Tina Jones Health History Completed

Tina Jones Health History

Transcript

Started: Mar 19, 2025 | Total Time: 97 min

All Lines (113)Interview Questions (97)Statements (4)Exam Actions (12)

	Weight: 90 kg	Exam Action 03/19/25 9:25 AM EDT
	BMI: 31	Exam Action 03/19/25 9:25 AM EDT
	Random blood glucose: 238	Exam Action 03/19/25 9:25 AM EDT
	Blood pressure: 142/82	Exam Action 03/19/25 9:25 AM EDT
	Respiratory rate: 19	Exam Action 03/19/25 9:25 AM EDT
	O2 sat: 99%	Exam Action 03/19/25 9:25 AM EDT
	Heart rate: 86	Exam Action 03/19/25 9:25 AM EDT
	Height: 170.2 cm	Exam Action 03/19/25 9:25 AM EDT
	Temperature: 38.4 °C	Exam Action 03/19/25 9:25 AM EDT
	Hello, my name is Mileidy. I will be your nurse today	Greet 03/23/25 12:39 AM EDT
	Hey.
	What brings you here today?	Question 03/23/25 12:39 AM EDT
	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!
	I am sorry for that	Empathize 03/23/25 12:39 AM EDT
	I appreciate you saying that.
	Can you rate the pain on a scale of 1 to 10	Question 03/23/25 12:40 AM EDT
	I’d say a 7. It hurts a lot, and the pain pills haven’t kicked in yet.
	Where is the paid located?	Question 03/23/25 12:40 AM EDT
	SSC is a community college. It’s downtown.
	When did the pain start?	Question 03/23/25 12:40 AM EDT
	Well, I got the scrape a week ago, but the scrape and the pain got a lot worse in the last few days.
	Have you gone for check up? (No matching questions found.)	Question 03/23/25 12:41 AM EDT
	Has the injury been assessed at the ER? (No matching questions found.)	Question 03/23/25 12:41 AM EDT
	was the injury assessed at the ER? (Clarified to What did the ER doctor tell you was wrong with your foot?.)	Question 03/23/25 12:42 AM EDT
	She said my ankle was fine, and I should just stay off it. And to keep the scrape clean and dry. Which I did. (Clarified to what the ER doctor told me was wrong with my foot.)
	Dose the wound have drainage? (Clarified to Is your foot wound draining?.)	Question 03/23/25 12:42 AM EDT
	Yeah, there’s definitely pus. (Clarified to if my foot wound is draining.)
	What colour is the pus?	Question 03/23/25 12:42 AM EDT
	It’s… white or maybe off-white.
	How did you treat the wound at home?	Question 03/23/25 12:43 AM EDT
	I made sure to clean it and just keep it bandaged. And I put Neosporin on it.
	What other symptoms does the wound have?	Question 03/23/25 12:43 AM EDT
	I mean, it’s all red and swollen, and there’s pus, it feels hot, it hurts like hell… It’s got all that going on.
	Has the injury affected your activities?	Question 03/23/25 12:43 AM EDT
	I mean, the last two days I couldn’t walk on my foot, so it’s gotten in the way of everything — I had to basically stay home and off my foot. I didn’t think it could get to the point where it caused so many problems.
	Do you have any preexisting condition?	Question 03/23/25 12:44 AM EDT
	Yeah. . . I have asthma and diabetes.
	How do you manage the diabetes?	Question 03/23/25 12:44 AM EDT
	I just watch what I eat and try to stay away from sweets.
	Which medication are you using for diabetes?	Question 03/23/25 12:44 AM EDT
	It’s just a regular Proventil inhaler.
	Which current diabetes medication are you using?	Question 03/23/25 12:45 AM EDT
	I don’t take anything for my diabetes anymore.
	Which diabetes medication were you using in the past? (Clarified to When were you taking diabetes medication?.)	Question 03/23/25 12:45 AM EDT
	I haven’t taken it in about three years, honestly. (Clarified to when I was taking diabetes medication.)
	Do you monitor your blood glucose?	Question 03/23/25 12:46 AM EDT
	I have a monitor at home, but to be honest I don’t really use it that often. It’s such a hassle to check my blood sugar, and my diabetes is under control right now so I don’t really need to.
	Do you often feel thirsty?	Question 03/23/25 12:46 AM EDT
	You know, I did notice lately that I’ve been really thirsty.
	Do you urinate frequently?	Question 03/23/25 12:47 AM EDT
	Yeah, but I’ve been drinking more water.
	Have you noted change in appetite? (Clarified to Is your appetite changing?.)	Question 03/23/25 12:47 AM EDT
	Yeah, lately I’ve definitely been much hungrier than usual. (Clarified to if I am experiencing appetite changes.)
	have you noted weight change?	Question 03/23/25 12:49 AM EDT
	Yeah, I’ve lost some weight recently.
	what is the reason for weight change? (Clarified to What led to your losing weight?.)	Question 03/23/25 12:49 AM EDT
	I don’t know what caused it, I just lost weight. (Clarified to what caused my weight loss.)
	When did you know you have asthma?	Question 03/23/25 12:50 AM EDT
	I think I was about two and a half? I used to have a lot of trouble with asthma attacks back then.
	WHat is your history of asthma exacerbation?	Question 03/23/25 12:50 AM EDT
	I haven’t had an asthma attack in a while, but I used to get them growing up, and my chest would feel really tight, like I couldn’t take in air, and I would wheeze really bad and get all sweaty. It was way worse than now, especially because I would use my inhaler and it wouldn’t help. It was really scary.
	Have you been hospitalized before?	Question 03/23/25 12:51 AM EDT
	Well, I went a week ago on the day I hurt my foot to get it checked out. That was the first time I’ve been in the hospital since I was probably sixteen, though.
	How many puffs do you take when using the inhaler?	Question 03/23/25 12:51 AM EDT
	I usually use two puffs from my albuterol inhaler — it’s 90 micgrograms a spray — but lately sometimes I need three puffs. [AUDIO COMING SOON]
	what triggers the asthma?	Question 03/23/25 12:51 AM EDT
	Being around cats is the worst, but dust and running up stairs can make my breathing bad, too.
	do you have any allergies?	Question 03/23/25 12:52 AM EDT
	Yeah, I’m allergic to cats.
	what are the cat allergy symptoms?	Question 03/23/25 12:52 AM EDT
	Whenever I’m around cats, I start sneezing, my eyes get itchy. . . and my asthma starts to act up.
	do you have latex allergy?	Question 03/23/25 12:52 AM EDT
	Nope.
	do you have medication allergies?	Question 03/23/25 12:52 AM EDT
	Yeah, I’m allergic to penicillin.
	How does penicillin react on you? (No matching questions found.)	Question 03/23/25 12:53 AM EDT
	How does penicillin affect you?	Question 03/23/25 12:53 AM EDT
	I don’t remember that well because the last time I had penicillin I was pretty little. . . I think I got a rash, like, hives. The doctor told me not to take it again after that.
	Do you have food allergies	Question 03/23/25 12:53 AM EDT
	Nope, no food allergies that I know of.
	Have you been immunized?	Question 03/23/25 12:54 AM EDT
	I’m pretty sure they are all taken care of.
	have you had all childhood immunization (Clarified to Have you had all your childhood immunizations?.)	Question 03/23/25 12:54 AM EDT
	I am pretty sure I received all my vaccines as a kid, like before registering for school. (Clarified to if I got vaccinated as a kid.)
	have you received flu vaccine?	Question 03/23/25 12:55 AM EDT
	No.
	Have you received tetanus immunization?	Question 03/23/25 12:55 AM EDT
	I got a tetanus booster about a year ago.
	Do you have hypertension?	Question 03/23/25 12:55 AM EDT
	No, I’ve never been diagnosed with blood pressure problems.
	Do you use pain medication?	Question 03/23/25 12:56 AM EDT
	Yeah, I had to start taking pain medication.
	How frequently do you use pain medication?	Question 03/23/25 12:56 AM EDT
	I’ve been taking the Tramadol morning, noon, and night. [AUDIO COMING SOON]
	what is the dose of pain medication?	Question 03/23/25 12:56 AM EDT
	I’m not 100% sure, but I think they’re 50 milligrams.
	how efficient is the pain medication? (Clarified to How effective is the pain medication?.)	Question 03/23/25 12:57 AM EDT
	They only help for a few hours at a time. (Clarified to how effective the pain medication is.)
	Do you use OTC medication?	Question 03/23/25 12:57 AM EDT
	I take Tylenol for a headache sometimes, or Advil for cramps, but not often.
	How is your access to healthcare?	Question 03/23/25 12:57 AM EDT
	I have health insurance through my job, so I can go to the doctor if I need to. It’s always a hassle though, so I try to avoid it unless I really have to like right now.
	What is your level of education?	Question 03/23/25 12:58 AM EDT
	Well, I’m finishing up my Bachelor’s degree right now.
	How is your living situation? (Clarified to What is your living situation?.)	Question 03/23/25 12:58 AM EDT
	I live at home with my mom and my sister — we’re a pretty tight-knit family. They’ve been helping me out. (Clarified to to tell you about my living situation.)
	Do you have stressors?	Question 03/23/25 12:58 AM EDT
	Generally, I get stressed when I have too much to do. I can get kind of scattered and disorganized, and then that just makes it worse. But nothing’s been too stressful lately, except for my foot, of course.
	how is your salt intake?	Question 03/23/25 12:58 AM EDT
	Honestly, I don’t pay much attention to how much salt I eat. My mom is always reaching for the salt shaker, but I don’t usually add salt to my food.
	How is your caffeine intake?	Question 03/23/25 12:59 AM EDT
	I don’t know how much caffeine is in them exactly, but I drink about four Diet Cokes a day.
	Do you use illicit drugs?	Question 03/23/25 12:59 AM EDT
	Well, I used to smoke pot. . . but I don’t do that anymore.
	WHen last did you use pot?	Question 03/23/25 12:59 AM EDT
	I haven’t smoked pot since I was twenty or twenty-one.
	do you take alcohol?	Question 03/23/25 12:59 AM EDT
	I do sometimes, yeah, when I go out with my friends.
	Do you smoke tobacco?	Question 03/23/25 1:00 AM EDT
	No. I think it’s gross.
	Do you drink alcohol?	Question 03/23/25 1:00 AM EDT
	I do sometimes, yeah, when I go out with my friends.
	how much alcohol do you drink?	Question 03/23/25 1:00 AM EDT
	I don’t drink very much — I only have a few drinks when I go out.
	are you exposed to secondhand smoke?	Question 03/23/25 1:00 AM EDT
	Some of my friends smoke when we go out drinking. But I don’t smoke, and nobody at home smokes.
	how is your mother’s health?	Question 03/23/25 1:01 AM EDT
	Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though.
	how is your father’s health?	Question 03/23/25 1:01 AM EDT
	Dad passed away last year, so…it’s been really hard.
	I am sorry for that	Empathize 03/23/25 1:01 AM EDT
	Thanks for understanding.
	What caused your father’s death?	Question 03/23/25 1:02 AM EDT
	He died in a car accident.
	How did you cope with your father’s death?	Question 03/23/25 1:02 AM EDT
	Well, right after he died, after the funeral and everything, I just tried to get through that. Mom was having such a hard time, crying a lot, everything made her sad, she was kinda depressed. So I guess at first I just focused on getting things done–groceries, laundry, insurance papers and stuff. Knowing that Mom needed me kinda helped me get through day by day. There was about a month where it was hard for us to get to church. Even getting up and ready for church was too overwhelming. But our church family helped us out, and gave us rides to church and brought meals and all that, so they really helped build us back up. Things were only hard like that for a few months.
	how is your paternal grandfather’s health?	Question 03/23/25 1:03 AM EDT
	Grandpa Jones passed away when I was really little.
	how is your paternal grandmother’s health?	Question 03/23/25 1:03 AM EDT
	Granny’s doing good. She’s still living on her own. She’s slowing down, but we help her out. She lives down the street from us, and she gets around okay. I think she takes some pills, maybe for blood pressure? She might have high cholesterol too. She seems happy.
	how is your maternal grandfather’s health?	Question 03/23/25 1:03 AM EDT
	Well, Poppa died about five years ago.
	how is your paternal grandmother’s health?	Question 03/23/25 1:04 AM EDT
	Granny’s doing good. She’s still living on her own. She’s slowing down, but we help her out. She lives down the street from us, and she gets around okay. I think she takes some pills, maybe for blood pressure? She might have high cholesterol too. She seems happy.
	How is your brother’s health?	Question 03/23/25 1:04 AM EDT
	He’s a healthy guy. Kinda big like me.
	how is your maternal grandmother’s health?	Question 03/23/25 1:04 AM EDT
	Nana was 73 when she died of a stroke about five years ago. I think she had high blood pressure and cholesterol, too.
	How us your sister’s health?	Question 03/23/25 1:04 AM EDT
	She’s pretty healthy. She has asthma too, but she almost never has attacks.
	Do you have a family history of obesity?	Question 03/23/25 1:05 AM EDT
	No, I don’t think so. My brother and my dad are kind of big, but I wouldn’t say they were obese or anything.
	Do you have a family history of thyroid issues?	Question 03/23/25 1:05 AM EDT
	No, I don’t think so.
	Do you have a family history of substance abuse?	Question 03/23/25 1:05 AM EDT
	No, no drugs in my family. The only thing like that is that one of my uncles is an alcoholic.
	Do you have a family history of headaches?	Question 03/23/25 1:06 AM EDT
	No, not that I know of.
	How is your general health?	Question 03/23/25 1:06 AM EDT
	Overall, my health is pretty good. I have a couple of problems, I guess, but they don’t bother me too much.
	Do you have head issues?	Question 03/23/25 1:06 AM EDT
	I don’t think I have any problems. I get headaches sometimes, but that’s all.
	Do you have any ear problem?	Question 03/23/25 1:06 AM EDT
	No. I think my ears are fine.
	Do you have any eye problem?	Question 03/23/25 1:06 AM EDT
	I’ve actually been noticing problems lately. When I’m reading or studying I’ll notice that things start to get kind of blurry.
	Do you have nose problem	Question 03/23/25 1:07 AM EDT
	My nose is fine right now. Sometimes it runs, but not very often.
	Do you have mouth problem?	Question 03/23/25 1:07 AM EDT
	No.
	Do you have neck problem?	Question 03/23/25 1:07 AM EDT
	Sometimes I get a crick in it when I’m reading, but nothing serious.
	Do you have any breast problem?	Question 03/23/25 1:07 AM EDT
	No, no problems in that area.
	Do you have any cardiovascular issue?	Question 03/23/25 1:08 AM EDT
	My heart’s fine, thank God!
	Do you have any gastrointestinal issue?	Question 03/23/25 1:08 AM EDT
	No. I’ve never really had stomach or bowel problems.
	Do you have any reproductive system issue?	Question 03/23/25 1:08 AM EDT
	I don’t think I have problems in that area. I just get really bad periods, that’s all.
	how is your menstrual symptoms? (Clarified to Do you have menstrual symptoms?.)	Question 03/23/25 1:08 AM EDT
	Yeah, I get cramps pretty bad. (Clarified to if I have menstrual symptoms.)
	how do you treat the cramps?	Question 03/23/25 1:09 AM EDT
	I take Advil. I try a heating pad sometimes and that only helps a little.
	how is your sexual activity?	Question 03/23/25 1:09 AM EDT
	Uh, I wouldn’t say I have a “sex life” right now.
	do you use contraception?	Question 03/23/25 1:09 AM EDT
	Nope. But I’ve been single for a while so I haven’t needed to.
	Have you tested for STI? (Clarified to Have you been tested for STDs?.)	Question 03/23/25 1:10 AM EDT
	Yeah, I’m sure they did those tests when I went for a pap smear before. (Clarified to if I have ever been tested for STDs.)
	Have you ever been pregnant?	Question 03/23/25 1:10 AM EDT
	I’ve never been pregnant.
	how is your musculoskeletal system? (No matching questions found.)	Question 03/23/25 1:10 AM EDT
	do you have a musculoskeletal system problem? (No matching questions found.)	Question 03/23/25 1:11 AM EDT
	do you have a muscle problem	Question 03/23/25 1:11 AM EDT
	Not really.
	Do you have nerve problem?	Question 03/23/25 1:11 AM EDT
	No.
	Do you have a skin problem??	Question 03/23/25 1:11 AM EDT
	Well…I guess I was noticing the other day that the skin around my neck is looking weird. Like the skin is getting darker. And my skin’s breaking out, but that’s how it is.
	Where is the wound on the foot located?	Question 03/23/25 1:12 AM EDT
	It’s on the ball of my foot.
	How is your menstrual flow?	Question 03/23/25 1:13 AM EDT
	I’d say it’s heavy. I use the like, extra absorbent tampons, and I still have to change it every two or three hours.
	It is important to monitor your blood glucose regurlaly	Educate 03/23/25 1:13 AM EDT
	Alright, thanks for letting me know.
	Diabetes should be managed throughout and therefore you are supposed to be taking medications for diabetes	Educate 03/23/25 1:14 AM EDT
	OK, I understand.
	Measured wound: 2 cm x 1.5 cm, 2.5 mm deep	Exam Action 03/23/25 2:14 AM EDT
	Swabbed wound and sent to lab for C & S	Exam Action 03/23/25 2:14 AM EDT
	Cleansed and irrigated wound with normal saline and applied dry sterile dressing.	Exam Action 03/23/25 2:14 AM EDT

Subjective Data Collection: 100 of 100 (100.0%)

Hover To Reveal…

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

Found:

Indicates an item that you found.

Available:

Indicates an item that is available to be found.

Category

Scored Items

Experts selected these topics as essential components of a strong, thorough interview with this patient.

Patient Data

Not Scored

A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.

Chief Complaint

Finding:

Established chief complaint

Finding:

Reports pain

(Found)

Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.

Example Question:

How severe is the pain?

Finding:

Reports foot wound

(Found)

Example Question:

What’s causing your pain?

History of Present Illness

Finding:

Asked to rate current pain level on a scale

Finding:

Reports current pain is 7/10

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

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

Finding:

Asked for details about the pain

Finding:

Reports pain is throbbing

(Available)

Example Question:

Can you please describe the pain?

Finding:

Reports pain is sharp when she attempts to stand

(Available)

Example Question:

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

Finding:

Reports pain has increased in the past 2 days

(Found)

Example Question:

How has the pain changed over time?

Finding:

Reports feeling pain radiating into ankle

(Available)

Example Question:

Does the pain radiate anywhere else?

Finding:

Reports pain prevents bearing weight on foot

(Found)

Example Question:

Can you bear weight on your foot?

Finding:

Asked location of wound

Finding:

Reports right foot is injured

(Available)

Example Question:

Which foot is in pain?

Finding:

Reports wound is on the plantar surface of her foot

(Found)

Example Question:

Where is the wound?

Finding:

Asked details of the injury

Finding:

Reports she scraped foot on a cement step

(Available)

Example Question:

How did your injury happen?

Finding:

Reports initial injury occurred 1 week ago

(Found)

Example Question:

When did the pain start?

Finding:

Reports mild ankle injury

(Available)

Example Question:

Did you injure anything besides your foot?

Finding:

Reports being barefoot at the time of injury

(Available)

Example Question:

Were you wearing shoes when you fell?

Finding:

Asked about the assessment of the injury at the ER

Finding:

Reports going to the ER after sustaining the injury

(Available)

Example Question:

When did you go to the ER?

Finding:

Reports going to the ER because she suspected an ankle sprain

(Available)

Example Question:

Why did you go to the ER?

Finding:

Reports receiving an X-ray at the ER

(Available)

Example Question:

Did they xray your foot at the ER?

Finding:

Reports X-ray showed no broken bones

(Available)

Example Question:

What did the x-ray show?

Finding:

Reports receiving a prescription for pain pills

(Available)

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)

Example Question:

Did your foot bleed?

Finding:

Reports seeing pus draining from wound

(Found)

Example Question:

Did you notice any discharge from the wound?

Finding:

Reports noticing pus 2 days ago

(Available)

Example Question:

When did you first notice the pus?

Finding:

Followed up on drainage

Finding:

Reports pus as white or yellow

(Found)

Example Question:

What color is the drainage from your wound?

Finding:

Denies odor from the wound

(Available)

Example Question:

Does the wound have an odor?

Finding:

Asked about home treatment of foot wound

Finding:

Reports wound care regimen of bandaging

(Found)

Example Question:

How did you treat your foot at home?

Finding:

Reports cleaning wound twice a day

(Available)

Example Question:

How often did you clean the wound?

Finding:

Reports cleaning wound with hydrogen peroxide

(Available)

Example Question:

What did you use to clean the wound?

Finding:

Reports applying bacitracin, neomycin and polymyxin B (Neosporin)

(Found)

Example Question:

Did you use any ointment on the wound?

Finding:

Asked about other foot wound symptoms

Finding:

Reports swelling around foot wound

(Found)

Example Question:

Is there swelling around the wound?

Finding:

Reports swelling worsened in the past 2 days

(Available)

Example Question:

How long have you noticed swelling around the wound?

Finding:

Reports redness around the wound

(Found)

Example Question:

Did you notice any redness around the wound?

Finding:

Reports that the wound feels warm

(Found)

Example Question:

Does the wound feel warm?

Finding:

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

Finding:

Reports pain affects ability to walk

(Found)

Example Question:

Does your injury impact your ability to walk?

Finding:

Reports pain affects ability to stand at work for long periods of time

(Available)

Example Question:

Does your foot pain affect your work?

Finding:

Reports pain prevented her from being able to walk to class

(Available)

Example Question:

Has your injury prevented you from going to class?

Past Medical History

Finding:

Asked about preexisting medical conditions

Finding:

Reports diabetes

(Found)

Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

Example Question:

Do you have diabetes?

Finding:

Reports asthma

(Found)

Example Question:

Do you have asthma?

Finding:

Followed up on diabetes diagnosis

Finding:

Reports specific age of diagnosis was 24

(Available)

Example Question:

At what age were you diagnosed with diabetes?

Finding:

Reports that her diabetes is Type 2

(Available)

Example Question:

Do you know what type of diabetes you have?

Finding:

Asked about diabetes management through lifestyle changes

Finding:

Reports staying away from sweets

(Found)

Example Question:

Tell me more about any sugars you consume.

Finding:

Reports drinking diet soda instead of regular

(Found)

Example Question:

Do you drink sugary drinks?

Finding:

Asked about current diabetes medication use

Finding:

Reports that she does not currently take medication for diabetes

(Found)

Example Question:

Do you take prescribed medication for your diabetes?

Finding:

Asked about past diabetes medication use

Finding:

Reports that she used to take diabetes medication

(Found)

Example Question:

Have you ever taken medication for your diabetes?

Finding:

Reports previous medication was prescription metformin

(Available)

Example Question:

Do you remember what you were prescribed for diabetes?

Finding:

Reports last use of medication was 3 years ago

(Found)

Example Question:

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

Finding:

Asked about blood glucose monitoring

Finding:

Reports infrequent blood glucose monitoring

(Found)

Example Question:

Tell me about your blood sugar monitoring.

Finding:

Reports last glucose check was a week ago at the ER

(Available)

Example Question:

How often do you check your blood sugar?

Finding:

Reports confusion about what the numbers mean

(Available)

Example Question:

What are your usual blood sugar levels?

Finding:

Asked about thirst

Finding:

Reports increased thirst

(Found)

Example Question:

Have you been more thirsty lately?

Finding:

Reports increased water intake

(Found)

Example Question:

Are you drinking more water than normal?

Finding:

Asked about frequency of urination

Finding:

Reports more frequent urination

(Found)

Example Question:

Have you been urinating more often than usual?

Finding:

Reports urinating every hour or two during the day

(Available)

Example Question:

How often do you urinate during the day?

Finding:

Reports urinating 2 to 3 times during the night

(Available)

Example Question:

How often do you wake up at night to urinate?

Finding:

Asked about change in appetite

Finding:

Reports increased appetite

(Found)

Example Question:

Have you noticed an increase in appetite?

Finding:

Reports change in appetite began a month ago

(Available)

Example Question:

When did you notice the increase in your appetite?

Finding:

Asked about weight change

Finding:

Reports recent loss of 10 lbs

(Available)

Example Question:

How much weight have you lost?

Finding:

Reports weight loss occurred over the past month

(Available)

Example Question:

How long did it take you to lose 10 pounds?

Finding:

Followed up on reason for weight change

Finding:

Reports weight loss was unintentional

(Found)

Example Question:

Was your weight loss intentional?

Finding:

Asked about history of asthma exacerbations

Finding:

Reports last asthma attack was in high school

(Available)

Example Question:

When was your last asthma attack?

Finding:

Reports last exacerbation was three days ago

(Available)

Example Question:

When did you last have issues with asthma?

Finding:

Asked about asthma symptoms

Finding:

Reports chest tightness during exacerbation

(Found)

Example Question:

What do your asthma symptoms feel like?

Finding:

Reports difficulty breathing during exacerbation

(Found)

Example Question:

Do you have trouble breathing?

Finding:

Reports wheezing during exacerbation

(Found)

Example Question:

Do you ever wheeze?

Finding:

Asked about prior hospitalizations

Finding:

Reports past hospitalizations

(Found)

Example Question:

Have you been hospitalized in the past?

Finding:

Reports last hospitalization was for asthma

(Available)

Example Question:

Why were you hospitalized last time?

Finding:

Reports last hospitalization was age 16

(Found)

Example Question:

When was your last hospitalization?

Finding:

Reports about 5 total hospitalizations for asthma as a child and teen

(Available)

Example Question:

How many times have you been hospitalized?

Finding:

Reports past nebulizer use

(Available)

Example Question:

Have you ever used a nebulizer?

Finding:

Asked about asthma diagnosis

Finding:

Reports specific age of diagnosis is 2.5 years old

(Found)

Example Question:

At what age were you diagnosed with asthma?

Finding:

Asked about asthma management

Finding:

Reports using an inhaler

(Found)

Example Question:

How do you manage your asthma?

Finding:

Reports inhaler is albuterol (Proventil)

(Found)

Example Question:

What is the name of the inhaler prescription?

Finding:

Reports last use of inhaler was 3 days ago

(Available)

Example Question:

When did you last use your inhaler?

Finding:

Reports using inhaler no more than 2 times per week

(Available)

Example Question:

How often do you use your inhaler?

Finding:

Asked about number of puffs when using asthma inhaler

Finding:

Reports recommended dose is 1-3 puffs as needed

(Found)

Example Question:

How many puffs of your inhaler are you prescribed?

Finding:

Reports typically taking 2 puffs

(Found)

Example Question:

Does your inhaler effectively relieve your symptoms?

Finding:

Reports sometimes needing 3 puffs to control symptoms

(Found)

Example Question:

What’s the most puffs you ever take?

Finding:

Asked about asthma triggers

Finding:

Reports asthma triggered by cats

(Found)

Example Question:

What triggers your asthma problems?

Finding:

Reports asthma triggered by dust

(Found)

Example Question:

Does dust trigger your asthma?

Finding:

Reports asthma triggered by running up stairs

(Found)

Example Question:

Does physical activity trigger your asthma?

Finding:

Denies seasonal triggers

(Available)

Example Question:

Do you have seasonal asthma triggers?

Finding:

Asked about general allergies

Finding:

Reports allergy to cats

(Found)

Example Question:

What allergies do you have?

Finding:

Followed up on cat allergy symptoms

Finding:

Reports sneezing, itchy eyes, and wheezing

(Found)

Example Question:

What is your reaction to cats?

Finding:

Asked about latex allergy

Finding:

Denies latex allergy

(Found)

Example Question:

Are you allergic to latex?

Finding:

Asked about medication allergies

Finding:

Reports penicillin allergy

(Found)

Example Question:

What medication allergies do you have?

Finding:

Asked about penicillin reaction

Finding:

Reports that penicillin resulted in hives in childhood

(Found)

Example Question:

What is your reaction to penicillin?

Finding:

Asked about food allergies

Finding:

Denies food allergies

(Found)

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)

Example Question:

Do you have any reaction to dust?

Finding:

Reports dust causes sneezing, itchy eyes, and wheezing

(Available)

Example Question:

Do you have any environmental allergies?

Finding:

Denies seasonal allergies

(Available)

Example Question:

Do you have any seasonal allergies?

Finding:

Asked about general immunizations received

Finding:

Reports being up to date on shots

(Found)

Example Question:

Are your immunizations current?

Finding:

Asked about childhood immunizations

Finding:

Reports receiving all necessary childhood immunizations

(Found)

Example Question:

Did you receive childhood vaccinations?

Finding:

Asked if the patient has received a flu vaccine

Finding:

Denies receiving annual flu vaccine

(Found)

Example Question:

Did you get a flu shot this year?

Finding:

Asked if the patient received a tetanus immunization

Finding:

Reports last tetanus vaccination was in the past year

(Found)

Example Question:

When was your last tetanus booster?

Finding:

Asked about hypertension

Finding:

Denies past diagnosis of hypertension

(Found)

Example Question:

Have you ever been diagnosed with hypertension?

Finding:

Reports that last BP reading was 140 over 80 or 90

(Available)

Example Question:

What is your usual blood pressure?

Finding:

Denies checking BP regularly

(Available)

Example Question:

How often do you check your blood pressure?

Home Medications

Finding:

Asked about use of pain medication

Finding:

Reports taking prescription pain medication

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Have you taken any prescription pain medications?

Finding:

Reports medication is tramadol

(Available)

Example Question:

What is the name of the pain medication?

Finding:

Followed up on pain medication frequency

Finding:

Reports taking pain medication for 2 days

(Available)

Example Question:

How many days have you needed pain medication?

Finding:

Reports taking tramadol 3 times a day

(Found)

Example Question:

How many times a day do you take pain medication?

Finding:

Reports last dose was this morning

(Available)

Example Question:

When was your last dose of pain medication?

Finding:

Followed up on pain medication dose

Finding:

Reports dosage is 50 mg

(Found)

Example Question:

What is the dose of the pain medication?

Finding:

Reports taking 2 pills each time

(Available)

Example Question:

How many pain pills do you take at a time?

Finding:

Followed up on efficacy of pain medication

Finding:

Reports that pain pills provide partial relief

(Found)

Example Question:

How effective is the pain medication?

Finding:

Reports pain returns in full every few hours

(Found)

Example Question:

How long does the pain medication last?

Finding:

Asked about other prescription medications

Finding:

Reports a prescription inhaler

(Found)

Example Question:

What prescription medications do you take?

Finding:

Asked about use of OTC medication

Finding:

Reports occasionally taking Advil (ibuprofen) for cramps

(Found)

Example Question:

Do you take any over the counter medications?

Finding:

Reports occasionally taking Tylenol (acetaminophen) for headaches

(Found)

Example Question:

Do you take any over the counter medications?

Finding:

Denies vitamin supplements

(Available)

Example Question:

Do you take any vitamins?

Finding:

Denies herbal supplements

(Available)

Example Question:

Do you take any herbal supplements?

Social Determinants of Health

Finding:

Asked about access to healthcare

Finding:

Denies finances are a barrier to healthcare

(Found)

Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.

Example Question:

Do you have trouble affording healthcare?

Finding:

Denies transportation is a barrier to healthcare

(Available)

Example Question:

Is transportation a barrier to your healthcare?

Finding:

Followed up on diabetes noncompliance

Finding:

Reports that she got sick of the demands of medication compliance

(Available)

Example Question:

Why aren’t you taking your diabetes medication?

Finding:

Reports disliking metformin side effects

(Available)

Example Question:

Did the metformin cause any side effects?

Finding:

Reports disliking checking blood glucose

(Found)

Example Question:

What’s preventing you from taking your diabetes medication?

Finding:

Denies that cost of metformin was reason for discontinuing medication

(Available)

Example Question:

Did you have problems affording the diabetes medication?

Finding:

Denies that glucometer-related costs are reason for not checking blood glucose

(Available)

Example Question:

Do you have problems affording the glucometer?

Finding:

Asked about patient’s level of education

Finding:

Reports currently working toward undergraduate degree

(Found)

Example Question:

What is your highest level of education?

Finding:

Reports her major is accounting

(Available)

Example Question:

What do you study?

Finding:

Asked about patient’s living situation

Finding:

Reports living with mother and sister

(Found)

Example Question:

Does anyone live at home with you?

Finding:

Reports family members will be able to help with activities

(Found)

Example Question:

Tell me more about living at home.

Social History

Finding:

Asked about stressors

Finding:

Reports she is currently under high stress

(Available)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

Can you tell me about your stress level?

Finding:

Asked about food intake

Finding:

Reports last meal was dinner time the previous night

(Available)

Example Question:

When was your last meal?

Finding:

Reports last meal consisted of baked chicken and mashed potatoes

(Available)

Example Question:

What did you eat for your last meal?

Finding:

Reports breakfast is usually a muffin or pumpkin bread

(Available)

Example Question:

What is your typical breakfast?

Finding:

Reports lunch is usually a sandwich

(Available)

Example Question:

What is your typical lunch?

Finding:

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

(Available)

Example Question:

What is your typical dinner?

Finding:

Reports snacks are pretzels or French fries

(Available)

Example Question:

What do you typically eat for snacks?

Finding:

Asked about salt intake

Finding:

Denies adding salt to food

(Found)

Example Question:

Do you add a lot of salt to your food?

Finding:

Asked about caffeine intake

Finding:

Denies drinking coffee

(Found)

Example Question:

Do you drink coffee?

Finding:

Reports habitual diet soda drinking

(Found)

Example Question:

Do you drink soda?

Finding:

Reports drinking up to 4 diet sodas per day

(Found)

Example Question:

How many diet sodas do you drink in a day?

Finding:

Asked about illicit drug use

Finding:

Reports history of recreational marijuana smoking

(Found)

Example Question:

Have you ever experimented with drugs?

Finding:

Followed up on drug use

Finding:

Reports last use was at age 20 or 21

(Found)

Example Question:

When did you last smoke marijuana?

Finding:

Reports she stopped because of health reasons and waning interest

(Available)

Example Question:

What happened to cause you to stop smoking pot?

Finding:

Asked about alcohol intake

Finding:

Reports last alcoholic drink was 3 weeks ago

(Available)

Example Question:

When was your last alcoholic drink?

Finding:

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

(Available)

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)

Example Question:

How many nights a week do you drink alcohol?

Finding:

Asked about tobacco use

Finding:

Denies smoking tobacco

(Found)

Example Question:

Have you ever smoked cigarettes?

Finding:

Denies vaping

(Available)

Example Question:

Do you vape?

Finding:

Asked about secondhand smoke

Finding:

Denies exposure to secondhand smoke

(Found)

Example Question:

Are you ever exposed to secondhand smoke?

Family Medical History

Finding:

Asked about mother’s health

Finding:

Reports mother diagnosed with high blood pressure

(Found)

Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.

Example Question:

Does your mother have health conditions?

Finding:

Reports mother diagnosed with high cholesterol

(Found)

Example Question:

Does your mother have health conditions?

Finding:

Asked about father’s health

Finding:

Reports father was diagnosed with Type 2 diabetes

(Available)

Example Question:

Does your father have health conditions?

Finding:

Reports father was diagnosed with high blood pressure

(Available)

Example Question:

Does your father have health conditions?

Finding:

Reports father was diagnosed with high cholesterol

(Available)

Example Question:

Does your father have health conditions?

Finding:

Followed up on father’s death

Finding:

Reports father died at age 58

(Available)

Example Question:

How old was your father when he died?

Finding:

Reports cause of death was a car accident

(Found)

Example Question:

What caused your father’s death?

Finding:

Followed up on coping with father’s death

Finding:

Reports past grief

(Found)

Example Question:

How are you coping with your father’s death?

Finding:

Reports feeling at peace now

(Found)

Example Question:

How are you coping now?

Finding:

Asked about paternal grandfather’s health

Finding:

Reports paternal grandfather diagnosed with Type 2 diabetes

(Available)

Example Question:

Does your paternal grandfather have health conditions?

Finding:

Reports paternal grandfather diagnosed with high blood pressure

(Available)

Example Question:

Does your paternal grandfather have health conditions?

Finding:

Reports paternal grandfather diagnosed with high cholesterol

(Available)

Example Question:

Does your paternal grandfather have health conditions?

Finding:

Reports paternal grandfather died of colon cancer

(Available)

Example Question:

Have you had any family members with cancer?

Finding:

Asked about paternal grandmother’s health

Finding:

Reports paternal grandmother diagnosed with high blood pressure

(Found)

Example Question:

Does your paternal grandmother have health conditions?

Finding:

Reports paternal grandmother diagnosed with high cholesterol

(Found)

Example Question:

Does your paternal grandmother have health conditions?

Finding:

Asked about maternal grandfather’s health

Finding:

Reports maternal grandfather diagnosed with high blood pressure

(Available)

Example Question:

Does your maternal grandfather have health conditions?

Finding:

Reports maternal grandfather diagnosed with high cholesterol

(Available)

Example Question:

Does your maternal grandfather have health conditions?

Finding:

Asked about maternal grandmother’s health

Finding:

Reports maternal grandmother diagnosed with high blood pressure

(Found)

Example Question:

Does your maternal grandmother have health conditions?

Finding:

Reports maternal grandmother diagnosed with high cholesterol

(Found)

Example Question:

Does your maternal grandmother have health conditions?

Finding:

Asked about brother’s health

Finding:

Denies brother having diagnosed health problems

(Found)

Example Question:

Does your brother have health conditions?

Finding:

Asked about sister’s health

Finding:

Reports sister diagnosed with asthma

(Found)

Example Question:

Does your sister have health conditions?

Finding:

Asked about family history of obesity

Finding:

Reports that family members are overweight

(Found)

Example Question:

Does obesity run in your family?

Finding:

Asked about family history of thyroid issues

Finding:

Denies family history of thyroid issues

(Found)

Example Question:

Do you have a family history of thyroid problems?

Finding:

Asked about family history of substance abuse

Finding:

Reports 1 uncle has alcoholism

(Found)

Example Question:

Do you have relatives with addiction problems?

Finding:

Asked about family history of headaches

Finding:

Denies family history of headaches

(Found)

Example Question:

Do you have a family history of headaches?

Review of Systems

Finding:

Asked about constitutional health

Finding:

Reports occasional tiredness or fatigue

(Available)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Are you fatigued?

Finding:

Reports typical sleep pattern

(Available)

Example Question:

Have you noticed changes in your sleep?

Finding:

Reports fever

(Available)

Example Question:

Are you feeling feverish right now?

Finding:

Reports chills

(Available)

Example Question:

Have you had chills?

Finding:

Denies night sweats

(Available)

Example Question:

Have you had night sweats?

Finding:

Asked about review of systems for mental health

Finding:

Denies depression

(Available)

Example Question:

Do you have a history of depression?

Finding:

Denies suicidal ideation or attempts

(Available)

Example Question:

Do you have a history of suicidal thinking?

Finding:

Asked about review of systems for head

Finding:

Reports occasional headaches

(Found)

Example Question:

Do you ever get headaches?

Finding:

Denies current headache

(Available)

Example Question:

Do you have a headache?

Finding:

Denies head injury

(Available)

Example Question:

Have you had any head injuries?

Finding:

Asked about review of systems for ears

Finding:

Denies change in hearing

(Available)

Example Question:

Has your hearing changed?

Finding:

Denies ringing or tinnitus

(Available)

Example Question:

Do you ever have ringing in your ears?

Finding:

Denies ear pain

(Available)

Example Question:

Have you had ear pain?

Finding:

Denies ear discharge

(Available)

Example Question:

Have you had ear discharge?

Finding:

Asked about review of systems for eyes and vision

Finding:

Reports periods of blurry vision

(Found)

Example Question:

Have you noticed any changes in your vision?

Finding:

Denies corrective lenses

(Available)

Example Question:

Do you wear glasses or contact?

Finding:

Denies double vision

(Available)

Example Question:

Do you ever get double vision?

Finding:

Reports infrequent itchy eyes

(Available)

Example Question:

Have you had itchy eyes?

Finding:

Denies eye redness

(Available)

Example Question:

Have you had red eyes?

Finding:

Denies discharge, crusting or wateriness

(Available)

Example Question:

Have you had watery eyes?

Finding:

Denies eye pain

(Available)

Example Question:

Have you had eye pain?

Finding:

Denies dry eyes

(Available)

Example Question:

Have you had dry eyes?

Finding:

Reports last eye exam was in childhood

(Available)

Example Question:

When was your last eye exam?

Finding:

Asked about review of systems for nose

Finding:

Reports infrequent nose problems

(Found)

Example Question:

Have you had nose problems?

Finding:

Reports infrequent runny nose

(Found)

Example Question:

Have you had a runny nose?

Finding:

Denies frequent sinus problems

(Available)

Example Question:

Have you had sinus pain?

Finding:

Denies change in sense of smell

(Available)

Example Question:

Has your sense of smell changed?

Finding:

Denies nosebleeds

(Available)

Example Question:

Have you had nosebleeds?

Finding:

Asked about review of systems for mouth and jaw

Finding:

Denies dental problems

(Available)

Example Question:

Have you had any recent dental problems?

Finding:

Reports last dental visit was several years ago

(Available)

Example Question:

When did you last see a dentist?

Finding:

Denies change in sense of taste

(Available)

Example Question:

Has your sense of taste changed?

Finding:

Denies dry mouth

(Available)

Example Question:

Have you had dry mouth?

Finding:

Denies mouth pain

(Available)

Example Question:

Have you had mouth pain?

Finding:

Denies mouth sores

(Available)

Example Question:

Have you had mouth sores?

Finding:

Denies gum problems

(Available)

Example Question:

Have you had gum problems?

Finding:

Denies tongue problems

(Available)

Example Question:

Have you had tongue problems?

Finding:

Denies jaw problems

(Available)

Example Question:

Have you had jaw problems?

Finding:

Asked about review of systems for neck, throat, and glands

Finding:

Denies difficulty swallowing

(Available)

Example Question:

Have you had difficulty swallowing?

Finding:

Denies sore throat

(Available)

Example Question:

Have you had a sore throat?

Finding:

Denies lymph node problems

(Available)

Example Question:

How are your lymph nodes?

Finding:

Denies frequent sore throat

(Available)

Example Question:

Do you have a history of throat problems?

Finding:

Denies swollen glands

(Available)

Example Question:

Do you have any swollen glands?

Finding:

Denies voice changes

(Available)

Example Question:

Have you had voice changes?

Finding:

Denies general neck problems

(Found)

Example Question:

Have you had neck pain?

Finding:

Asked about breast health

Finding:

Reports doing occasional breast exams

(Available)

Example Question:

Do you do regular breast exams?

Finding:

Denies general breast problems

(Found)

Example Question:

Do you have any problems with your breasts?

Finding:

Denies breast lumps

(Available)

Example Question:

Have you noticed any lumps in your breasts?

Finding:

Denies breast pain

(Available)

Example Question:

Have you felt pain in your breasts?

Finding:

Denies nipple changes

(Available)

Example Question:

Have you noticed changes in your nipples?

Finding:

Denies nipple discharge

(Available)

Example Question:

Have you noticed any nipple discharge?

Finding:

Denies ever having a mammogram

(Available)

Example Question:

Have you ever had a mammogram?

Finding:

Asked about review of systems for respiratory

Finding:

Denies current breathing problems

(Available)

Example Question:

Have you had breathing problems?

Finding:

Denies current wheezing

(Available)

Example Question:

Have you been wheezing?

Finding:

Denies current chest tightness

(Available)

Example Question:

Have you had chest tightness?

Finding:

Denies pain while breathing

(Available)

Example Question:

Does it hurt when you breathe?

Finding:

Denies frequent coughing

(Available)

Example Question:

Have you been coughing?

Finding:

Asked about review of systems for cardiovascular

Finding:

Denies chest pain or discomfort

(Available)

Example Question:

Do you ever have chest pain?

Finding:

Denies palpitations

(Available)

Example Question:

Have you had palpitations?

Finding:

Denies irregular heartbeat

(Available)

Example Question:

Has your heartbeat been irregular?

Finding:

Denies easy bruising

(Available)

Example Question:

Have you noticed bruising more than usual?

Finding:

Denies edema

(Available)

Example Question:

Have you noticed any swelling in your legs?

Finding:

Denies circulation problems

(Available)

Example Question:

Do you have circulation problems?

Finding:

Denies vascular diseases

(Available)

Example Question:

Do you have any vascular diseases?

Finding:

Asked review of systems for gastrointestinal

Finding:

Denies nausea

(Available)

Example Question:

Have you had nausea?

Finding:

Denies vomiting

(Available)

Example Question:

Have you been vomiting?

Finding:

Denies stomach pain

(Available)

Example Question:

Do you have stomach pain?

Finding:

Denies change in bowel movements

(Available)

Example Question:

Have you had changes in your bowel movements?

Finding:

Denies heartburn, GERD, or indigestion

(Available)

Example Question:

Do you ever get heartburn?

Finding:

Denies constipation

(Available)

Example Question:

Do you have constipation?

Finding:

Denies diarrhea or loose stool

(Available)

Example Question:

Do you have diarrhea?

Finding:

Denies flatulence or bloating

(Available)

Example Question:

Do you have flatulence?

Finding:

Denies bloody or tarry stool

(Available)

Example Question:

Do you have tarry stools?

Finding:

Asked review of systems for genitourinary

Finding:

Denies painful or difficult urination

(Available)

Example Question:

Does it hurt when you urinate?

Finding:

Reports waking up to urinate during the night

(Available)

Example Question:

Do you wake up at night to urinate?

Finding:

Reports large amount of urine

(Found)

Example Question:

Do you urinate frequently?

Finding:

Denies blood in urine

(Available)

Example Question:

Do you ever notice blood in your urine?

Finding:

Denies flank pain

(Available)

Example Question:

Do you have flank pain?

Finding:

Denies incontinence

(Available)

Example Question:

Are you able to hold your urine?

Finding:

Denies history of urinary tract or bladder infection

(Available)

Example Question:

Have you ever had a urinary infection?

Finding:

Reports normal vaginal discharge

(Available)

Example Question:

What is your vaginal discharge like?

Finding:

Asked review of systems for reproductive

Finding:

Reports last menstrual period was 3 weeks ago

(Available)

Example Question:

When was your last menstrual period?

Finding:

Reports that periods are irregular

(Available)

Example Question:

Are your periods regular?

Finding:

Reports menstruating every 6 weeks to 2 months

(Available)

Example Question:

How often do you get your period?

Finding:

Reports typical period lasts 9 days

(Available)

Example Question:

How many days does your period last?

Finding:

Followed up on menstrual flow

Finding:

Reports heavy periods

(Found)

Example Question:

Do you have heavy periods?

Finding:

Reports heavy flow for 4 to 5 days

(Available)

Example Question:

How many days is your period heavy?

Finding:

Reports changing tampon every 2 to 3 hours

(Found)

Example Question:

How often do you change your tampon or pad?

Finding:

Reports using super absorbency tampons

(Found)

Example Question:

What absorbency are your tampons?

Finding:

Denies anemia

(Available)

Example Question:

Have you ever been diagnosed with low iron?

Finding:

Followed up on menstrual symptoms

Finding:

Reports heavy cramping

(Found)

Example Question:

Do you get menstrual cramps?

Finding:

Reports cramps for the first 2 days of period

(Available)

Example Question:

How many days do your cramps last?

Finding:

Asked about treatment of menstrual symptoms

Finding:

Reports using a heating pad at home to treat cramps

(Found)

Example Question:

Do you use a heating pad?

Finding:

Reports taking ibuprofen for first 3 days of period

(Available)

Example Question:

How many days do you need Advil for your cramps?

Finding:

Reports ibuprofen effectively reduces pain from cramps

(Available)

Example Question:

Does the Advil reduce your cramps?

Finding:

Asked about sexual activity

Finding:

Denies recent sexual activity

(Found)

Example Question:

Are you sexually active?

Finding:

Reports past sexual activity

(Available)

Example Question:

Have you ever been sexually active?

Finding:

Reports that she prefers to sleep with men

(Available)

Example Question:

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

Finding:

Reports first sexual activity was at age 18

(Available)

Example Question:

When were you first sexually active?

Finding:

Reports last sexual activity was 2 years ago

(Available)

Example Question:

When was your last sexual encounter?

Finding:

Reports total number of partners is 3

(Available)

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)

Example Question:

Are you currently taking oral contraception?

Finding:

Reports past use of oral contraception

(Found)

Example Question:

Have you ever taken oral contraception?

Finding:

Reports last taking oral contraception a couple of years ago

(Available)

Example Question:

When did you last take oral contraception?

Finding:

Reports she didn’t see the point in taking contraception while single

(Available)

Example Question:

Why did you stop taking birth control?

Finding:

Asked about condom use

Finding:

Reports past condom use

(Found)

Example Question:

Have you ever used a condom?

Finding:

Reports past sexual encounters without condoms

(Available)

Example Question:

Have you ever had sex without using a condom?

Finding:

Reports oral contraceptive use while sexually active

(Available)

Example Question:

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

Finding:

Asked about STI testing

Finding:

Reports last STI testing was 4 years ago

(Available)

Example Question:

When were you last tested for STIs?

Finding:

Denies STI symptoms

(Available)

Example Question:

Do you have STI symptoms?

Finding:

Reports uncertainty about past partners and STI testing

(Available)

Example Question:

Have your previous partners been tested for STIs?

Finding:

Asked about history of pap smears

Finding:

Reports last pap smear was 4 years ago

(Available)

Example Question:

When was your last pap smear?

Finding:

Reports no abnormal pap smears

(Available)

Example Question:

Have you ever had an abnormal pap smear?

Finding:

Asked about history of pregnancy

Finding:

Denies current pregnancy

(Available)

Example Question:

Do you think you are pregnant?

Finding:

Denies past pregnancies

(Found)

Example Question:

Have you ever tested positive for pregnancy?

Finding:

Asked review of systems for musculoskeletal

Finding:

Denies muscle pain

(Available)

Example Question:

Do you have muscle pain?

Finding:

Denies joint pain

(Available)

Example Question:

Do you have joint pain?

Finding:

Denies muscle weakness

(Available)

Example Question:

Do you have muscle weakness?

Finding:

Denies joint swelling

(Available)

Example Question:

Do you ever have swelling in your joints?

Finding:

Denies back pain

(Available)

Example Question:

Do you ever have back pain?

Finding:

Denies history of fractures or breaks

(Available)

Example Question:

Have you ever broken a bone?

Finding:

Asked review of systems for neurological

Finding:

Denies recent loss of consciousness or fainting

(Available)

Example Question:

Have you ever passed out?

Finding:

Denies dizziness or vertigo

(Available)

Example Question:

Do you get dizzy?

Finding:

Denies lightheadedness

(Available)

Example Question:

Do you get light-headed?

Finding:

Denies vision disturbances

(Available)

Example Question:

Do you ever see spots?

Finding:

Denies tingling

(Available)

Example Question:

Do you ever get tingling?

Finding:

Denies loss of coordination

(Available)

Example Question:

Do you notice being more clumsy than usual?

Finding:

Denies loss of sensation

(Available)

Example Question:

Do you have a loss of sensation anywhere?

Finding:

Denies history of seizures

(Available)

Example Question:

Have you ever had a seizure?

Finding:

Denies problems with balance or disequilibrium

(Available)

Example Question:

Do you lose your balance often?

Finding:

Denies memory loss

(Available)

Example Question:

Have you ever experienced memory loss?

Finding:

Asked review of systems for skin, hair, and nails

Finding:

Denies skin rashes

(Available)

Example Question:

Do you get skin rashes?

Finding:

Reports rarely using sunscreen

(Available)

Example Question:

When do you wear sunscreen?

Finding:

Reports acne

(Found)

Example Question:

Do you still have acne?

Finding:

Reports excessive facial or body hair

(Available)

Example Question:

Do you have an increase in body hair?

Finding:

Reports changes to neck skin

(Available)

Example Question:

Do you have any skin discoloration?

Finding:

Reports moles

(Available)

Example Question:

Have your moles changed?

Finding:

Reports no body sores (aside from foot wound)

(Available)

Example Question:

Do you have any sores?

Finding:

Denies dandruff

(Available)

Example Question:

Do you have dandruff?

Finding:

Denies nail abnormalities

(Available)

Example Question:

Do you have any problems with your nails?

Finding:

Reports occasional dry skin

Objective Data Collection: 1 of 1 (100.0%)

Hover To Reveal…

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

Found:

Indicates an item that you found.

Available:

Indicates an item that is available to be found.

Category

Scored Items

Experts selected these examinations as essential components of objective data collection for this patient.

Patient Data

Not Scored

Thorough examinations will yield better patient data. The following actions reveal the objective data of the patient’s case.

Wound Treatment

Finding:

Inspected wound

Finding:

Measured wound: 2 cm x 1.5 cm, 2.5 mm deep

(Found)

Pro Tip: Measuring a patient’s wound will help you track whether it worsens or heals in future visits.

Example Question:

Finding:

Swabbed wound and sent to lab for C & S

(Found)

Pro Tip: Sending a culture of wound drainage to a medical lab will help you choose the best antibiotic for that microbe type, and can rule out dangerous infections such as MRSA.

Example Question:

Finding:

Cleansed and irrigated wound with normal saline and applied dry sterile dressing.

Education & Empathy : 2 of 11 (18.2%)

During the patient interview, there are a number of opportunities to provide patient education and empathy. The opportunities listed below are those identified by nursing experts to be of particular importance to this patient. A Model Statement is provided as an example of an appropriate response to each opportunity.

Opportunities marked as Not Encountered are opportunities that were not elicited in the interview
Opportunities marked as Not Followed Up are missed opportunities that were present in the interview, but where no statements were made
Opportunities marked as Followed Up were followed up by students, and include the dialogue between student and patient

1 Expression of pain

Followed Up

	Description: Tina expresses frustration about her level of pain.
	What brings you here today?	Question 12:39 AM EDT
	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!
	I am sorry for that	Empathize 12:39 AM EDT
	I appreciate you saying that.
	Model Statement: “I’m sorry to hear that your pain is returning. We want you to be in as little pain as possible. Together we can figure out the best way to reduce your pain quickly.”

2 Impact of injury on daily life

Not Followed Up

	Description: Tina brings up her pain and frustration at how being unable to bear weight on her foot impacts her life.
	Has the injury affected your activities?	Question 12:43 AM EDT
	I mean, the last two days I couldn’t walk on my foot, so it’s gotten in the way of everything — I had to basically stay home and off my foot. I didn’t think it could get to the point where it caused so many problems.
	Do you have any preexisting condition?	Question 12:44 AM EDT
	Yeah. . . I have asthma and diabetes.
	How do you manage the diabetes?	Question 12:44 AM EDT
	Model Statement: “This sounds like a challenging time for you. I understand your frustration at having your life interrupted by foot pain. We’ll do our best to get your foot healed, and have you back to your usual routine as soon as possible.”

3 Gaps in health literacy around diabetic diet

Not Followed Up

	Description: Tina describes controlling her diabetes by avoiding “sweets.”
	How do you manage the diabetes?	Question 12:44 AM EDT
	I just watch what I eat and try to stay away from sweets.
	Which medication are you using for diabetes?	Question 12:44 AM EDT
	It’s just a regular Proventil inhaler.
	Which current diabetes medication are you using?	Question 12:45 AM EDT
	Model Statement: “Staying away from sugar is a great start. I can give you some more information on what a balanced diet looks like for someone with diabetes. For example, many starchy foods break down into glucose in the body, like pasta, and so you can eat those in moderation, too. Most people with diabetes feel better when they limit all starches, eat protein, and take regular medication.”

4 Lack of treatment with diabetes medication

Not Followed Up

	Description: Tina reveals that she does not treat her diabetes with medication.
	Which current diabetes medication are you using?	Question 12:45 AM EDT
	I don’t take anything for my diabetes anymore.
	Which diabetes medication were you using in the past? (Clarified to: When were you taking diabetes medication?)	Question 12:45 AM EDT
	I haven’t taken it in about three years, honestly. (Clarified to: when I was taking diabetes medication)
	Do you monitor your blood glucose?	Question 12:46 AM EDT
	Model Statement: “I understand that it can be challenging to keep up with daily medication. But it’s important to keep your blood sugar under control to prevent long-term damage to your health, and medication can really help. I’d like to talk with you more about getting back onto a prescription. We could start you at a low dose, which reduces the side effects.”

5 Lack of blood glucose monitoring

Not Followed Up

	Description: Tina reveals that she does not check her blood sugar.
	Do you monitor your blood glucose?	Question 12:46 AM EDT
	I have a monitor at home, but to be honest I don’t really use it that often. It’s such a hassle to check my blood sugar, and my diabetes is under control right now so I don’t really need to.
	Do you often feel thirsty?	Question 12:46 AM EDT
	You know, I did notice lately that I’ve been really thirsty.
	Do you urinate frequently?	Question 12:47 AM EDT
	Yeah, but I’ve been drinking more water.
	Model Statement: “I understand how it can feel like a frustrating chore to check your sugar every day. But it is important to keeping your diabetes under control. When you monitor your sugar, it helps you understand what foods, activities, and times of day contribute to you feeling your best. And keeping your sugar down will help your foot wound heal quickly, too. If you would like, I can help you find a monitor that is as painless as possible. I can also teach you more about what the numbers mean.”

6 Gaps in health literacy around asthma control

Not Followed Up

	Description: Tina describes increased inhaler use and decreased effectiveness, indicating that her asthma is uncontrolled.
	How many puffs do you take when using the inhaler?	Question 12:51 AM EDT
	I usually use two puffs from my albuterol inhaler — it’s 90 micgrograms a spray — but lately sometimes I need three puffs. [AUDIO COMING SOON]
	what triggers the asthma?	Question 12:51 AM EDT
	Being around cats is the worst, but dust and running up stairs can make my breathing bad, too.
	do you have any allergies?	Question 12:52 AM EDT
	Yeah, I’m allergic to cats.
	Model Statement: “It sounds like your asthma is giving you some problems, and you’re not getting full relief from your inhaler. I would like to talk with you about changing your medication and your regimen, to reduce your frequent breathing problems, so that you feel better day-to-day. Most patients find that using a daily inhaler is an easy way to reduce your asthma symptoms even more.”

7 Loss of a family member

Followed Up

	Description: Tina shares information about her father dying.
	how is your father’s health?	Question 01:01 AM EDT
	Dad passed away last year, so…it’s been really hard.
	I am sorry for that	Empathize 01:01 AM EDT
	Thanks for understanding.
	Model Statement: “I’m sorry to hear about your father’s passing. That sounds like a difficult situation.”

8 Counseling around past drug use

Not Followed Up

	Description: Tina discusses her past history of marijuana smoking.
	Do you use illicit drugs?	Question 12:59 AM EDT
	Well, I used to smoke pot. . . but I don’t do that anymore.
	WHen last did you use pot?	Question 12:59 AM EDT
	I haven’t smoked pot since I was twenty or twenty-one.
	do you take alcohol?	Question 12:59 AM EDT
	I do sometimes, yeah, when I go out with my friends.
	Do you smoke tobacco?	Question 01:00 AM EDT
	No. I think it’s gross.
	Model Statement: “Thank you for sharing that information. It’s good to hear that you no longer smoke pot. It’s better for your asthma and your overall health.”

9 Gap in sexual health literacy

Not Followed Up

	Description: Tina reveals that she doesn’t fully understand the importance of testing for STIs.
	do you use contraception?	Question 01:09 AM EDT
	Nope. But I’ve been single for a while so I haven’t needed to.
	Have you tested for STI? (Clarified to: Have you been tested for STDs?)	Question 01:10 AM EDT
	Yeah, I’m sure they did those tests when I went for a pap smear before. (Clarified to: if I have ever been tested for STDs)
	Have you ever been pregnant?	Question 01:10 AM EDT
	I’ve never been pregnant.
	Model Statement: “There are many sexually transmitted infections that don’t necessarily present symptoms, for either men or women, and can persist for years if left untreated. The only way to be certain you and your partners are free of STIs is for both of you to get tested. This can be done as a part of a typical gynecological exam. Because your past partner was not tested, I would recommend that you get tested during your next annual pap smear.”

10 Risk for hypertension

Not Followed Up

	Description: Tina discusses her blood pressure readings as usually high, and her family’s history of hypertension.
	Do you have hypertension?	Question 12:55 AM EDT
	No, I’ve never been diagnosed with blood pressure problems.
	Do you use pain medication?	Question 12:56 AM EDT
	Yeah, I had to start taking pain medication.
	How frequently do you use pain medication?	Question 12:56 AM EDT
	I’ve been taking the Tramadol morning, noon, and night. [AUDIO COMING SOON]
	Model Statement: “It sounds like your blood pressure is typically high. For normal blood pressure, we like to see a top number of below 120 and a bottom number below 80. Because of your family’s history of hypertension, it’s important for us to determine your blood pressure over time. We have your BP reading from today, and then I’d like you to come back and get a reading two more times. That way, we can establish how your blood pressure runs over time. If your pattern is high blood pressure, we may want to get you on a medication to lower it. Having low blood pressure reduces your risk of other health problems such as stroke.”

11 Describes problematic menstrual cycle and symptoms

Not Followed Up

	Description: Tina describes her periods as painful, long, and heavy.
	how is your menstrual symptoms? (Clarified to: Do you have menstrual symptoms?)	Question 01:08 AM EDT
	Yeah, I get cramps pretty bad. (Clarified to: if I have menstrual symptoms)
	how do you treat the cramps?	Question 01:09 AM EDT
	I take Advil. I try a heating pad sometimes and that only helps a little.
	how is your sexual activity?	Question 01:09 AM EDT
	Uh, I wouldn’t say I have a “sex life” right now.
	do you use contraception?	Question 01:09 AM EDT
	Model Statement: “Those periods sound painful and difficult to deal with. I’m sorry you have so many challenging symptoms. If you are interested, we can talk about hormonal birth control options that can make your periods less painful, or even lighter.”

Documentation / Electronic Health Record

Document: Provider Notes

Document: Provider Notes

Student Documentation	Model Documentation
Identifying Data & Reliability Name: Tina Jones Age: 28 years old Gender: Female Race: African American	Ms. Jones is a 28-year-old African American single woman who presents to establish care and with a recent right foot injury. She is the primary source of the history and offers information freely, without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview.
General Survey Ms. Tina Jones is well nourished and pleasant patient. She is awake, alert and orineted to place, time, situation and the environment. She experiences moderate pain on her right foot near the ankle after an injury. She has good eye contact and responds to questions appropriately. She is well groomed and dressed appropriately.	Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. She is dressed appropriately with good hygiene.
Chief Complaint “painful right foot infected wound from a scraped of that foot”	“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 presented today for injury on the right foot. She stated that she tripped on the stairs and acraped her right foot. She was barefoot. She was provided woundcare at the ER. She was given Tramadol 50ml for the pain. She has been cleaning the wound twice a day with soap and applies Neosporin on the wound. She had fever of 102 F. She has difficulty walking. She rates the pain as 7/10. She has increased thirst and lost appetite. She has lost weight of 10 lb without changes in diet or food intake.	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 x-rays were negative and was provided tramadol for pain. She has been cleansing the site twice a day and is applying antibiotic ointment and a bandage. She reports that ankle edema and pain have resolved but 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 that has since resolved. Pain is rated 7 out of 10 with medication, but is a 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; so she has been wearing slip-ons. She reports fever of 102 degrees Fahrenheit 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 1- Tramadol 50ml 3 times a day PO for pain 2 – Ibuprofen 200mg – 3 tablets for menstrual cramps 3 – Tylenol 500 – 1000mg for headache 4 – Aluterol 90 mcg – 2-3 puffs for asthma, 2-3 times a week and PRN 5 – Metformin She does not know the frequency, dosage Last took 3 years ago. Patient stopped Metformin since it made her sick and gassy	Acetaminophen 500-1000 mg PO prn (headaches) Ibuprofen 600 mg PO TID prn (menstrual cramps) Tramadol 50 mg PO TID prn (foot pain) Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (wheezing)
Allergies Cats: Difficulty breathing, sneezing, itching eyes, exacerbation of asthma attack Penicillin as a child: Experienced rath and hives Dusts: Asthma attack triggers	Medications: Penicillin (rash). Environmental: cats and dust (runny nose, itchy and swollen eyes, and increased asthma symptoms).
Medical History Asthma; at 2.5 years old Diabetes Type 2; 4 years ago, stopped the medicine after 3 years. Controlled by diet	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”. 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. Menarche, age 11. 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.
Health Maintenance Jones last visits to her pprimary doctor was 2 yrs ago. Last dental check was few years ago. Vision tested when she was a kid. Last pap smear was 4 years ago. She denies any exercise. Diet: muffin, pumpkin bread for breakfast, sandwich for lunch, and meat vegetable for dinner Love pizza, macorini and cheese. Immunization: Up to date for childhood vaccine, flu vaccine 5-6 years ago, tetanus booster 1 year ago	Last Pap smear 4 years ago. Last eye exam in childhood. Last dental exam “a few 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 is 50 years old and living with hypertension and cholesterol. Father passed away in a motor vehicle accident. Was living with high cholesteral diabetes and hypertension. Sister is 14 years old and has asthma. Brother is 25 yrs old and is healthy. Paternal grandmother is 82 y/o, has HTN, high cholesterol. Maternal grandmoth: Died at 73 y/o and had HTN, cholesterol. Uncle: Has been abusing alcohol. Maternal grandfather- died at 79 y/o and had HTN, cholesterol and HTN.	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); living Sister: (Britney, 14): asthma Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol Maternal grandfather: died at age 80 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
Social History She is sincle and no children, Works as a manager at a company. She is studying for bachelor degree in accounting, She takes alcohol socially with friends, Denies smoking but had used pot in the past.	Single. 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 is a part-time student, in her last semester to earn a bachelor’s degree in accounting. 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.
Review of Systems General: Reports unintentional weight lose of 10 lb over a month. Fever os 102 F HEENT: Head: No alopecial, itching Eyes: blurr vision withe reading Ears: Denies any issues Nose: Denies any issues Mouth/thorat: No moth sores pain, throat pain or difficulty swallowing Neck: No neck pain or stiffness Breats: No tenderness,, lumps or pain Respiratory: denies cough, difficulty breathing Cardiovascula: No palpitations, chest pain or discomfort Gastrointestinal: Denies any nausea, vomiting, diarrhea or constipation Genitourinary: Frequent urination Musculoskeletal: Difficulty ambulating dut to foot wound Psychiatry: no depression Neurological: occasional headaches Skin: Reports discoloration around the neck Hematology: Denies any bruising or bleeding gum Endocrine: Increased thirst and appetite	Constitutional – Affirms: occasional tiredness or fatigue. Denies: fever, chills, night sweats HEENT (Head) – Denies: head injury HEENT (Eyes) – Affirms: periods of blurry vision, infrequent pruritic eyes. Denies: corrective lenses, double vision, erythema, exudate, pain, and dryness HEENT (Ears) – Denies: changes in hearing, tinnitus, pain, and discharge HEENT (Nose) – Affirms: infrequent nose problems and runny nose. Denies: frequent sinus problems, epistaxis, and changes in olfaction HEENT (Mouth/Throat) – Denies: dry mouth, pain, sores, gum problems, jaw problems, sore throat, voice changes Respiratory – Denies: current breathing problems, cough, wheezing, shortness of breath Cardiac – Denies: chest pain, palpitations, arrhythmia, ecchymosis, edema, vascular diseases, circulation problems Gastrointestinal – Denies: abdominal pain, nausea, vomiting, diarrhea, loss of appetite, indigestion, constipation, bloating, hematochezia Genitourinary – Affirms: nocturia. Denies: hematuria, incontinence, urinary retention, frequency, pain with urination Neurological – Denies: dizziness, lightheadedness, numbness, tingling, loss of sensation, loss of coordination, seizures Musculoskeletal – Denies: joint pain, muscle pain, muscle weakness, joint edema, back pain Integumentary – Affirms: lesion on foot, moles, facial/body hair. Denies: rash, pruritis, acne, dandruff, nail anomalies, xerosis Reproductive – Affirms: menorrhagia, amenorrhea, heavy cramping. Denies: anemia Psychiatric – Denies: depression, suicidal ideation or attempts
Objective Vital SIgns: BP: 142/82, HR: 86, Temp 101.1, General: No acute distress. Obese Wound 2cm x 1.5 cm, 2.5 mm deep Red wound with drainage No edema, Mild erythema surrounding the wound LABS: No labs available for review TESTS; No tests for review Mild erythema surrounding the wound	Vitals: Height: 170.2 cm Weight: 90 kg BMI: 31 Temp: 38.4 C BP: 142/82 HR: 86 RR: 19 O2 Sat: 99% 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. Labs: Glucose: 238
Assessment Acute Foot Pain (ICD R52) Local infection of skin and subscutaneous tissue of the foot (ICD A36.3) Uncontrolled type 2 diabetes mellitus (ICD E11)	Relevant Diagnoses: Acute pain of the foot Local infection of skin and subcutaneous tissue of the foot Uncontrolled NIDDM Asthma Dysmenorrhea HTN Menorrhagia Obesity Oligomenorrhea PCOS
Plan Assess the pain level using a pain scale Prescibe Tremadol 50 mg PO BID for pain Educate patient on medications for pain releief Educate patient on non-phrmaceutical methods to reduce pain level Obtain a wound culture Order a complete blood count test (CBC) Prescribe antibiotics clean the wound Educate patient on wound care Educate patient on diabetes pathophysiology and risks	Acute pain of the foot: Prescribe analgesic. Educate on analgesic effective use and potential side effects. Provide patient with options for non-pharmacological pain relief, such as RICE (rest, ice, compression, elevation). Local infection of skin and subcutaneous tissue of the foot: Obtain culture of wound. Clean and re-dress wound. Prescribe an anti-infective (verify specificity post-culture results). Educate patient on treating the wound, using anti-infective medication, reporting symptoms of a worsening infection, and importance of regular foot care for those with diabetes. Uncontrolled NIDDM: Assess peripheral pulses. Assess for peripheral and sensory neuropathy, and retinopathy. Order labs: renal function, lipids, fasting glucose. Educate patient on need for regular blood glucose monitoring, signs and symptoms of hyperglycemia, diabetic diet, and treatment regimens. Prescribe first-line drug for glucose control. Asthma: Educate patient on developing and enacting any asthma treatment plan Dysmenorrhea: Prescribe NSAIDs and/or oral contraceptives for pain. Educate on NSAIDs and/or oral contraceptives – pros and cons. Collect urinalysis. Perform manual pelvic exam. HTN: Educate on HTN pathophysiology, associated risks relating to morbidity and mortality, and lifestyle interventions. Auscultate renal artery bruits. Menorrhagia: Order labs to evaluate for poly-cystic ovarian syndrome and thyroid disease. Inspect hair growth and for acanthosis nigricans. Educate patient on keeping a menstrual calendar and using oral medications to reduce symptoms. Obesity: Educate on diet and exercise interventions to reduce her body weight. Assess for signs and symptoms of hirsutism, acanthosis nigricans, sleep apnea, dyslipidemia, and non-alcoholic fatty liver disease. Order labs to evaluate for thyroid disease. Oligomenorrhea: Order labs to evaluate for poly-cystic ovarian syndrome and thyroid disease. Inspect hair growth and for acanthosis nigricans. Educate patient on keeping a menstrual calendar. PCOS: Perform pelvic exam. Order pelvic ultrasound. Educate on PCOS and relationship to diabetes. Refer GYN.

Information Processing : 18 of 40 (45.0%)

Each relevant diagnosis is scored on a four-point scale:

Priority (1 point): the correct priority of the diagnosis was chosen
Evidence (up to 2 points): the strength of the patient cue(s) selected as evidence for the identified diagnosis
- Required Evidence: selecting at least one cue that directly indicates the presence of a problem or risk is worth 2 points
- Supporting Evidence: selecting at least one cue that is a contributing factor or cause of a problem or risk, without the presence of Required Evidence, is worth 1 point
Planning (1 point): the plan proposed to address the diagnosis includes at least one correct component

Relevant Diagnoses

Acute pain of the foot

4 of 4 points

Priority 1 / 1
Student Response: High Correct Priority: High	Priority Pro Tip: Managing acute pain is an immediate high priority, because other health concerns cannot be effectively addressed while a patient experiences severe pain.
Evidence 2 / 2
Relevant “I’d say a 7. It hurts a lot, and the pain pills haven’t kicked in yet.” Required Evidence Irrelevant (None provided)	Evidence Pro Tip: Tina reports intense pain and rates her pain on a numerical scale. She also reports characteristics of the pain, including its duration of one week; this timespan defines her pain as acute.
Planning 1 / 1
Relevant Intervene – Prescribe: Prescribe medications to treat pain. Educate – Medication: Educate the patient on medications used for pain relief. Educate – Medication: Educate the patient on non-pharmaceutical methods to reduce pain intensity. Irrelevant (None provided)	Planning Pro Tip: Intervene to reduce the pain by prescribing an appropriate analgesic and educating the patient on its effective use and potential side effects. Provide the patient with options for non-pharmacological pain relief, such as RICE (rest, ice, compression, elevation).

Local infection of skin and subcutaneous tissue of the foot

4 of 4 points

Priority 1 / 1
Student Response: High Correct Priority: High	Priority Pro Tip: Treating this infection is a high priority, as failure to treat the infection may lead to it spreading to surrounding tissues or systemically. Treating the infection can prevent adverse events such as osteomyelitis and bacteremia.
Evidence 2 / 2
Relevant “I mean, it’s all red and swollen, and there’s pus, it feels hot, it hurts like hell… It’s got all that going on.” Required Evidence Irrelevant “Yeah, there’s definitely pus.”	Evidence Pro Tip: Tina presents with an open wound on the plantar surface of the foot. The wound is red, swollen, warm, and produces purulent discharge. Tina reports that the appearance and level of discomfort have worsened with time- all of these factors support a diagnosis of acute infection.
Planning 1 / 1
Relevant Assess – Integumentary: Assess wound parameters (size, depth). Intervene – Labs: Obtain a wound culture. Intervene – Labs: Order a complete blood count test (CBC). Intervene – Other: Clean wound and cover with sterile dressing. Educate – Medication: Educate the patient on the course of antibiotics, importance of taking all prescribed antibiotics, and side-effects. Educate – Health Maintenance: Educate the patient on wound care procedure. Educate – Disease Process: Educate the patient on the signs and symptoms of worsening infection. Irrelevant (None provided)	Planning Pro Tip: Assess the wound directly and obtain a culture so that the infectious organism may be identified, then clean and re-dress the wound. Regional lymph nodes may be swollen. Because the infection is the root cause of Tina’s other acute issues, prescribing an anti-infective will begin to resolve the issues; after receiving culture results, the specific anti-infective given may be changed. Ensure that Tina understands how to treat the wound, use the anti-infective effectively, and to report symptoms of a worsening infection. Foot care is especially important for diabetics, so you should help Tina better understand diabetes’ impact on wound healing and the need to proactively monitor her foot health.

Uncontrolled type 2 diabetes mellitus

2 of 4 points

Priority 1 / 1
Student Response: High Correct Priority: High	Priority Pro Tip: Tina’s uncontrolled diabetes will delay her wound healing and places her at risk for end organ damage. The need to provide better glucose control for Tina makes this a high priority.
Evidence 0 / 2
Relevant (None provided) Irrelevant “I don’t take anything for my diabetes anymore.” “I have a monitor at home, but to be honest I don’t really use it that often. It’s such a hassle to check my blood sugar, and my diabetes is under control right now so I don’t really need to.”	Evidence Pro Tip: Tina’s current blood glucose level supports a diagnosis of uncontrolled type 2 DM. Tina reports symptoms consistent with poor control such as polyuria, polydipsia, and nocturia.
Planning 1 / 1
Relevant Intervene – Prescribe: Prescribe a first-line drug for blood glucose control, such as metformin. Educate – Medication: Educate the patient on diabetes medication action, dose, and schedule. Educate – Health Maintenance: Educate the patient on self-monitoring of blood glucose level procedure and its role in treating diabetes. Educate – Health Maintenance: Educate the patient on the impact of diet, exercise, and weight loss on glycemic control. Educate – Health Maintenance: Educate the patient on the importance of screening tests and foot care, as relates to diabetes. Educate – Disease Process: Educate the patient on diabetes pathophysiology, risks of morbidity and mortality, importance of self-care. Irrelevant Educate – Health Maintenance: Educate the patient on the role of lifestyle changes, including diet and exercise, in improving health outcomes. Educate – Disease Process: Educate the patient on associated risks of hypertension with diabetes. Educate – Disease Process: Educate the patient on relation of genetic and lifestyle factors, including diet, with hypertension. Educate – Disease Process: Educate the patient on the role of diabetes mellitus in the healing of wounds. Educate – Disease Process: Educate the patient regarding the relationship of diabetes mellitus and peripheral vascular disease.	Planning Pro Tip: Assess for impacts of Tina’s uncontrolled diabetes including diminished peripheral pulses, peripheral and sensory neuropathy, and retinopathy, and order labs to check for renal function and abnormal lipid levels. Establish a baseline fasting glucose level and educate Tina on the need to monitor her blood glucose and be aware of symptoms of hyperglycemia. Provide better control by prescribing a first-line drug for glucose control. As Tina’s diabetes is uncontrolled, educate her on appropriate diet, monitoring, and treatment regimens.

Asthma

4 of 4 points

Priority 1 / 1
Student Response: Low Correct Priority: Low	Priority Pro Tip: Although Tina requires education to better manage her asthma, she does not report active respiratory complaints, making this a lower priority diagnosis.
Evidence 2 / 2
Relevant “I think I was about two and a half? I used to have a lot of trouble with asthma attacks back then.” Required Evidence Irrelevant (None provided)	Evidence Pro Tip: Tina reports a personal history of asthma, including past hospitalizations for asthma attacks, as well as her use of an albuterol inhaler. Her sibling’s asthma is of interest, given the strong genetic and environmental factors in the development of asthma.
Planning 1 / 1
Relevant Intervene – Other: Develop an asthma action plan with the patient. Educate – Health Maintenance: Educate the patient on avoiding triggers of asthma. Educate – Health Maintenance: Educate the patient on enacting her asthma action plan including proper use of rescue inhaler. Irrelevant (None provided)	Planning Pro Tip: Because Tina does not report treatment for maintenance of her asthma, instead relying on a rescue inhaler for sporadic attacks, educate her on developing and enacting a proactive plan to manage the disease. Though Tina does not report an active respiratory complaint, it is valuable to assess for abnormal findings that she may not report.

Dysmenorrhea

0 of 4 points

Priority 0 / 1
Student Response: Correct Priority: Low	Priority Pro Tip: This is a lower priority diagnosis for Tina because she is not currently menstruating; her current pain must be addressed immediately, but it is due to her foot wound.
Evidence 0 / 2
Relevant (None provided) Irrelevant (None provided)	Evidence Pro Tip: Dysmenorrhea is the symptom of excessive pain with menstruation, which Tina directly reports when asked about the characteristics of her periods.
Planning 0 / 1
Relevant (None provided) Irrelevant (None provided)	Planning Pro Tip: Menstrual pain can be reduced by the use of NSAIDs and/or oral contraceptives, so you should provide these options to Tina and educate her on their pros and cons. Urinalysis and a manual pelvic exam are useful tools to rule out causes other than her metabolic and endocrine issues.

Hypertension

0 of 4 points

Priority 0 / 1
Student Response: Correct Priority: Low	Priority Pro Tip: Tina’s hypertension should be addressed in this visit, as reducing her blood pressure may reduce her risks relating to cardiovascular sequelae. However it is lower priority than her acute complaints as her hypertension will not be significantly improved in a single visit.
Evidence 0 / 2
Relevant (None provided) Irrelevant (None provided)	Evidence Pro Tip: Hypertension is established via measurement of elevated blood pressure (systolic > 140 or diastolic > 90) on two separate occasions. Tina’s records reveal an elevated BP at the time of her ER visit, so the elevated BP at today’s visit establishes Tina’s diagnosis of hypertension. Tina’s risk factors include: race, family history of hypertension, diet, and diabetes.
Planning 0 / 1
Relevant (None provided) Irrelevant (None provided)	Planning Pro Tip: Tina should be educated regarding hypertension (pathophysiology, associated risks relating to morbidity and mortality, and lifestyle interventions). It is important to consider Tina’s risk for secondary hypertension. Auscultate for renal artery bruits as they may be present in renal artery stenosis. Other causes of secondary hypertension should also be considered including hyperaldosteronism, pheochromocytoma, etc.

Menorrhagia

4 of 4 points

Priority 1 / 1
Student Response: Low Correct Priority: Low	Priority Pro Tip: Menorrhagia is a secondary issue caused by Tina’s endocrine and metabolic disorders and thus is a lower priority diagnosis.
Evidence 2 / 2
Relevant “I’d say it’s heavy. I use the like, extra absorbent tampons, and I still have to change it every two or three hours.” Required Evidence Irrelevant “Yeah, I get cramps pretty bad.”	Evidence Pro Tip: Tina reports menstruation lasting longer than 7 days, with heavy bleeding. Tina reports no recent sexual activity or potential for pregnancy, ruling out a common cause of irregular bleeding. Other potential causes ruled out by Tina’s history are hormone use, oral contraceptives, and intrauterine devices.
Planning 1 / 1
Relevant Educate – Medication: Educate the patient on the use of NSAIDs to reduce menstrual blood flow. Educate – Medication: Educate the patient on the use of oral contraceptives to reduce menstrual flow and regulate the menstrual cycle. Educate – Health Maintenance: Educate the patient to keep a menstrual calendar to assist assessing her pattern. Irrelevant Educate – Medication: Educate the patient on the use of NSAIDs to relieve menstrual pain. Educate – Disease Process: Educate the patient on the pathophysiology of polycystic ovarian syndrome.	Planning Pro Tip: Endocrine disorders are the cause of Tina’s heavy and irregular menstruation, so order labs to evaluate for poly-cystic ovarian syndrome and thyroid disease. Inspect for both hair growth indicative of excessive androgen production and that indicative of deficient production, and inspect for acanthosis nigricans. Educate your patient on keeping a menstrual calendar to more precisely identify irregularities in her cycle, and using oral medications to reduce symptoms.

Obesity

0 of 4 points

Priority 0 / 1
Student Response: Correct Priority: Low	Priority Pro Tip: Although Tina’s obesity should be addressed in this office visit, addressing it cannot appreciably alter the patient’s health in a single visit.
Evidence 0 / 2
Relevant (None provided) Irrelevant (None provided)	Evidence Pro Tip: Based on the WHO’s BMI based classification, Tina’s BMI of 31 identifies her as obese.
Planning 0 / 1
Relevant (None provided) Irrelevant (None provided)	Planning Pro Tip: Tina should be advised during this visit regarding diet and exercise interventions to reduce her body weight. Educate her on the risks of obesity and comorbidities. Assess Tina for the presence of comorbidities, such as hirsutism, acanthosis nigricans, sleep apnea, dyslipidemia, and non-alcoholic fatty liver disease. Test the patient’s thyroid function to rule out hypothyroidism as a contributing factor.

Oligomenorrhea

0 of 4 points

Priority 0 / 1
Student Response: Correct Priority: Low	Priority Pro Tip: Oligomenorrhea is a secondary issue caused by Tina’s endocrine and metabolic disorders and thus is a lower priority diagnosis.
Evidence 0 / 2
Relevant (None provided) Irrelevant (None provided)	Evidence Pro Tip: Tina reports having about 6 periods per year, meeting the criteria for oligomenorrhea, which are periods more than 35 days apart or 9 per year. Her periods occur fewer than 90 days apart, making oligomenorrhea the correct diagnosis rather than amenorrhea.
Planning 0 / 1
Relevant (None provided) Irrelevant (None provided)	Planning Pro Tip: Endocrine disorders are the cause of Tina’s irregular menstruation, so order labs to evaluate for poly-cystic ovarian syndrome and thyroid disease. Inspect for both hair growth indicative of excessive androgen production and that indicative of deficient production, and inspect for acanthosis nigricans. Educate your patient on keeping a menstrual calendar to more precisely identify irregularities in her cycle.

Polycystic ovarian syndrome

0 of 4 points

Priority 0 / 1
Student Response: Correct Priority: Low	Priority Pro Tip: PCOS is the root cause of several of Tina’s symptoms and should be addressed. However it is lower priority than Tina’s acute problems; addressing her pain and hyperglycemia are more immediate needs to improve her status.
Evidence 0 / 2
Relevant (None provided) Irrelevant (None provided)	Evidence Pro Tip: The Rotterdam criteria should be used to establish a diagnosis of PCOS. At least two of the following must be present: ovulatory dysfunction (Tina reports infrequent menstruation), androgen excess (Tina reports excess hair in a male pattern), or poly-cystic ovaries. Diabetes, obesity, and acanthosis nigricans – all reported by Tina – are common signs and symptoms of PCOS.
Planning 0 / 1
Relevant (None provided) Irrelevant (None provided)	Planning Pro Tip: A pelvic exam should be performed in order to assess for palpable enlargement of the ovaries. An ultrasound may be needed to evaluate for cysts of the ovaries. Educate Tina regarding PCOS and its relationship to diabetes. Work with Tina to assist her in establishing GYN care. Further assessment and lab work may be performed to evaluate for androgen excess.

Are you struggling to create a sound and comprehensive nursing paper? Do you feel overwhelmed with the amount of time and effort it takes to write a good piece? Are you looking for the best nursing paper writing service that can assist you in your nursing paper needs? Look no further than our skilled team of professional writers who specialize in providing high-quality papers with the best nursing paper writing services reviews. Make your order at nursingpaperhelp.com

Needs help with similar assignment?

We are available 24x7 to deliver the best services and assignment ready within 3-4 hours? Order a custom-written, plagiarism-free paper

Get Answer Over WhatsApp

Order Paper Now

Tina Jones Health History Completed

Needs help with similar assignment?

About Nursingpaperhelp

Quick Links

We Accept

Contact Us