Tina Jones Health History Subjective Data

Tina Jones Health History Subjective Data

Shadow Health History Assessment

Subjective Data Collection:104 of 104 (100%)

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Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.

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  • Available:

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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. Tina Jones Health History Subjective Data

Chief Complaint

Finding:

Established chief complaint

Finding:

Reports pain

(Found)

Pro Tip: Beginning your conversation with your patient by asking an open-ended question is a best practice for gauging your patient’s general condition.

Example Question:

How severe is the pain?

Finding:

Reports open foot wound

(Found)

Pro Tip: If a patient mentions pain, it’s important to determine what specifically is causing her pain.

Example Question:

What’s causing your pain?

History of Present Illness

Finding:

Asked for details about the pain

Finding:

Describes the pain as throbbing

(Available)

Pro Tip: Determining how your patient describes the characteristics of the pain can be important data to support the cause of the pain.

Example Question:

Can you please describe the pain?

Finding:

Describes the pain as sharp when she attempts to stand

(Found)

Pro Tip: Determining how your patient describes the characteristics of the pain can be important data to support the cause of the pain.

Example Question:

What is the pain like when you stand on your foot?

Finding:

Initial injury occurred 1 week ago

(Available)

Pro Tip: Discovering how long ago the pain began is the first step in understanding whether the pain is chronic or acute.

Example Question:

When did the pain start?

Finding:

Pain has increased in the past 2 days

(Available)

Pro Tip: Finding out how the patient’s pain has changed will give you insight into the acceleration of infection.

Example Question:

How has the pain changed over time?

Finding:

Reports feeling pain radiating into ankle

(Available)

Pro Tip: Asking about where else the patient’s pain radiates can help determine the progression of infection.

Example Question:

Does the pain radiate anywhere else?

Finding:

Pain prevents bearing weight on foot

(Found)

Pro Tip: Determining if your patient can bear weight on an injury is important to determine their risk for falls while in your care.

Example Question:

Can you bear weight on your foot?

Finding:

Asked to rate pain on a scale

Finding:

Rates present pain at a 7 out of 10

(Found)

Pro Tip: Asking your patient to rate her pain on a scale of 0 to 10 is important to gauge how it ebbs and flows while she is in your care. Tina Jones Health History Subjective Data

Example Question:

Can you rate the pain on a scale of 0 to 10?

Finding:

Clarified location of wound

Finding:

Confirmed that right foot is injured

(Found)

Pro Tip: Confirming which extremity an injury is located is a best practice for your patient’s safety.

Example Question:

Which foot is in pain?

Finding:

Confirmed that wound is on the plantar surface of her foot

(Available)

Pro Tip: Confirming where a wound is located ensures you are aware of your patient’s biggest complaint.

Example Question:

Where is the wound?

Finding:

Determined details of the injury

Finding:

Scraped foot on a cement step

(Found)

Pro Tip: Discovering how an injury happened helps to assess your patient’s risk factors for injury.

Example Quest

How did your injury happen?

Finding:

Reports mild ankle injury

(Available)

Pro Tip: Discovering additional injuries can reveal more information about the circumstances that caused the presenting injury.

Example Question:

Did you injure anything besides your foot?

Finding:

Was not drinking at the time of the injury

(Available)

Pro Tip: Finding out if alcohol is involved in an injury can give you insight into a patient’s potential substance abuse, and can uncover aggravating factors.

Example Question:

Did you have any alcoholic drinks before your injury?

Finding:

Was not wearing shoes at the time of injury

(Found)

Pro Tip: Asking about clothing, footwear, and other protective elements being worn at the time of injury helps you discover the totality of the circumstances.

Example Question:

Were you wearing shoes when you fell?

Finding:

Asked about the assessment of the injury at the ER

Finding:

Went to the ER after sustaining the injury

(Available)

Pro Tip: Finding out how long ago a patient sought care helps you understand the evolution of symptoms.

Example Question:

When did you go to the ER?

Finding:

Decided to go because she suspected an ankle sprain

(Available)

Pro Tip: Asking why a patient sought care gives you more information about the initial injury and symptoms.

Example Question:

Why did you go to the ER?

Finding:

Received an x-ray

(Available)

Pro Tip: Determining what procedures were done by other healthcare providers gives insight into the symptoms at the onset.

Example Question:

Did they xray your foot at the ER?

Finding:

X-ray showed no broken bones

(Available)

Pro Tip: Confirming the results of the x-ray gives you a subjective report of the seriousness of the initial injury.

Example Question:

What did the x-ray show?

Finding:

Received a prescription for pain pills

(Available)

Pro Tip: Finding out if the patient has been prescribed medications is an important piece of data for your own care plan. Tina Jones Health History Subjective Data

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 about bleeding helps you determine the characteristics of a wound.

Example Question:

Did your foot bleed?

Finding:

Reports seeing pus draining from wound

(Found)

Pro Tip: Asking about discharge helps you determine the characteristics of a wound.

Example Question:

Did you notice any discharge from the wound?

Finding:

Began noticing pus 2 days ago

(Available)

Pro Tip: Pinpointing exactly when the patient noticed the arrival of pus gives you an important data point for when an active infection began.

Example Question:

When did you first notice the pus?

Finding:

Followed up about character of drainage from the foot wound

Finding:

Describes pus as white or yellow in color

(Available)

Pro Tip: The color of discharge from a wound can provide insight into its severity and characteristics.

Example Question:

What color is the drainage from your wound?

Finding:

Reports no odor from the wound

(Available)

Pro Tip: The odor of discharge from a wound can provide insight into its severity and characteristics.

Example Question:

Does the wound have an odor?

Finding:

Asked about home treatment of foot wound

Finding:

Describes wound care regimen of cleaning and bandaging. Tina Jones Health History Subjective Data

(Available)

Pro Tip: Listening to a patient’s wound care routine provides insight into the history of the wound, as well as the patient’s health literacy.

Example Question:

How did you treat your foot at home?

Finding:

Cleaned wound twice a day

(Available)

Pro Tip: Asking specifically how often a patient cleaned a wound will let you know if an infection spread through improper hygiene, or for other reasons such as uncontrolled blood sugar.

Example Question:

How often did you clean the wound?

Finding:

Cleaned wound with hydrogen peroxide

(Available)

Pro Tip: Determining what products a patient used to clean a wound provides insight into the history of the wound, as well as the patient’s health literacy.

Example Question:

What did you use to clean the wound?

Finding:

Changed bandage twice a day

(Available)

Pro Tip: Asking specifically how often a patient changed a bandage will let you know if an infection spread through improper hygiene, or for other reasons such as uncontrolled blood sugar.

Example Question:

How often do you change your bandage?

Finding:

Applied neosporin

(Available)

Pro Tip: Determining what products a patient used to sterilize or treat a wound establishes home care routines and health literacy.

Example Question:

Did you use any ointment on the wound?

Finding:

Asked about other foot wound symptoms

Finding:

Reports swelling around foot wound

(Available)

Pro Tip: Asking about the presence of swelling helps you gather information about your patient’s complaint, as well as potential related illnesses.

Example Question:

Is there swelling around the wound?

Finding:

Noticed swelling getting worse in the past 2 days

(Available)

Pro Tip: Finding out how long swelling appeared will help you understand the timeline for the infection’s progression.

Example Question:

How long have you noticed swelling around the wound?

Finding:

Reports redness around the wound

(Available)

Pro Tip: Asking about redness will help you understand the timeline for the infection’s progression.

Example Question:

Did you notice any redness around the wound?

Finding:

Reports that the wound feels warm

(Available)

Pro Tip: Asking about warmth will help you understand the timeline for the infection’s progression.

Example Question:

Does the wound feel warm?

Finding:

Explored impact of patient’s foot injury on activities of daily living

Finding:

Pain affects ability to walk

(Found)

Pro Tip: Learning the impact of your patient’s wound on daily activities helps inform your plan for care.

Example Question:

Does your injury impact your ability to walk? Tina Jones Health History Subjective Data

Finding:

Pain affects job performance

(Available)

Pro Tip: Learning how severely the wound has interfered with an essential aspect of daily life, and can uncover a source of stress for the patient.

Example Question:

Does your foot pain affect your work?

Finding:

Pain prevented her from attending class

(Available)

Pro Tip: For patients who are also students, you can find out what schoolwork they are missing, and help them make accommodations so they don’t fall behind.

Example Question:

Has your injury prevented you from going to class?

Finding:

Asked about recent fever

Finding:

Reports a fever last night

(Available)

Pro Tip: The presence or absence of fever can indicate if an infection is approaching sepsis, a life-threatening condition.

Example Question:

Are you feeling feverish right now?

Medical History: Medication

Finding:

Asked about use of pain medication

Finding:

Has been taking prescription pain medication

(Available)

Pro Tip: Discovering how a patient has been medicating for pain is a crucial element of understanding and treating her condition or injury.

Example Question:

Have you taken any prescription pain medications?

Finding:

Medication is Tramadol

(Found)

Pro Tip: The differences between prescription and over-the-counter pain medications can be vast, and asking about the type of pain medication your patient has been using will help you fully understand her home treatment habits.

Example Question:

What is the name of the pain medication?

Finding:

Asked about pain medication frequency

Finding:

Has been taking pain medication for 2 days

(Available)

Pro Tip: Discovering how long your patient has been taking pain medication is a crucial part of the history of her condition or injury.

Example Question:

How many days have you needed pain medication?

Finding:

Takes dose 3 times a day

(Available)

Pro Tip: The frequency with which your patient takes pain medication can indicate the severity of her condition or injury.

Example Question:

How many times a day do you take pain medication?

Finding:

Last dose was this morning

(Found)

Pro Tip: Confirming the patient’s most recent dose sheds insight into her current pain level, and lets you know what substances may be in her system.

Example Question:

When was your last dose of pain medication?

Finding:

Asked about pain medication dose

Finding:

Dosage is 50 milligrams

(Found)

Pro Tip: Determining the exact dose of pain medication your patient takes helps determine the severity of her condition or injury and will factor in to your care plan.

Example Question:

What is the dose of the pain medication?

Finding:

Takes 2 pills each time

(Available)

Pro Tip: Determining the exact dose of pain medication your patient takes helps determine the severity of her condition or injury and will factor in to your care plan.

Example Question:

How many pain pills do you take at a time?

Finding:

Asked about the efficacy of pain medication

Finding:

Reports that pain pills provide partial relief

(Available)

Pro Tip: The efficacy of pain medication varies from patient to patient. Discovering a patient’s individual response to pain medication is an important factor in your overall treatment plan.

Example Question:

How effective is the pain medication?

Finding:

Pain returns in full every few hours

(Available)

Pro Tip: The efficacy of pain medication varies from patient to patient. Discovering a patient’s individual response to pain medication is an important factor in your overall treatment plan. Tina Jones Health History Subjective Data

Example Question:

How long does the pain medication last?

Finding:

Asked about other prescription medications

Finding:

Uses a prescription inhaler

(Found)

Pro Tip: Determining what, if any, prescription medications a patient is taking is a crucial element of a thorough health history and will help you avoid unwanted drug interactions.

Example Question:

What prescription medications do you take?

Finding:

Asked about use of OTC medication

Finding:

Occasionally takes Advil (ibuprofen) for cramps

(Available)

Pro Tip: Finding out about your patient’s use of over-the-counter medications, vitamins, and supplements will help you get a complete health history and avoid unwanted drug interactions.

Example Question:

Do you take any over the counter medications?

Finding:

Occasionally takes Tylenol (acetaminophen) for headaches

(Found)

Pro Tip: Finding out about your patient’s use of over-the-counter medications, vitamins, and supplements will help you get a complete health history and avoid unwanted drug interactions.

Example Question:

Do you take any over the counter medications?

Finding:

Does not take vitamin supplements

(Available)

Pro Tip: Finding out about your patient’s use of over-the-counter medications, vitamins, and supplements will help you get a complete health history and avoid unwanted drug interactions.

Example Question:

Do you take any vitamins?

Finding:

Does not take herbal supplements

(Available)

Pro Tip: Finding out about your patient’s use of over-the-counter medications, vitamins, and supplements will help you get a complete health history and avoid unwanted drug interactions.

Example Question:

Do you take any herbal supplements?

Medical History: Allergies

Finding:

Asked about general allergies

Finding:

Reports allergy to cats

(Found)

Pro Tip: Asking general questions about allergies is the first step to a conversation with a patient about her complete set of allergies.

Example Question:

What allergies do you have?

Finding:

Asked follow up on cat allergy reaction

Finding:

Reports sneezing, itchy eyes, and wheezing

(Available)

Pro Tip: Determining a patient’s reaction to an allergen is essential to gauge if the allergy is life-threatening.

Example Question:

What is your reaction to cats?

Finding:

Asked if the patient is allergic to latex

Finding:

Denies latex allergy

(Available)

Pro Tip: Confirming absence or presence of a latex allergy is essential in a hospital setting, where some instruments have latex parts.

Example Question:

Are you allergic to latex?

Finding:

Asked if the patient is allergic to any medications

Finding:

Reports a penicillin allergy

(Found)

Pro Tip: Asking specifically about allergies to medications is crucial to the patient’s safety while she is in your care.

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: Determining a patient’s reaction to an allergen is essential to gauge if the allergy is life-threatening.

Example Question:

What is your reaction to penicillin?

Finding:

Asked if the patient has any food allergies

Finding:

Denies food allergies

(Available)

Pro Tip: Inquiring about food allergies is important for an admitted patient, who will be receiving food during her stay.

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: Dust is a common allergen, and discovering its effect on asthmatic patients is particularly important.

Example Question:

Do you have any reaction to dust?

Finding:

Dust causes sneezing, itchy eyes, and wheezing

(Available)

Pro Tip: Dust is a common allergen, and discovering its effect on asthmatic patients is particularly important. Tina Jones Health History Subjective Data

Example Question:

Do you have any environmental allergies?

Finding:

Denies seasonal allergies

(Available)

Pro Tip: Asking about seasonal allergies can help you understand a patient’s complete set of allergies over the course of a year.

Example Question:

Do you have any seasonal allergies?

Medical History: Immunizations

Finding:

Asked about general immunizations received

Finding:

Reports being “up to date on shots”

(Available)

Pro Tip: Discovering your patient’s immunization history is important to her safety and reveals any susceptibilities she may have to infectious disease.

Example Question:

Are your immunizations current?

Finding:

Asked about childhood immunizations

Finding:

Reports receiving all necessary childhood immunizations

(Available)

Pro Tip: Discovering information about your patient’s childhood vaccinations reveals information about both her medical history and her susceptibility to infectious disease.

Example Question:

Did you receive childhood vaccinations?

Finding:

Asked if the patient has received a flu vaccine

Finding:

Has not received annual flu vaccine

(Available)

Pro Tip: The flu virus can be particularly hazardous in a hospital setting. It is important to ask your patient about the flu vaccine.

Example Question:

Did you get a flu shot this year?

Finding:

Asked if the patient received a tetanus immunization

Finding:

Last tetanus vaccination was in the past year

(Available)

Pro Tip: For a patient with a recent scrape on a metal surface, confirming the last date of a tetanus shot is essential to prevent any diseases from contact.

Example Question:

When was your last tetanus booster?

Medical History: Diabetes

Finding:

Asked details about diabetes diagnosis

Finding:

Diagnosed as an adult

(Found)

Pro Tip: Learning the diagnosis date of your patient’s illness is an essential element of the illness’s history.

Example Question:

When were you diagnosed with diabetes?

Finding:

Specific age of diagnosis is 24 years old

(Found)

Pro Tip: Learning the diagnosis date of your patient’s illness is an essential element of the illness’s history.

Example Question:

At what age were you diagnosed with diabetes?

Finding:

Reports that her diabetes is Type 2

(Found)

Pro Tip: The type of diabetes your patient has will drastically affect how you care for her,

Example Question:

Do you know what type of diabetes you have?

Finding:

Asked about diabetes management

Finding:

Reports that she tries to manage diabetes with diet

(Available)

Pro Tip: Understanding how your patient cares for her diabetes is an essential element to learning the history of her illness.

Example Question:

Do you follow a diabetic diet?

Finding:

Reports “staying away from sweets”

(Available)

Pro Tip: Asking your patient specifically about sugar intake can help you understand the history of her diabetes as well as her health literacy.

Example Question:

Tell me more about any sugars you consume.

Finding:

Reports drinking diet soda instead of regular

(Found)

Pro Tip: Particularly for diabetic patients, asking about intake of drinks that contain sugar can reveal additional sources of carbohydrates that the patient may not consider.

Example Question:

Do you drink sugary drinks?

Finding:

Asked about current diabetes medication use

Finding:

Does not currently take medication for diabetes

(Found)

Pro Tip: Asking about diabetes medication is important to understanding if your patient’s disease is under control.

Example Question:

Do you take prescribed medication for your diabetes?

Finding:

Asked about past diabetes medication use

Finding:

Used to take diabetes medication

(Found)

Pro Tip: Asking about diabetes medication is important to understanding if your patient’s disease is under control.

Example Question:

Have you ever taken medication for your diabetes?

Finding:

Previous medication was prescription metformin

(Available)

Pro Tip: Asking about diabetes medication is important to understanding if your patient’s disease is under control.

Example Question:

Do you remember what you were prescribed for diabetes?

Finding:

Last use of medication was 3 years ago

(Found)

Pro Tip: Asking about diabetes medication is important to understanding if your patient’s disease is under control.

Example Question:

When was the last time you took your diabetes medication on a regular basis?

Finding:

Explored the reasons the patient stopped her diabetes regimen

Finding:

Reports that she “got sick of dealing with it”

(Available)

Pro Tip: Asking reasons for noncompliance can reveal information about your patient’s health literacy, side effects, financial situation, and more.

Example Question:

Why aren’t you taking your diabetes medication?

Finding:

Reports disliking metformin side effects

(Available)

Pro Tip: Asking about side effects from medication can provide information about your patient’s reaction to treatment.

Example Question:

Did the metformin cause any side effects?

Finding:

Describes that she didn’t like checking sugar and taking daily pills

(Available)

Pro Tip: Asking reasons for noncompliance can reveal information about your patient’s health literacy, side effects, financial situation, and more.

Example Question:

What’s preventing you from taking your diabetes medication?

Finding:

Asked about patient’s blood sugar monitoring

Finding:

Does not monitor blood glucose

(Found)

Pro Tip: Your patient’s blood sugar monitoring habits are an important part of her health literacy and home treatment.

Example Question:

Tell me about your blood sugar monitoring.

Finding:

Last glucose check was a week ago at the ER

(Available)

Pro Tip: Your patient’s blood sugar monitoring habits are an important part of her health literacy and home treatment.

Example Question:

How often do you check your blood sugar? Tina Jones Health History Subjective Data

Finding:

Reports confusion about “what the numbers mean”

(Available)

Pro Tip: Your patient’s blood sugar monitoring habits are an important part of her health literacy and home treatment.

Example Question:

What are your usual blood sugar levels?

Finding:

Asked about increased thirst

Finding:

Reports increased thirst

(Found)

Pro Tip: Your patient’s thirst and fluid intake can offer insight into underlying medical conditions.

Example Question:

Have you been more thirsty lately?

Finding:

Reports increased water intake

(Found)

Pro Tip: Your patient’s thirst and fluid intake can offer insight into underlying medical conditions.

Example Question:

Are you drinking more water than normal?

Finding:

Asked about frequency of urination

Finding:

Reports more frequent urination

(Found)

Pro Tip: Your patient’s urination habits can offer insight into underlying medical conditions and general health.

Example Question:

Have you been urinating more often than usual?

Finding:

Reports urinating “every hour or so” during the day

(Available)

Pro Tip: Your patient’s urination habits can offer insight into underlying medical conditions and general health.

Example Question:

How often do you urinate during the day?

Finding:

Reports urinating 2 to 3 times during the night

(Available)

Pro Tip: Your patient’s urination habits can offer insight into underlying medical conditions and general health.

Example Question:

How often do you wake up at night to urinate?

Finding:

Asked about change in appetite

Finding:

Reports an increase in appetite

(Available)

Pro Tip: Changes in appetite can indicate underlying health conditions.

Example Question:

Have you noticed an increase in appetite?

Finding:

Reports increase in appetite began a month ago

(Available)

Pro Tip: Determining the onset of a symptom can reveal important details about underlying health conditions.

Example Question:

When did you notice the increase in your appetite?

Finding:

Asked about weight loss

Finding:

Reports recent weight loss

(Found)

Pro Tip: Weight changes can be indicative of underlying health problems or an unhealthy lifestyle.

Example Question:

Have you had any recent weight changes?

Finding:

Lost 10 lbs

(Found)

Pro Tip: Determining the exact amount of weight loss can indicate whether it’s within expected ranges, or extreme, which may indicate an underlying health problem.

Example Question:

How much weight have you lost?

Finding:

Weight loss occurred over the past month

(Found)

Pro Tip: Finding out the timeline for weight loss can indicate if it’s sudden or gradual.

Example Question:

How long did it take you to lose 10 pounds?

Finding:

Followed up on weight loss by asking if it was intentional

Finding:

Weight loss was not caused by intent or lifestyle changes

(Available)

Pro Tip: Unintentional weight loss can be a sign of underlying medical conditions or a reflection of unhealthy lifestyle choices. Asking your patient about this can inform your care plan.

Example Question:

Was your weight loss intentional?

Medical History: Asthma

Finding:

Asked details about asthma and breathing problems

Finding:

Last breathing problem was 3 days ago

(Found)

Pro Tip: Asthma can have a profound impact on health, and it is important to learn about the characteristics of your patient’s condition.

Example Question:

When did you last have issues with asthma?

Finding:

Describes asthma symptoms as chest tightness and inability to “take in air”

(Available)

Pro Tip: Asthma can have a profound impact on health, and it is important to learn about the characteristics of your patient’s condition.

Example Question:

What do your asthma symptoms feel like?

Finding:

Describes wheezing as an asthma symptom

(Available)

Pro Tip: Asthma can have a profound impact on health, and it is important to learn about the characteristics of your patient’s condition.

Example Question:

Do you ever wheeze?

Finding:

Reports last asthma attack was in high school

(Available)

Pro Tip: Asthma can have a profound impact on health, and it is important to learn about the characteristics of your patient’s condition.

Example Question:

When was your last asthma attack?

Finding:

Asked about prior hospitalizations

Finding:

Reports past hospitalizations

(Found)

Pro Tip: Finding out if the patient has any past hospitalizations is the first step in understanding any past serious medical issues.

Example Question:

Have you been hospitalized in the past?

Finding:

Last hospitalization was for asthma

(Found)

Pro Tip: Learning the details of your patient’s past hospitalizations is crucial to understanding her medical history.

Example Question:

Why were you hospitalized last time?

Finding:

Last hospitalization was age 16

(Found)

Pro Tip: Learning the details of your patient’s past hospitalizations is crucial to understanding her medical history.

Example Question:

When was your last hospitalization?

Finding:

Estimates 5 total hospitalizations for asthma as a child and teen

(Available)

Pro Tip: Learning the details of your patient’s past hospitalizations is crucial to understanding her medical history.

Example Question:

How many times have you been hospitalized?

Finding:

Reports that she has never been intubated during a hospitalization

(Available)

Pro Tip: Discovering past intubations can reveal details about the history and severity of your patient’s disease.

Example Question:

Have you ever been intubated for asthma?

Finding:

Asked about asthma diagnosis

Finding:

Diagnosed with asthma in childhood

(Available)

Pro Tip: Asthma can have a profound impact on health, and it is important to learn about the characteristics of your patient’s condition.

Example Question:

When were you diagnosed with asthma?

Finding:

Specific age of diagnosis is 2.5 years old

(Available)

Pro Tip: Asthma can have a profound impact on health, and it is important to learn about the characteristics of your patient’s condition.

Example Question:

At what age were you diagnosed with asthma?

Finding:

Asked about asthma inhaler drug

Finding:

Uses an inhaler

(Found)

Pro Tip: Asking how your patient treats her asthma can provide important information about her medical history and health literacy.

Example Question:

How do you manage your asthma?

Finding:

Inhaler is Proventil (albuterol)

(Found)

Pro Tip: Finding out the specific medication type or brand is essential in understanding whether it’s a maintenance or rescue medication.

Example Question:

What is the name of the inhaler prescription?

Finding:

Asked about frequency of asthma inhaler use

Finding:

Last use of inhaler was 3 days ago

(Found)

Pro Tip: Determining the patient’s last use of an inhaler clues you in to any recent breathing problems.

Example Question:

When did you last use your inhaler?

Finding:

Uses inhaler 2 or 3 times per week

(Available)

Pro Tip: Discovering the frequency with which your patient uses her inhaler is an important aspect of determining the severity of her condition.

Example Question:

How often do you use your inhaler?

Finding:

Asked about number of puffs when using asthma inhaler

Finding:

Prescribed usage is 2 puffs

(Available)

Pro Tip: Discovering how much your patient uses her inhaler at any given time is a good indicator of the efficacy of her medication.

Example Question:

How many puffs of your inhaler are you prescribed?

Finding:

Sometimes needs more than 2 puffs to control symptoms

(Available)

Pro Tip: Asking about a medication’s efficacy is an important part of planning future care for your patient.

Example Question:

Does your inhaler effectively relieve your symptoms?

Finding:

Asked about asthma triggers

Finding:

Asthma triggered by cats

(Found)

Pro Tip: Discovering occasional environmental triggers, such as animal allergies, gives you insight into exacerbating factors of your patient’s condition.

Example Question:

What triggers your asthma problems?

Finding:

Asthma triggered by dust

(Found)

Pro Tip: Dust is a common allergen, and discovering its effect on asthmatic patients is particularly important.

Example Question:

Does dust trigger your asthma?

Finding:

Asthma triggered by running up stairs

(Found)

Pro Tip: Asthma’s effect on the lungs can be exacerbated by physical activity. This can impact your patient’s quality of life. Tina Jones Health History Subjective Data

Example Question:

Does physical activity trigger your asthma?

Finding:

Reports no seasonal triggers

(Available)

Pro Tip: Asking about seasonal triggers can help you understand a patient’s complete set of asthma triggers over the course of a year.

Example Question:

Do you have seasonal asthma triggers?

Medical History: Hypertension

Finding:

Asked about personal history of hypertension

Finding:

Denies past diagnosis of hypertension

(Found)

Pro Tip: It’s best to determine specifically whether or not the condition has been diagnosed by a healthcare professional.

Example Question:

Have you ever been diagnosed with hypertension?

Finding:

Reports that last BP reading was 140 over 80 or 90

(Available)

Pro Tip: Confirming the specific blood pressure number gives you a specific subjective data point.

Example Question:

What is your usual blood pressure?

Finding:

Does not check BP regularly

(Available)

Pro Tip: Asking about how often a patient checks her blood pressure will give you an indication of whether she is currently trying to manage this area of her health.

Example Question:

How often do you check your blood pressure?

Finding:

Last check was a few months ago

(Available)

Pro Tip: Finding out when a patient’s last blood pressure check gives you the most recent data point, if it is known.

Example Question:

When did you last check your blood pressure

Finding:

Is aware of family history of hypertension

(Available)

Pro Tip: Asking about a patient’s perception of her own risk gives you a sense of her health literacy related to hypertension.

Example Question:

Does your family have a history of hypertension?

Finding:

Is aware of own increased risk

(Available)

Pro Tip: Asking about a patient’s perception of her own risk gives you a sense of her health literacy related to hypertension.

Example Question:

Tell me what you think about your risk for hypertension.

Medical History: Gynecological and Sexual History

Finding:

Asked about menstrual frequency and duration

Finding:

Last menstrual period “about 3 weeks ago”

(Found)

Pro Tip: Finding out when a patient’s LMP was indicates whether she might be pregnant (although this question alone can’t rule out pregnancy).

Example Question:

When was your last menstrual period?

Finding:

Reports irregular periods

(Found)

Pro Tip: Asking about the frequency of a patient’s periods helps you understand what is typical for that particular patient.

Example Question:

Are your periods regular?

Finding:

Reports menstruating every 6 weeks to 2 months

(Found)

Pro Tip: Quantifying the frequency of a patient’s periods is a specific piece of subjective data that can show the severity of a patient’s irregularity.

Example Question:

How often do you get your period?

Finding:

Typical period lasts 9 days

(Available)

Pro Tip: Quantifying the number of days a period lasts will help you understand what is typical for the patient, and also can indicate related risks for health problems such as anemia.

Example Question:

How many days does your period last?

Finding:

Asked about menstrual flow

Finding:

Reports heavy periods

(Found)

Pro Tip: Asking about the heaviness of a patient’s periods helps you understand what is typical for that particular patient, and can also indicate related risks for health problems such as anemia.

Example Question:

Do you have heavy periods?

Finding:

Reports heavy flow for 4 to 5 days

(Available)

Pro Tip: Quantifying the number of days a period is heavy will help you understand what is typical for the patient, and also can indicate related risks for health problems such as anemia.

Example Question:

How many days is your period heavy?

Finding:

Reports changing tampon every 2 to 3 hours

(Found)

Pro Tip: Determining how often a patient replaces tampons or pads is a specific piece of subjective data that can indicate the heaviness of a patient’s period.

Example Question:

How often do you change your tampon or pad?

Finding:

Uses super absorbency tampons

(Found)

Pro Tip: Determining the absorbency of a patient’s tampons can help you understand the severity of a patient’s period.

Example Question:

What absorbency are your tampons?

Finding:

Denies any known anemia

(Available)

Pro Tip: Asking whether a patient has had an iron deficiency in the past can help determine a current risk of anemia, and could shed light on other symptoms the patient experiences.

Example Question:

Have you ever been diagnosed with low iron?

Finding:

Asked about menstrual symptoms

Finding:

Reports heavy cramping

(Available)

Pro Tip: Asking a patient for her subjective report on the heaviness of her cramps will help you understand her feelings about her menstrual symptoms.

Example Question:

Do you get menstrual cramps?

Finding:

Reports cramps for the first 2 days of period

(Available)

Pro Tip: Determining the number of days that a patient’s cramps last helps you understand how her menstrual symptoms affect her life.

Example Question:

How many days do your cramps last?

Finding:

Asked about treatment of menstrual symptoms

Finding:

Uses a heating pad at home to treat cramps

(Available)

Pro Tip: Asking the details of how a patient treats menstrual symptoms will give you an idea of what interventions she tries at home.

Example Question:

Do you use a heating pad?

Finding:

Takes Advil for first 3 days of period

(Available)

Pro Tip: Finding out how many days a patient needs pain medication helps you correlate that with the duration of her pain.

Example Question:

How many days do you need Advil for your cramps?

Finding:

Reports that Advil effectively reduces pain from cramps

(Available)

Pro Tip: Determining the efficacy of pain medication helps you understand the severity of the pain.

Example Question:

Does the Advil reduce your cramps?

Finding:

Asked about sexual activity

Finding:

Reports no recent sexual activity

(Found)

Pro Tip: Finding out a patient’s current perceived level of sexual activity is a good baseline for beginning this sensitive conversation.

Example Question:

Are you sexually active?

Finding:

Reports past sexual activity

(Found)

Pro Tip: Determining whether a patient has been sexually active in the past is important, because a patient’s past and current levels may differ.

Example Question:

Have you ever been sexually active?

Finding:

Reports that she prefers to sleep with men

(Available)

Pro Tip: Asking a patient a non-judgemental question about the perceived gender of sexual partners is a neutral way to enter a conversation about sexual or romantic orientation.

Example Question:

Do you prefer to sleep with men, women, or both?

Finding:

First sexual activity was at age 18

(Available)

Pro Tip: Confirming a patient’s age of first sexual activity tells you the number of sexually active years, and will help you understand the context of a patient’s attitudes toward sex and sexual health literacy.

Example Question:

When were you first sexually active?

Finding:

Last sexual activity was “about 2 years ago”

(Available)

Pro Tip: Quantifying the timeline for the patient’s last sexual activity is important for determining any present risks for STIs or pregnancy.

Example Question:

When was your last sexual encounter?

Finding:

Total number of partners is 3

(Found)

Pro Tip: Quantifying a patient’s number of partners gives you a baseline for determining risk level for STIs (although more information about barrier contraception is needed).

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: Asking specifically about hormonal contraception helps you understand a patient’s risk for pregnancy, and could shed light on other symptoms the patient may experience.

Example Question:

Are you currently taking oral contraception?

Finding:

Reports past use of oral contraception

(Found)

Pro Tip: Determining a patient’s past use of hormonal contraception is essential, because a patient’s current and past use may differ.

Example Question:

Have you ever taken oral contraception?

Finding:

Last took oral contraception “a couple of years” ago

(Available)

Pro Tip: Confirming the patient’s most recent dose sheds lets you know what substances may be in her system.

Example Question:

When did you last take oral contraception?

Finding:

Describes the reasons why she stopped use: “didn’t see the point” while single

(Available)

Pro Tip: Asking a patient directly, in a non-judgemental way, about her motivations for stopping a medication is the best method for understanding her attitudes and beliefs about her own health.

Example Question:

Why did you stop taking birth control?

Finding:

Asked about condom use

Finding:

Reports past condom use

(Found)

Pro Tip: Asking about any condom use, present or past, is a good entry point into conversations about protection against STIs.

Example Question:

Have you ever used a condom?

Finding:

Reports past sexual encounters without condoms

(Available)

Pro Tip: Finding out if your patient has had sexual activity without the use of a condom can help you understand her attitudes regarding STI prevention.

Example Question:

Have you ever had sex without using a condom?

Finding:

Reports oral contraceptive use while sexually active

(Available)

Pro Tip: If a patient reports sexual activity without condoms, it’s important to determine if they used other methods of birth control at that time.

Example Question:

Were you on oral contraception when you did not use a condom?

Finding:

Asked about STI testing

Finding:

Last STI testing was 4 years ago

(Available)

Pro Tip: Determining when a patient’s last STI testing was will inform your recommendations for future gynecological care.

Example Question:

When were you last tested for STIs?

Finding:

Reports no known STI symptoms

(Found)

Pro Tip: Asking a patient about STI symptoms is a good place to begin conversation about gynecological health (although many STIs do no present symptoms).

Example Question:

Do you have STI symptoms?

Finding:

Expresses a gap in knowledge of STI symptoms and prevention

(Found)

Pro Tip: Learning about a patient’s perception of STI symptoms and protection will highlight any areas where she needs additional education.

Example Question:

Can you tell me what you know about sexually transmitted infections?

Finding:

Expresses uncertainty about past partners and STI testing

(Available)

Pro Tip: Asking a patient about the STI status of past partners will highlight any areas where she needs additional education about STI protection.

Example Question:

Have your previous partners been tested for STIs?

Finding:

Asked about history of pap smears

Finding:

Last pap smear was 4 years ago

(Found)

Pro Tip: Determining when a patient’s last pap smear was given will inform your recommendations for future gynecological care.

Example Question:

When was your last pap smear?

Finding:

Reports no abnormal pap smears

(Available)

Pro Tip: Asking a patient about the results of a pap smear will give you a subjectively reported idea of any potential gynecological problems.

Example Question:

Have you ever had an abnormal pap smear?

Finding:

Asked about history of pregnancy

Finding:

Reports that she is not currently pregnant

(Available)

Pro Tip: Asking specifically about a patient’s current pregnancy status is important for your treatment plan.

Example Question:

Do you think you are pregnant?

Finding:

Reports no previous pregnancies

(Available)

Pro Tip: Learning about a patient’s past pregnancies is an important part of her comprehensive health history.

Example Question:

Have you ever tested positive for pregnancy?

Social History: Daily Life

Finding:

Asked about patient’s level of education

Finding:

Currently working toward undergraduate degree

(Found)

Pro Tip: Finding out a patient’s level of education can give you a baseline for her health literacy.

Example Question:

What is your highest level of education?

Finding:

Asked what subject the patient is studying in college

Finding:

Majoring in accounting

(Found)

Pro Tip: Asking about a patient’s course of study is a good practice to establish rapport with your patient.

Example Question:

What do you study?

Finding:

Discussed the patient’s stress level

Finding:

Reports stress related to injury, missing work and school, and cost of care

(Available)

Pro Tip: Stress can cause both physical and mental health problems and complications. Determining your patient’s stress level is part of an overall picture of her health.

Example Question:

Can you tell me about your stress level?

Finding:

Asked about patient’s living situation

Finding:

Lives at home with mother and sister

(Available)

Pro Tip: Learning about your patient’s living situation helps develop rapport and gives you a broad picture of her lifestyle.

Example Question:

Does anyone live at home with you?

Finding:

Reports that family members will be able to help with activities

(Available)

Pro Tip: Learning about your patient’s living situation helps develop rapport and gives you a broad picture of her lifestyle.

Example Question:

Tell me more about living at home.

Social History: Diet and Nutrition

Finding:

Asked about food intake

Finding:

Last meal was dinner time the previous night

(Available)

Pro Tip: Finding out when a patient last ate can provide evidence for any current stomach upset and for their current level of hunger and blood sugar status, and can affect medications given while in your care.

Example Question:

When was your last meal?

Finding:

Last meal consisted of baked chicken and mashed potatoes

(Available)

Pro Tip: Finding out the foods a patient last ate can provide evidence for any current stomach upset and for their current level of hunger and blood sugar status, and can affect medications given while in your care.

Example Question:

What did you eat for your last meal?

Finding:

Breakfast is usually a muffin or pumpkin bread

(Found)

Pro Tip: Asking comprehensive questions about a patient’s diet includes finding out what she typically eats for breakfast, which contributes to your understanding of the complete patient’s diet and nutrition status.

Example Question:

What is your typical breakfast?

Finding:

Lunch is usually a sandwich

(Found)

Pro Tip: Asking comprehensive questions about a patient’s diet includes finding out what she typically eats for lunch, which contributes to your understanding of the patient’s complete diet and nutrition status.

Example Question:

What is your typical lunch?

Finding:

Dinner is usually a home-cooked meat dish and side of vegetables

(Found)

Pro Tip: Asking comprehensive questions about a patient’s diet includes finding out what she typically eats for dinner, which contributes to your understanding of the patient’s complete diet and nutrition status.

Example Question:

What is your typical dinner?

Finding:

Snacks are pretzels or French fries

(Found)

Pro Tip: Asking a patient about snacking habits and choices can help you understand additional caloric, fat, and sugar intake that the patient may overlook.

Example Question:

What do you typically eat for snacks?

Finding:

Asked about salt intake

Finding:

Is uncertain about salt intake, describes “not adding a lot of salt to my food”

(Available)

Pro Tip: Determining how a patient perceives her sodium intake helps you understand her level of nutrition health literacy.

Example Question:

Do you add a lot of salt to your food?

Finding:

Asked about caffeine intake

Finding:

Does not drink coffee

(Available)

Pro Tip: Finding out specifically if a patient drinks coffee helps you understand what constitutes her typical caffeine intake.

Example Question:

Do you drink coffee?

Finding:

Reports habitual diet soda drinking

(Found)

Pro Tip: Asking about all sources of caffeine helps you understand a patient’s comprehensive caffeine intake.

Example Question:

Do you drink soda?

Finding:

Drinks up to 4 diet sodas per day

(Found)

Pro Tip: Quantifying the patient’s amount of caffeine consumed provides insight into other areas of their health, such as digestive health and sleep.

Example Question:

How many diet sodas do you drink in a day?

Social History: Substance Use

Finding:

Asked about illicit drug use

Finding:

Reports past history of marijuana smoking

(Found)

Pro Tip: Determining any recent or past history of drug use is essential to revealing any substance abuse issues, and if the patient is likely to seek drugs while admitted.

Example Question:

Have you ever experimented with drugs?

Finding:

Followed up on patient’s marijuana use

Finding:

Last use was at age 20 or 21

(Found)

Pro Tip: When a patient reports drug use, it’s important to determine when exactly when she last took the drug, which, if recent, can interfere with medications.

Example Question:

When did you last smoke marijuana?

Finding:

Stopped because of health reasons and lost interest

(Available)

Pro Tip: Communicating about why a patient stopped or started drug use gives insight into their attitudes and dependencies on a substance.

Example Question:

What happened to cause you to stop smoking pot?

Finding:

Asked about the quantity of alcoholic drinks consumed

Finding:

Last alcoholic drink was 3 weeks ago

(Available)

Pro Tip: Confirming when a patient had her last alcohol intake is important, because she will receive medications while admitted, and alcohol is often contraindicated.

Example Question:

When was your last alcoholic drink?

Finding:

Reports no more than 2 or 3 alcoholic drinks in one sitting

(Available)

Pro Tip: Finding out how many alcoholic drinks a patient has in a single day or sitting is essential to uncover any binge-drinking habits that can be unhealthy for your patient.

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

(Available)

Pro Tip: Finding out how many nights a week your patient has alcohol gives insight into their habitual use.

Example Question:

How many nights a week do you drink alcohol?

Finding:

Reports no more than 6 to 10 alcoholic drinks per month

(Available)

Pro Tip: Finding out the patient’s estimate of their number of drinks each month helps you understand their alcohol use patterns over time.

Example Question:

How many alcoholic drinks do you have in a month?

Finding:

Asked about tobacco use

Finding:

Denies smoking tobacco

(Available)

Pro Tip: Finding out if a patient smokes cigarettes is important to understanding her overall health, and is a potential factor in delayed wound healing.

Example Question:

Have you ever smoked cigarettes?

Finding:

Asked about secondhand smoke

Finding:

Denies exposure to secondhand smoke

(Found)

Pro Tip: Exposure to secondhand smoke can be especially detrimental to an asthmatic patient’s health.

Example Question:

Are you ever exposed to secondhand smoke?

Review of Systems

Finding:

Asked about general symptoms

Finding:

Denies recent or frequent illnesses

(Available)

Pro Tip: Asking about recent or frequently presenting illness is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint.

Example Question:

Have you been sick recently?

Finding:

Reports occasional tiredness or fatigue

(Available)

Pro Tip: Asking about tiredness or fatigue is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint.

Example Question:

Are you fatigued?

Finding:

Reports some recent fever-related chills

(Available)

Pro Tip: Asking about additional symptoms, such as chills, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint.

Example Question:

Have you had chills?

Finding:

Denies night sweats

(Available)

Pro Tip: Asking about additional symptoms, such as night sweats, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint.

Example Question:

Have you had night sweats?

Finding:

Describes typical sleep patterns

(Available)

Pro Tip: Asking about the patient’s typical sleep pattern is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems, such as sleep disturbance, not discovered during the discussion of the patient’s chief complaint.

Example Question:

Have you noticed changes in your sleep?

Finding:

Asked about review of systems for mental health

Finding:

Denies history of depression

(Available)

Pro Tip: Asking about about the patient’s history with depression is one possible component of a review of systems interview and may provide insight into their ability to cope in the event of painful physical trauma.. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint.

Example Question:

Do you have a history of depression?

Finding:

Denies history of suicidal ideation or attempts

(Available)

Pro Tip: Asking about about the patient’s suicidal ideation one possible component of a review of systems interview and may provide insight into their ability to cope in the event of painful physical trauma. Higher levels of pain have been associated with thoughts of self-harm. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint.

Example Question:

Do you have a history of suicidal thinking?

Finding:

Denies past diagnosis of mental health conditions

(Available)

Pro Tip: Asking about about the patient’s mental health history is one possible component of a review of systems interview and may provide insight into their ability to cope in the event of painful physical trauma.. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint.

Example Question:

Have you ever been diagnosed with a mental health condition?

Finding:

Asked about review of systems for head

Finding:

Reports occasional headaches

(Found)

Pro Tip: Asking about headache frequency is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint.

Example Question:

Do you ever get headaches?

Finding:

Denies current headache

(Available)

Pro Tip: Asking about headache frequency is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint.

Example Question:

Do you have a headache?

Finding:

Denies head injury

(Available)

Pro Tip: Asking about the patient’s history of physical trauma, including head injury, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint.

Example Question:

Have you had any head injuries?

Finding:

Asked about review of systems for ears

Finding:

Denies general ear problems

(Available)

Pro Tip: Asking about ear problems is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint.

Example Question:

Have you had ear problems?

Finding:

Denies change in hearing

(Available)

Pro Tip: Asking about changes in hearing is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems, such as hearing loss, not discovered during the discussion of the patient’s chief complaint.

Example Question:

Has your hearing changed?

Finding:

Denies ear pain

(Available)

Pro Tip: Ear pain can suggest an ear infection, during which the middle of the ear becomes clogged with fluid and mucous, which can affect hearing. Asking Tina if she has ear pain might indicate a possible ear infection and a reason for changes in her hearing.

Example Question:

Have you had ear pain?

Finding:

Denies ear discharge

(Available)

Pro Tip: Ear discharge is the leakage of blood, pus, or wax from the ear and can be the result of a ruptured eardrum, eczema, or swimmer’s ear. Asking whether she’s noticed ear discharge could indicate whether she has a ruptured eardrum.

Example Question:

Have you had ear discharge?

Finding:

Denies ringing or tinnitus

(Available)

Pro Tip: Ringing in the ears can suggest an ear infection, during which the middle of the ear becomes clogged with fluid and mucous, which can affect hearing, or hearing loss. Asking Tina if she has ear pain might indicate a possible ear infection and a reason for changes in her hearing.

Example Question:

Do you ever have ringing in your ears?

Finding:

Asked about review of systems for eyes and vision

Finding:

Reports changes in vision

(Available)

Pro Tip: Asking about changes in vision is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint, such as vision loss.

Example Question:

Have you noticed any changes in your vision?

Finding:

Denies eye pain

(Available)

Pro Tip: Asking about symptoms, such as eye pain, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint, such as allergic reactions, infection, or physical trauma.

Example Question:

Have you had eye pain?

Finding:

Reports infrequent itchy eyes

(Available)

Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.

Example Question:

Have you had itchy eyes?

Finding:

Denies eye redness

(Available)

Pro Tip: Asking about symptoms, such as eye redness, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint, such as allergic reactions or infection.

Example Question:

Have you had red eyes?

Finding:

Denies dry eyes

(Available)

Pro Tip: Dry eyes occur when the eyes do not produce enough tears to lubricate them. Asking Tina if she has dry eyes solicits information about one particular symptom.

Example Question:

Have you had dry eyes?

Finding:

Denies discharge, crusting or wateriness

(Available)

Pro Tip: Asking about symptoms, such as eye discharge, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint, such as allergic reactions or infection.

Example Question:

Have you had watery eyes?

Finding:

Does not have corrective lenses

(Available)

Pro Tip: Asking about the patient’s use of corrective lenses is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint, such as vision loss.

Example Question:

Do you wear glasses or contact?

Finding:

Reports last eye exam was in childhood

(Found)

Pro Tip: Asking about the patient’s past vision exams, is one possible component of a review of systems interview. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint.

Example Question:

When was your last eye exam?

Finding:

Reports occasional blurry vision

(Available)

Pro Tip: Asking about sight disturbances, such as blurry vision, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint, such as vision loss.

Example Question:

Do you ever get blurry vision?

Finding:

Denies double vision

(Available)

Pro Tip: Asking about sight disturbances, such as double vision, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint, such as vision loss.

Example Question:

Do you ever get double vision?

Finding:

Asked about review of systems for nose

Finding:

Reports infrequent nose problems

(Available)

Pro Tip: Asking about symptoms, such as nose problems, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint, such as allergic reactions, infection, or physical trauma.

Example Question:

Have you had nose problems?

Finding:

Denies change in sense of smell

(Available)

Pro Tip: Asking about symptoms, such as a change in smell, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint.

Example Question:

Has your sense of smell changed?

Finding:

Reports occasional sneezing around cats and dust

(Available)

Pro Tip: Asking about symptoms, such as frequent sneezing, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint, such as additional allergens that could exacerbate existing triggers such as allergies and asthma.

Example Question:

Have you been sneezing?

Finding:

Denies nosebleeds

(Available)

Pro Tip: Asking about symptoms, such as frequent nosebleeds, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint.

Example Question:

Have you had nosebleeds?

Finding:

Denies frequent sinus problems

(Available)

Pro Tip: Asking about symptoms, such as frequent sinus issues, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint, such as unspecified allergies.

Example Question:

Have you had sinus pain?

Finding:

Reports infrequent runny nose

(Available)

Pro Tip: Asking about symptoms, such as runny nose, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint, such as unspecified allergies.

Example Question:

Have you had a runny nose?

Finding:

Asked about review of systems for mouth and jaw

Finding:

Denies general mouth problems

(Found)

Pro Tip: Asking about symptoms, such as general mouth problems, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint, such as oral infection.

Example Question:

Do you have any mouth problems?

Finding:

Denies change in sense of taste

(Available)

Pro Tip: Asking about symptoms, such as a change in taste, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint.

Example Question:

Has your sense of taste changed?

Finding:

Denies dry mouth

(Available)

Pro Tip: Asking about symptoms, such as dry mouth, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint.

Example Question:

Have you had dry mouth?

Finding:

Denies mouth pain

(Available)

Pro Tip: Asking about symptoms, such as oral pain, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint, such as oral infection or recent trauma.

Example Question:

Have you had mouth pain?

Finding:

Denies mouth sores

(Available)

Pro Tip: Asking about symptoms, such as oral pain, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint, such as oral infection or recent trauma.

Example Question:

Have you had mouth sores?

Finding:

Denies gum problems

(Available)

Pro Tip: Asking about symptoms, such as gum problems, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint, such as oral infection or recent trauma.

Example Question:

Have you had gum problems?

Finding:

Denies tongue problems

(Available)

Pro Tip: Asking about symptoms, such as tongue pain, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint, such as oral infection or recent trauma.

Example Question:

Have you had tongue problems?

Finding:

Denies jaw problems

(Available)

Pro Tip: Asking about symptoms, such as jaw problems, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint.

Example Question:

Have you had jaw problems?

Finding:

Reports no known dental problems

(Found)

Pro Tip: Asking about symptoms, such as dental problems, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint, such as oral infections that can by the underlying cause of many health issues.

Example Question:

Have you had any recent dental problems?

Finding:

Reports last dental visit was several years ago

(Found)

Pro Tip: Asking about a patient’s dental care is one possible component of a review of systems interview. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint.

Example Question:

When did you last see a dentist?

Finding:

Asked about review of systems for neck, throat and glands

Finding:

Denies difficulty swallowing

(Available)

Pro Tip: Asking if a patient has difficulty swallowing is one possible component of a review of systems interview. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint.

Example Question:

Have you had difficulty swallowing?

Finding:

Denies sore throat

(Available)

Pro Tip: Asking if a patient has a sore throat is one possible component of a review of systems interview. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint.

Example Question:

Have you had a sore throat?

Finding:

Denies history of frequent throat problems

(Available)

Pro Tip: Asking if a patient has recurring throat problems is one possible component of a review of systems interview. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint.

Example Question:

Do you have a history of throat problems?

Finding:

Denies voice changes

(Available)

Pro Tip: Asking about changes in a patient’s voice is one possible component of a review of systems interview. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint.

Example Question:

Have you had voice changes?

Finding:

Denies general neck problems

(Available)

Pro Tip: Asking about the presence of neck pain is one possible component of a review of systems interview. The patient’s response to these questions may uncover additional not discovered during discussion of the patient’s chief complaint.

Example Question:

Have you had neck pain?

Finding:

Denies history of lymph node problems

(Available)

Pro Tip: Asking about a patient’s lymph nodes is one possible component of a review of systems interview. Swollen lymph nodes may appear in the neck when an infection is present.

Example Question:

How are your lymph nodes?

Finding:

Denies swollen glands

(Available)

Pro Tip: Asking about a patient’s glands in general could include lymph nodes or thyroid glands. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint.

Example Question:

Do you have any swollen glands?

Finding:

Asked about review of systems for respiratory

Finding:

Denies current breathing problems

(Available)

Pro Tip: Asking about general breathing problems can provide a comparative baseline for assessing Tina’s current condition and previous breathing concerns.

Example Question:

Have you had breathing problems?

Finding:

Denies current wheezing

(Available)

Pro Tip: Patients who experience chronic asthma may be accustomed to wheezing and, as a result, might not volunteer this information. Asking Tina if she’s been wheezing illustrates how her asthma is presenting.

Example Question:

Have you been wheezing?

Finding:

Denies current chest tightness

(Available)

Pro Tip: Asking about chest tightness is one possible component of a review of systems interview. As a currently presenting symptom, it could indicate a change in patient status. If the patient reports a history of chest tightness, it could be a symptom of asthma or another respiratory problem.

Example Question:

Have you had chest tightness?

Finding:

Denies pain while breathing

(Available)

Pro Tip: Asking about pain during breathing is one possible component of a review of systems interview. As a currently presenting symptom, it could indicate a change in patient status. If the patient reports a history of pain during breathing, it could be a symptom of asthma or another respiratory problem.

Example Question:

Does it hurt when you breathe?

Finding:

Denies coughing

(Available)

Pro Tip: Asking about coughing is one possible component of a review of systems interview. As a currently presenting symptom, it could indicate an asthma exacerbation or a new respiratory infection.

Example Question:

Have you been coughing?

Finding:

Asked about review of systems for cardiovascular

Finding:

Denies chest pain or discomfort

(Available)

Pro Tip: Asking about chest pain is one possible component of a review of systems interview. As a currently presenting symptom, it could indicate a change in patient status. If the patient reports a history of chest pain, it could be a symptom of a recurring cardiovascular problem.

Example Question:

Do you ever have chest pain?

Finding:

Denies palpitations

(Available)

Pro Tip: Asking about palpitations is one possible component of a review of systems interview. As a currently presenting symptom, it could indicate a change in patient status. If the patient reports a history of palpitations, it could be a symptom of a recurring cardiovascular problem.

Example Question:

Have you had palpitations?

Finding:

Denies irregular heartbeat

(Available)

Pro Tip: Asking about heartbeat patterns is one possible component of a review of systems interview. As a currently presenting symptom, it could indicate a change in patient status. If the patient reports a history of irregular heartbeat, it could be a symptom of a recurring cardiovascular problem.

Example Question:

Has your heartbeat been irregular?

Finding:

Denies easy bruising

(Available)

Pro Tip: Asking if a patient bruises easily is one possible component of a review of systems interview. Bruising easily can be indicative of anemia or a more serious blood disorder.

Example Question:

Have you noticed bruising more than usual?

Finding:

Reports no edema (other than foot swelling due to infection)

(Available)

Pro Tip: Asking about edema is one possible component of a review of systems interview. Edema is caused by the presence of excess fluid in the tissues, and it can indicate an infection, weak heart or veins, or other organ problems.

Example Question:

Have you noticed any swelling in your legs?

Finding:

Denies circulation problems

(Available)

Pro Tip: Poor circulation is the result of other diseases like obesity, diabetes, or cardiac conditions. Asking Tina whether she’s experienced poor circulation indicates whether she might suffer from underlying cardiac concerns.

Example Question:

Do you have circulation problems?

Finding:

Denies vascular diseases (varicose veins, peripheral vascular disease)

(Available)

Pro Tip: Asking about vascular diseases is one possible component of a review of systems interview. A history of vascular disease could affect a patient’s care plan or risk factors for bed sores.

Example Question:

Do you have any vascular diseases?

Finding:

Asked review of systems for gastrointestinal

Finding:

Denies nausea

(Available)

Pro Tip: Currently presenting nausea can be caused by changes in blood sugar, a reaction to medication, stress, or even spreading infection. If the patient reports a history of nausea, it could be a symptom of a recurring gastrointestinal problem.

Example Question:

Have you had nausea?

Finding:

Denies vomiting

(Available)

Pro Tip: Vomiting can be caused by a pain response, a reaction to medication, stress, or even spreading infection. If the patient reports a history of vomiting, it could be a symptom of a recurring gastrointestinal problem

Example Question:

Have you been vomiting?

Finding:

Denies stomach pain

(Available)

Pro Tip: Asking about stomach pain is one possible component of a review of systems interview. As a currently presenting symptom, it could indicate a change in patient status. If the patient reports recurring stomach pain, it could be a symptom of a gastrointestinal problem.

Example Question:

Do you have stomach pain?

Finding:

Denies heartburn, GERD, or indigestion

(Available)

Pro Tip: Asking about stomach conditions such as heartburn or GERD is one possible component of a review of systems interview. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint.

Example Question:

Do you ever get heartburn?

Finding:

Denies constipation

(Available)

Pro Tip: Asking about constipation is one possible component of a review of systems interview. As a currently presenting symptom, it could impact the patient’s care plan. If the patient reports a history of constipation, it could be a symptom of dietary or gastrointestinal problems.

Example Question:

Do you have constipation?

Finding:

Denies changes in bowel movements

(Available)

Pro Tip: Asking about changes in bowel movements can help you understand a patient’s baseline patterns. Any recent or abrupt changes could impact the patient’s care plan, such as administering treatment for constipation or diarrhea.

Example Question:

Have you had changes in your bowel movements?

Finding:

Denies diarrhea or loose stool

(Available)

Pro Tip: Asking about diarrhea is one possible component of a review of systems interview. As a currently presenting symptom, it could impact the patient’s care plan. If the patient reports a history of diarrhea, it could be a symptom of dietary or gastrointestinal problems.

Example Question:

Do you have diarrhea?

Finding:

Denies flatulence or bloating

(Available)

Pro Tip: Asking about gas or bloating is one possible component of a review of systems interview. As a currently presenting symptom, it could impact the patient’s care plan. If the patient reports a history of gas, it could be a symptom of dietary or gastrointestinal problems.

Example Question:

Do you have flatulence?

Finding:

Denies bloody or tarry stool

(Available)

Pro Tip: Asking about bloody or tarry stools is one possible component of a review of systems interview. As a currently presenting symptom, it could impact the patient’s care plan. If the patient reports a history of blood in the stool, it could be a symptom of dietary or gastrointestinal problems

Example Question:

Do you have tarry stools?

Finding:

Asked review of systems for genitourinary

Finding:

Denies dysuria

(Available)

Pro Tip: Asking about pain during urination is one possible component of a review of systems interview. As a currently presenting symptom, it could result in a change to the patient’s care plan. A history of pain during urination could be a symptom of genitourinary problems.

Example Question:

Does it hurt when you urinate?

Finding:

Reports nocturia

(Available)

Pro Tip: Frequent urination at night can be a sign of uncontrolled blood sugar or UTI. As a currently presenting symptom, nocturia could result in a change to the patient’s care plan. A history of nocturia could be a symptom of genitourinary or endocrine problems such as diabetes.

Example Question:

Do you wake up at night to urinate?

Finding:

Reports polyuria

(Found)

Pro Tip: Frequent urination can be a sign of uncontrolled blood sugar or UTI. As a currently presenting symptom, polyuria could result in a change to the patient’s care plan. A history of polyuria could be a symptom of genitourinary or endocrine problems such as diabetes.

Example Question:

Do you urinate frequently?

Finding:

Denies hematuria

(Available)

Pro Tip: As a currently presenting symptom, blood in the urine is a serious symptom that requires immediate intervention. A history of hematuria could be a symptom of genitourinary problems.

Example Question:

Do you ever notice blood in your urine?

Finding:

Denies flank pain

(Available)

Pro Tip: Flank pain can be a sign of kidney infection. As a currently presenting symptom, flank pain could result in a change to the patient’s care plan. A history of flank pain could be a symptom of genitourinary problems.

Example Question:

Do you have flank pain?

Finding:

Denies incontinence

(Available)

Pro Tip: As a currently presenting symptom, incontinence could result in a change to the patient’s care plan. A history of incontinence could be a symptom of genitourinary or pelvic problems.

Example Question:

Are you able to hold your urine?

Finding:

Denies history of urinary tract or bladder infection

(Available)

Pro Tip: Asking about a history of bladder or urinary tract infections is one possible component of a review of systems interview. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint.

Example Question:

Have you ever had a urinary infection?

Finding:

Reports normal vaginal discharge

(Available)

Pro Tip: Asking about vaginal discharge is one possible component of a review of systems interview. If a patient reports atypical discharge, it could indicate a yeast or sexually transmitted infection.

Example Question:

What is your vaginal discharge like?

Finding:

Asked review of systems for breasts

Finding:

Denies general breast problems

(Available)

Pro Tip: Asking a general question about breast health allows a patient to prioritize her observations.

Example Question:

Do you have any problems with your breasts?

Finding:

Denies breast lumps

(Available)

Pro Tip: Checking breasts for lumps is important in monitoring for signs of breast cancer. Asking Tina if she’s noticed any lumps in her breasts will help you to assess whether she needs a follow-up breast exam.

Example Question:

Have you noticed any lumps in your breasts?

Finding:

Denies breast pain

(Available)

Pro Tip: Breast changes can indicate breast problems, from infection to cancer. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint.

Example Question:

Have you felt pain in your breasts?

Finding:

Denies nipple changes

(Available)

Pro Tip: Nipple changes can indicate breast problems, from infection to cancer. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint.

Example Question:

Have you noticed changes in your nipples?

Finding:

Denies nipple discharge

(Available)

Pro Tip: Nipple discharge can indicate breast problems, from infection to cancer. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint.

Example Question:

Have you noticed any nipple discharge?

Finding:

Reports no past mammograms

(Available)

Pro Tip: It’s important to ask questions about a history of mammography or other breast diagnostic tests. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint.

Example Question:

Have you ever had a mammogram?

Finding:

Reports doing self-breast exams

(Available)

Pro Tip: Self-performed breast exams are an important screening tool for patients. Asking if the patient performs them can start a conversation about healthy self-care practices.

Example Question:

Do you do regular breast exams?

Finding:

Asked review of systems for musculoskeletal

Finding:

Denies muscle pain

(Available)

Pro Tip: Asking about muscle pain is one possible component of a review of systems interview. The most common causes of muscle pain are strain, overuse, illness, or infection.

Example Question:

Do you have muscle pain?

Finding:

Denies joint pain

(Available)

Pro Tip: Asking about joint pain is one possible component of a review of systems interview. The most common causes of muscle pain are overuse, and conditions such as arthritis.

Example Question:

Do you have joint pain?

Finding:

Denies muscle weakness

(Available)

Pro Tip: Asking about muscle weakness is one possible component of a review of systems interview. Muscle weakness can be a sign of neurological problems, or a reaction to medication.

Example Question:

Do you have muscle weakness?

Finding:

Denies joint swelling

(Available)

Pro Tip: Asking about joint swelling is one possible component of a review of systems interview. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint.

Example Question:

Do you ever have swelling in your joints?

Finding:

Denies back pain

(Available)

Pro Tip: Back pain can have many sources, and can impact a patient’s mobility, comfort, and overall health. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint.

Example Question:

Do you ever have back pain?

Finding:

Denies history of fractures or breaks

(Available)

Pro Tip: A history of fractures can help identify patients with bone disorders, or even a history of abuse. Asking your patient about past fractures may uncover additional problems not discovered during discussion of the patient’s chief complaint.

Example Question:

Have you ever broken a bone?

Finding:

Asked review of systems for neurological

Finding:

Denies dizziness, lightheadedness, or vertigo

(Available)

Pro Tip: Asking about dizziness or vertigo is one possible component of a review of systems interview. Presence of dizziness could indicate a reaction to medication, an inner ear problem, or changes in blood sugar or blood pressure.

Example Question:

Do you get dizzy?

Finding:

Denies vision disturbances

(Available)

Pro Tip: Vision disturbances can be a sign of neurological problems. Asking your patient about past fractures may uncover additional problems not discovered during discussion of the patient’s chief complaint.

Example Question:

Do you ever see spots?

Finding:

Denies numbness or tingling

(Available)

Pro Tip: Asking about tingling sensations or numbness is one possible component of a review of systems interview. Diabetic patients often experience numbness due to neuropathy, especially in the arms, legs, hands, and feet.

Example Question:

Do you ever get tingling?

Finding:

Denies loss of coordination

(Available)

Pro Tip: Asking if the patient has experienced loss of coordination is one possible component of a review of systems interview. The patient’s response to these questions may uncover neurological problems.

Example Question:

Do you notice being more clumsy than usual?

Finding:

Denies loss of sensation

(Available)

Pro Tip: Diabetic patients often experience numbness due to neuropathy, especially in the arms, legs, hands, and feet. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint.

Example Question:

Do you have a loss of sensation anywhere?

Finding:

Denies past history of seizures

(Available)

Pro Tip: Asking about seizures is one possible component of a review of systems interview. The patient’s response to these questions may uncover neurological problems.

Example Question:

Have you ever had a seizure?

Finding:

Denies problems with balance or disequilibrium

(Available)

Pro Tip: Problems with balance can indicate neurological problems, or issues with the inner ear. Asking your patient about past fractures may uncover additional problems not discovered during discussion of the patient’s chief complaint.

Example Question:

Do you lose your balance often?

Finding:

Denies memory loss

(Available)

Pro Tip: Memory loss can indicate serious neurological problems or traumatic brain injury. Asking your patient about past fractures may uncover additional problems not discovered during discussion of the patient’s chief complaint.

Example Question:

Have you ever experienced memory loss?

Finding:

Denies recent loss of consciousness or fainting

(Available)

Pro Tip: Syncope (loss of consciousness) or fainting could indicate serious neurological problems, or changes in blood pressure. Asking your patient about past fractures may uncover additional problems not discovered during discussion of the patient’s chief complaint.

Example Question:

Have you ever passed out?

Finding:

Asked review of systems for skin, hair and nails

Finding:

Reports acne

(Available)

Pro Tip: Adult acne can suggest stress or changes in hormone levels. Asking Tina about her present acne and history of acne can help you understand any skin conditions or hormonal changes.

Example Question:

Do you still have acne?

Finding:

Reports changes to neck skin

(Available)

Pro Tip: Asking about changes in skin color is one possible component of a review of systems interview. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint.

Example Question:

Do you have any skin discoloration?

Finding:

Reports excessive facial or body hair

(Available)

Pro Tip: Increases in body hair can suggest changes in hormone levels. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint.

Example Question:

Do you have an increase in body hair?

Finding:

Reports moles

(Available)

Pro Tip: Monitoring moles is key in preventing cancerous growths. Asking Tina if her moles have changed will indicate whether any of her moles should be assessed further.

Example Question:

Have your moles changed?

Finding:

Reports no body sores (aside from foot wound)

(Available)

Pro Tip: Sores on the body can be due to skin diseases or slow wound-healing, which is a problem for many diabetics. Asking a patient about any additional body sores can help you identify additional skin or endocrine problems.

Example Question:

Do you have any sores?

Finding:

Denies dandruff

(Available)

Pro Tip: Dandruff is a chronic scalp condition characterized by flaking skin. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint.

Example Question:

Do you have dandruff?

Finding:

Denies nail abnormalities

(Available)

Pro Tip: Nail problems can indicate local problems, such as fungus or injury to the nail bed, or larger problems such as poor circulation. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint.

Example Question:

Do you have any problems with your nails?

Finding:

Reports occasional dry skin

(Available)

Pro Tip: Chronic or severe dry skin might require a patient to be seen by a dermatologist. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint.

Example Question:

Do you have dry skin?

Finding:

Denies rashes

(Available)

Pro Tip: Chronic or severe dry skin might require a patient to be seen by a dermatologist. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint.

Example Question:

Do you get skin rashes?

Finding:

Reports rarely using sunscreen

(Available)

Pro Tip: Wearing sunscreen is important in protecting the skin from the sun’s powerful UV rays. Asking Tina when she wears sunscreen solicits information about the ways in which she cares for her skin.

Example Question:

When do you wear sunscreen?

Family History: 3 Generations

Finding:

Asked about mother’s health

Finding:

Mother diagnosed with hypertension

(Found)

Pro Tip: Asking specifically about each family member’s health conditions can help you understand how inherited diseases impact your patient’s health history.

Example Question:

Does your mother have health conditions?

Finding:

Mother diagnosed with high cholesterol

(Found)

Pro Tip: Asking specifically about each family member’s health conditions can help you understand how inherited diseases impact your patient’s health history.

Example Question:

Does your mother have health conditions?

Finding:

Asked about father’s health

Finding:

Father diagnosed with Type 2 diabetes

(Found)

Pro Tip: Asking specifically about each family member’s health conditions can help you understand how inherited diseases impact your patient’s health history.

Example Question:

Does your father have health conditions?

Finding:

Father diagnosed with hypertension

(Found)

Pro Tip: Asking specifically about each family member’s health conditions can help you understand how inherited diseases impact your patient’s health history.

Example Question:

Does your father have health conditions?

Finding:

Father diagnosed with high cholesterol

(Found)

Pro Tip: Asking specifically about a family member’s health conditions can help you understand how inherited diseases impact your patient’s health history.

Example Question:

Does your father have health conditions?

Finding:

Followed up to ask about coping after father’s death

Finding:

Reports grief at the time but feeling “at peace” with it now

(Available)

Pro Tip: Communicating empathetically about grief builds rapport and can provide insight into your patient’s lifestyle, stress factors, mental health, and more.

Example Question:

How are you coping with your father’s death?

Finding:

Asked father’s age at death

Finding:

Died at age 58

(Found)

Pro Tip: Determining the age of death of a family member can provide insight into risk factors for inherited diseases, or can reveal stress caused by premature death.

Example Question:

How old was your father when he died?

Finding:

Asked cause of father’s death

Finding:

Cause of death: car accident

(Found)

Pro Tip: Determining the cause of death indicates whether the death was from a health condition that the patient may share, or whether it was accidental.

Example Question:

What caused your father’s death?

Finding:

Asked about paternal grandfather’s health

Finding:

Paternal grandfather diagnosed with Type 2 diabetes

(Found)

Pro Tip: Asking specifically about each family member’s health conditions can help you understand how inherited diseases impact your patient’s health history.

Example Question:

Does your paternal grandfather have health conditions?

Finding:

Paternal grandfather diagnosed with hypertension

(Found)

Pro Tip: Asking specifically about each family member’s health conditions can help you understand how inherited diseases impact your patient’s health history.

Example Question:

Does your paternal grandfather have health conditions?

Finding:

Paternal grandfather diagnosed with high cholesterol

(Found)

Pro Tip: Asking specifically about each family member’s health conditions can help you understand how inherited diseases impact your patient’s health history.

Example Question:

Does your paternal grandfather have health conditions?

Finding:

Asked about paternal grandmother’s health

Finding:

Paternal grandmother diagnosed with hypertension

(Available)

Pro Tip: Asking specifically about each family member’s health conditions can help you understand how inherited diseases impact your patient’s health history.

Example Question:

Does your paternal grandmother have health conditions?

Finding:

Paternal grandmother diagnosed with high cholesterol

(Available)

Pro Tip: Asking specifically about each family member’s health conditions can help you understand how inherited diseases impact your patient’s health history.

Example Question:

Does your paternal grandmother have health conditions?

Finding:

Asked about maternal grandfather’s health

Finding:

Maternal grandfather diagnosed with hypertension

(Found)

Pro Tip: Asking specifically about each family member’s health conditions can help you understand how inherited diseases impact your patient’s health history.

Example Question:

Does your maternal grandfather have health conditions?

Finding:

Maternal grandfather diagnosed with high cholesterol

(Found)

Pro Tip: Asking specifically about each family member’s health conditions can help you understand how inherited diseases impact your patient’s health history.

Example Question:

Does your maternal grandfather have health conditions?

Finding:

Asked about maternal grandmother’s health

Finding:

Maternal grandmother diagnosed with hypertension

(Found)

Pro Tip: Asking specifically about each family member’s health conditions can help you understand how inherited diseases impact your patient’s health history.

Example Question:

Does your maternal grandmother have health conditions?

Finding:

Maternal grandmother diagnosed with high cholesterol

(Found)

Pro Tip: Asking specifically about each family member’s health conditions can help you understand how inherited diseases impact your patient’s health history.

Example Question:

Does your maternal grandmother have health conditions?

Finding:

Asked about brother’s health

Finding:

Reports no diagnosed health problems

(Found)

Pro Tip: Asking specifically about each family member’s health conditions can help you understand how inherited diseases impact your patient’s health history.

Example Question:

Does your brother have health conditions?

Finding:

Asked about sister’s health

Finding:

Sister diagnosed with asthma

(Found)

Pro Tip: Asking specifically about each family member’s health conditions can help you understand how inherited diseases impact your patient’s health history.

Example Question:

Does your sister have health conditions?

Family History: Inherited Risk Factors

Finding:

Asked about family history of diabetes

Finding:

Father and paternal grandfather have diabetes

(Found)

Pro Tip: Asking about trends can help you fill in holes in the history that your patient may have missed, and can allow you insight into other inherited diseases that affect relatives outside of immediate family.

Example Question:

Does anyone else in your family have diabetes?

Finding:

Asked about family history of asthma

Finding:

Younger sister has asthma

(Available)

Pro Tip: Asking about trends can help you fill in holes in the history that your patient may have missed, and can allow you insight into other inherited diseases that affect relatives outside of immediate family.

Example Question:

Does anyone else in your family have asthma?

Finding:

Asked about family history of obesity

Finding:

Confirms that family members are overweight

(Available)

Pro Tip: Asking about trends can help you fill in holes in the history that your patient may have missed, and can allow you insight into other inherited diseases that affect relatives outside of immediate family.

Example Question:

Does obesity run in your family?

Finding:

Asked about family history of cancer

Finding:

Paternal grandfather died of colon cancer

(Found)

Pro Tip: Asking about trends can help you fill in holes in the history that your patient may have missed, and can allow you insight into other inherited diseases that affect relatives outside of immediate family.

Example Question:

Have you had any family members with cancer?

Finding:

Asked about family history of thyroid issues

Finding:

No known family history of thyroid issues

(Available)

Pro Tip: Asking about trends can help you fill in holes in the history that your patient may have missed, and can allow you insight into other inherited diseases that affect relatives outside of immediate family.

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

(Available)

Pro Tip: Asking about trends in substance abuse can help you understand your patient’s risk for inherited diseases linked to addiction.

Example Question:

Do you have relatives with addiction problems?

Finding:

Asked about family history of headaches

Finding:

No known family history of headaches

Documentation / Electronic Health Record

x

Student Documentation Model Documentation

 

Identifying Data & Reliability

 

Ms. Jones is a pleasant, 28-year-old obese African American single woman who presents to establish care and with a recent right foot injury. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview.

 

General Survey

 

Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. She is well-nourished, well-developed, and dressed appropriately with good hygiene. Tina Jones Health History Subjective Data

 

Chief Complaint

 

“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

 

Ms. Jones reports that a week ago she tripped while walking on concrete stairs outside, twisting her right ankle and scraping the ball of her foot. She sought care in a local emergency department where she had x-rays that were negative; she was treated with tramadol for pain. She has been cleansing the site twice a day. She has been applying antibiotic ointment and a bandage. She reports that ankle swelling and pain have resolved but that the bottom of the foot is increasingly painful. The pain is described as “throbbing” and “sharp” with weight bearing. She states her ankle “ached” but is resolved. Pain is rated 7 out of 10 after a recent dose of tramadol. Pain is rated 9 with weight bearing. She reports that over the past two days the ball of the foot has become swollen and increasingly red; yesterday she noted discharge oozing from the wound. She denies any odor from the wound. Her shoes feel tight. She has been wearing slip-ons. She reports fever of 102 last night. She denies recent illness. Reports a 10-pound, unintentional weight loss over the month and increased appetite. Denies change in diet or level of activity.

 

Medications

 

Acetaminophen 500-1000 mg PO prn (headaches) • Ibuprofen 600 mg PO TID prn (menstrual cramps) • Tramadol 50 mg PO BID prn (foot pain) • Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (Wheezing: “when around cats,” last use three days ago)

 

 

Penicillin: rash • Denies food and latex allergies • Allergic to cats and dust. When she is exposed to allergens she states that she has runny nose, itchy and swollen eyes, and increased asthma symptoms.

 

Medical History

 

Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler when she is around cats and dust. She uses her inhaler 2 to 3 times per week. She was exposed to cats three days ago and had to use her inhaler once with positive relief of symptoms. She was last hospitalized for asthma “in high school”. Never intubated. Type 2 diabetes, diagnosed at age 24. She previously took metformin, but she stopped three years ago, stating that the pills made her gassy and “it was overwhelming, taking pills and checking my sugar.” She doesn’t monitor her blood sugar. Last blood glucose was elevated last week in the emergency room. No surgeries. OB/GYN: Menarche, age 11. First sexual encounter at age 18, sex with men, identifies as heterosexual. Never pregnant. Last menstrual period 3 weeks ago. For the past year cycles irregular (every 4-8 weeks) with heavy bleeding lasting 9-10 days. No current partner. Used oral contraceptives in the past. When sexually active, reports she did not use condoms. Never tested for HIV/AIDS. No history of STIs or STI symptoms. Last tested for STIs four years ago. Hematologic: Denies bleeding, bruising, blood transfusions and history of blood clots. Skin: Reports acne since puberty and bumps on the back of her arms when her skin is dry. Complains of darkened skin on her neck and increase facial and body hair. She reports a few moles but no other hair or nail changes.

 

Health Maintenance

 

Last Pap smear 4 years ago. Last eye exam in childhood. Last dental exam “a few years ago.” PPD (negative) ~2 years ago. No exercise. 24-hour Diet Recall: States that she skipped breakfast yesterday, and would typically have a baked good for breakfast, a sandwich for lunch, and a meatloaf or chicken for dinner. Her snacks consist of pretzels or French fries. Immunizations: Tetanus booster was received within the past year, influenza is not current, and human papillomavirus has not been received. She reports that she believes she is up to date on childhood vaccines and received the meningococcal vaccine in college. Safety: Has smoke detectors in the home, wears seatbelt in car, and does not ride a bike. Does not use sunscreen. Guns, having belonged to her dad, are in the home, locked in parent’s room.

 

Family History

 

 

  • Mother: age 50, hypertension, elevated cholesterol
  • Father: deceased in car accident one year ago at age 58, hypertension, high cholesterol, and type 2 diabetes
  • Brother (Michael, 25): overweight
  • Sister (Britney, 14): asthma
  • Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol
  • Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol
  • Paternal grandmother: still living, age 82, hypertension
  • Paternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes
  • Paternal uncle: alcoholism
  • Negative for mental illness, other cancers, sudden death, kidney disease, sickle cell anemia, thyroid problems

 

Social History

 

Never married, no children. Lived independently since age 20, currently lives with mother and sister in a single family home to support family after death of father one year ago. Employed 32 hours per week as a supervisor at Mid-American Copy and Ship. She enjoys her work and was recently promoted to shift supervisor. She is a part-time student, in her last semester to earn a bachelor’s degree in accounting. She hopes to advance to an accounting position within her company. She has a car, cell phone, and computer. She receives basic health insurance from work, but is deterred from healthcare due to out-of-pocket costs. She enjoys spending time with friends, attending Bible study, volunteering in her church, and dancing. Tina is active in her church and describes a strong family and social support system. She reports stressors relating to the death of her father and balancing work and school demands, and finances. She states that family and church help her cope with stress. No tobacco. Occasional cannabis use from age 15 to age 21. Reports no use of cocaine, methamphetamines, and heroin. Uses alcohol when “out with friends, 2-3 times per month,” reports drinking no more than 3 drinks per episode. She drinks 4 caffeinated drinks per day (diet soda). No foreign travel. No pets. Not currently in an intimate relationship, ended a three-year serious monogamous relationship two years ago. She plans on getting married and having children someday. Tina Jones Health History Subjective Data

 

Objective

 

Wound: 2 cm x 1.5 cm, 2.5 mm deep wound, red wound edges, right ball of foot, serosanguinous drainage. Mild erythema surrounding wound, no edema, no tracking.