of consciousness or fainting
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you ever passed out?
Finding:
Denies dizziness or vertigo
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you get dizzy?
Finding:
Denies lightheadedness
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you get light-headed?
Finding:
Denies vision disturbances
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you ever see spots?
Finding:
Denies tingling
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you ever get tingling?
Finding:
Denies loss of coordination
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you notice being more clumsy than usual?
Finding:
Denies loss of sensation
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you have a loss of sensation anywhere?
Finding:
Denies history of seizures
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you ever had a seizure?
Finding:
Denies problems with balance or disequilibrium
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you lose your balance often?
Finding:
Denies memory loss
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you ever experienced memory loss?
Finding:
Asked review of systems for skin, hair, and nails
Finding:
Denies skin rashes
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you get skin rashes?
Finding:
Reports rarely using sunscreen
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
When do you wear sunscreen?
Finding:
Reports acne
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you still have acne?
Finding:
Reports excessive facial or body hair
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you have an increase in body hair?
Finding:
Reports changes to neck skin
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you have any skin discoloration?
Finding:
Reports moles
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have your moles changed?
Finding:
Reports no body sores (aside from foot wound)
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you have any sores?
Finding:
Denies dandruff
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you have dandruff?
Finding:
Denies nail abnormalities
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you have any problems with your nails?
Finding:
Reports occasional dry skin
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In Week 3, you began your DCE: Health History Assessment. For this week, you will complete this Health History Assessment in your simulation tool, Shadow Health and finalize for submission.
