Newborn Skincare and Hygiene

Symmetry (1/2 point)

Symmetric

Appearance (1/2 point)

Discoloration

Inspected shoulders

Right: Appearance (1/3 point)

No visible abnormal findings

Left: Appearance (1/3 point)

No visible abnormal findings

Symmetry (1/3 point)

Symmetric bilaterally

Inspected arms

Right: Appearance (1/3 point)

No visible abnormal findings

Left: Appearance (1/3 point)

No visible abnormal findings

Symmetry (1/3 point)

Symmetric bilaterally

Inspected elbows

Right: Appearance (1/3 point)

No visible abnormal findings

Left: Appearance (1/3 point)

No visible abnormal findings

Symmetry (1/3 point)

Symmetric bilaterally

Inspected wrists

Right: Appearance (1/3 point)

No visible abnormal findings

Left: Appearance (1/3 point)

No visible abnormal findings

Symmetry (1/3 point)

Symmetric bilaterally

Inspected hands and fingers

Right: Appearance (1/3 point)

No visible abnormal findings

Left: Appearance (1/3 point)

No visible abnormal findings

Symmetry (1/3 point)

Symmetric bilaterally

Inspected hips

Appearance (1/1 point)

No visible abnormal findings

Inspected thighs

Right: Appearance (1/3 point)

No visible abnormal findings

Left: Appearance (1/3 point)

No visible abnormal findings

Symmetry (1/3 point)

Symmetric bilaterally

Inspected knees

Right: Appearance (1/3 point)

No visible abnormal findings

Left: Appearance (1/3 point)

No visible abnormal findings

Symmetry (1/3 point)

Symmetric bilaterally

Inspected lower legs

Right: Appearance (1/3 point)

No visible abnormal findings

Left: Appearance (1/3 point)

No visible abnormal findings

Symmetry (1/3 point)

Symmetric bilaterally

Inspected ankles

Right: Appearance (1/3 point)

No visible abnormal findings

Left: Appearance (1/3 point)

No visible abnormal findings

Symmetry (1/3 point)

Symmetric bilaterally

Inspected feet

0.8 of 1 point

Right: Appearance (1/5 point)

No visible abnormal findings

Right: Arch Shape (1/5 point)

Expected curvature

Left: Appearance (1/5 point)

No visible abnormal findings

Left: Arch Shape (1/5 point)

Expected curvature
Pes planus
Pes cavus

Symmetry (1/5 point)

Symmetric bilaterally

Tested neck range of motion

Flexion (1/4 point)

Expected range of motion (approx. 45 degrees)

Extension (1/4 point)

Expected range of motion (approx. 45 degrees)

Lateral Bending (1/4 point)

Expected range of motion (approx. 40 degrees) on both sides

Rotation (1/4 point)

Expected range of motion (approx. 70 degrees) on both sides

Tested shoulder range of motion

Forward Flexion (1/3 point)

Expected range of motion (approx. 180 degrees)

Extension (1/3 point)

Expected range of motion (approx. 50 degrees)

Adduction (1/3 point)

Expected range of motion (approx. 50 degrees)

Tested elbow range of motion

Right: Flexion And Extension (1/4 point)

Expected range of motion (approx. flexion of 160 degrees and 180 of full extension)

Left: Flexion And Extension (1/4 point)

Expected range of motion (approx. flexion of 160 degrees and 180 of full extension)

Right: Supination And Pronation (1/4 point)

Expected range of motion (approx. pronation of 90 degrees and supination of 90 degrees)

Left: Supination And Pronation (1/4 point)

Expected range of motion (approx. pronation of 90 degrees and supination of 90 degrees)

Tested wrist range of motion

Right: Flexion (1/8 point)

Expected range of motion (approx. 90 degrees)

Left: Flexion (1/8 point)

Expected range of motion (approx. 90 degrees)

Right: Extension (1/8 point)

Expected range of motion (approx. 70 degrees)

Left: Extension (1/8 point)

Expected range of motion (approx. 70 degrees)

Right: Ulnar Deviation (1/8 point)

Expected range of motion (approx. 55 degrees)

Left: Ulnar Deviation (1/8 point)

Expected range of motion (approx. 55 degrees)

Right: Radial Deviation (1/8 point)

Expected range of motion (approx. 20 degrees)

Left: Radial Deviation (1/8 point)

Expected range of motion (approx. 20 degrees)

Tested spine range of motion

Extension (1/4 point)

Reduced extension

Flexion (1/4 point)

Reduced flexion

Lateral Bending (1/4 point)

Reduced lateral bending to the right
Reduced lateral bending to the left

Rotation (1/4 point)

Reduced rotation to the right
Reduced rotation to the left

Tested hip range of motion

Flexion (1/4 point)

Expected range of motion (approx. 90 degrees)

Extension (1/4 point)

Expected range of motion (approx. 30 degrees)

Abduction (1/4 point)

Expected range of motion (approx. 45 degrees)

Adduction (1/4 point)

Expected range of motion (approx. 30 degrees)

Tested knee range of motion

Right: Flexion (1/4 point)

Expected range of motion (approx. 130 degrees)

Left: Flexion (1/4 point)

Expected range of motion (approx. 130 degrees)

Right: Extension (1/4 point)

Expected range of motion (approx. 0 to 15 degrees)

Left: Extension (1/4 point)

Expected range of motion (approx. 0 to 15 degrees)

Tested ankle range of motion

Right: Eversion And Inversion (1/4 point)

Expected range of motion (approx. inversion of 30 degrees and eversion of 20 degrees)

Left: Eversion And Inversion (1/4 point)

Expected range of motion (approx. inversion of 30 degrees and eversion of 20 degrees)
Reduced inversion
Reduced eversion

Right: Dorsiflexion And Plantar Flexion (1/4 point)

Expected range of motion (approx. flexion of 160 degrees and 180 of full extension)

Left: Dorsiflexion And Plantar Flexion (1/4 point)

Expected range of motion (approx. flexion of 160 degrees and 180 of full extension)

Tested neck strength

Strength (1/1 point)

5 – Active movement against full resistance without fatigue (normal)

Tested shoulder strength

Strength (1/1 point)

0 – No muscle contraction
1 – Barely detectable contraction
2 – Active movement with gravity eliminated
3 – Active movement against gravity
4 – Active movement against gravity and resistance
5 – Active movement against full resistance without fatigue (normal)

Tested elbow strength

Right (1/2 point)

5 – Active movement against full resistance without fatigue (normal)

Left (1/2 point)

5 – Active movement against full resistance without fatigue (normal)

Tested wrist strength

Right (1/2 point)

5 – Active movement against full resistance without fatigue (normal)

Left (1/2 point)

5 – Active movement against full resistance without fatigue (normal)

Tested hand strength

Right (1/2 point)

5 – Active movement against full resistance without fatigue (normal)

Left (1/2 point)

5 – Active movement against full resistance without fatigue (normal)

Tested hip strength

Strength (1/1 point)

5 – Active movement against full resistance without fatigue (normal)

Tested knee strength

Right (1/2 point)

5 – Active movement against full resistance without fatigue (normal)

Left (1/2 point)

5 – Active movement against full resistance without fatigue (normal)

Tested ankle strength

Right (1/2 point)

5 – Active movement against full resistance without fatigue (normal)

Left (1/2 point)

5 – Active movement against full resistance without fatigue (normal)

Education & Empathy : 1 of 4 (25.0%)

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

	Description: Tina describes the symptoms that have been bothering her.
	What brings you here today?	Question 04:19 AM EDT
	Well, I have a lot of pain in my lower back. It really hurts, and it doesn’t seem to be going away. It’s making it kind of hard to get things done, so I decided to come in and have it looked at.
	I am sorry for that	Empathize 04:19 AM EDT
	Thanks for understanding.
	Model Statement: “I’m sorry to hear you’re in pain. I would like to learn more about your pain and how it may have happened, and then we can talk about treating it so you feel better.”

2 Cause of Injury

Not Encountered

	Description: Tina discusses her lifting technique.
	Model Statement: “You’re right; proper lifting technique is important to prevent injuries. We can go over how to lift things safely, so that you don’t further injure yourself when you go back to work.”

	Description: Tina describes her medication regimen, which includes taking 8 to 10 tablets of ibuprofen per day to treat her back pain.
	What relieves the pain?	Question 04:23 AM EDT
	Taking Advil has been helping a little.
	Do you use any medication?	Question 04:23 AM EDT
	I’ve been taking Advil for my back, and I also have my inhalers.
	Hos long have you been taking advil?	Question 04:24 AM EDT
	I’ve been taking the Advil about three days, maybe a little less–since the night after I hurt myself.
	Do you have any allergies?	Question 04:24 AM EDT
	Yeah, I’m allergic to cats.
	Do you have a history of back pain?	Question 04:24 AM EDT
	No, nothing like this has ever happened to me. . . my back is usually totally fine.
	Model Statement: “Thank you for letting me know that you’re taking ibuprofen in addition to the medications you usually take. I will ask you a few questions about how you’re using each medication.”

4 Activities of Daily Living

	Description: Tina discusses her activity level and work tasks while on the job.
	How has the pain impacted your income and education?	Question 04:25 AM EDT
	I haven’t missed any work. . . work isn’t so bad, since I’m mostly standing up for it.
	Do you have fever?	Question 04:25 AM EDT
	No, I don’t get a lot of fevers.
	Do you have head related injury?	Question 04:26 AM EDT
	No, never.
	Model Statement: “It sounds like you keep busy at work. Being on your feet all day can aggravate your back. We can talk about footwear and postural changes that will help you be more comfortable at work.”

Documentation / Electronic Health Record

Document: Provider Notes

Document: Provider Notes

Student Documentation	Model Documentation
Subjective Tina Jones presents to the clinic complaining of lower back pain which she hurt while lifting a box. The pain has been contant for the last 3 days. The pain does not radiate. She rates the pain as 5/10. Uses Advil to releave the pain. She has difficulty sitting and walking but is able to do her daily tasks. She has no new allergies. Has no history of back pain. Dhe has no fever, numbness or dizziness.	HPI: Ms. Jones presents to the clinic complaining of back pain that began 3 days ago after she “tweaked it” while lifting a heavy box while helping a friend move. She states that lifted several boxes before this event without incident and does not know the weight of the box that caused her pain. The pain is in her low back and bilateral buttocks, is a constant aching with stiffness, and does not radiate. The pain is aggravated by sitting (rates a 7/10) and decreased by rest and lying flat on her back (pain of 3-4/10). The pain has not changed over the past three days and she has treated with 2 over the counter ibuprofen tablets every 5-6 hours. Her current pain is a 5/10, but she states that the ibuprofen can decrease her pain to 2-3/10. She denies numbness, tingling, muscle weakness, bowel or bladder incontinence. She presents today as the pain has continued and is interfering with her activities of daily living. Social History: Ms. Jones’ job is mostly supervisory, although she does report that she may have to sit or stand for extended periods of time. She denies lifting at work or school. She states that her pain has limited her activities of daily living. She denies use of tobacco, alcohol, and illicit drugs. She does not exercise. Review of Systems: General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats. • Musculoskeletal: Denies muscle weakness, pain, joint instability, or swelling. She does state that she has difficulties with range of motion. She does state that the pain in her lower back has impacted her comfort while sleeping and sitting in class. She denies numbness, tingling, radiation, or bowel/bladder dysfunction. She denies previous musculoskeletal injuries or fractures. • Neurologic: Denies loss of sensation, numbness, tingling, tremors, weakness, paralysis, fainting, blackouts, or seizures.
Objective Tina Jones is pleasant. She is obese and is in no acute distress. She is alert and well orineted. Spinal ROM extension, flexion and lateral bending are reduced. Spinal ROM rotation is reduced. Hip strength is 5 out of 5. No joint deformity.	General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented. She maintains eye contact throughout interview and examination. Musculoskeletal: Bilateral upper extremities without muscle atrophy or joint deformity. Bilateral upper extremities with full range of motion of shoulder, elbow, and wrist. No evidence of swollen joints or signs of infection. Bilateral lower extremities without muscle atrophy or joint deformity, full range of motion of bilateral hips, knees, and ankles. No evidence of swollen joints or signs of infection. Flexion, extension, lateral bending, and rotation of the spine with reduced ROM – pain and difficulty. Bilateral upper extremity strength equal and 5/5 in neck, shoulders, elbows, wrists, hands. Bilateral lower extremity strength equal and 5/5 in hip flexors, knees, and ankles.
Assessment Low back muscle strain related to lifting	Low back muscle strain related to lifting
Plan Educate patint on how to avoid lower back pain in the future. Initiate treatment with ibuprofen and acetaminophen 500-1000 mg by mouth Use heat or ice per comfort TID-QID Educate patient on lifting techniques. Seek medical attentio in case of acute changes Limit movment of lower back Review after two weeks for follow up	Provide Ms. Jones with materials detailing stretching techniques for the lower back. • Initiate treatment with ibuprofen 600 mg by mouth every six to eight hours with food as needed for pain for the next two weeks. She may use acetaminophen 500-1000 mg by mouth every 8 hours for breakthrough pain. • Ms. Jones can also use adjunct therapy of topical heat or ice per comfort TID-QID. • Educate on proper body mechanics and lifting techniques. • Educate on when to seek emergent care including loss of bowel or bladder function, acute changes in sensation of lower extremities, or limitations in movement of lower extremities. • Return to clinic in two weeks for follow up and evaluation of symptoms.

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Tina Jones Shadow Health Neurological Results

May 5, 2025/in BLOGS /by admin

Tina Jones Shadow Health Neurological Results

Experience Overview

Patient: Tina Jones

Digital Clinical Experience Score

96.4%

This score measures your performance on the Student Performance Index in relation to other students in comparable academic programs. Your instructor has chosen to scale your Student Performance Index score so that the average score on the index is a 87.0%. This score may not be your final grade if your instructor chooses to include additional components, such as documentation or time spent.

Student Performance Index

59.75

out of

62

Proficiency Level:

Proficient

Students rated as “proficient” demonstrate an entry-level expertise in advanced practice competencies and clinical reasoning skills. In comparable programs, the top 25% of students perform at the level of a proficient practitioner.

Subjective Data Collection

21

out of

21

Objective Data Collection

36.75

out of

37

Education and Empathy

2

out of

4

Time

64 minutes total spent in assignment

Interaction with patient

64 minutes

Transcript

Started: Apr 27, 2025 | Total Time: 64 min

All Lines (179)Interview Questions (51)Statements (1)Exam Actions (127)

	Hello, my name is Mileidy. I will be your nurse today	Greet 04/27/25 5:55 AM EDT
	Hey.
	What brings you here today?	Question 04/27/25 5:56 AM EDT
	Well, I got into a little fender bender a week ago and I’ve been getting these headaches ever since. And my neck is sore too.
	I am sorry for that	Empathize 04/27/25 5:56 AM EDT
	Thanks for understanding.
	When did the symptoms start?	Question 04/27/25 5:56 AM EDT
	Well, I was in the car accident a week ago, but the headaches and neck stuff started a few days after that.
	Were you wearing seatbelts?	Question 04/27/25 5:57 AM EDT
	Yes, I always do.
	How is the frequency and duration of the symptoms?	Question 04/27/25 5:57 AM EDT
	I’ve had a headache just about once a day since a couple days after my accident. Once I feel it coming on, I take something for it and it pretty much goes away for the day.
	Where is the pain located?	Question 04/27/25 5:58 AM EDT
	It’s really just been the headaches, but my neck is sore, too.
	How severe is the pain?	Question 04/27/25 5:58 AM EDT
	I’ve had worse, but the headaches have gotten bad enough to stop me from what I was doing a couple times.
	How does the headache feels like?	Question 04/27/25 5:58 AM EDT
	The headaches feel like a dull ache, kind of in the crown of my head, and the back of my head.
	What makes the pain worse?	Question 04/27/25 5:59 AM EDT
	I can’t tell if anything makes it worse. It just seems to come and go.
	What relieves the pain?	Question 04/27/25 5:59 AM EDT
	Acetaminophen helps a little. [AUDIO COMING SOON]
	Have you used any medication? (Clarified to Have you been taking any medication?.)	Question 04/27/25 5:59 AM EDT
	Just some acetaminophen for my headaches and my neck. And I use my daily inhaler, too. [AUDIO COMING SOON] (Clarified to if I have been taking any medication.)
	Do you have any allergies?	Question 04/27/25 6:00 AM EDT
	Yeah, I’m allergic to cats.
	Do you have a history of headaches?	Question 04/27/25 6:00 AM EDT
	Yeah, I’ve been getting headaches.
	Do you have a history of migraine?	Question 04/27/25 6:01 AM EDT
	No, I’m pretty sure my headaches aren’t migraines.
	How is your sleep pattern?	Question 04/27/25 6:01 AM EDT
	I try to be in bed by eleven or midnight, and I get up at seven or eight.
	How has the accident affected your finances?	Question 04/27/25 6:02 AM EDT
	My friend was the one driving, so it was their car that got hit. Thankfully, I don’t have to deal with the repairs. [AUDIO COMING SOON]
	Do you have any fever?	Question 04/27/25 6:02 AM EDT
	No.
	Do you have any neurological issue?	Question 04/27/25 6:02 AM EDT
	I don’t think so.
	Do you have stress?	Question 04/27/25 6:03 AM EDT
	I haven’t been particularly stressed lately.
	Do you have depression?	Question 04/27/25 6:03 AM EDT
	No, I’ve been fine.
	How is your vision?	Question 04/27/25 6:03 AM EDT
	Well — first off, my vision’s been fine since the car accident. But in general, my vision isn’t that great. Sometimes it gets blurry when I read for a long time.
	Do you have nasal congestion?	Question 04/27/25 6:04 AM EDT
	No, I haven’t been congested.
	Do you have a family history of migraine?	Question 04/27/25 6:04 AM EDT
	I don’t think so.
	What is your name and date of birth?	Question 04/27/25 6:05 AM EDT
	My name is Tina Jones, and I was born on February 17th.
	Evaluated orientation to person	Exam Action 04/27/25 6:05 AM EDT
	What building are you in now?	Question 04/27/25 6:05 AM EDT
	I’m at the doctor’s office. . . it’s Shadow Health General Clinic.
	Evaluated orientation to place	Exam Action 04/27/25 6:05 AM EDT
	What us the date and year	Question 04/27/25 6:06 AM EDT
	Um, today’s date is . . . [Ms. Jones reports correct date and year].
	Evaluated orientation to time	Exam Action 04/27/25 6:06 AM EDT
	How are apples and oranges alike?	Question 04/27/25 6:06 AM EDT
	How are they alike? Um…. they’re both kinds of fruit.
	Evaluated abstract thinking: similarities among fruit	Exam Action 04/27/25 6:06 AM EDT
	How are a lake and an ocean alike?	Question 04/27/25 6:06 AM EDT
	Uh…. they’re both bodies of water.
	Evaluated abstract thinking: similarities among bodies of water	Exam Action 04/27/25 6:07 AM EDT
	How are a trumpet and a flute alike?	Question 04/27/25 6:07 AM EDT
	They…… they’re both musical instruments.
	Evaluated abstract thinking: similarities among instruments	Exam Action 04/27/25 6:07 AM EDT
	count backwards by 7s from 100	Question 04/27/25 6:09 AM EDT
	Okay. . . 100, 93. . . 86, 79, 72. . . 65. . . 58, 51. . . 44. . . 37, 30, 23, 16. . . 9, and 2.
	Evaluated attention with serial sevens	Exam Action 04/27/25 6:09 AM EDT
	Read and follow these instructions?	Question 04/27/25 6:10 AM EDT
	Established one-stage comprehension	Exam Action 04/27/25 6:10 AM EDT
	Read and follow these instructions	Question 04/27/25 6:10 AM EDT
	Established two-stage comprehension	Exam Action 04/27/25 6:10 AM EDT
	Who was the first president of the united states?	Question 04/27/25 6:10 AM EDT
	That’s George Washington.
	Evaluated knowledge of first president	Exam Action 04/27/25 6:11 AM EDT
	Who are the last four presidents of the united states?	Question 04/27/25 6:11 AM EDT
	Well,.. .[Ms. Jones reports the correct last four presidents.]
	Evaluated knowledge of last four presidents	Exam Action 04/27/25 6:11 AM EDT
	Name five large cities in the united states?	Question 04/27/25 6:11 AM EDT
	Let’s see. . . New York City. . . and Chicago. . . Detroit. . . Los Angeles. . . and Houston. That’s five.
	Evaluated knowledge of five large cities	Exam Action 04/27/25 6:12 AM EDT
	what would you do if you found a stamped and addressed envelope on the sidewalk?	Question 04/27/25 6:12 AM EDT
	What would I do…. Hmm.. Well, I’d try to figure out who dropped the envelope, but if not… Well, I’d probably just drop it in the first mailbox I saw, if there was one nearby.
	Evaluated judgment	Exam Action 04/27/25 6:13 AM EDT
	Repeat and remember burger, tulip, nose, and tea	Question 04/27/25 6:13 AM EDT
	Burger, tulip, nose, and tea.
	Evaluated immediate memory	Exam Action 04/27/25 6:13 AM EDT
	Observed patient’s general vocabulary	Exam Action 04/27/25 6:13 AM EDT
	Observed patient’s general ability to articulate	Exam Action 04/27/25 6:13 AM EDT
	Tested CN I (olfactory nerve) with smell test	Exam Action 04/27/25 6:14 AM EDT
	E D E O X F
	P E C F D
	Tested visual acuity of right eye	Exam Action 04/27/25 6:14 AM EDT
	P E C F D
	E D F C Z P
	F E L O P Z D
	D E F P O T E C
	Tested visual acuity of left eye	Exam Action 04/27/25 6:15 AM EDT
	D E F P O T E C
	Tested visual acuity of both eyes	Exam Action 04/27/25 6:15 AM EDT
	I can’t read that line. It’s too little.
	Inspected fundus of right eye	Exam Action 04/27/25 6:16 AM EDT
	Inspected fundus of left eye	Exam Action 04/27/25 6:16 AM EDT
	Inspected left pupil and tested left pupillary light reflex	Exam Action 04/27/25 6:16 AM EDT
	Inspected right pupil and tested pupillary light reflex	Exam Action 04/27/25 6:16 AM EDT
	Follow my finger with just your eyes	Question 04/27/25 6:17 AM EDT
	Ok.
	Tested EOM to the upper left	Exam Action 04/27/25 6:17 AM EDT
	Tested EOM to the upper center	Exam Action 04/27/25 6:17 AM EDT
	Tested EOM to the upper right	Exam Action 04/27/25 6:17 AM EDT
	Tested convergence	Exam Action 04/27/25 6:17 AM EDT
	Tested EOM to the lower left	Exam Action 04/27/25 6:17 AM EDT
	Tested EOM to the lower center	Exam Action 04/27/25 6:17 AM EDT
	Tested EOM to the lower right	Exam Action 04/27/25 6:17 AM EDT
	Close your eyes and tell me if the touch is sharp, dull or soft	Question 04/27/25 6:18 AM EDT
	Ok.
	Tested facial sensation: dull stimulus	Exam Action 04/27/25 6:18 AM EDT
	Dull.
	Tested facial sensation: dull stimulus	Exam Action 04/27/25 6:18 AM EDT
	Dull.
	Tested facial sensation: dull stimulus	Exam Action 04/27/25 6:18 AM EDT
	Dull.
	Tested facial sensation: dull stimulus	Exam Action 04/27/25 6:18 AM EDT
	Dull.
	Tested facial sensation: soft stimulus	Exam Action 04/27/25 6:18 AM EDT
	Soft.
	Tested facial sensation: soft stimulus	Exam Action 04/27/25 6:18 AM EDT
	Soft.
	Tested facial sensation: soft stimulus	Exam Action 04/27/25 6:18 AM EDT
	Soft.
	Tested facial sensation: soft stimulus	Exam Action 04/27/25 6:18 AM EDT
	Soft.
	Tested facial sensation: sharp stimulus	Exam Action 04/27/25 6:18 AM EDT
	Sharp.
	Tested facial sensation: sharp stimulus	Exam Action 04/27/25 6:18 AM EDT
	Sharp.
	Tested facial sensation: sharp stimulus	Exam Action 04/27/25 6:18 AM EDT
	Sharp.
	Tested facial sensation: sharp stimulus	Exam Action 04/27/25 6:18 AM EDT
	Sharp.
	Inspected front of face for asymmetry and facial droop	Exam Action 04/27/25 6:18 AM EDT
	Inspected right side of face for asymmetry and facial droop	Exam Action 04/27/25 6:18 AM EDT
	Inspected back of head for asymmetry	Exam Action 04/27/25 6:18 AM EDT
	Inspected right side of face for asymmetry and facial droop	Exam Action 04/27/25 6:19 AM EDT
	Inspected front of face for asymmetry and facial droop	Exam Action 04/27/25 6:19 AM EDT
	Inspected left side of face for asymmetry and facial droop	Exam Action 04/27/25 6:19 AM EDT
	Inspected front of face for asymmetry and facial droop	Exam Action 04/27/25 6:19 AM EDT
	Inspected left side of face for asymmetry and facial droop	Exam Action 04/27/25 6:19 AM EDT
	Inspected back of head for asymmetry	Exam Action 04/27/25 6:19 AM EDT
	Inspected left side of face for asymmetry and facial droop	Exam Action 04/27/25 6:19 AM EDT
	Inspected front of face for asymmetry and facial droop	Exam Action 04/27/25 6:19 AM EDT
	is the volume the same in both ears or louder in one ear	Question 04/27/25 6:19 AM EDT
	Ok.
	Same in both ears.
	Performed Weber test with tuning fork	Exam Action 04/27/25 6:19 AM EDT
	Tell me when you no longer hear rhe ringing	Question 04/27/25 6:20 AM EDT
	Ok, I will.
	Now.
	Performed Rinne test on right side with tuning fork	Exam Action 04/27/25 6:21 AM EDT
	Now.
	Now.
	Now.
	Performed Rinne test on left side with tuning fork	Exam Action 04/27/25 6:21 AM EDT
	Tell me when you no longer hear rhe ringing	Question 04/27/25 6:21 AM EDT
	Ok, I will.
	Now.
	Performed Rinne test on left side with tuning fork	Exam Action 04/27/25 6:22 AM EDT
	Now.
	Now.
	Now.
	Performed Rinne test on right side with tuning fork	Exam Action 04/27/25 6:23 AM EDT
	Tested gag reflex	Exam Action 04/27/25 6:23 AM EDT
	Tested trapezius muscle strength against resistance: 5 strength against resistance	Exam Action 04/27/25 6:23 AM EDT
	Tested sternocleidomastoid muscle strength against resistance – head turned to the right: 5 strength against resistance	Exam Action 04/27/25 6:23 AM EDT
	Tested sternocleidomastoid muscle strength against resistance – head turned to the left: 5 strength against resistance	Exam Action 04/27/25 6:24 AM EDT
	Inspected mouth	Exam Action 04/27/25 6:24 AM EDT
	Inspected mouth: pushed tongue left with tongue blade	Exam Action 04/27/25 6:24 AM EDT
	Inspect mouth: pushed tongue right with tongue blade	Exam Action 04/27/25 6:24 AM EDT
	Inspect mouth: lifted tongue with tongue blade	Exam Action 04/27/25 6:24 AM EDT
	Inspected mouth: depressed tongue with tongue blade	Exam Action 04/27/25 6:24 AM EDT
	Tested reflexes of right triceps: 2+	Exam Action 04/27/25 6:25 AM EDT
	Tested reflexes of left triceps: 2+	Exam Action 04/27/25 6:25 AM EDT
	Tested reflexes of right biceps: 2+	Exam Action 04/27/25 6:25 AM EDT
	Tested reflexes of left biceps: 2+	Exam Action 04/27/25 6:25 AM EDT
	Tested reflexes of right brachioradialis: 2+	Exam Action 04/27/25 6:25 AM EDT
	Tested reflexes of left brachioradialis: 2+	Exam Action 04/27/25 6:25 AM EDT
	Tested reflexes of right patellar tendon: 2+	Exam Action 04/27/25 6:26 AM EDT
	Tested reflexes of left patellar tendon: 2+	Exam Action 04/27/25 6:26 AM EDT
	Tested reflexes of right achilles tendon: 2+	Exam Action 04/27/25 6:26 AM EDT
	close your eyes and touch your fingers to your nose	Question 04/27/25 6:26 AM EDT
	I can do that.
	Observed left index finger to nose	Exam Action 04/27/25 6:27 AM EDT
	Observed right index finger to nose	Exam Action 04/27/25 6:27 AM EDT
	run your right foot down your shin	Question 04/27/25 6:27 AM EDT
	Sure.
	Observed right heel moving to shin	Exam Action 04/27/25 6:27 AM EDT
	run your left foot down your right shin	Question 04/27/25 6:28 AM EDT
	Ok.
	Observed left heel moving to shin	Exam Action 04/27/25 6:28 AM EDT
	place your hands on your knees and turn them over	Question 04/27/25 6:28 AM EDT
	Ok, like this?
	Observed rapid alternating hand movements: Movement is smooth, performed without difficulty	Exam Action 04/27/25 6:28 AM EDT
	Observed patient’s gait	Exam Action 04/27/25 6:28 AM EDT
	close your eyes and tell me what I trace on your palm	Question 04/27/25 6:29 AM EDT
	Ok.
	That’s an “A.”
	Tested left-hand graphesthesia by letter identification	Exam Action 04/27/25 6:29 AM EDT
	A figure “8.”
	Tested right-hand graphesthesia by number identification	Exam Action 04/27/25 6:29 AM EDT
	close your eyes and tell me if the touch is sharp, dull or soft	Question 04/27/25 6:30 AM EDT
	Ok.
	Tested right arm proximal dull sensation	Exam Action 04/27/25 6:30 AM EDT
	Dull.
	Tested right arm distal dull sensation	Exam Action 04/27/25 6:30 AM EDT
	Dull.
	Tested left arm proximal dull sensation	Exam Action 04/27/25 6:30 AM EDT
	Dull.
	Tested left arm distal dull sensation	Exam Action 04/27/25 6:30 AM EDT
	Dull.
	Tested right arm proximal soft sensation	Exam Action 04/27/25 6:30 AM EDT
	Soft.
	Tested right arm distal soft sensation	Exam Action 04/27/25 6:30 AM EDT
	Soft.
	Tested left arm proximal soft sensation	Exam Action 04/27/25 6:30 AM EDT
	Soft.
	Tested left arm distal soft sensation	Exam Action 04/27/25 6:30 AM EDT
	Soft.
	Tested right arm proximal sharp sensation	Exam Action 04/27/25 6:30 AM EDT
	Sharp.
	Tested right arm distal sharp sensation	Exam Action 04/27/25 6:30 AM EDT
	Sharp.
	Tested left arm proximal sharp sensation	Exam Action 04/27/25 6:30 AM EDT
	Sharp.
	Tested left arm distal sharp sensation	Exam Action 04/27/25 6:30 AM EDT
	Sharp.
	close your eyes and tell me if the touch is sharp, dull or soft	Question 04/27/25 6:31 AM EDT
	Ok.
	Tested right leg proximal dull sensation	Exam Action 04/27/25 6:31 AM EDT
	Dull.
	Tested right leg distal dull sensation	Exam Action 04/27/25 6:31 AM EDT
	Dull.
	Tested left leg proximal dull sensation	Exam Action 04/27/25 6:31 AM EDT
	Dull.
	Tested left leg distal dull sensation	Exam Action 04/27/25 6:31 AM EDT
	Dull.
	Tested right leg proximal light sensation	Exam Action 04/27/25 6:31 AM EDT
	Soft.
	Tested right leg distal light sensation	Exam Action 04/27/25 6:31 AM EDT
	Soft.
	Tested left leg proximal light sensation	Exam Action 04/27/25 6:31 AM EDT
	Soft.
	Tested left leg distal light sensation	Exam Action 04/27/25 6:31 AM EDT
	Soft.
	Tested right leg proximal sharp sensation	Exam Action 04/27/25 6:31 AM EDT
	Sharp.
	Tested right leg distal sharp sensation	Exam Action 04/27/25 6:31 AM EDT
	Sharp.
	Tested left leg proximal sharp sensation	Exam Action 04/27/25 6:31 AM EDT
	Sharp.
	Tested left leg distal sharp sensation	Exam Action 04/27/25 6:31 AM EDT
	Sharp.
	close your eyes and tell me when you feel the touch	Question 04/27/25 6:32 AM EDT
	Ok, I will.
	Tested sensation of right big toe with monofilament	Exam Action 04/27/25 6:32 AM EDT
	Tested sensation of left big toe with monofilament	Exam Action 04/27/25 6:32 AM EDT
	Tested sensation of left ball of foot under big toe with monofilament	Exam Action 04/27/25 6:32 AM EDT
	Tested sensation of right ball of foot under big toe with monofilament	Exam Action 04/27/25 6:32 AM EDT
	Yes.
	Tested sensation of right ball of foot under small toe with monofilament	Exam Action 04/27/25 6:32 AM EDT
	Tested sensation of right heel with monofilament	Exam Action 04/27/25 6:32 AM EDT
	Yes.
	Tested sensation of left heel with monofilament	Exam Action 04/27/25 6:32 AM EDT
	Yes.
	Tested sensation of left ball of foot under small toe with monofilament	Exam Action 04/27/25 6:32 AM EDT
	close your eyes and tell me if your finger or toe moves up or down	Question 04/27/25 6:33 AM EDT
	Ok, I will.
	Down.
	Tested position sense of finger on right hand	Exam Action 04/27/25 6:33 AM EDT
	Up.
	Tested position sense of finger on left hand	Exam Action 04/27/25 6:33 AM EDT
	…I think that was up.
	Tested position sense of toe on right foot	Exam Action 04/27/25 6:33 AM EDT
	Down.
	Tested position sense of toe on left foot	Exam Action 04/27/25 6:34 AM EDT
	close your eyes and tell me what I put in your hand	Question 04/27/25 6:34 AM EDT
	Ok, sure.
	Tested right-hand stereognosis with coin	Exam Action 04/27/25 6:34 AM EDT
	…Some kind of coin.
	This is… some wire thing… paperclip?
	Tested right-hand stereognosis with paper clip	Exam Action 04/27/25 6:34 AM EDT
	Um… that feels like a key.
	Tested right-hand stereognosis with key	Exam Action 04/27/25 6:35 AM EDT
	…Some kind of coin.
	Tested left-hand stereognosis with coin	Exam Action 04/27/25 6:35 AM EDT
	Tested left-hand stereognosis with paper clip	Exam Action 04/27/25 6:35 AM EDT
	The paperclip again.
	Um… that feels like a key.
	Tested left-hand stereognosis with key	Exam Action 04/27/25 6:35 AM EDT

Subjective Data Collection: 21 of 21 (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 recent “fender bender”

(Found)

Pro Tip: Patients choose to seek treatment for a variety of reasons. Asking why Tina chose to seek treatment today might indicate primary concerns, the severity of her symptoms, or failure to manage symptoms herself.

Example Question:

Why are you seeking treatment today?

Finding:

Reports headaches

(Found)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina if she’s had headaches specifies the way her individual symptoms and pain manifest.

Example Question:

Have you had any headaches?

Finding:

Reports neck symptoms

(Found)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina if she’s had neck stiffness specifies the way her individual symptoms and pain manifest.

Example Question:

Have you had any neck stiffness?

History of Present Illness

Finding:

Asked about onset of symptoms

Finding:

Reports accident occurred 1 week ago

(Found)

Pro Tip: Soliciting a relevant history of Tina’s car accident will allow you to understand the context in which she was injured and the injuries she sustained.

Example Question:

When did the accident happen?

Finding:

Reports symptoms began 2 days after accident

(Found)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina when the headaches begin specifies the way her individual symptoms and pain manifest.

Example Question:

When did the headaches begin?

Finding:

Followed up on details of car accident

Finding:

Denies loss of consciousness

(Available)

Pro Tip: Soliciting a relevant history of Tina’s car accident will allow you to understand the context in which she was injured and the injuries she sustained.

Example Question:

Did you lose consciousness during the car accident?

Finding:

Reports low vehicle speed

(Available)

Pro Tip: Soliciting a relevant history of Tina’s car accident will allow you to understand the context in which she was injured and the injuries she sustained.

Example Question:

How fast was the car going?

Finding:

Reports wearing seatbelt

(Found)

Pro Tip: Soliciting a relevant history of Tina’s car accident will allow you to understand the context in which she was injured and the injuries she sustained.

Example Question:

Were you wearing your seatbelt?

Finding:

Reports sitting in front passenger seat

(Available)

Pro Tip: Soliciting a relevant history of Tina’s car accident will allow you to understand the context in which she was injured and the injuries she sustained.

Example Question:

Where in the car were you sitting?

Finding:

Reports no alcohol or drug use during accident

(Available)

Pro Tip: Soliciting a relevant history of Tina’s car accident will allow you to understand the context in which she was injured and the injuries she sustained.

Example Question:

Was anyone in the car under the influence of alcohol?

Finding:

Asked about frequency and duration of symptoms

Finding:

Reports headaches are daily since they began

(Found)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina how often she gets headaches specifies the way her individual symptoms and pain manifest.

Example Question:

How many days have you had a headache since they started?

Finding:

Reports headaches last 1-2 hours

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina how long the headaches last specifies the way her individual symptoms and pain manifest.

Example Question:

How long do the headaches last?

Finding:

Reports last headache was yesterday afternoon

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina when she got her last headaches specifies the way her individual symptoms and pain manifest.

Example Question:

When was your last headache?

Finding:

Asked location of pain

Finding:

Reports headache pain in crown and back of head

(Found)

Pro Tip: Because symptoms often vary from patient to patient, asking Tina where her headaches are occurring will allow you to most effectively treat her specific symptoms.

Example Question:

Where are the headaches located?

Finding:

Reports pain does not radiate into shoulders, back, or arms

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina to describe what her injury feels like specifies the way her symptoms and pain manifest.

Example Question:

Does the pain radiate?

Finding:

Reports slight pain in back of neck muscles

(Found)

Pro Tip: Because symptoms often vary from patient to patient, asking Tina how her neck feels will allow you to see the ways in which her individual pain manifests.

Example Question:

How does your neck feel?

Finding:

Denies scalp tenderness or injury

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina if her scalp is tender specifies the way her individual symptoms and pain manifest.

Example Question:

Is your scalp tender?

Finding:

Denies jaw symptoms

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina if her jaw is tender specifies the way her individual symptoms and pain manifest.

Example Question:

Do you have jaw pain?

Finding:

Denies facial pain

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina if she is experiencing facial pain specifies the way her individual symptoms and pain manifest.

Example Question:

Do you have any facial pain?

Finding:

Asked about severity of pain

Finding:

Rates current head and neck pain severity at 3 out of 10

(Available)

Pro Tip: Pain severity might change over time for a variety of reasons. Asking Tina to rate the severity of her current pain on a scale of 1-10 will provide a quantified and relative measurement of her condition.

Example Question:

How would you rate your current pain on a scale from 0 to 10?

Finding:

Rates pain severity at its worst is 4 out of 10

(Available)

Pro Tip: Pain severity might change over time for a variety of reasons. Asking Tina to rate the severity of her pain when it started on a scale of 1-10 will provide a quantified and relative measurement of her condition.

Example Question:

How would you rate your pain at its worst on a scale from 0 to 10?

Finding:

Followed up on headache characteristics

Finding:

Reports headache pain as a dull ache

(Found)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina to describe what her headaches feel like specifies the way her individual symptoms and pain manifest.

Example Question:

What do your headaches feel like?

Finding:

Denies sharp pain

(Available)

Pro Tip: Because symptoms often vary from patient to patient, asking Tina whether her headaches feel sharp will allow you to most effectively treat her specific symptoms.

Example Question:

Is the headache pain sharp?

Finding:

Reports headaches not cyclic

(Available)

Pro Tip: By understanding the nature of Tina’s pain, you can most effectively treat her. Asking Tina whether her headaches are cyclic will give you a sense for the extent of her pain.

Example Question:

Are your headaches cyclic?

Finding:

Reports headaches do not occur in clusters

(Available)

Pro Tip: By understanding the nature of Tina’s pain, you can most effectively treat her. Asking Tina whether her headaches come in clusters will give you a sense for the extent of her pain.

Example Question:

Do your headaches come in clusters?

Finding:

Reports headaches not rapid in crescendo

(Available)

Pro Tip: By understanding the nature of Tina’s pain, you can most effectively treat her. Asking Tina whether her headaches crescendo will give you a sense for the extent of her pain.

Example Question:

Do your headaches crescendo?

Finding:

Asked about aggravating factors

Finding:

Reports that car accident seems to be primary cause

(Available)

Pro Tip: It’s important to ask the patient if they know the primary cause of an injury.

Example Question:

What caused your pain?

Finding:

Reports pain upon head or neck movement

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina if it hurts to move her head specifies the way her individual symptoms and pain manifest.

Example Question:

Does it hurt to move your head?

Finding:

Reports headaches don’t have a discernible trigger

(Found)

Pro Tip: Pain severity might change for a variety of reasons. Asking Tina what makes her headaches worse might help you to understand sounds, movements, or times that trigger her pain.

Example Question:

What makes your headaches worse?

Finding:

Asked about relieving factors for neck pain and headaches

Finding:

Denies home remedies such as heat or cold

(Available)

Pro Tip: Finding out the non-medication modalities that a patient is treating her pain with will help you understand the severity of the pain.

Example Question:

Have you tried home remedies?

Finding:

Symptoms improve with rest

(Available)

Pro Tip: Understanding all of the relieving factors, including how a symptom changes at motion or at rest, can help you understand all of the contributing pain factors.

Example Question:

Does the headache get better with rest?

Medical History

Finding:

Confirmed use of medications

Finding:

Confirms medications (no new medications reported)

(Found)

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

Example Question:

Are you taking any new medications?

Finding:

Reports increased acetaminophen use

(Found)

Pro Tip: The amount of pain medication a patient is taking is an important consideration in understanding their level of pain. For a patient who takes pain medication but still experiences pain, it can indicate higher pain severity than she is reporting.

Example Question:

Have you been taking acetaminophen?

Finding:

Followed up on acetaminophen use

Finding:

Unsure of dosage

(Available)

Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina how much acetaminophen she takes will illustrate how effectively OTC medication works for her injury.

Example Question:

What dose of acetaminophen do you take?

Finding:

Takes 2 acetaminophen at a time

(Available)

Pro Tip: Asking how many pills a patient takes at once time can help you make sure a patient is not taking an unsafe dose.

Example Question:

How much acetaminophen do you take at a time?

Finding:

Takes acetaminophen once a day

(Available)

Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina how often she takes acetaminophen will illustrate how effectively OTC medication works for her injury.

Example Question:

How often do you take acetaminophen?

Finding:

Reports minor relief from acetaminophen

(Found)

Pro Tip: Asking Tina if the acetaminophen helps will allow you to assess the severity of her headaches and whether her current treatment plan is effective.

Example Question:

Does acetaminophen help?

Finding:

Confirmed allergies

Finding:

Confirms allergies (no new allergies reported)

(Found)

Pro Tip: Asking Tina if she has any new allergies will allow you to understand how, beyond the chief complaint, Tina’s health has been.

Example Question:

Do you have any new allergies?

Finding:

Asked about relevant neurological history

Finding:

Reports past frequent headaches

(Available)

Pro Tip: Assessing which of Tina’s pain (if any) is “normal” versus caused by the accident will allow you to understand the scope of her injuries.

Example Question:

Do you usually get headaches?

Finding:

Denies history of migraine

(Found)

Pro Tip: Assessing which of Tina’s pain (if any) is “normal” versus caused by the accident will allow you to understand the scope of her injuries.

Example Question:

Do you ever get migraines?

Finding:

Denies head trauma

(Available)

Pro Tip: After Tina’s car accident, it is important to establish whether head trauma she might be experiencing predates the accident or, rather, is a result of the crash.

Example Question:

Have you ever had any head trauma?

Finding:

Denies history of seizures

(Available)

Pro Tip: A car accident can result in a traumatic brain injury (TBI). Asking Tina if she’s had seizures might indicate whether or not she is experiencing symptoms of a traumatic brain injury.

Example Question:

Have you had any seizures?

Social History

Finding:

Asked about sleep

Finding:

Denies changes in sleep

(Available)

Pro Tip: A car accident can result in a traumatic brain injury (TBI). Asking Tina if her sleep habits have changed lately might indicate whether she is experiencing symptoms of a traumatic brain injury.

Example Question:

Have your sleep habits changed?

Finding:

Denies increased sleepiness or yawning

(Available)

Pro Tip: A car accident can result in a traumatic brain injury (TBI). Asking Tina if she’s felt more sleepy lately might indicate whether she is experiencing symptoms of a traumatic brain injury.

Example Question:

Have you felt more sleepy lately?

Social Determinants of Health

Finding:

Asked about impact of accident on finances

Finding:

Reports having car insurance

(Available)

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

Example Question:

Do you have car insurance?

Finding:

Denies accident places extra burden on her financially

(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:

Is the car accident going to be a financial burden?

Review of Systems

Finding:

Asked about general symptoms

Finding:

Denies fever

(Found)

Pro Tip: Following a head injury, asking Tina whether she’s had a fever might indicate if she’s suffered any additional complications to her neck trauma.

Example Question:

Have you had a fever?

Finding:

Denies chills

(Available)

Pro Tip: Chills after a car accident might indicate shock. Asking Tina if she’s had any chills will reveal whether or not she’s had shock following her accident.

Example Question:

Have you had any chills?

Finding:

Denies fatigue or changes in energy level

(Available)

Pro Tip: A car accident can result in a traumatic brain injury (TBI). Asking Tina if she’s felt more fatigued lately might indicate whether she is experiencing symptoms of a traumatic brain injury.

Example Question:

Have you felt fatigued?

Finding:

Denies nausea or vomiting

(Available)

Pro Tip: One symptom of a concussion is nausea. Asking Tina whether she’s felt nausea might reveal that she sustained a concussion in her car accident.

Example Question:

Have you had nausea?

Finding:

Denies night sweats

(Available)

Pro Tip: One symptom of a concussion is nausea. Asking Tina whether she’s been vomiting might reveal that she sustained a concussion in her car accident.

Example Question:

Have you had night sweats?

Finding:

Asked about review of systems for neurological

Finding:

Denies hemiparesis

(Available)

Pro Tip: A car accident can result in muscle damage and feeling weak on one side of the body. Asking Tina whether she feels weak on one side of her body can indicate whether she is suffering from muscle damage.

Example Question:

Has one side of your body felt weaker than the other?

Finding:

Denies gait disturbance

(Available)

Pro Tip: A car accident can result in muscle damage or nerve damage. Asking Tina whether her gait has changed might indicate a muscle or tissue injury that is impacting the way she walks.

Example Question:

Have you had any changes in your gait?

Finding:

Denies body weakness

(Available)

Pro Tip: A car accident can result in muscle damage and feeling weakness. Asking Tina whether she feels weak can indicate whether or not she is suffering from muscle damage.

Example Question:

Have you felt weak?

Finding:

Denies seeing auras or halos

(Available)

Pro Tip: After Tina’s car accident, it is important to establish whether neurological problems she might be experiencing predate the accident or, rather, are a result of the crash. Asking Tina if she’s been seeing auras will indicate whether she’s experiencing a neurological disturbance.

Example Question:

Have you experienced any auras?

Finding:

Denies dizziness, light-headedness, syncope, or disequilibrium

(Available)

Pro Tip: A car accident can result in a traumatic brain injury (TBI). Asking Tina if she’s felt dizzy might indicate whether she is experiencing symptoms of a traumatic brain injury.

Example Question:

Have you felt dizzy?

Finding:

Denies loss of coordination

(Available)

Pro Tip: People with traumatic brain injuries commonly report loss of coordination. Asking Tina whether she’s lost coordination can indicate that she suffered a traumatic brain injury during her accident.

Example Question:

Have you had any loss of coordination?

Finding:

Denies scotoma

(Available)

Pro Tip: People with traumatic brain injuries commonly report scotoma. Asking Tina whether she’s noticed any scotoma can indicate that she suffered a traumatic brain injury during her accident.

Example Question:

Have you noticed any scotoma?

Finding:

Denies numbness or tingling

(Available)

Pro Tip: Tingling sensations after a car accident can suggest a herniated disc. Asking Tina whether she’s experiencing tingling sensations might indicate additional musculoskeletal damage caused by the accident.

Example Question:

Have you had any tingling sensations?

Finding:

Denies facial flushing

(Available)

Pro Tip: A prolonged flush face can indicate cerebral compression. Asking Tina whether her face has been flushed will indicate if she is suffering from head trauma.

Example Question:

Has your face been flushed?

Finding:

Asked about review of systems for psych and behavioral history

Finding:

Denies depression

(Found)

Pro Tip: After an accident, it is not uncommon to feel anxious or depressed. Asking Tina whether she’s felt depressed can indicate long-term concerns following her accident.

Example Question:

Have you felt depressed?

Finding:

Denies increased irritability

(Available)

Pro Tip: One symptom of a concussion is irritability. Asking Tina whether she’s been irritable might reveal that she sustained a concussion in her car accident.

Example Question:

Have you felt more irritable?

Finding:

Denies problems with concentration or memory

(Available)

Pro Tip: One symptom of a concussion is problems concentrating. Asking Tina whether she’s been experiencing problems concentrating might reveal that she sustained a concussion in her car accident.

Example Question:

Have you had any problems concentrating?

Finding:

Denies confusion

(Available)

Pro Tip: One symptom of a concussion is confusion. Asking Tina whether she’s felt confusion might reveal that she sustained a concussion in her car accident.

Example Question:

Have you felt confused?

Finding:

Asked about review of systems for eyes and vision

Finding:

Denies changes in vision since accident

(Found)

Pro Tip: Eye and vision problems are fairly common after a brain injury. Asking Tina whether her vision changed since her accident might indicate that she sustained a head injury.

Example Question:

Has your vision changed since the accident?

Finding:

Reports occasional blurry vision (pre-dating accident)

(Found)

Pro Tip:

Example Question:

Have you ever had blurry vision?

Finding:

Denies unilateral vision disturbance

(Available)

Pro Tip: Eye and vision problems are fairly common after a brain injury. Asking Tina whether she’s had vision problems in just one eye since her accident might indicate that she sustained a head injury.

Example Question:

Have you had any vision problems in just one eye?

Finding:

Denies sensitivity to light

(Available)

Pro Tip: Eye and vision problems are fairly common after a brain injury. Asking Tina whether she is sensitive to light since her accident might indicate that she sustained a head injury.

Example Question:

Are you sensitive to light since the accident?

Finding:

Asked about review of systems for ears, nose, and throat

Finding:

Denies nasal congestion or rhinorrhea

(Found)

Pro Tip: Whiplash from Tina’s car accident might result in congestion and sinus problems. Asking Tina if she’s been congested can indicate that she suffered from whiplash during the accident.

Example Question:

Have you had any congestion?

Finding:

Denies tinnitus

(Available)

Pro Tip: Tinnitus, or hearing ringing, can result from the loudness of a car accident. Asking Tina whether she’s hearing ringing can indicate whether she is suffering from Tinnitus.

Example Question:

Have you had ringing in your ears?

Finding:

Denies changes in hearing

(Available)

Pro Tip: Sudden Sensorineural Hearing Losses can be associated with head trauma caused by car accidents. Asking Tina if she’s experiencing hearing loss can indicate possible head trauma.

Example Question:

Have you had any hearing loss?

Finding:

Denies difficulty swallowing

(Available)

Pro Tip: Whiplash from Tina’s car accident might result in damage to the soft tissue of her neck. Asking Tina if she is having trouble swallowing might suggest an injury that she sustained in the crash.

Example Question:

Have you had any difficulty swallowing?

Family History

Finding:

Asked about relevant family history

Finding:

Denies family history of migraine

(Found)

Pro Tip: Some causes of migraines can be inherited, and so it’s important to understand your patient’s risk level.

Example Question:

Is there a history of migraines in your family?

Finding:

Denies family history of epilepsy or seizures

(Available)

Pro Tip: Epilepsy or other forms of seizures can be inherited, and so it’s important to understand your patient’s risk level.

Example Question:

Do you have a family history of epilepsy?

Finding:

Denies family history of Alzheimer’s disease

(Available)

Pro Tip: Conditions like Alzheimer’s disease can be inherited, and so it’s important to understand your patient’s risk level.

Example Question:

Do you have a family history of Alzheimer’s disease?

Finding:

Denies family history of Parkinson’s disease

Objective Data Collection: 36.75 of 37 (99.32%)

Correct
Partially correct

Incorrect
Missed

Confirmed orientation

To Person (1/3 point)

Oriented to person

To Place (1/3 point)

Oriented to place

To Time (1/3 point)

Oriented to time

Evaluated abstract thinking

Abstractness (1/2 point)

Abstract

Relevance (1/2 point)

Relevant

Evaluated attention span

Serial 7s Test (1/1 point)

Accurate

Evaluated comprehension

Observations (1/1 point)

Able to follow instructions

Evaluated general knowledge

Accuracy (1/1 point)

Accurate

Evaluated judgment

Observations (1/1 point)

Intact

Evaluated memory

Remote Memory (1/3 point)

Intact

Immediate Memory (1/3 point)

Intact

New Learning Ability (1/3 point)

Accurate

Observed vocabulary

Complexity (1/1 point)

Expected complex for patient’s age, education level, and general ability

Observed articulation

Observations (1/1 point)

No observed problems with pronunciation or expression

Tested olfactory nerve

Sense Of Smell (1/2 point)

Able to discriminate

Symmetric (1/2 point)

Symmetric bilaterally

Tested visual acuity (optic nerve)

Examined retina with ophthalmoscope (optic nerve)

Right (1/2 point)

20/40

Left (1/2 point)

20/20

0.75 of 1 point

Right: Fundus (1/4 point)

Cotton wool bodies

Right: Disc Margin (1/4 point)

Sharp

Left: Fundus (1/4 point)

No visible abnormal findings

Left: Disc Margin (1/4 point)

Sharp

Inspected pupils (optic and oculomotor nerves)

Tested extraocular eye movements (extraocular movements: oculomotor, trochlear, abducens nerves)

Observations With Penlight (1/1 point)

No visible abnormal findings (PERRL)

Tested facial sensation (trigeminal nerve)

Cardinal Fields (1/2 point)

No visible abnormal findings

Convergence (1/2 point)

No visible abnormal findings

Inspected head and face (facial nerve)

Observations (1/1 point)

Intact

Performed Weber test (auditory nerve)

Skull Symmetry (1/2 point)

Symmetric

Facial Feature Symmetry (1/2 point)

Symmetric

Performed Rinne test (auditory nerve)

Results (1/1 point)

Normal

Tested gag reflex (glossopharyngeal, vagus nerves)

Right (1/2 point)

Normal

Left (1/2 point)

Normal

Tested shoulder shrugging (accessory nerve)

Observations (1/1 point)

Intact

Tested neck strength (accessory nerve)

Observations (1/2 point)

Symmetric

Strength (1/2 point)

0 – No evidence of movement
1 – Trace of movement
2 – Full range of motion with passive movement only
3 – Full range of motion against gravity, with no resistance
4 – Full but weak range of motion against gravity, with some resistance
5 – Full range of motion against gravity, with resistance

Inspected tongue (hypoglossal nerve)

Strength (1/1 point)

5 – Full range of motion against gravity, with resistance

Tested deep tendon reflexes in triceps

Symmetry (1/2 point)

Symmetric

Observations (1/2 point)

No visible abnormal findings

Tested deep tendon reflexes in biceps

Right (1/2 point)

2 – Expected (active)

Left (1/2 point)

2 – Expected (active)

Tested deep tendon reflexes in brachioradialis

Right (1/2 point)

2 – Expected (active)

Left (1/2 point)

2 – Expected (active)

Tested deep tendon reflexes in patellar tendon

Right (1/2 point)

2 – Expected (active)

Left (1/2 point)

2 – Expected (active)

Tested deep tendon reflexes in Achilles tendon

Right (1/2 point)

2 – Expected (active)

Left (1/2 point)

2 – Expected (active)

Tested point-to-point movements: Finger to nose

Right (1/2 point)

2 – Expected (active)

Left (1/2 point)

2 – Expected (active)

Tested point-to-point movements: Heel to shin

Right (1/2 point)

Smooth and accurate

Left (1/2 point)

Smooth and accurate

Tested coordination with rapid alternating hand movements

Right (1/2 point)

Smooth and accurate

Left (1/2 point)

Smooth and accurate

Observations (1/1 point)

Able to perform without difficulty

Observed gait

Balance (1/2 point)

Steady

Gait (1/2 point)

Continuous, symmetric steps

Tested graphesthesia

Right (1/2 point)

Able to identify

Left (1/2 point)

Able to identify

Tested sensation in arms

Right: Dull Touch (1/6 point)

Expected sensation in proximal and distal

Left: Dull Touch (1/6 point)

Expected sensation in proximal and distal

Right: Soft Touch (1/6 point)

Expected sensation in proximal and distal

Left: Soft Touch (1/6 point)

Expected sensation in proximal and distal
Right: Sharp Touch (1/6 point)

Expected sensation in proximal and distal

Left: Sharp Touch (1/6 point)

Expected sensation in proximal and distal

Tested sensation in legs

Right: Dull Touch (1/6 point)

Expected sensation in proximal and distal

Left: Dull Touch (1/6 point)

Expected sensation in proximal and distal

Right: Soft Touch (1/6 point)

Expected sensation in proximal and distal

Left: Soft Touch (1/6 point)

Expected sensation in proximal and distal

Right: Sharp Touch (1/6 point)

Expected sensation in proximal and distal

Left: Sharp Touch (1/6 point)

Expected sensation in proximal and distal

Tested sensation in feet

Right (1/2 point)

Decreased sensation

Left (1/2 point)

Decreased sensation

Tested position sense

Fingers (1/2 point)

Intact

Toes (1/2 point)

Intact

Tested stereognosis

Right (1/2 point)

Able to identify

Left (1/2 point)

Able to identify

Education & Empathy : 2 of 4 (50.0%)

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

	Description: Tina describes the symptoms that have been bothering her.
	What brings you here today?	Question 05:56 AM EDT
	Well, I got into a little fender bender a week ago and I’ve been getting these headaches ever since. And my neck is sore too.
	I am sorry for that	Empathize 05:56 AM EDT
	Thanks for understanding.
	Model Statement: “I’m sorry to hear that you were in a car accident, and that you’re experiencing pain and headaches. Because car accidents can cause injury to your head and neck, it’s important that I learn about how the injury happened and your symptoms so that we can determine if you need treatment.”

2 Cause of Injury

	Description: Tina describes her recent “fender bender.”
	What brings you here today?	Question 05:56 AM EDT
	Well, I got into a little fender bender a week ago and I’ve been getting these headaches ever since. And my neck is sore too.
	I am sorry for that	Empathize 05:56 AM EDT
	Thanks for understanding.
	Model Statement: “I’m sorry. Car accidents can be stressful and scary, even if they are minor. I’m glad you are safe.”

	Description: Tina describes her medication regimen, which includes Tylenol for her symptoms.
	What relieves the pain?	Question 05:59 AM EDT
	Acetaminophen helps a little. [AUDIO COMING SOON]
	Have you used any medication? (Clarified to: Have you been taking any medication?)	Question 05:59 AM EDT
	Just some acetaminophen for my headaches and my neck. And I use my daily inhaler, too. [AUDIO COMING SOON] (Clarified to: if I have been taking any medication)
	Do you have any allergies?	Question 06:00 AM EDT
	Yeah, I’m allergic to cats.
	Do you have a history of headaches?	Question 06:00 AM EDT
	Model Statement: “Thank you for letting me know about the medications you usually take. I will ask you a few questions about how you’re using each medication.”

4 Vision

	Description: Tina describes her eyecare and vision.
	How is your vision?	Question 06:03 AM EDT
	Well — first off, my vision’s been fine since the car accident. But in general, my vision isn’t that great. Sometimes it gets blurry when I read for a long time.
	Do you have nasal congestion?	Question 06:04 AM EDT
	No, I haven’t been congested.
	Do you have a family history of migraine?	Question 06:04 AM EDT
	I don’t think so.
	My name is Tina Jones, and I was born on February 17th.
	I’m at the doctor’s office. . . it’s Shadow Health General Clinic.
	Um, today’s date is . . . [Ms. Jones reports correct date and year].
	How are they alike? Um…. they’re both kinds of fruit.
	Uh…. they’re both bodies of water.
	They…… they’re both musical instruments.
	Okay. . . 100, 93. . . 86, 79, 72. . . 65. . . 58, 51. . . 44. . . 37, 30, 23, 16. . . 9, and 2.
	That’s George Washington.
	Well,.. .[Ms. Jones reports the correct last four presidents.]
	Let’s see. . . New York City. . . and Chicago. . . Detroit. . . Los Angeles. . . and Houston. That’s five.
	What would I do…. Hmm.. Well, I’d try to figure out who dropped the envelope, but if not… Well, I’d probably just drop it in the first mailbox I saw, if there was one nearby.
	Burger, tulip, nose, and tea.
	E D E O X F
	P E C F D
	P E C F D
	E D F C Z P
	F E L O P Z D
	D E F P O T E C
	D E F P O T E C
	I can’t read that line. It’s too little.
	Ok.
	Ok.
	Dull.
	Dull.
	Dull.
	Dull.
	Soft.
	Soft.
	Soft.
	Soft.
	Sharp.
	Sharp.
	Sharp.
	Sharp.
	Ok.
	Same in both ears.
	Ok, I will.
	Now.
	Now.
	Now.
	Now.
	Ok, I will.
	Now.
	Now.
	Now.
	Now.
	I can do that.
	Sure.
	Ok.
	Ok, like this?
	Ok.
	That’s an “A.”
	A figure “8.”
	Ok.
	Dull.
	Dull.
	Dull.
	Dull.
	Soft.
	Soft.
	Soft.
	Soft.
	Sharp.
	Sharp.
	Sharp.
	Sharp.
	Ok.
	Dull.
	Dull.
	Dull.
	Dull.
	Soft.
	Soft.
	Soft.
	Soft.
	Sharp.
	Sharp.
	Sharp.
	Sharp.
	Ok, I will.
	Yes.
	Yes.
	Yes.
	Ok, I will.
	Down.
	Up.
	…I think that was up.
	Down.
	Ok, sure.
	…Some kind of coin.
	This is… some wire thing… paperclip?
	Um… that feels like a key.
	…Some kind of coin.
	The paperclip again.
	Um… that feels like a key.
	Model Statement: “Blurry vision can be a sign of eye strain, or changes to the retina caused by conditions like diabetes. I’d like to examine your eyes to determine what might be causing your vision changes.”

Documentation / Electronic Health Record

Document: Provider Notes

Document: Provider Notes

Student Documentation	Model Documentation
Subjective Ms. Jones presents to the clinic complaining of neck stiffness that started 2 days ago after a car accident on the parking lot. She gets headaches daily since the accident. She states she has soreness in the neck that radiaes to the head. The neck hurts on both sides. She rates the pain a 3 on scale of 0-10. No allergies No fever, chills, night sweats, nausea and vomiting No fatigue Fells dizzy, numbness or tingling No vision changes	HPI: Ms. Jones presents to the clinic complaining of a headache and neck stiffness that started 2 days after she was in a minor fender bender. One week ago she states that she was a restrained passenger in an accident in a parking lot and estimates the speed to be approximately 5-10 mph. She and the driver did not seek emergent care and felt fine after the accident. Two days later, however, she developed a bilateral temporal dull ache accompanied by neck ache. She states that she feels as though her neck may be slightly swollen as well. She did not lose consciousness in the accident and denies changes in level of consciousness since that time. She states that she gets a headache every day that lasts approximately 1-2 hours. She occasionally takes 650 mg of over the counter Tylenol with relief of the pain. She denies known associated symptoms. Review of Systems: General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats. • Head: Denies history of trauma before this incident. Denies current headache. • Eyes: She does not wear corrective lenses, but notes that her vision has been worsening over the past few years, but no acute changes. She complains of blurry vision after reading for extended periods. Denies increased tearing or itching. • Ears: Denies hearing loss, tinnitus, vertigo, discharge, or earache. • Nose/Sinuses: Denies rhinorrhea. Denies stuffiness, sneezing, itching, previous allergy, epistaxis, or sinus pressure. • Musculoskeletal: Denies muscle weakness, pain, difficulties with range of motion, joint instability, or swelling. • Neurologic: Denies loss of sensation, numbness, tingling, tremors, weakness, paralysis, fainting, blackouts, or seizures. Denies bowel or bladder dysfunction. Denies changes in concentration, sleep, coordination, appetite.
Objective Ms. Jones is a pleasant woman in no acute distress. She is alert and oriented. Eyes: Bilateral Neurologic: Sense of smell intact, right eye vision 20/40	General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress, but appears uncomfortable while sitting in exam chair. She is alert and oriented. She maintains eye contact throughout interview and examination. • Head: Head is normocephalic and atraumatic • Eyes: Bilateral eyes with equal hair distribution. • Neurologic: Sense of smell intact and symmetric. Left eye vision: 20/20. Right eye vision: 20/40. Left fundoscopic exam reveals sharp disc margins, no hemorrhages. Right fundoscopic exam reveals mild retinopathic changes. Pupils equal, round, and reactive to light bilaterally. Extraocular movements intact bilaterally. Normal convergence. Facial sensation intact; facial features and symmetric. Rinne and Weber tests normal bilaterally. Gag reflex intact. Ability to shrug shoulders symmetric; 5 strength against resistance. Neck with full range of motion against resistance; 5 strength against resistance. Tongue symmetric with no abnormal findings. Bilateral upper and lower extremity DTRs equal and 2+ bilaterally. Point-to-point movements smooth and accurate for finger-to-nose and heel-to-shin. Rapid alternating movements of the upper extremities intact bilaterally. Gait steady with continuous, symmetric steps. Sensation intact to bilateral upper and lower extremities; sense of extremity position intact. Stereognosis and graphesthesia intact bilaterally.
Assessment Acute post-traumatic headache following an accident where the patient was a passenger	Acute post-traumatic headache following low-speed MVA where Ms. Jones was a restrained passenger
Plan Continue monitoring the headaches Ibuprofen 800 mg every 8hrs for the next 5 days Educate on how to relieve the neck pain through nexk stretches Educate on when to seek emergent care Observe changes in vision, nausea or vomiting	Encourage Ms. Jones to continue to monitor symptoms and report any increase in frequency or severity of her headaches. • Initiate treatment with ibuprofen 800 mg by mouth every 8 hours as needed with food for the next 5 days. • Ms. Jones can also use adjunct therapy of topical heat or ice per comfort TID-QID. • Educate on mild stretches for upper back and neck. • Educate on when to seek emergent care including the worst headache of her life, acute changes in vision, hearing, or consciousness, episodes of nausea or vomiting associated with headache, or numbness, tingling, or paralysis of new onset. • Ask Ms. Jones to call the office in two days to discuss symptoms. If no decrease in symptoms, order a computerized tomography scan or magnetic resonance imaging.

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Tina Jones Shadow Health Gastrointestinal Results

May 5, 2025/in BLOGS /by admin

Tina Jones Shadow Health Gastrointestinal Results

Experience Overview

Patient: Tina Jones

Digital Clinical Experience Score

98.1%

This score measures your performance on the Student Performance Index in relation to other students in comparable academic programs. Your instructor has chosen to scale your Student Performance Index score so that the average score on the index is a 84.0%. This score may not be your final grade if your instructor chooses to include additional components, such as documentation or time spent.

Student Performance Index

52

out of

53

Proficiency Level:

Proficient

Students rated as “proficient” demonstrate an entry-level expertise in advanced practice competencies and clinical reasoning skills. In comparable programs, the top 25% of students perform at the level of a proficient practitioner.

Subjective Data Collection

31

out of

31

Objective Data Collection

18

out of

18

Education and Empathy

3

out of

4

Time

70 minutes total spent in assignment

Interaction with patient

70 minutes

Transcript

Started: Apr 15, 2025 | Total Time: 70 min

All Lines (113)Interview Questions (46)Statements (3)Exam Actions (64)

	Hi, my name is Mileidy. I will be your nurse today	Greet 04/15/25 4:59 AM EDT
	Hey.
	What brings you here today?	Question 04/15/25 5:00 AM EDT
	I’ve been having this stomach pain for awhile. It keeps coming back, and it really is starting to bother me.
	I am sorry for that	Empathize 04/15/25 5:00 AM EDT
	I appreciate you telling me that.
	How often do you have bowel movements?	Question 04/15/25 5:03 AM EDT
	Usually every other day.
	When did the stomach ache start? (Clarified to When did the abdominal discomfort begin?.)	Question 04/15/25 5:03 AM EDT
	Probably at least a month ago. Maybe longer. It started out really minor so it took me awhile to realize it was getting bad. (Clarified to when the abdominal discomfort began.)
	Do you experience constipation?	Question 04/15/25 5:04 AM EDT
	No.
	Have you had diarrhea recently?	Question 04/15/25 5:04 AM EDT
	No.
	What color is your stool?	Question 04/15/25 5:05 AM EDT
	Uh… usually light or dark brown, I guess?
	How frequent is the pain?	Question 04/15/25 5:07 AM EDT
	It started really gradually, so I didn’t notice for awhile that it was happening more and more often. Now it’s like, every day.
	WHat is the duration of the pain?	Question 04/15/25 5:08 AM EDT
	For a few hours after I eat.
	How severe is the pain on a scale of 0-10? (Clarified to Can you rate your current pain level on a scale of 0 to 10?.)	Question 04/15/25 5:08 AM EDT
	Right now, it’s like a 1 or 2. But after I eat, it’s like a. . . 5? (Clarified to how I would rate my pain on a scale.)
	How can you describe the pain?	Question 04/15/25 5:08 AM EDT
	Um, it feels like heartburn. But sometimes, if it’s bad, it’s sharper than that.
	Where is the location of the pain?	Question 04/15/25 5:09 AM EDT
	It’s like… my upper stomach. Like right below my breastbone, in the middle.
	What relieves the pain?	Question 04/15/25 5:09 AM EDT
	I feel the best in-between meals. And sitting up on the couch seems to help. And sometimes I take an antacid.
	How is your appetite?	Question 04/15/25 5:10 AM EDT
	I haven’t been wanting to eat lately.
	Do you have burping?	Question 04/15/25 5:10 AM EDT
	Yeah, that’s been happening after I eat.
	Have you noticed changes in weight?	Question 04/15/25 5:11 AM EDT
	No, I don’t think so.
	Do you use any medication?	Question 04/15/25 5:11 AM EDT
	I have a daily inhaler. And I’ve been taking antacid chews sometimes for my stomach, too.
	How often do you take antacids?	Question 04/15/25 5:11 AM EDT
	I take them every few days. Just if the heartburn gets bad.
	Antacids actually works best when you take them before a meal	Educate 04/15/25 5:14 AM EDT
	That makes sense.
	What are the common foods that you take? (No matching questions found.)	Question 04/15/25 5:15 AM EDT
	Which foods do you take?	Question 04/15/25 5:15 AM EDT
	Oh, I know vegetables are healthy. Anything with vegetables is going to be healthier. I mean, an extra-healthy meal at our house would be baked chicken and some green beans. I make that like once a week.
	What is you typical diet? (Clarified to What do you eat in an average day?.)	Question 04/15/25 5:15 AM EDT
	Let’s see. . . a muffin or pumpkin bread for breakfast, a sandwich for lunch, and some kind of meat with a veggie for dinner. (Clarified to what I typically eat in a day.)
	Your meal has a high level of carbohydrate which is not recommended for diabetes patients.	Educate 04/15/25 5:16 AM EDT
	Sure, I think I understand what you mean.
	Do you have any allergy?	Question 04/15/25 5:18 AM EDT
	Yeah, I’m allergic to cats.
	Do you have a history of GERD?	Question 04/15/25 5:19 AM EDT
	I’m not really sure what GERD is. I’ve never been diagnosed with it, or anything. [AUDIO COMING SOON]
	Does the stomach pain radiate?	Question 04/15/25 5:22 AM EDT
	No, it’s right in the center of my stomach, like between my belly button and my ribs.
	Does it hurt after you eat?	Question 04/15/25 5:22 AM EDT
	Yes. Every time I eat it hurts. I’ve been eating less because I don’t like being in pain.
	Have you ever been hospitalized?	Question 04/15/25 5:25 AM EDT
	I went a bunch of times when I was little, for asthma attacks, then a few months ago–I guess it’s been about six months, now–I went in for my foot.
	Have you had any surgery?	Question 04/15/25 5:26 AM EDT
	Nope. No surgeries. . . I’ve been lucky.
	Do you drink alcohol?	Question 04/15/25 5:28 AM EDT
	Not lately, but I do every so often.
	How many times a week do you drink alcohol?	Question 04/15/25 5:28 AM EDT
	I don’t drink every week — I only drink a few times a month.
	How many drinks do you have at a time?	Question 04/15/25 5:29 AM EDT
	Never any more than 2 or 3.
	Have you traveled recently?	Question 04/15/25 5:29 AM EDT
	No. I’ve been here in Shadowville working my butt off!
	Do you smoke cigarettes?	Question 04/15/25 5:30 AM EDT
	No, I’ve never smoked a cigarette in my life.
	Does your family have a history of bowel movements? (No matching questions found.)	Question 04/15/25 5:32 AM EDT
	Does your family have a history of bowel disease? (Clarified to Do you have a family history of irritable bowel syndrome?.)	Question 04/15/25 5:32 AM EDT
	No, I haven’t heard anything about that. (Clarified to if I have a family history of irritable bowel syndrome.)
	Do you have liver problem? (Clarified to Have you ever had problems with your liver?.)	Question 04/15/25 5:33 AM EDT
	No, I’ve never had any problems with my liver. (Clarified to if I have had liver problems.)
	Do you have kidney problem?	Question 04/15/25 5:34 AM EDT
	No. As far as I know, I’ve never had anything wrong with my kidneys.
	Do you have a sore throat?	Question 04/15/25 5:35 AM EDT
	No, my throat doesn’t hurt.
	Do you have any mental issue?	Question 04/15/25 5:36 AM EDT
	No, definitely not.
	Do you have fever or fatigue?	Question 04/15/25 5:36 AM EDT
	No. No fever.
	Do you have access to fresh foods?	Question 04/15/25 5:37 AM EDT
	There’s a grocery store pretty near Mom’s house so that’s where I usually go. It has pretty good produce. [AUDIO COMING SOON]
	Tested skin turgor on forearm	Exam Action 04/15/25 6:40 AM EDT
	Inspected right side of abdomen	Exam Action 04/15/25 6:40 AM EDT
	Inspected front of abdomen	Exam Action 04/15/25 6:41 AM EDT
	Inspected left side of abdomen	Exam Action 04/15/25 6:41 AM EDT
	Inspected front of abdomen	Exam Action 04/15/25 6:41 AM EDT
	Inspected right side of abdomen	Exam Action 04/15/25 6:41 AM EDT
	Inspected front of abdomen	Exam Action 04/15/25 6:41 AM EDT
	Auscultated breath sounds in anterior right upper lobe	Exam Action 04/15/25 6:41 AM EDT
	Auscultated breath sounds in anterior left upper lobe	Exam Action 04/15/25 6:41 AM EDT
	Auscultated breath sounds in anterior left mid-chest (upper lobe)	Exam Action 04/15/25 6:41 AM EDT
	Auscultated breath sounds in anterior right middle lobe	Exam Action 04/15/25 6:41 AM EDT
	Auscultated breath sounds in anterior right lower lobe	Exam Action 04/15/25 6:41 AM EDT
	Auscultated breath sounds in anterior left lower lobe	Exam Action 04/15/25 6:41 AM EDT
	Auscultated breath sounds in posterior left upper lobe	Exam Action 04/15/25 6:41 AM EDT
	Auscultated breath sounds in posterior right upper lobe	Exam Action 04/15/25 6:41 AM EDT
	Auscultated breath sounds in posterior left mid-back (lower lobe)	Exam Action 04/15/25 6:41 AM EDT
	Auscultated breath sounds in posterior right mid-back (lower lobe)	Exam Action 04/15/25 6:41 AM EDT
	Auscultated breath sounds in posterior left lower lobe	Exam Action 04/15/25 6:41 AM EDT
	Auscultated breath sounds in posterior right lower lobe	Exam Action 04/15/25 6:41 AM EDT
	Auscultated breath sounds in posterior left lower lobe on side	Exam Action 04/15/25 6:41 AM EDT
	Auscultated breath sounds in posterior left lower lobe near spine	Exam Action 04/15/25 6:41 AM EDT
	Auscultated breath sounds in posterior right lower lobe near spine	Exam Action 04/15/25 6:41 AM EDT
	Auscultated breath sounds in posterior right lower lobe on side	Exam Action 04/15/25 6:41 AM EDT
	Auscultated aortic area with the bell	Exam Action 04/15/25 6:42 AM EDT
	Auscultated pulmonic area with the bell	Exam Action 04/15/25 6:42 AM EDT
	Auscultated pulmonic area with the diaphragm	Exam Action 04/15/25 6:42 AM EDT
	Auscultated pulmonic area with the bell	Exam Action 04/15/25 6:42 AM EDT
	Auscultated Erb’s point with the bell	Exam Action 04/15/25 6:42 AM EDT
	Auscultated Erb’s point with the diaphragm	Exam Action 04/15/25 6:42 AM EDT
	Auscultated Erb’s point with the bell	Exam Action 04/15/25 6:42 AM EDT
	Auscultated tricuspid area with the bell	Exam Action 04/15/25 6:42 AM EDT
	Auscultated mitral area with the bell	Exam Action 04/15/25 6:42 AM EDT
	Auscultated right upper quadrant	Exam Action 04/15/25 6:42 AM EDT
	Auscultated left upper quadrant	Exam Action 04/15/25 6:42 AM EDT
	Auscultated right lower quadrant	Exam Action 04/15/25 6:42 AM EDT
	Auscultated left lower quadrant	Exam Action 04/15/25 6:43 AM EDT
	Auscultated aorta in abdomen	Exam Action 04/15/25 6:43 AM EDT
	Auscultated right renal artery	Exam Action 04/15/25 6:43 AM EDT
	Auscultated left renal artery	Exam Action 04/15/25 6:43 AM EDT
	Auscultated right iliac artery	Exam Action 04/15/25 6:43 AM EDT
	Auscultated left iliac artery	Exam Action 04/15/25 6:43 AM EDT
	Auscultated right femoral artery	Exam Action 04/15/25 6:43 AM EDT
	Auscultated left femoral artery	Exam Action 04/15/25 6:43 AM EDT
	Percussed left upper quadrant	Exam Action 04/15/25 6:44 AM EDT
	Percussed left lower quadrant	Exam Action 04/15/25 6:44 AM EDT
	Percussed right upper quadrant	Exam Action 04/15/25 6:44 AM EDT
	Percussed right lower quadrant	Exam Action 04/15/25 6:44 AM EDT
	Percussed left flank for CVA tenderness	Exam Action 04/15/25 6:44 AM EDT
	Percussed right flank for CVA tenderness	Exam Action 04/15/25 6:44 AM EDT
	Percussed spleen	Exam Action 04/15/25 6:44 AM EDT
	Percussed for liver span: 7 cm in the mid-clavicular line	Exam Action 04/15/25 6:45 AM EDT
	Palpated right upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension	Exam Action 04/15/25 6:45 AM EDT
	Palpated left upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension	Exam Action 04/15/25 6:45 AM EDT
	Palpated right lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension	Exam Action 04/15/25 6:45 AM EDT
	Palpated left upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension	Exam Action 04/15/25 6:45 AM EDT
	Palpated left lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension	Exam Action 04/15/25 6:45 AM EDT
	Palpated right upper quadrant with deep pressure: No masses	Exam Action 04/15/25 6:45 AM EDT
	Palpated left upper quadrant with deep pressure: No masses	Exam Action 04/15/25 6:45 AM EDT
	Palpated right lower quadrant: with deep pressure: No masses	Exam Action 04/15/25 6:45 AM EDT
	Palpated left lower quadrant with deep pressure: No masses	Exam Action 04/15/25 6:46 AM EDT
	Palpated liver: Palpable 1 cm below right costal margin	Exam Action 04/15/25 6:46 AM EDT
	Palpated for spleen: Not palpable	Exam Action 04/15/25 6:46 AM EDT
	Palpated for right kidney: Not palpable	Exam Action 04/15/25 6:46 AM EDT
	Palpated for left kidney: Not palpable	Exam Action 04/15/25 6:46 AM EDT
	Do you have normal bowel movements?	Question 04/15/25 6:54 AM EDT
	Um, I don’t go every day… I probably go every two days. That’s normal for me.
	How is your urination?	Question 04/15/25 6:56 AM EDT
	I just have to pee a lot, but it’s not really a problem.
	How is your sexual activity?	Question 04/15/25 7:00 AM EDT
	Uh, I wouldn’t say I have a “sex life” right now.
	How is your menstruation?	Question 04/15/25 7:02 AM EDT
	My periods are always the same–They’re bad. Cramps. Lots of bleeding for more than week.
	Do you have normal sexual activity? (Clarified to Are you sexually active?.)	Question 04/15/25 7:02 AM EDT
	Um, not right now. (Clarified to if I am sexually active.)
	What was your most recent meal?	Question 04/15/25 7:03 AM EDT
	This morning, I had toast with butter and honey, and some orange juice.
	Do you recall what you have eaten for the last 24 hours? (Clarified to Can you tell me what you ate in the last day?.)	Question 04/15/25 7:04 AM EDT
	Um …Yesterday, I had … Let me start at breakfast. I had a bowl of cereal. For lunch … I had a piece of pizza. For dinner, I made baked potatoes with broccoli and cheese soup. This morning I had toast with butter and honey, and some orange juice, and that’s the last thing I’ve had. (Clarified to what I have eaten in the past twenty four hours.)

Subjective Data Collection: 31 of 31 (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 frequently occurring stomach pain

(Found)

Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.

Example Question:

How are you feeling?

History of Present Illness

Finding:

Asked about onset of pain

Finding:

Reports noticing pain for “at least a month”

(Found)

Pro Tip: By establishing a timeline of Tina’s abdominal pain, you’re soliciting information that can help you to understand the nature and extent of her stomach pain.

Example Question:

How long have you had abdominal pain?

Finding:

Reports that pain increased gradually

(Found)

Pro Tip: By establishing a timeline of Tina’s abdominal pain, you’re soliciting information that can help you to understand the nature and extent of her stomach pain.

Example Question:

Did the abdominal pain start suddenly?

Finding:

Asked about frequency of pain

Finding:

Reports pain occurs every day

(Found)

Pro Tip: By establishing a timeline of Tina’s abdominal pain, you’re soliciting information that can help you to understand the nature and extent of her stomach pain.

Example Question:

Do you have abdominal pain every day?

Finding:

Reports 3 to 4 episodes a week that are more severe

(Available)

Pro Tip: By establishing a timeline of Tina’s abdominal pain, you’re soliciting information that can help you to understand the nature and extent of her stomach pain.

Example Question:

How many times a week do you have abdominal pain?

Finding:

Asked about duration of pain

Finding:

Pain begins right after finishing a meal

(Available)

Pro Tip: Soliciting information about what triggers Tina’s stomach pain can allow you to understand the nature of her symptoms and most effectively treat her.

Example Question:

How long after a meal does the pain start?

Finding:

Each episode lasts “a few hours”

(Found)

Pro Tip: Soliciting information about the duration of Tina’s stomach pain can allow you to understand the nature of her symptoms and most effectively treat her.

Example Question:

How many hours does the abdominal pain last?

Finding:

Asked about severity of pain on a scale

Finding:

Rates present pain as 1 or 2 out of 10

(Found)

Pro Tip: Pain severity might change over time for a variety of reasons. Asking Tina to rate the severity of her pain on a scale of 1-10 will provide a quantified and relative measurement of her condition.

Example Question:

Can you rate your current stomach pain on a scale of 0 to 10?

Finding:

Rates worst pain after eating as 5 out of 10

(Found)

Pro Tip: Pain severity might change for a variety of reasons. Asking Tina to rate the severity of her pain on a scale of 1-10 after she eats will provide a quantified and relative measurement of her condition.

Example Question:

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

Finding:

Rates pain when supine as a 6 or 7 out of 10

(Available)

Pro Tip: Pain severity might change for a variety of reasons. Asking Tina to rate the severity of her pain when she’s lying down, on a scale of 1-10, will provide a quantified and relative measurement of her condition.

Example Question:

Can you rate the stomach pain when you’re lying down on a scale of 0 to 10?

Finding:

Asked about character of the pain

Finding:

Describes the pain as similar to heartburn

(Found)

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

Example Question:

Does the pain feel like heartburn?

Finding:

Denies crushing pain

(Available)

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

Example Question:

Is the pain crushing?

Finding:

Denies gnawing pain

(Available)

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

Example Question:

Is the pain gnawing?

Finding:

Denies cramping pain

(Available)

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

Example Question:

Does the stomach pain feel like cramps?

Finding:

Denies that abdomen is tender to the touch

(Available)

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

Example Question:

Is your stomach tender to the touch?

Finding:

Asked location of the pain

Finding:

Pain is in center of upper stomach, below breastbone

(Found)

Pro Tip: Specifying the location of pain can narrow and define where Tina’s pain is occurring. Soliciting this information allows you to more accurately treat her symptoms.

Example Question:

Where is your stomach pain the worst?

Finding:

Pain does not radiate

(Found)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina to describe what her pain feels like specifies the way that her symptoms and pain manifest.

Example Question:

Does the stomach pain radiate?

Finding:

Denies shoulder pain

(Available)

Pro Tip: Determining where Tina’s pain is occurring will allow you to most effectively treat her symptoms. Asking Tina if she has shoulder pain will help you to determine precisely where her pain is located.

Example Question:

Do you have shoulder pain?

Finding:

Denies back pain

(Available)

Pro Tip: Determining where Tina’s pain is occurring will allow you to most effectively treat her symptoms. Asking Tina if she has back pain will help you to determine precisely where her pain is located.

Example Question:

Do you have back pain?

Finding:

Denies arm pain

(Found)

Pro Tip: Determining where Tina’s pain is occurring will allow you to most effectively treat her symptoms. Asking Tina if either arm hurts will help you to determine precisely where her pain is located.

Example Question:

Does either arm hurt?

Finding:

Denies flank pain

(Available)

Pro Tip: Determining where Tina’s pain is occurring will allow you to most effectively treat her symptoms. Asking Tina if she has flank pain will help you to determine precisely where her pain is located.

Example Question:

Do you have flank pain?

Finding:

Denies pain on right side of abdomen

(Available)

Pro Tip: Determining where Tina’s pain is occurring will allow you to most effectively treat her symptoms. Asking Tina if she has pain on the right side of her stomach will help you to determine precisely where her pain is located.

Example Question:

Do you have pain on the right side of your stomach?

Finding:

Asked about aggravating factors

Finding:

Pain occurs after eating

(Found)

Pro Tip: By determining what factors aggravate Tina’s pain you can develop a treatment plan for her. Asking if her pain is worse after she eats will help you to most effectively treat Tina’s symptoms.

Example Question:

Do you feel the pain after you eat?

Finding:

Pain worsens with larger meals

(Available)

Pro Tip: By determining what factors aggravate Tina’s pain you can develop a treatment plan for her. Asking if her pain is worse after she eats larger meals will help you to most effectively treat Tina’s symptoms.

Example Question:

Is the pain worse with larger meals?

Finding:

Reports that spicy foods increase the pain

(Available)

Pro Tip: By determining what factors aggravate Tina’s pain you can develop a treatment plan for her. Asking if her pain is worse after she eats spicy food will help you to most effectively treat Tina’s symptoms.

Example Question:

Does spicy food make the pain worse?

Finding:

Denies high-fat foods as an aggravating factor

(Available)

Pro Tip: By determining what factors aggravate Tina’s pain you can develop a treatment plan for her. Asking if her pain is worse after she eats greasy food will help you to most effectively treat Tina’s symptoms.

Example Question:

Does greasy food make the pain worse?

Finding:

Pain worsens when supine

(Available)

Pro Tip: Pain severity might change for a variety of reasons. Asking Tina if her pain is worse when she is supine will provide a relative measurement of her condition.

Example Question:

Is the pain worse when you lay down?

Finding:

Pain worsens when bending over

(Available)

Pro Tip: Pain severity might change for a variety of reasons. Asking Tina if her pain is worse when she bends over will provide a relative measurement of her condition.

Example Question:

Is the pain worse when you bend over?

Finding:

Asked about relieving factors

Finding:

Pain improves between meals

(Found)

Pro Tip: Pain might change over time for a variety of reasons. Asking Tina if her pain improves between meals establishes a timeline of when her symptoms are most aggravated.

Example Question:

Does your pain improve between meals?

Finding:

Pain improves when upright

(Found)

Pro Tip: Pain might change for a variety of reasons. Asking Tina if her pain improves when she is standing will solicit information about which positions are least uncomfortable for Tina.

Example Question:

Does your pain improve when you sit up?

Finding:

Asked about effects of pain on diet and appetite

Finding:

Reports decreased appetite

(Found)

Pro Tip: Pain can have a substantial effect on diet and appetite. Asking Tina how her appetite has been will illustrate the ways in which her symptoms are manifesting.

Example Question:

How has your appetite been?

Finding:

Describes not wanting to eat out of anticipation of pain

(Found)

Pro Tip: Pain can have a substantial effect on diet and appetite. Asking Tina why she has been eating less will illustrate the ways in which her symptoms are manifesting.

Example Question:

Why have you been eating less?

Finding:

Reports eating smaller meals

(Available)

Pro Tip: Pain can have a substantial effect on diet and appetite. Asking Tina if she has been eating smaller meals will illustrate the ways in which her symptoms are manifesting.

Example Question:

Have you been eating smaller meals?

Finding:

Reports avoiding spicy foods

(Available)

Pro Tip: Pain can have a substantial effect on diet and appetite. Asking Tina if she still eats spicy foods will illustrate the ways in which her symptoms are manifesting.

Example Question:

Do you still eat spicy foods?

Finding:

Asked about increased burping

Finding:

Reports burping

(Found)

Pro Tip: Increased burping can be a result of heartburn, acid reflux, or indigestion. Asking Tina if she’s been burping more would indicate that Tina has been swallowing more air recently.

Example Question:

Have you been burping?

Finding:

Burping occurs after eating

(Found)

Pro Tip: Increased burping can be a result of heartburn, acid reflux, or indigestion. Asking Tina when she burps the most would indicate that Tina has been swallowing more air recently.

Example Question:

When do you burp the most?

Finding:

Asked about changes in weight

Finding:

Denies recent weight loss

(Found)

Pro Tip: Foundational questions about general health and wellbeing can help you to determine how your patient perceives her health. Asking Tina if her weight changed recently can indicate whether Tina has concerns about recent weight loss.

Example Question:

Have you lost weight recently?

Medical History

Finding:

Confirmed use of medications

Finding:

Confirms medications (no new medications reported)

(Found)

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

Example Question:

What medications do you take?

Finding:

Reports occasional antacid use

(Found)

Pro Tip: Tina’s response to a question about pain management will reveal the severity of her pain, her health literacy, and the way she’s managing her symptoms.

Example Question:

Have you been taking antacids?

Finding:

Denies frequent Advil (ibuprofen) use

(Available)

Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina how frequently she is taking the Ibuprofen will illustrate the extent of her pain and how effectively OTC medication works for her injury.

Example Question:

How often do you take ibuprofen?

Finding:

Followed up on use of antacids and relieving factors

Finding:

Antacid brand is Tums

(Available)

Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina what kind of antacids she takes will illustrate the extent of her pain and how effectively OTC medication works for her pain.

Example Question:

What kind of antacids do you take?

Finding:

Takes antacids every few days

(Found)

Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina how often she takes an antacid will illustrate the extent of her pain and how effectively OTC medication works for her pain.

Example Question:

How often do you take an antacid?

Finding:

Takes between 2 and 4 antacid tablets at a time

(Available)

Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina how many antacids she takes at a time will illustrate the extent of her pain and how effectively OTC medication works for her pain.

Example Question:

How many antacids do you take at a time?

Finding:

Reports that antacids offer partial relief

(Available)

Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina if the antacids have been helping will illustrate the extent of her pain and how effectively OTC medication works for her injury.

Example Question:

Do the antacids help?

Finding:

Confirmed allergies

Finding:

Confirms allergies (no new allergies reported)

(Found)

Pro Tip: It’s best practice to ask a patient about her allergies each visit, even with an established patient, to uncover any new allergy triggers or symptoms.

Example Question:

Have you had any new allergies?

Finding:

Asked about past gastrointestinal history

Finding:

Denies past history of ulcers

(Available)

Pro Tip: Soliciting a relevant medical history from your patient will aid in effectively treating your patient’s symptoms. Asking Tina if she ever had any ulcers will allow her to describe any historical concerns or problems she’s had.

Example Question:

Have you ever had any ulcers?

Finding:

Denies gastrointestinal disease

(Found)

Pro Tip: Soliciting a relevant medical history from your patient will aid in effectively treating your patient’s symptoms. Asking Tina about her gastrointestinal history will allow her to describe any historical concerns or problems she’s had.

Example Question:

Do you have any gastrointestinal diseases?

Finding:

Denies past history of GERD

(Found)

Pro Tip: Soliciting a relevant medical history from your patient will aid in effectively treating your patient’s symptoms. Asking Tina if she’s ever been diagnosed with GERD will allow her to describe any historical concerns or problems she’s had.

Example Question:

Have you ever been diagnosed with GERD?

Finding:

Denies past gastrointestinal surgery

(Available)

Pro Tip: Soliciting a relevant medical history from your patient will aid in effectively treating your patient’s symptoms. Asking Tina if she’s had any gastrointestinal surgeries will allow her to describe any historical concerns or problems she’s had.

Example Question:

Have you had any gastrointestinal surgeries?

Finding:

Denies past history of appendicitis

(Available)

Pro Tip: Soliciting a relevant medical history from your patient will aid in effectively treating your patient’s symptoms. Asking Tina if she’s had appendicitis will allow her to describe any historical concerns or problems she’s had.

Example Question:

Have you had appendicitis?

Finding:

Denies past history of cholecystitis

(Available)

Pro Tip: Soliciting a relevant medical history from your patient will aid in effectively treating your patient’s symptoms. Asking Tina if she ever had her gallbladder removed will allow her to describe any historical concerns or problems she’s had.

Example Question:

Have you ever had your gallbladder removed?

Finding:

Denies past history of stomach cancer

(Available)

Pro Tip: Soliciting a relevant medical history from your patient will aid in effectively treating your patient’s symptoms. Asking Tina if she ever had stomach cancer will allow her to describe any historical concerns or problems she’s had.

Example Question:

Have you ever had stomach cancer?

Finding:

Denies past history of liver disease

(Found)

Pro Tip: Soliciting a relevant medical history from your patient will aid in effectively treating your patient’s symptoms. Asking Tina if she’s ever been diagnosed with liver disease will allow her to describe any historical concerns or problems she’s had.

Example Question:

Have you ever been diagnosed with liver disease?

Finding:

Denies past history of kidney disease

(Found)

Pro Tip: Soliciting a relevant medical history from your patient will aid in effectively treating your patient’s symptoms. Asking Tina if she’s ever had any kidney diseases will allow her to describe any historical concerns or problems she’s had.

Example Question:

Have you ever had any kidney diseases?

Finding:

Denies past history of bladder disease

(Available)

Pro Tip: Soliciting a relevant medical history from your patient will aid in effectively treating your patient’s symptoms. Asking Tina if she’s ever had a bladder disease will allow her to describe any historical concerns or problems she’s had.

Example Question:

Have you ever had a bladder disease?

Finding:

Asked about typical bowel movements

Finding:

Reports bowel movement every 2 days

(Found)

Pro Tip: GERD and IBS often occur together. Asking Tina about her bowel movements is significant in understanding her gastrointestinal symptoms.

Example Question:

How often do you have a bowel movement?

Finding:

Denies pain during bowel movements

(Available)

Pro Tip: GERD and IBS often occur together. Asking Tina about her bowel movements is significant in understanding her gastrointestinal symptoms.

Example Question:

Do you have any pain with your bowel movements?

Finding:

Denies bloody or tarry stools

(Available)

Pro Tip: GERD and IBS often occur together. Asking Tina if there are any abnormalities in her stools is significant in understanding her gastrointestinal symptoms.

Example Question:

Do you have dark colored stools?

Finding:

Denies mucus in stool

(Available)

Pro Tip: GERD and IBS often occur together. Asking Tina if there are any abnormalities in her stools is significant in understanding her gastrointestinal symptoms.

Example Question:

Do you notice mucus in your stools?

Finding:

Describes consistency of bowel movements

(Available)

Pro Tip: GERD and IBS often occur together. Asking Tina about her bowel movements is significant in understanding her gastrointestinal symptoms.

Example Question:

Are your bowel movements consistent?

Finding:

Asked about typical urination

Finding:

Reports increased urination

(Found)

Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if she has been urinating more than usual can help you to determine the cause of Tina’s symptoms.

Example Question:

Have you been urinating more than usual?

Finding:

Reports urine is a clear or light-yellow color

(Available)

Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina what color her urine is can help you to determine the cause of Tina’s symptoms.

Example Question:

What color is your urine?

Finding:

Reports nocturia

(Available)

Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if she has to wake up to urinate can help you to determine the cause of Tina’s symptoms.

Example Question:

Have you had to wake up to urinate?

Finding:

Denies pain during urination

(Available)

Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if it is painful when she urinates can help you to determine the cause of Tina’s symptoms.

Example Question:

Is it painful when you urinate?

Finding:

Describes urine character as normal

(Available)

Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina what her urine looks like can help you to determine the cause of Tina’s symptoms.

Example Question:

What does your urine look like?

Finding:

Denies pink or bloody urine

(Available)

Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if her urine is ever red can help you to determine the cause of Tina’s symptoms.

Example Question:

Is your urine ever red?

Finding:

Denies incontinence

(Available)

Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if she ever has trouble holding her urine in can help you to determine the cause of Tina’s symptoms.

Example Question:

Do you ever have trouble holding your urine in?

Finding:

Asked about menstruation and sexual activity

Finding:

LMP was 3 weeks ago

(Available)

Pro Tip: Gynecologic disorders appear to be more common in people with IBS. Soliciting information about Tina’s menstrual patterns can indicate whether her menstrual patterns are normal.

Example Question:

When was your last menstrual period?

Finding:

Denies sexual activity

(Found)

Pro Tip: Some sexually active people with IBD report pain and bloating during sex. Asking Tina if she is sexually active can help you to determine the extent of her gastrointestinal symptoms.

Example Question:

Are you currently sexually active?

Social History

Finding:

Asked about most recent meal

Finding:

Most recent meal was breakfast this morning

(Found)

Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina when she most recently ate will illustrate her dietary recent patterns.

Example Question:

When was your most recent meal?

Finding:

Most recent meal was toast with butter and honey and orange juice

(Found)

Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she ate for breakfast will indicate how she has been eating recently.

Example Question:

What did you eat for breakfast?

Finding:

Asked 24-hour diet recall

Finding:

Yesterday’s breakfast was cereal

(Found)

Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she had for breakfast yesterday will illustrate her recent dietary patterns.

Example Question:

What did you have for breakfast yesterday?

Finding:

Yesterday’s lunch was pizza

(Found)

Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she had for lunch yesterday will illustrate her recent dietary patterns.

Example Question:

What did you have for lunch yesterday?

Finding:

Yesterday’s dinner was a baked potato

(Found)

Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she had for dinner yesterday will illustrate her recent dietary patterns.

Example Question:

What did you have for dinner yesterday?

Finding:

Asked about typical diet

Finding:

Reports typical intake is 3 meals a day plus snacks

(Found)

Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina how many means she typically eats in a day will illustrate her recent dietary patterns.

Example Question:

How many meals do you eat in a typical day?

Finding:

Typical breakfast is cereal, bread, or a muffin

(Found)

Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she typically has for breakfast will illustrate her recent dietary patterns.

Example Question:

What is your typical breakfast?

Finding:

Typical lunch is a sandwich and chips

(Found)

Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she typically has for lunch will illustrate her recent dietary patterns.

Example Question:

What is your typical lunch?

Finding:

Typical dinner is chicken, a vegetable or potatoes, and bread

(Found)

Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she typically has for dinner will illustrate her recent dietary patterns.

Example Question:

What is your typical dinner?

Finding:

Reports fast food intake 3 times a week

(Available)

Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina how often she eats fast food will illustrate her recent dietary patterns.

Example Question:

How often do you eat fast food?

Finding:

Typical snack is pretzels, French fries, crackers or chips

(Available)

Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she typically has for a snack will illustrate her recent dietary patterns.

Example Question:

What is a typical snack for you?

Finding:

Asked about typical beverages

Finding:

Last alcoholic drink was 2 weeks ago

(Available)

Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina when she last had an alcoholic drink will illustrate her recent dietary patterns.

Example Question:

When did you last have an alcoholic drink?

Finding:

Typical alcohol frequency is 2 – 3 times a month

(Found)

Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina how many drinks she typically has in a month will illustrate her recent dietary patterns.

Example Question:

How many times a month do you drink alcohol?

Finding:

Typical alcohol intake is 2 – 3 drinks at a time

(Found)

Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina how many alcoholic drinks she typically has at a time will illustrate her recent dietary patterns.

Example Question:

How many alcoholic drinks do you typically have at one time?

Finding:

Reports that alcohol intake bothered her stomach

(Available)

Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina if the alcohol makes her stomach pain worse will indicate whether alcohol is causing some of her GI symptoms.

Example Question:

Does alcohol make your stomach pain worse?

Finding:

Reports drinking soda

(Available)

Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina if she drinks soda will illustrate her recent dietary patterns.

Example Question:

Do you drink soda?

Finding:

Reports drinking 3 – 4 diet cokes a day

(Available)

Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina how many diet cokes she drinks a day will illustrate her recent dietary patterns.

Example Question:

How many diet cokes do you drink in a day?

Finding:

Reports that she hasn’t noticed a connection between soda intake and pain

(Available)

Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina if the diet coke makes her stomach pain worse will indicate whether diet coke is causing some of her GI symptoms.

Example Question:

Does the diet coke make your stomach pain worse?

Finding:

Reports drinking 6 – 8 glasses of water a day

(Available)

Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina how many glasses of water she has a day will indicate her current patterns of diet and consumption.

Example Question:

How many glasses of water do you drink each day?

Finding:

Asked about recent dietary and life experiences

Finding:

Denies recent travel

(Found)

Pro Tip: Recent dietary or new life experiences can result in digestive problems. Asking Tina if she’s traveled recently might point to something new that is triggering digestive problems for Tina.

Example Question:

Have you traveled recently?

Finding:

Denies food poisoning

(Available)

Pro Tip: Recent dietary or new life experiences can result in digestive problems. Asking Tina if she thinks she could have food poisoning might indicate what’s triggering Tina’s digestive problems.

Example Question:

Do you think you could have food poisoning?

Finding:

Asked about substance use

Finding:

Denies illicit drug use

(Available)

Pro Tip: Drug use can cause damage to the cells of the digestive tract and inhibit the secretion enzymes needed for digestion. Asking Tina if she currently uses and illicit drugs might indicate whether drug use is causing problems for her digestion.

Example Question:

Do you currently use any recreational drugs?

Finding:

Denies cigarette smoking

(Found)

Pro Tip: Smoking or inhaling substances can have adverse effects on the digestive system. Asking Tina if she currently smokes can help you to discern whether smoking was a factor in Tina’s recent digestive problems.

Example Question:

Do you smoke cigarettes?

Social Determinants of Health

Finding:

Asked about food access

Finding:

Reports living near grocery store

(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:

How far away is the grocery store from where you live?

Finding:

Reports access to fresh foods

(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 access to fresh produce?

Review of Systems

Finding:

Asked about general symptoms

Finding:

Denies fever

(Found)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like fever, details the way her individual symptoms and pain manifest.

Example Question:

Have you had any fever recently?

Finding:

Denies chills

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like getting chills, details the way her individual symptoms and pain manifest.

Example Question:

Have you been feeling chills?

Finding:

Denies fatigue

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like fatigue, details the way her individual symptoms and pain manifest.

Example Question:

Have you been fatigued?

Finding:

Denies night sweats

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her injury, like night sweats, details the way her individual symptoms and pain manifest.

Example Question:

Have you had night sweats?

Finding:

Asked about review of systems for mental health

Finding:

Reports occasional feelings of anxiety

(Available)

Pro Tip: Anxiety can manifest in symptoms like heartburn or acid reflux. Asking Tina if she’s experienced anxiety would suggest a cyclical relationship between her physical symptoms and anxiety.

Example Question:

Have you been experiencing anxiety?

Finding:

Reports feelings of stress

(Available)

Pro Tip: Anxiety can manifest in symptoms like heartburn or acid reflux. Asking Tina about her recent stress levels would suggest a cyclical relationship between her physical symptoms and anxiety.

Example Question:

How is your recent stress level?

Finding:

Asked about review of systems for gastrointestinal

Finding:

Denies nausea

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like nausea, details the way her individual symptoms and pain manifest.

Example Question:

Have you had any nausea?

Finding:

Denies vomiting

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like vomiting, details the way her individual symptoms and pain manifest.

Example Question:

Have you been vomitting?

Finding:

Denies diarrhea

(Found)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like diarrhea, details the way her individual symptoms and pain manifest.

Example Question:

Have you had any diarrhea?

Finding:

Denies constipation

(Found)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like constipation, details the way her individual symptoms and pain manifest.

Example Question:

Have you been constipated?

Finding:

Denies flatus

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like gas, details the way her individual symptoms and pain manifest.

Example Question:

Have you had gas?

Finding:

Denies bloating

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like feeling bloated, details the way her individual symptoms and pain manifest.

Example Question:

Have you felt bloated?

Finding:

Asked about review of systems for respiratory

Finding:

Denies sore throat

(Found)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like throat pain, details the way her individual symptoms and pain manifest.

Example Question:

Do you have any throat pain?

Finding:

Denies coughing

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like coughing, details the way her individual symptoms and pain manifest.

Example Question:

Have you been coughing?

Finding:

Denies dysphagia

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like difficulty swallowing, details the way her individual symptoms and pain manifest.

Example Question:

Do you have difficulty swallowing?

Finding:

Denies difficulty breathing

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like difficulty breathing, details the way her individual symptoms and pain manifest.

Example Question:

Have you had difficulty breathing?

Finding:

Denies chest pain

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like chest pain, details the way her individual symptoms and pain manifest.

Example Question:

Have you had any chest pain?

Finding:

Denies palpitations

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like palpitations, details the way her individual symptoms and pain manifest.

Example Question:

Have you had any palpitations?

Finding:

Denies change in sense of taste

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like change in her sense of taste, details the way her individual symptoms and pain manifest.

Example Question:

Has there been any change to your sense of taste?

Family History

Finding:

Asked about relevant family history

Finding:

Reports family history of colon cancer

(Available)

Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina has a family history of colon cancer might reveal a predisposition to gastrointestinal issues.

Example Question:

Do you have a family history of colon cancer?

Finding:

Denies family history of GERD

(Available)

Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina has a family history of GERD might reveal a predisposition to gastrointestinal issues.

Example Question:

Do you have a family history of GERD?

Finding:

Denies family history of IBS

(Found)

Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina has a family history of irritable bowel syndrome might reveal a predisposition to gastrointestinal issues.

Example Question:

Do you have a family history of irritable bowel syndrome?

Finding:

Denies family history of cholecystitis

(Available)

Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina has a family history of cholecystitis might reveal a predisposition to gastrointestinal issues.

Example Question:

Do you have a family history of cholecystitis?

Finding:

Denies family history of liver disease

(Available)

Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina has a family history of liver disease might reveal a predisposition to gastrointestinal issues.

Example Question:

Do you have a family history of liver disease?

Finding:

Denies family history of kidney disease

(Available)

Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina has a family history of kidney disease might reveal a predisposition to gastrointestinal issues.

Example Question:

Do you have a family history of kidney disease?

Finding:

Denies family history of bladder disease

Objective Data Collection: 18 of 18 (100%)

Correct
Partially correct

Incorrect
Missed

Inspected skin turgor

Observations (1/1 point)

No tenting

Inspected abdomen

Symmetry (1/3 point)

Symmetric

Contour (1/3 point)

Protuberant

Appearance (1/3 point)

Striae
Excessive hair growth

Breath Sounds (1/3 point)

Present in all areas

Adventitious Sounds (1/3 point)

No adventitious sounds

Location (1/3 point)

All areas clear

Auscultated heart sounds

Heart Sounds (1/2 point)

S1 and S2 audible

Extra Heart Sounds (1/2 point)

No extra sounds

Auscultated bowel sounds

Sounds (1/2 point)

Normoactive

Location Of Non Normoactive Bowel Sounds (1/2 point)

All quadrants normoactive

Auscultated abdominal aorta

Sound (1/1 point)

No bruit

Auscultated renal arteries

Right (1/2 point)

No bruit

Left (1/2 point)

No bruit

Auscultated iliac arteries

Right (1/2 point)

No bruit

Left (1/2 point)

No bruit

Auscultated femoral arteries

Right (1/2 point)

No bruit

Left (1/2 point)

No bruit

Percussed abdomen

Observations (1/1 point)

All areas generally tympanic

Percussed CVA tenderness

Patient Reaction (1/1 point)

Did not react

Percussed spleen

Spleen (1/1 point)

Tympany

Percussed liver span

Size (1/1 point)

Between 6 and 12 cm

Palpated abdomen – light

Tenderness (1/3 point)

None reported

Location Of Tenderness (1/3 point)

No quadrants tender

Observations (1/3 point)

No additional observations

Palpated abdomen – deep

Presence Of Unexpected Mass (1/2 point)

No palpable mass

Location Of Mass (1/2 point)

No palpable mass

Palpated liver

Detection (1/1 point)

Palpable

Palpated spleen

Detection (1/1 point)

Not palpable

Palpated kidneys

Right (1/2 point)

Not palpable

Left (1/2 point)

Not palpable

Education & Empathy : 3 of 4 (75.0%)

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

	Description: Tina describes the symptoms that have been bothering her.
	What brings you here today?	Question 05:00 AM EDT
	I’ve been having this stomach pain for awhile. It keeps coming back, and it really is starting to bother me.
	I am sorry for that	Empathize 05:00 AM EDT
	I appreciate you telling me that.
	Model Statement: “I’m sorry to hear you’re having stomach pain. I’m glad you came in to see me. Stomach pain can be caused by several different things, so I will ask you questions and we’ll see if we can determine what’s causing yours.”

2 Medications

	Description: Tina describes her medication regimen, including antacids for her stomach pain.
	Do you use any medication?	Question 05:11 AM EDT
	I have a daily inhaler. And I’ve been taking antacid chews sometimes for my stomach, too.
	How often do you take antacids?	Question 05:11 AM EDT
	I take them every few days. Just if the heartburn gets bad.
	Antacids actually works best when you take them before a meal	Educate 05:14 AM EDT
	That makes sense.
	Model Statement: “Thank you for letting me know that you’re using antacids in addition to the medications you usually take. I will ask you a few questions about how you’re using each medication.”

3 Diet

	Description: Tina’s diet contains high levels of carbohydrates, which is not recommended for a person with diabetes.
	Which foods do you take?	Question 05:15 AM EDT
	Oh, I know vegetables are healthy. Anything with vegetables is going to be healthier. I mean, an extra-healthy meal at our house would be baked chicken and some green beans. I make that like once a week.
	What is you typical diet? (Clarified to: What do you eat in an average day?)	Question 05:15 AM EDT
	Let’s see. . . a muffin or pumpkin bread for breakfast, a sandwich for lunch, and some kind of meat with a veggie for dinner. (Clarified to: what I typically eat in a day)
	Your meal has a high level of carbohydrate which is not recommended for diabetes patients.	Educate 05:16 AM EDT
	Sure, I think I understand what you mean.
	Model Statement: “It sounds like you’re eating quite a few carbohydrates, which can be unhealthy for people with diabetes. Carbohydrates are found in things like pizza crust, potatoes, bread, and juice. Let’s talk about eating foods with fewer carbohydrates.”

4 Soda Intake

Not Encountered

	Description: Tina drinks Diet Coke every day, which is acidic and could irritate her symptoms.
	Model Statement: “Some forms of stomach pain can be irritated by acidic drinks or foods. Drinking less soda and more water could relieve some of your stomach pain.”

Documentation / Electronic Health Record

Document: Provider Notes

Document: Provider Notes

Student Documentation	Model Documentation
Subjective Ms. Jones is 28 y/o African American woman who presents to the clinic with complaints of upper stomach pain after eating. The pain started a month ago. She experiences the pain daily but is worse 3-4 times per week. Pain is 5/10 and is located in her upper stomach. She says it feels like a heartburn but can be sharper. It increases with consumption of food which causes increased burning after meals. Has no recent changes in meals. She has increased water intake. She takes a muffin or pumpkin break for breakfast. Dinner is homemade meal of a meat and vegerable, snacks are French fries. She denies coffee intake.	HPI: Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of upper stomach pain after eating. She noticed the pain about a month ago. She states that she experiences pain daily, but notes it to be worse 3-4 times per week. Pain is a 5/10 and is located in her upper stomach. She describes it “kind of like heartburn” but states that it can be sharper. She notes it to increase with consumption of food and specifically fast food and spicy food make pain worse. She does notice that she has increased burping after meals. She states that time generally makes the pain better, but notes that she does treat the pain “every few days” with an over the counter antacid with some relief. Social History: She denies any specific changes in her diet recently, but notes that she has increased her water intake. Breakfast is usually a muffin or pumpkin bread, lunch is a sandwich with chips, dinner is a homemade meal of a meat and vegetable, snacks are French fries or pretzels. She denies coffee intake, but does drink diet cola on a regular basis. She denies use of tobacco and illicit drugs. She drinks alcohol occasionally, last was 2 weeks ago, and was 1 drink. She does not exercise. Review of Systems: General: Denies changes in weight and general fatigue. She denies fevers, chills, and night sweats. • Cardiac: Denies a diagnosis of hypertension, but states that she has been told her blood pressure was high in the past. She denies known history of murmurs, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, or edema. • Respiratory: She denies shortness of breath, wheezing, cough, sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. She has a history of asthma, last hospitalization was age 16, last chest XR was age 16. • Gastrointestinal: States that in general her appetite is unchanged, although she does note that she will occasionally experience loss of appetite in anticipation of the pain associated with eating. Denies nausea, vomiting, diarrhea, and constipation. Bowel movements are daily and generally brown in color. Denies any change in stool color, consistency, or frequency. Denies blood in stool, dark stools, or maroon stools. No blood in emesis. No known jaundice, problems with liver or spleen.
Objective Ms. Jones is 28 y/o African American woman and is no acute distress. She is alert and oriented. -Abdominal: Soft and protuberant without scars or skin lesions, skin is warm and dry, without tenting. Bowel sounds present and normoactive in all quadrants No CVA tenderness – Cardiovascular: Regular rate and thythm, S1 and S2 present, no murmurs, rubs, gallops. Respiratory: Chest is symmetrical. Lung sound clear to auscultation anteriorly and posteriorly without wheezes, crackles or cough.	General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented. She maintains eye contact throughout interview and examination. • Abdominal: Abdomen is soft and protuberant without scars or skin lesions; skin is warm and dry, without tenting. Bowel sounds present and normoactive in all quadrants. No tenderness to light or deep palpation. Tympanic throughout. Liver is 7 cm at the MCL and 1 cm below the right costal margin. Spleen and bilateral kidneys are not palpable. No CVA tenderness. • Cardiovascular: Regular rate and rhythm, S1 and S2 present, no murmurs, rubs, gallops, clicks, precordial movements. No bruits with auscultation over abdominal aorta. No femoral, iliac, or renal bruits. • Respiratory: Chest is symmetrical with respirations. Lung sounds clear to auscultation anteriorly and posteriorly without wheezes, crackles, or cough.
Assessment GERD	Gastroesophageal reflux disease without evidence of esophagitis
Plan Educate the patient on lifestyle changes to help in weight loss by enganging in daily physical activity. Have a confortable place to sleep and reduce symptoms. Encourage to eat smaller meals and avoid eating 2-3 hours before bedtime. Educate on dietary reduction in fat to decrease symptoms Give famotidine 10 mg by mouth twice daily for two weeks Follow up may include tests such at H pylori and	Educate on lifestyle changes including weight loss, engagement in daily physical activity, and limitation of foods that may aggravate symptoms including chocolate, citrus, fruits, mints, coffee, alcohol, and spicy foods. • Ms. Jones may elevate the head of her bed or sleep on a wedge-shaped bolster for comfort or symptom reduction. • Encourage to eat smaller meals and to avoid eating 2-3 hours before bedtime. • Educate on dietary reduction in fat to decrease symptoms. • Trial of famotidine 10 mg by mouth twice daily for two weeks. If reduction in symptoms, Ms. Jones may continue therapy. If symptoms persist, follow up for subsequent recommendations and consider testing for helicobacter pylori, trial of a proton pump inhibitor, or upper endoscopy. • Educate on when to seek emergent care including signs and symptoms of upper and lower gastrointestinal bleed, weight loss, and chest pain. • Return to clinic in two weeks for evaluation and follow up.

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Tina Jones Cardiovascular Results

April 30, 2025/in BLOGS /by admin

Tina Jones Cardiovascular Results

Experience Overview

Patient: Tina Jones

Digital Clinical Experience Score

89.7%

This score measures your performance on the Student Performance Index in relation to other students in comparable academic programs. Your instructor has chosen to scale your Student Performance Index score so that the average score on the index is a 86.0%. This score may not be your final grade if your instructor chooses to include additional components, such as documentation or time spent.

Student Performance Index

42.17

out of

47

Proficiency Level:

Developing

Students rated as “developing” demonstrate increasing clinical reasoning abilities as they apply their knowledge of advanced practice competencies. In comparable programs, 25% of students perform at the level of a developing practitioner. Review your results in the tabs on the left side of the page to identify areas for improvement.

Subjective Data Collection

19

out of

19

Objective Data Collection

22.17

out of

23

Education and Empathy

1

out of

5

Time

59 minutes total spent in assignment

Interaction with patient

57 minutes

Post-exam activities

2 minutes

Transcript

Started: Apr 11, 2025 | Total Time: 57 min

All Lines (140)Interview Questions (44)Statements (4)Exam Actions (92)

	Inspected anterior chest wall	Exam Action 04/11/25 6:57 AM EDT
	Inspected left side chest wall	Exam Action 04/11/25 6:57 AM EDT
	Hi, my name is Mileidy	Greet 04/11/25 7:17 AM EDT
	Hey.
	I will be your nurse today	Question 04/11/25 7:17 AM EDT
	Hello.
	What brings you here today?	Question 04/11/25 7:18 AM EDT
	I’ve been noticing my heart seems to be beating too fast every once in a while lately, and it started to worry me. My mom said I should make an appointment. You don’t want to ignore heart stuff, I guess.
	I am sorry for that	Empathize 04/11/25 7:18 AM EDT
	I appreciate you telling me that.
	When did your heart condition start?	Question 04/11/25 7:18 AM EDT
	I think the first time was about a month ago.
	What are your symptoms?	Question 04/11/25 7:19 AM EDT
	Well, aside from these palpitations, I’ve felt really low energy lately. I feel pretty exhausted by the end of the day. [AUDIO COMING SOON]
	WHich symptoms do you have?	Question 04/11/25 7:19 AM EDT
	Well, aside from these palpitations, I’ve felt really low energy lately. I feel pretty exhausted by the end of the day. [AUDIO COMING SOON]
	Do you take any medication?	Question 04/11/25 7:20 AM EDT
	I have a daily inhaler and a rescue inhaler for my asthma.
	Do you have any allergies?	Question 04/11/25 7:20 AM EDT
	Yeah, I’m allergic to cats and dust.
	Do you have any stress?	Question 04/11/25 7:20 AM EDT
	Yeah, I’ve been pretty stressed lately.
	Do you have a history of heart conditions in your family? (Clarified to Does heart disease run in your family?.)	Question 04/11/25 7:21 AM EDT
	Um, none that I know of. Wait, my Poppa–that’s Mom’s dad–died of a heart attack. (Clarified to if I have a family history of heart problems.)
	How is your diet?	Question 04/11/25 7:21 AM EDT
	It’s pretty good, I think. I’m not a huge health nut or anything.
	How are your heartbeats? (Clarified to What is your heartbeat like?.)	Question 04/11/25 7:24 AM EDT
	It’s usually normal, but it’s way faster during these episodes I’ve been having. (Clarified to what my heartbeat is like.)
	Do you have high blood pressure?	Question 04/11/25 7:25 AM EDT
	…I’ve never been diagnosed with blood pressure problems. But I think it can be on the high side sometimes.
	Do you have heart murmurs?	Question 04/11/25 7:26 AM EDT
	No.
	Do you have any swelling?	Question 04/11/25 7:26 AM EDT
	No, not that I have noticed.
	Do you have blue skin?	Question 04/11/25 7:26 AM EDT
	Nope.
	Have you had any cardiac tests? (Clarified to Have you had other heart tests?.)	Question 04/11/25 7:27 AM EDT
	Nope. (Clarified to if I have had other heart tests.)
	Have you had any cardiac surgeries?	Question 04/11/25 7:27 AM EDT
	Nope. No surgeries… I’ve been lucky.
	Do you have chest pain?	Question 04/11/25 7:28 AM EDT
	No, I’ve never had any chest pain. It doesn’t hurt, it just feels like my heart is beating really fast.
	Do you have chest tightness?	Question 04/11/25 7:28 AM EDT
	Not really.
	Do you have breathing problems?	Question 04/11/25 7:28 AM EDT
	No, my breathing is fine right now.
	Do you drink alcohol?	Question 04/11/25 7:58 AM EDT
	I do sometimes, yeah, when I go out with my friends.
	Do you smoke?	Question 04/11/25 7:59 AM EDT
	No. I think it’s gross.
	Do you drink coffee?	Question 04/11/25 7:59 AM EDT
	Never. I don’t like it. Too bitter for my taste. I drink energy drinks instead.
	How many energy drinks do you drink per day?	Question 04/11/25 7:59 AM EDT
	Usually just one in the morning, kind of like some people have a cup of coffee. Some mornings lately I’ve had two, though.
	Do you use drugs?	Question 04/11/25 7:59 AM EDT
	No.
	Which medication do you use? (Clarified to What medications do you take?.)	Question 04/11/25 8:00 AM EDT
	I have a daily inhaler and a rescue inhaler for my asthma. (Clarified to what medications I am taking.)
	What were you doing when you got the palpitations?	Question 04/11/25 8:02 AM EDT
	I usually notice them on my way to class in the mornings. My schoolwork has really been picking up and I’ve been drinking energy drinks to help keep me focused during the day, so maybe the caffeine or whatever else is in those things has something to do with it.
	Where if the location of the palpitations?	Question 04/11/25 8:03 AM EDT
	Well, it must be my heart…so, the left side of my chest. Left-center, I guess.
	Drinking high levels of caffeine can make you feel stressed and anxious.	Educate 04/11/25 8:04 AM EDT
	Alright, thanks for letting me know.
	How often do you experience these symptoms? (Clarified to How frequently do you experience difficulty breathing?.)	Question 04/11/25 8:04 AM EDT
	Not too often. I really haven’t had issues since I started my new daily inhaler about a month ago. (Clarified to how often I have trouble breathing.)
	How often were you experiencing these symptoms? (Clarified to Have you had these symptoms before?.)	Question 04/11/25 8:04 AM EDT
	No. (Clarified to if I have had these symptoms before.)
	How often do you have the symptoms? (Clarified to What are your PMS symptoms?.)	Question 04/11/25 8:05 AM EDT
	I get bad cramps, and I get grumpy for a couple days. (Clarified to what my PMS symptoms are.)
	What makes the palpitations better?	Question 04/11/25 8:05 AM EDT
	I try to slow down and breathe, and just relax. The feeling usually goes away after awhile.
	How do you fell when your heart is racing fast? (Clarified to What do you do when your heart races?.)	Question 04/11/25 8:06 AM EDT
	I try to slow down and breathe, and just relax. The feeling usually goes away after awhile. (Clarified to what I do when my heart races.)
	Do you take any medications?	Question 04/11/25 8:06 AM EDT
	I have a daily inhaler and a rescue inhaler for my asthma.
	What medications are you taking?	Question 04/11/25 8:07 AM EDT
	I have a daily inhaler and a rescue inhaler for my asthma.
	Do you have a history of hypertension	Question 04/11/25 8:07 AM EDT
	…I’ve never been diagnosed with blood pressure problems. But I think it can be on the high side sometimes.
	Do you check your blood pressure?	Question 04/11/25 8:07 AM EDT
	Only when I’m here at the clinic.
	Do you have diabetes?	Question 04/11/25 8:07 AM EDT
	Yeah, I was diagnosed a few years ago.
	Do you have any stress?	Question 04/11/25 8:08 AM EDT
	Yeah, I’ve been pretty stressed lately.
	Do you exercise?	Question 04/11/25 8:08 AM EDT
	I’m pretty exhausted by the end of the day, so I don’t have the energy to do any extra exercise. But I’m on my feet all the time at work so I feel like that’s a little bit of exercise most days at least.
	Do you drink alcohol?	Question 04/11/25 8:08 AM EDT
	I do sometimes, yeah, when I go out with my friends.
	When do the palpitations occur?	Question 04/11/25 8:13 AM EDT
	I’ve only noticed them in the mornings, usually on the way to class. Maybe like once a week.
	How does your heart feel during the palpitations?	Question 04/11/25 8:14 AM EDT
	Well, my heart doesn’t hurt, but it feels like thumping. Just a fast, thumping heartbeat, I guess.
	What is the name of your daily inhaler?	Question 04/11/25 8:15 AM EDT
	The daily inhaler is Flovent, and the rescue inhaler is Proventil.
	Exercise is health for your body and can help relief stress	Educate 04/11/25 8:15 AM EDT
	Alright, thanks for letting me know.
	A family history of hypertension means that you may be at risk of developing it and its therefore important to monitor it.	Educate 04/11/25 8:16 AM EDT
	OK, I understand.
	Inspected anterior chest wall	Exam Action 04/11/25 8:18 AM EDT
	Inspected left side chest wall	Exam Action 04/11/25 8:18 AM EDT
	Inspected posterior chest wall	Exam Action 04/11/25 8:18 AM EDT
	Inspected left side chest wall	Exam Action 04/11/25 8:18 AM EDT
	Inspected anterior chest wall	Exam Action 04/11/25 8:18 AM EDT
	Inspected right side chest wall	Exam Action 04/11/25 8:18 AM EDT
	Inspected anterior chest wall	Exam Action 04/11/25 8:18 AM EDT
	Inspected for jugular venous distention: JVP 1 cm above sternal angle	Exam Action 04/11/25 8:18 AM EDT
	Inspected fingernails of right hand	Exam Action 04/11/25 8:19 AM EDT
	Inspected fingernails of left hand	Exam Action 04/11/25 8:19 AM EDT
	Checked capillary refill in fingernails	Exam Action 04/11/25 8:19 AM EDT
	Checked capillary refill in fingernails	Exam Action 04/11/25 8:19 AM EDT
	Checked capillary refill in fingernails	Exam Action 04/11/25 8:19 AM EDT
	Checked capillary refill in fingernails	Exam Action 04/11/25 8:19 AM EDT
	Checked capillary refill in fingernails	Exam Action 04/11/25 8:19 AM EDT
	Checked capillary refill in fingernails	Exam Action 04/11/25 8:19 AM EDT
	Checked capillary refill in fingernails	Exam Action 04/11/25 8:20 AM EDT
	Checked capillary refill in fingernails	Exam Action 04/11/25 8:20 AM EDT
	Inspected legs	Exam Action 04/11/25 8:20 AM EDT
	Inspected right leg for edema: No edema	Exam Action 04/11/25 8:20 AM EDT
	Inspected left leg for edema: No edema	Exam Action 04/11/25 8:20 AM EDT
	Inspected right leg	Exam Action 04/11/25 8:20 AM EDT
	Inspected legs	Exam Action 04/11/25 8:20 AM EDT
	Inspected left leg	Exam Action 04/11/25 8:20 AM EDT
	Inspected legs	Exam Action 04/11/25 8:20 AM EDT
	Inspected toenails	Exam Action 04/11/25 8:20 AM EDT
	Checked capillary refill in toenails	Exam Action 04/11/25 8:20 AM EDT
	Checked capillary refill in toenails	Exam Action 04/11/25 8:20 AM EDT
	Checked capillary refill in toenails	Exam Action 04/11/25 8:20 AM EDT
	Checked capillary refill in toenails	Exam Action 04/11/25 8:21 AM EDT
	Checked capillary refill in toenails	Exam Action 04/11/25 8:21 AM EDT
	Checked capillary refill in toenails	Exam Action 04/11/25 8:21 AM EDT
	Checked capillary refill in toenails	Exam Action 04/11/25 8:21 AM EDT
	Checked capillary refill in toenails	Exam Action 04/11/25 8:21 AM EDT
	Checked capillary refill in toenails	Exam Action 04/11/25 8:21 AM EDT
	Checked capillary refill in toenails	Exam Action 04/11/25 8:21 AM EDT
	Inspected legs	Exam Action 04/11/25 8:21 AM EDT
	Palpated temporal arteries: No thrill on either side, 2+ on both sides	Exam Action 04/11/25 8:22 AM EDT
	Palpated right carotid pulse: No thrill, 2+	Exam Action 04/11/25 8:22 AM EDT
	Palpated left carotid pulse: No thrill, 2+	Exam Action 04/11/25 8:22 AM EDT
	Palpated chest at PMI: Present at midclavicular line and 5th intercostal space, brisk and tapping, diameter 2 cm	Exam Action 04/11/25 8:22 AM EDT
	Palpated right radial pulse: No thrill, 2+	Exam Action 04/11/25 8:23 AM EDT
	Palpated left radial pulse: No thrill, 2+	Exam Action 04/11/25 8:23 AM EDT
	Palpated right brachial pulse: No thrill, 2+	Exam Action 04/11/25 8:23 AM EDT
	Palpated left brachial pulse: No thrill, 2+	Exam Action 04/11/25 8:23 AM EDT
	Palpated right femoral pulse: No thrill, 2+	Exam Action 04/11/25 8:23 AM EDT
	Palpated left femoral pulse: No thrill, 2+	Exam Action 04/11/25 8:23 AM EDT
	Palpated right popliteal pulse: No thrill, 2+	Exam Action 04/11/25 8:24 AM EDT
	Palpated left popliteal pulse: No thrill, 2+	Exam Action 04/11/25 8:24 AM EDT
	Palpated right tibial pulse: No thrill, 2+	Exam Action 04/11/25 8:24 AM EDT
	Palpated left tibial pulse: No thrill, 2+	Exam Action 04/11/25 8:24 AM EDT
	Palpated right dorsalis pedis pulse: No thrill, 2+	Exam Action 04/11/25 8:24 AM EDT
	Palpated left dorsalis pedis pulse: No thrill, 2+	Exam Action 04/11/25 8:25 AM EDT
	Auscultated left temporal pulse	Exam Action 04/11/25 8:25 AM EDT
	Auscultated right temporal pulse	Exam Action 04/11/25 8:25 AM EDT
	Auscultated right carotid pulse	Exam Action 04/11/25 8:25 AM EDT
	Auscultated left carotid pulse	Exam Action 04/11/25 8:25 AM EDT
	Auscultated breath sounds in anterior right upper lobe	Exam Action 04/11/25 8:25 AM EDT
	Auscultated breath sounds in anterior left upper lobe	Exam Action 04/11/25 8:26 AM EDT
	Auscultated breath sounds in anterior right middle lobe	Exam Action 04/11/25 8:26 AM EDT
	Auscultated breath sounds in anterior left mid-chest (upper lobe)	Exam Action 04/11/25 8:26 AM EDT
	Auscultated breath sounds in anterior right lower lobe	Exam Action 04/11/25 8:26 AM EDT
	Auscultated breath sounds in anterior left lower lobe	Exam Action 04/11/25 8:26 AM EDT
	Auscultated breath sounds in posterior left upper lobe	Exam Action 04/11/25 8:26 AM EDT
	Auscultated breath sounds in posterior right upper lobe	Exam Action 04/11/25 8:26 AM EDT
	Auscultated breath sounds in posterior left mid-back (lower lobe)	Exam Action 04/11/25 8:26 AM EDT
	Auscultated breath sounds in posterior right mid-back (lower lobe)	Exam Action 04/11/25 8:26 AM EDT
	Auscultated breath sounds in posterior left lower lobe	Exam Action 04/11/25 8:26 AM EDT
	Auscultated breath sounds in posterior right lower lobe	Exam Action 04/11/25 8:26 AM EDT
	Auscultated breath sounds in posterior left lower lobe on side	Exam Action 04/11/25 8:26 AM EDT
	Auscultated breath sounds in posterior left lower lobe near spine	Exam Action 04/11/25 8:26 AM EDT
	Auscultated breath sounds in posterior right lower lobe near spine	Exam Action 04/11/25 8:26 AM EDT
	Auscultated breath sounds in posterior right lower lobe on side	Exam Action 04/11/25 8:26 AM EDT
	Auscultated aortic area with the bell	Exam Action 04/11/25 8:27 AM EDT
	Auscultated pulmonic area with the bell	Exam Action 04/11/25 8:27 AM EDT
	Auscultated pulmonic area with the diaphragm	Exam Action 04/11/25 8:27 AM EDT
	Auscultated pulmonic area with the bell	Exam Action 04/11/25 8:27 AM EDT
	Auscultated Erb’s point with the bell	Exam Action 04/11/25 8:27 AM EDT
	Auscultated Erb’s point with the diaphragm	Exam Action 04/11/25 8:27 AM EDT
	Auscultated tricuspid area with the diaphragm	Exam Action 04/11/25 8:27 AM EDT
	Auscultated mitral area with the diaphragm	Exam Action 04/11/25 8:27 AM EDT
	Auscultated aorta in abdomen	Exam Action 04/11/25 8:27 AM EDT
	Auscultated right renal pulse	Exam Action 04/11/25 8:27 AM EDT
	Auscultated left renal pulse	Exam Action 04/11/25 8:27 AM EDT
	Auscultated right iliac pulse	Exam Action 04/11/25 8:27 AM EDT
	Auscultated left iliac pulse	Exam Action 04/11/25 8:27 AM EDT
	Auscultated right femoral pulse	Exam Action 04/11/25 8:28 AM EDT
	Auscultated left femoral pulse	Exam Action 04/11/25 8:28 AM EDT
	Tested ABI: 141/145 = 0.972	Exam Action 04/11/25 8:28 AM EDT
	Performed EKG: Regular sinus rhythm, no ST changes	Exam Action 04/11/25 8:28 AM EDT

Subjective Data Collection: 19 of 19 (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 recent episodes of palpitations

(Found)

Pro Tip: Broad questions like this one enable the patient to establish their chief complaint. Asking Tina if she’s had any problems with her heart will allow her to mention any concerns she’s recently had regarding her heart.

Example Question:

Have you ever had palpitations?

Finding:

Describes heart rate during episodes as feeling “faster than usual”

(Found)

Pro Tip: Broad questions like this one enable the patient to establish their chief complaint. Asking Tina if she’s had any problems with her heart will allow her to mention any concerns she’s recently had regarding her heart.

Example Question:

Have you had any problems with your heart?

History of Presenting Illness

Finding:

Asked about onset

Finding:

Reports first episode a month ago

(Found)

Pro Tip: Determining the onset of a health problem is the first step to understanding if the underlying condition is acute or chronic.

Example Question:

How long ago did you start having palpitations?

Finding:

Asked about frequency and duration of fast heartbeat episodes

Finding:

Reports episodes occur “about once a week”

(Found)

Pro Tip: Conditions, like palpitations, might change over time. Asking Tina when her palpitations began will give you a broader sense for her condition and her chief complaint.

Example Question:

When do the palpitations occur?

Finding:

Reports 3-4 episodes total

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina how many palpitation episodes she’s experienced in the last month specifies the way her individual symptoms manifest.

Example Question:

How many palpitation episodes have you had?

Finding:

Reports fast heartbeat episodes last 5-10 minutes

(Available)

Pro Tip: Conditions, like palpitations, might change over time. Asking Tina about the duration of her palpitations recently will allow you to assess the recent severity of her condition.

Example Question:

How long do your palpitations last?

Finding:

Asked about character of palpitations

Finding:

Describes palpitations as “thumping” or “pounding”

(Found)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina to describe her palpitations specifies the way her individual symptoms manifest.

Example Question:

How does your heart feel during the palpitations?

Finding:

Reports episodes accompanied by mild anxiety

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina whether she is anxious during her palpitations specifies the way her individual symptoms manifest.

Example Question:

Do you feel anxious during the palpitations?

Finding:

Asked about aggravating factors

Finding:

Reports that palpitations seem to occur more often in the morning

(Found)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina to describe when her palpitations began specifies the way her individual symptoms manifest.

Example Question:

When do you feel the palpitations?

Finding:

Reports episodes not exacerbated by exertion

(Available)

Pro Tip: Conditions, like palpitations, might change over time. Asking Tina if the palpitations are worse with exertion will allow you to assess the recent severity of her condition.

Example Question:

Do the palpitations get worse with exertion?

Finding:

Reports that episodes do not occur after eating

(Available)

Pro Tip: Some people experience palpitation after eating certain foods. Asking Tina whether she experiences palpitations after eating might indicate she is sensitive to certain foods (like foods that are spicy or contain MSG or caffeine).

Example Question:

Does food make your palpitations worse?

Finding:

Reports caffeine as a possible aggravating factor

(Found)

Pro Tip: Some people who drink caffeinated beverages have higher blood pressure than those who don’t drink caffeinated beverages. Asking Tina whether the caffeine is affecting her heart rate might point to the caffeine as a contributing factor to Tina’s palpitations.

Example Question:

Does the caffeine affect your heart rate?

Finding:

Asked about relieving factors

Finding:

Reports deep breathing and trying to relax

(Found)

Pro Tip: By asking Tina what relieves her palpitations you’re soliciting information about the way she treats, manages, or endures an uncomfortable symptom.

Example Question:

What relieves your palpitations?

Finding:

Denies medication or other treatment

(Available)

Pro Tip: Tina’s response to a question about the management of her palpitations will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.

Example Question:

What treatments have you tried for your palpitations?

Medical History

Finding:

Confirmed use of medications

Finding:

Confirms medications from previous visit

(Found)

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

Example Question:

Have you started any new medications?

Finding:

Reports new inhaler

(Found)

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

Example Question:

Do you use an inhaler?

Finding:

Followed up on new inhaler

Finding:

New inhaler is Flovent

(Found)

Pro Tip: You must find out the specific name or brand of a patient’s medication.

Example Question:

What is the name of your daily inhaler?

Finding:

Prescribed dose is two puffs

(Available)

Pro Tip: When you ask about the specific dosage that a patient is supposed to take, you learn more about their medication regiment, and their level of health literacy surrounding medication use.

Example Question:

How many puffs do you take of your inhaler?

Finding:

Inhaler is prescribed for daily use

(Available)

Pro Tip: Increased inhaler use, or using more puffs of an inhaler than prescribed, can indicate poorly managed asthma.

Example Question:

How often do you use your inhaler?

Finding:

Describes new inhaler regiment as effective

(Available)

Pro Tip: Finding out the patient’s perception of how effective an inhaler is gives you insight into how they feel their asthma is managed.

Example Question:

Is your inhaler working?

Finding:

Confirmed allergies

Finding:

Confirms allergies (no new allergies reported)

(Found)

Pro Tip: It’s best practice to ask a patient about her allergies each visit, even with an established patient, to uncover any new allergy triggers or symptoms.

Example Question:

Have you had any new allergies?

Finding:

Asked about personal history of hypertension

Finding:

Reports usual blood pressure “might be on the high side”

(Available)

Pro Tip: Blood pressure might change over time due to such factors as caffeine consumption, stress, diet, and exercise. Asking Tina what her usual blood pressure is will provide a baseline for comparing her last reading to her blood pressure now.

Example Question:

What is your usual blood pressure?

Finding:

Denies past diagnosis of hypertension

(Found)

Pro Tip: Cardiovascular disease can manifest in various conditions. Inquiring into Tina’s relevant history can reveal past diagnoses and previous conditions or concerns.

Example Question:

Have you been diagnosed with high blood pressure?

Finding:

Does not check BP regularly

(Found)

Pro Tip: Blood pressure might change over time due to such factors as caffeine consumption, stress, diet, and exercise. Asking Tina how frequently she checks her blood pressure will show how often she is monitoring her cardiovascular health.

Example Question:

How often do you check your blood pressure?

Finding:

Is aware of risk factors for hypertension

(Available)

Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking Tina if she is aware that her family history of hypertension puts her at risk for cardiovascular disease indicates Tina’s health literacy.

Example Question:

Do you know your family history of high blood pressure is a risk factor for heart disease?

Finding:

Asked about possible contributing factors in health history

Finding:

Reports no known history of heart disease

(Available)

Pro Tip: Heart disease is the umbrella term to describe many conditions that might affect your heart. Asking Tina whether she has a history of heart disease is the first question in determining her specific cardiovascular concerns.

Example Question:

Do you have any history of heart disease

Finding:

Reports type 2 diabetes

(Found)

Pro Tip: Adults with diabetes are between two and four times more likely to suffer from cardiovascular disease. Determining whether Tina has diabetes will indicate if she is at a higher risk for heart disease.

Example Question:

Do you have diabetes?

Finding:

Reports no past diagnosis of high cholesterol

(Available)

Pro Tip: High cholesterol can lead to cardiovascular disease. Asking Tina whether she’s had a history of high cholesterol reveals her recent medical history.

Example Question:

Do you have high cholesterol?

Finding:

Reports no history of rheumatic fever

(Available)

Pro Tip: Rheumatic fever can cause irreversible damage to the heart. Asking Tina whether she’s had rheumatic fever would point to a condition that might have affected her cardiovascular health.

Example Question:

Do you have any history of rheumatic fever?

Finding:

Reports no history of heart murmur

(Found)

Pro Tip: Some heart murmurs can indicate a damaged or overworked heart valve. Asking Tina whether she’s experienced a heart murmur allows you to assess whether she’s noticed a symptom that indicates a heart condition.

Example Question:

Do you have any history of heart murmur?

Finding:

Reports no EKG or other diagnostic cardiac tests

(Available)

Pro Tip: An EKG test checks for electrical problems with the heart. Asking Tina whether she’s had an EKG will reveal her recent medical history and medical literacy.

Example Question:

Have you ever had an EKG?

Social Determinants of Health

Finding:

Asked about stress and anxiety

Finding:

Reports occasional feelings of anxiety

(Available)

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

Example Question:

Have you ever experienced anxiety?

Finding:

Reports recent increase in stress

(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:

Have you been more stressed lately?

Finding:

Reports stress related to school and work

(Available)

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

Example Question:

What causes you stress?

Social History

Finding:

Asked about typical diet

Finding:

Breakfast is usually a muffin or pumpkin bread

(Available)

Pro Tip: A healthy and balanced diet is crucial in the prevention of heart disease. Asking Tina about her typical breakfast will allow you to assess whether her eating habits put her at risk of cardiovascular disease.

Example Question:

What’s your usual breakfast?

Finding:

Lunch is usually a sandwich

(Available)

Pro Tip: A healthy and balanced diet is crucial in the prevention of heart disease. Asking Tina about her typical lunch will allow you to assess whether her eating habits put her at risk of cardiovascular disease.

Example Question:

What’s your usual lunch?

Finding:

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

(Available)

Pro Tip: A healthy and balanced diet is crucial in the prevention of heart disease. Asking Tina about her typical dinner will allow you to assess whether her eating habits put her at risk of cardiovascular disease.

Example Question:

What’s your usual dinner?

Finding:

Snacks are pretzels or French fries

(Available)

Pro Tip: A healthy and balanced diet is crucial in the prevention of heart disease. Asking Tina about her typical snacks will allow you to assess whether her eating habits put her at risk of cardiovascular disease.

Example Question:

What’s your usual snack?

Finding:

Asked about caffeine consumption

Finding:

Reports increased caffeine consumption

(Available)

Pro Tip: Drinking more caffeine might point to underlying conditions like increased fatigue. Asking why Tina is drinking more caffeine will indicate a context for broader physical or mental health concerns.

Example Question:

Have you been drinking more caffeine lately?

Finding:

Reports consuming diet soda or energy drinks

(Found)

Pro Tip: Diet soda consumption has been linked to heart disease. Asking Tina if she drinks soda allows you to assess if her dietary habits put her at increased risk for cardiovascular disease.

Example Question:

Do you drink soda?

Finding:

Reports caffeine increase was over last month

(Available)

Pro Tip: Some people who drink caffeinated beverages have higher blood pressure than those who don’t drink caffeinated beverages. Asking Tina how long she has been drinking more caffeine might point to the caffeine as a contributing factor to Tina’s palpitations.

Example Question:

How long have you been drinking more caffeine?

Finding:

Typical drinks 2 energy drinks before class

(Found)

Pro Tip: Most energy drinks have more caffeine per ounce than caffeine found in coffee or tea. Asking Tina about her energy drink consumption will indicate whether she is consuming too many energy drinks.

Example Question:

How many energy drinks do you drink in a day?

Finding:

Reports caffeine “keeps me focused but sometimes makes me jittery”

(Available)

Pro Tip: Some people who drink caffeinated beverages have higher blood pressure than those who don’t drink caffeinated beverages. Asking Tina about how caffeine affects her will indicate whether Tina’s caffeine habits might be linked to her cardiac condition.

Example Question:

What effect does caffeine have on you?

Finding:

Asked about exercise and activity level

Finding:

Reports general low activity level

(Found)

Pro Tip: Regular exercise, when paired with a healthy diet, is one of the most effective ways to limit the risk of cardiovascular disease. Asking Tina whether she exercises will reveal her lifestyle and level of fitness, two factors that are fundamental to a healthy cardiovascular system.

Example Question:

Do you exercise?

Finding:

Asked about substance use

Finding:

Reports occasional consumption of alcohol

(Found)

Pro Tip: Alcohol consumption can cause palpitations in certain types of conditions. Asking about consumption can help you determine if it’s a factor in this patient’s case.

Example Question:

Do you ever drink alcohol?

Finding:

Last alcoholic drink was two weeks ago

(Available)

Pro Tip: Use of nicotine-containing products can cause cardiovascular problems. Asking about use can help you determine if it’s a factor in this patient’s case.

Example Question:

When did you last have alcohol?

Finding:

Denies history of tobacco use, including cigarettes

(Found)

Pro Tip: Tobacco affects the heart by reducing the amount of oxygen the blood is able to carry. Asking Tina if she uses tobacco will allow you to assess whether the condition is caused, in part, by tobacco use.

Example Question:

Do you use tobacco?

Finding:

Denies drug use

(Found)

Pro Tip: Many drugs affect the central nervous system or can cause cardiovascular complications. Asking Tina if she uses illicit drugs will indicate whether drug use is a factor in her palpitations.

Example Question:

Do you use drugs?

Review of Systems

Finding:

Asked about general symptoms

Finding:

Denies recent respiratory or other illness

(Available)

Pro Tip: Broad, open questions will allow Tina to describe, in her own words, the specific pain and discomfort that she is experiencing.

Example Question:

Have you been sick recently?

Finding:

Denies fever

(Available)

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

Example Question:

Have you had any fever symptoms?

Finding:

Denies nausea or vomitting

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like nausea, details the way her individual symptoms and pain manifest.

Example Question:

Have you had nausea or vomiting?

Finding:

Denies chills

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like getting chills, details the way her individual symptoms and pain manifest.

Example Question:

Have you had chills?

Finding:

Reports low energy level

(Found)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like fatigue, details the way her individual symptoms and pain manifest.

Example Question:

Are you fatigued?

Finding:

Denies night sweats

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her injury, like night sweats, details the way her individual symptoms and pain manifest.

Example Question:

Have you had night sweats?

Finding:

Asked about review of systems for cardiovascular

Finding:

Denies shortness of breath

(Found)

Pro Tip: Conditions, like palpitations, might change over time. Asking Tina whether she has shortness of breath during palpitations will allow you to assess the recent severity of her condition.

Example Question:

Do you have any shortness of breath during the palpitations?

Finding:

Denies chest pain or tightness

(Found)

Pro Tip: Chest pain manifests in various ways, from a muted ache to a stabbing pain. Asking Tina whether she’s had chest pain can point to such conditions as angina or heart attack, among others.

Example Question:

Have you ever had any chest pain?

Finding:

Denies edema

(Found)

Pro Tip: When the heart weakens and pumps blood less effective, the resulting fluid that accumulates can lead to edema. Asking Tina whether she’s experienced edema allows you to assess if her heart is pumping less effectively.

Example Question:

Have you ever had any swelling?

Finding:

Denies circulation problems

(Found)

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

Example Question:

Have you ever had problems with circulation?

Finding:

Denies easy bleeding or bruising

(Available)

Pro Tip: Bleeding or bruising easily means that the capillaries under the skin break easily and often and can be indicative of a severe blood disorder. Asking Tina whether she has been bleeding easily allows you to assess other conditions that might be affecting her chief complaint.

Example Question:

Do you bleed easily?

Finding:

Denies dizziness, lightheadedness, or syncope

(Available)

Pro Tip: Lightheadedness might be a symptom of arrhythmias. Asking Tina whether she has a history of lightheadedness illustrates her medical history relating to her chief complaint.

Example Question:

Have you had any lightheadedness?

Family History

Finding:

Asked about relevant family history

Finding:

Reports family history of heart disease or CAD

(Found)

Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina’s family has a history of high cholesterol might reveal her health literacy and predisposition to heart disease.

Example Question:

Do you have a family history of coronary artery disease?

Finding:

Reports family history of high cholesterol

(Available)

Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina’s family has a history of hypertension might reveal her health literacy and predisposition to heart disease.

Example Question:

Do you have a family history of high cholesterol?

Finding:

Reports family history of hypertension

(Available)

Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina’s family has a history of myocardial infarction might reveal her health literacy and predisposition to heart disease.

Example Question:

Do you have a family history of high blood pressure?

Finding:

Reports family history of myocardial infarction

(Found)

Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina’s family has a history of coronary artery disease might reveal her health literacy and predisposition to heart disease.

Example Question:

Do you have a family history of heart attack?

Finding:

Reports family history of stroke

(Available)

Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina’s family has a history of stroke might reveal her health literacy and predisposition to heart disease.

Example Question:

Do you have a family history of stroke?

Finding:

Reports family history of obesity

Objective Data Collection: 22.17 of 23 (96.39%)

Correct
Partially correct

Incorrect
Missed

Inspected chest

Inspected for jugular venous distention

Symmetry (1/2 point)

Symmetric

Appearance (1/2 point)

No visible abnormal findings

Height Of Venous Pressure (1/1 point)

4 cm or less above the sternal angle

Inspected hands and fingernails

Inspected lower extremities and toenails

Right: Nail Changes (1/3 point)

No visible abnormal findings

Left: Nail Changes (1/3 point)

No visible abnormal findings

Capillary Refill Time (1/3 point)

3 seconds or less

0.67 of 1 point

Right: Edema (No point)

No edema

Right: Severity Of Edema (No point)

No edema

Right: Appearance (No point)

No visible abnormal findings

Right: Nail Changes (1/9 point)

No visible abnormal findings
Left: Edema (1/9 point)

No edema

Left: Severity Of Edema (1/9 point)

No edema

Left: Appearance (1/9 point)

No visible abnormal findings

Left: Nail Changes (1/9 point)

No visible abnormal findings

Capillary Refill Time (1/9 point)

3 seconds or less

Palpated temporal arteries

Right: Vibration (1/4 point)

No thrill

Right: Amplitude (1/4 point)

2+ Expected

Left: Vibration (1/4 point)

No thrill

Left: Amplitude (1/4 point)

2+ Expected

Palpated carotid arteries

Right: Vibration (1/4 point)

No thrill

Right: Amplitude (1/4 point)

2+ Expected

Left: Vibration (1/4 point)

No thrill

Left: Amplitude (1/4 point)

2+ Expected

Palpated PMI

Location (1/3 point)

Present at midclavicular line and 5th intercostal space

Amplitude (1/3 point)

Brisk and tapping

Diameter (1/3 point)

Less than 3 cm

Palpated radial arteries

Right: Vibration (1/4 point)

No thrill

Right: Amplitude (1/4 point)

2+ Expected

Left: Vibration (1/4 point)

No thrill

Left: Amplitude (1/4 point)

2+ Expected

Palpated brachial arteries

Right: Vibration (1/4 point)

No thrill

Right: Amplitude (1/4 point)

2+ Expected

Left: Vibration (1/4 point)

No thrill

Left: Amplitude (1/4 point)

2+ Expected

Palpated femoral arteries

Right: Vibration (1/4 point)

No thrill
Thrill

Right: Amplitude (1/4 point)

2+ Expected

Left: Vibration (1/4 point)

No thrill

Left: Amplitude (1/4 point)

2+ Expected

Palpated popliteal arteries

Right: Vibration (1/4 point)

No thrill

Right: Amplitude (1/4 point)

2+ Expected

Left: Vibration (1/4 point)

No thrill

Left: Amplitude (1/4 point)

2+ Expected

Palpated tibial arteries

0.75 of 1 point

Right: Vibration (1/4 point)

No thrill

Right: Amplitude (No point)

2+ Expected

Left: Vibration (1/4 point)

No thrill

Left: Amplitude (1/4 point)

2+ Expected

Palpated dorsalis pedis arteries

0.75 of 1 point

Right: Vibration (1/4 point)

No thrill

Right: Amplitude (No point)

2+ Expected

Left: Vibration (1/4 point)

No thrill
Thrill

Left: Amplitude (1/4 point)

0 Absent
1+ Diminished or barely palpable
2+ Expected
3+ Increased
4+ Bounding pulse

Auscultated temporal arteries

Right (1/2 point)

No bruit

Left (1/2 point)

No bruit

Auscultated carotid arteries

Right (1/2 point)

No bruit

Left (1/2 point)

No bruit

Breath Sounds (1/3 point)

Present in all areas

Adventitious Sounds (1/3 point)

No adventitious sounds

Location (1/3 point)

All areas clear

Auscultated heart sounds

Heart Sounds (1/2 point)

S1 and S2 audible

Extra Heart Sounds (1/2 point)

No extra sounds

Auscultated abdominal aorta

Sounds (1/1 point)

No bruit

Auscultated renal arteries

Right (1/2 point)

No bruit

Left (1/2 point)

No bruit

Auscultated iliac arteries

Right (1/2 point)

No bruit

Left (1/2 point)

No bruit

Auscultated femoral arteries

Right (1/2 point)

No bruit

Left (1/2 point)

No bruit

Performed ankle-brachial index test

Abi (1/1 point)

0.90 – 0.99 (borderline ischemia)

Performed EKG

Sinus Rhythm (1/2 point)

Regular

St Changes (1/2 point)

No ST changes

Education & Empathy : 1 of 5 (20.0%)

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

	Description: Tina describes the symptoms that have been bothering her.
	When do the palpitations occur?	Question 08:13 AM EDT
	I’ve only noticed them in the mornings, usually on the way to class. Maybe like once a week.
	How does your heart feel during the palpitations?	Question 08:14 AM EDT
	Well, my heart doesn’t hurt, but it feels like thumping. Just a fast, thumping heartbeat, I guess.
	What is the name of your daily inhaler?	Question 08:15 AM EDT
	The daily inhaler is Flovent, and the rescue inhaler is Proventil.
	Exercise is health for your body and can help relief stress	Educate 08:15 AM EDT
	Alright, thanks for letting me know.
	A family history of hypertension means that you may be at risk of developing it and its therefore important to monitor it.	Educate 08:16 AM EDT
	OK, I understand.
	Model Statement: “I’m sorry to hear you’re experiencing those symptoms; they can be very uncomfortable. I’ll ask you some questions to learn more about your symptoms, and we will try to determine what’s causing you to feel this way.”

2 Hypertension

	Description: Tina has signs of hypertension and a strong family history of the disease, but does not take any action.
	Do you have a history of hypertension	Question 08:07 AM EDT
	…I’ve never been diagnosed with blood pressure problems. But I think it can be on the high side sometimes.
	Do you check your blood pressure?	Question 08:07 AM EDT
	Only when I’m here at the clinic.
	Do you have diabetes?	Question 08:07 AM EDT
	Yeah, I was diagnosed a few years ago.
	Do you have any stress?	Question 08:08 AM EDT
	Model Statement: “A family history of hypertension means that you may be at risk for developing it, too, and you’ve had some high blood pressure readings. Keeping your blood pressure low is important to avoid health problems in the future with your heart and other organs.”

3 Stress

	Description: Tina describes being busy, anxious, and stressed out.
	Do you have any stress?	Question 08:08 AM EDT
	Yeah, I’ve been pretty stressed lately.
	Do you exercise?	Question 08:08 AM EDT
	Model Statement: “Sounds like you’re working really hard. I’m sorry you’re dealing with so much stress.”

4 Caffeine

	Description: Tina drinks a high level of caffeine and does not stay hydrated with water.
	Do you drink coffee?	Question 07:59 AM EDT
	Never. I don’t like it. Too bitter for my taste. I drink energy drinks instead.
	How many energy drinks do you drink per day?	Question 07:59 AM EDT
	Usually just one in the morning, kind of like some people have a cup of coffee. Some mornings lately I’ve had two, though.
	Do you use drugs?	Question 07:59 AM EDT
	No.
	Which medication do you use? (Clarified to: What medications do you take?)	Question 08:00 AM EDT
	I have a daily inhaler and a rescue inhaler for my asthma. (Clarified to: what medications I am taking)
	Model Statement: “Drinking high levels of caffeine can make you feel stressed or anxious, and can dehydrate you. Over time, lots of caffeine can make you experience “crashes” during the day, too. Let’s talk about healthy alternatives.”

5 Exercise

	Description: Tina does not exercise on a regular basis.
	Do you exercise?	Question 08:08 AM EDT
	I’m pretty exhausted by the end of the day, so I don’t have the energy to do any extra exercise. But I’m on my feet all the time at work so I feel like that’s a little bit of exercise most days at least.
	Do you drink alcohol?	Question 08:08 AM EDT
	I do sometimes, yeah, when I go out with my friends.
	When do the palpitations occur?	Question 08:13 AM EDT
	Model Statement: “I understand being busy and having very little free time. However, exercise is healthy for you, and can even relieve stress. Even small amounts of exercise, such as taking a short walk, can improve your health.”

Documentation / Electronic Health Record

Document: Provider Notes

Document: Provider Notes

Student Documentation	Model Documentation
Subjective Tina JOnes present to the clinit with complaints of 3-4 episodes of rapid heart rates over the last month. She says it feels like “thumping in her chest” with a heart rate “way faster than usual”. This usually happens once per week. The episodes last between 5 to 10 minutes. She denies SOB. Has not taken any medications. She has increased consumption of energy drinks to 2 drinks before class to help being focused. She does not use tobacco, alcohol, and illicit drugs. She does not exercise.	Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of 3-4 episodes of rapid heart rate over the last month. She is a good historian. She describes these episodes as “thumping in her chest” with a heart rate that is “way faster than usual”. She does not associate the rapid heart rate with a specific event, but notes that they usually occur about once per week in the morning on her commute to class. The episodes generally last between 5 and 10 minutes and resolve spontaneously. She does not know her normal heart rate or her heart rate during these episodes. She denies chest pain during the episodes, but does endorse discomfort of 3/10 which she attributes to associated anxiety regarding her rapid heart rate. She denies shortness of breath. She denies any association of symptoms with exertion. She has no known cardiac history and has never had episodes prior to this last month. She has not attempted any treatment at home and states that she is only coming to the clinic today because her family has expressed concern regarding these episodes. Social History: Ms. Jones has a job at a copy and shipping store and is a student at Shadowville Community College. She states that she has been feeling more “stressed” lately due to her school and work. She has been feeling tired at the end of the day. She denies any specific changes in her diet recently, but notes that she has not been drinking as much water as her normal. Breakfast is usually a muffin or pumpkin bread, lunch is a sandwich, dinner is a homemade meal of a meat and vegetable, snacks are French fries or pretzels. Over the past month she has increased her consumption of diet soda and “energy” drinks due to her feelings of tiredness. She generally drinks 2 energy drinks before class to “keep her focused” but states that they also make her “jittery”. She denies use of tobacco, alcohol, and illicit drugs. She does not exercise. Review of Systems: General: Denies changes in weight, but complains of end of day fatigue. She denies fevers, chills, and night sweats. She complains of intermittent dizziness. • Cardiac: Denies a diagnosis of hypertension, but states that she has been told her blood pressure was high in the past. She checks it at CVS periodically. At last check it was “140/80 or 90”. She denies known history of murmurs, angina, previous palpitations, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, or edema. She has never had an EKG. • Respiratory: She denies shortness of breath, wheezing, cough, sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. She has a history of asthma, last hospitalization was age 16 for asthma, last chest XR was age 16. • Hematologic: She denies history of anemia, easy bruising or bleeding, petechiae, purpura, or blood transfusions.
Objective Ms. Jones is a pleasant African American woman. She is in no acute distress. She is alert and well oriented. PMI is non-displace, brisk and tapping, diameter 2 cm Regular rate and rhythm, S1 amd S2 present, no murmurs, rubs, gallops, precordial movements, pulses 2+ and equal bilaterally. No thrills. No temporal, carotid, abdominal aorta, femoral, renal bruits, No JVD, No peripheral edema, EKG with regurlar sinus rhythm, no ST changes, ABI is 0.97	• General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented. She maintains eye contact throughout interview and examination. • Cardiovascular: PMI is non-displaced, brisk and tapping, diameter 2 cm. Regular rate and rhythm, S1 and S2 present, no murmurs, rubs, gallops, clinics, precordial movements. Pulses 2+ and equal bilaterally in upper extremities and lower extremities without thrills. No temporal, carotid, abdominal aorta, femoral, iliac, or renal bruits. No JVD. Capillary refill < 3 seconds. No peripheral edema. EKG with regular sinus rhythm, no ST changes. ABI is 0.97. • Respiratory: Chest is symmetrical with respirations; no physical abnormalities present on chest wall. Lung sounds clear to auscultation without wheezes, crackles, or cough.
Assessment Palpitations related to caffeine and anxiety	Palpitations related to caffeine and/or anxiety
Plan – Continue monitoting symptoms – Obtain EKG to rule out cardiac abnormality – Decrease caffeine consumption – Educate on anxiety reduction strategies – Maintain a stable blood pressure – continue monitoring – Seek care when you notice symptoms – Revisit clinic in 2-4 weeks	Encourage Ms. Jones to continue to monitor symptoms and log her episodes of palpitations with associated factors and bring log to next visit. • Obtain EKG to rule out any cardiac abnormality and assess for symptom-correlated EKG changes. If inconclusive, consider ambulatory EKG monitoring and referral to cardiology. • Encourage to decrease caffeine consumption and increase intake of water and other fluids. • Educate on anxiety reduction strategies including deep breathing, relaxation, and guided imagery. Continue to monitor and explore the need for possible referral to social work/psychiatry or pharmacologic intervention. • Discuss the need to maintain a stable blood pressure. Encourage Ms. Jones to continue to monitor her blood pressure when a cuff or machine is available. • Educate Ms. Jones on when to seek emergent care including episodes of chest pain unrelieved by rest, palpitations that do not dissipate after anxiety related strategies were implemented, changes in vision, loss of consciousness, and sense of impending doom. • Revisit clinic in 2-4 weeks for follow up and evaluation.

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Tina Jones Respiratory Results

April 30, 2025/in BLOGS /by admin

Tina Jones Respiratory Results

Experience Overview

Patient: Tina Jones

Digital Clinical Experience Score

92.3%

This score measures your performance on the Student Performance Index in relation to other students in comparable academic programs. Your instructor has chosen to scale your Student Performance Index score so that the average score on the index is a 80.0%. This score may not be your final grade if your instructor chooses to include additional components, such as documentation or time spent.

Student Performance Index

28

out of

31

Proficiency Level:

Proficient

Students rated as “proficient” demonstrate an entry-level expertise in advanced practice competencies and clinical reasoning skills. In comparable programs, the top 25% of students perform at the level of a proficient practitioner.

Subjective Data Collection

21

out of

21

Objective Data Collection

6

out of

6

Education and Empathy

1

out of

4

Time

54 minutes total spent in assignment

Interaction with patient

54 minutes

Transcript

Started: Apr 11, 2025 | Total Time: 54 min

All Lines (142)Interview Questions (36)Statements (1)Exam Actions (105)

	Hello, my name is Mileidy. I will be your nurse today	Greet 04/11/25 5:20 AM EDT
	Hey.
	What brings you here today?	Question 04/11/25 5:21 AM EDT
	I came in because I’ve been having breathing problems, and my inhaler just isn’t working the way it normally does.
	I am sorry for that	Empathize 04/11/25 5:21 AM EDT
	I appreciate you telling me that.
	When did the symptoms start?	Question 04/11/25 5:21 AM EDT
	I don’t know if I’d call it an asthma attack, but my asthma started acting up two days ago at my cousin’s house. She has cats, and I’m allergic, so I’m used to it being a problem there, but usually the inhaler fixes it. . . it doesn’t feel totally under control, though.
	What are the frequency of the episodes? (No matching questions found.)	Question 04/11/25 5:22 AM EDT
	How severe are the symptoms?	Question 04/11/25 5:22 AM EDT
	My asthma used to be really scary. I haven’t had a full attack in years, and if you had asked me before this I would have said my asthma wasn’t that bad anymore, but the last couple days I’ve had a lot of trouble breathing.
	How frequent are the asthma attacks?	Question 04/11/25 5:23 AM EDT
	I haven’t had a full attack in years, though lately my asthma’s definitely been worse than usual.
	What are the characteristics of the symptoms? (Clarified to What would you describe your symptoms as?.)	Question 04/11/25 5:23 AM EDT
	Well, I’m having breathing problems. I keep feeling tight in my chest and I’ve had some wheezing. (Clarified to how I would describe my symptoms.)
	Do you cough?	Question 04/11/25 5:23 AM EDT
	I’ve been coughing a lot, yeah.
	What aggravates the symptoms?	Question 04/11/25 5:23 AM EDT
	If I move around or try to be too active, I cough more.
	How frequently do you have shortness of breath?	Question 04/11/25 5:24 AM EDT
	Maybe as much as every four hours? It’s a lot.
	Do you use medications?	Question 04/11/25 5:25 AM EDT
	No.
	Have you been using any medications?	Question 04/11/25 5:25 AM EDT
	I don’t take anything, unless my inhaler counts.
	When did you know you have asthma? (Clarified to When did your asthma start?.)	Question 04/11/25 5:26 AM EDT
	I think I was about two and a half? I used to have a lot of trouble with asthma attacks back then. (Clarified to when I first got asthma.)
	Have you been hospitalized for asthma?	Question 04/11/25 5:26 AM EDT
	I went a bunch of times when I was little, for asthma attacks.
	How do you manage the asthma?	Question 04/11/25 5:27 AM EDT
	I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler.
	What are the forms of non-medication forms of asthma management? (No matching questions found.)	Question 04/11/25 5:28 AM EDT
	do you use any non-medical form of asthma management?	Question 04/11/25 5:28 AM EDT
	All I really do is keep my inhaler with me and use it if I need it.
	How do you control your environment?	Question 04/11/25 5:29 AM EDT
	I’m not sure what you mean by “control.” [AUDIO COMING SOON]
	Where do you leave? (Clarified to Where do you live?.)	Question 04/11/25 5:29 AM EDT
	Right now I’m living at my mom’s place, which is out in the suburbs a bit. It’s like a half hour from here. (Clarified to where I live.)
	How is the condition of where to live? (No matching questions found.)	Question 04/11/25 5:30 AM EDT
	Do you exercise?	Question 04/11/25 5:30 AM EDT
	It’s really not my thing. I get some exercise by being on my feet at work and walking around campus, that sort of thing. But jumping around in spandex is not my idea of a good time.
	Do you smoke?	Question 04/11/25 5:30 AM EDT
	No. I think it’s gross.
	Do you have any other respiratory issue?	Question 04/11/25 5:31 AM EDT
	Other than what I’ve told you? I don’t think so. It’s just needing my inhaler so much and the cough that’s been bothering me.
	Do you have a family history of respiratory issue?	Question 04/11/25 5:31 AM EDT
	My baby sister has asthma, too, but no one else in the family has lung problems, I don’t think.
	Do you have a history of COPD?	Question 04/11/25 5:38 AM EDT
	No, I don’t think so.
	Do you have a history of COPD?	Question 04/11/25 5:43 AM EDT
	No, I don’t think so.
	Have you had eczema?	Question 04/11/25 5:48 AM EDT
	No, I don’t have that kind of skin problem.
	Do you have allergy?	Question 04/11/25 5:52 AM EDT
	Yeah, I’m allergic to cats.
	are you exposed to allergens?	Question 04/11/25 5:53 AM EDT
	Two days ago, at my cousin’s house. She has three of them, and my asthma always goes crazy when I’m there.
	What started your recent asthma problem?	Question 04/11/25 5:53 AM EDT
	This all started at my cousin’s house. She has cats, and I’m allergic, so my asthma always goes crazy when I’m there.
	Does being around dust trigger the asthma?	Question 04/11/25 5:54 AM EDT
	Yeah, being around a lot of dust, especially hanging out in a really dusty house, can make my asthma act up.
	Do changes in weather make your asthma worse?	Question 04/11/25 5:56 AM EDT
	Not that I’ve noticed.
	Do you have seasonal asthma problems?	Question 04/11/25 5:57 AM EDT
	A little while ago, I had some seasonal allergies, but it didn’t really bother my asthma, and it’s better now.
	Do you have environmental exposures at home or at work?	Question 04/11/25 5:58 AM EDT
	No, unless cats count.
	How is your social determinant of health?	Question 04/11/25 5:58 AM EDT
	I’ve known most of my girlfriends since high school. We’ve been a pretty tight group for a long time. I am really close to people at church too, especially the ones in my bible study group. I sometimes get drinks with the other shift-supervisors at work, but we’re not super close.
	Are you exposed to secondhand smoke?	Question 04/11/25 6:00 AM EDT
	Some of my friends smoke when we go out drinking. But I don’t smoke, and nobody at home smokes.
	Inspected anterior chest wall	Exam Action 04/11/25 6:04 AM EDT
	Inspected right side chest wall	Exam Action 04/11/25 6:04 AM EDT
	Inspected posterior chest wall	Exam Action 04/11/25 6:04 AM EDT
	Inspected left side chest wall	Exam Action 04/11/25 6:04 AM EDT
	Inspected anterior chest wall	Exam Action 04/11/25 6:04 AM EDT
	Inspected left side chest wall	Exam Action 04/11/25 6:04 AM EDT
	Inspected posterior chest wall	Exam Action 04/11/25 6:04 AM EDT
	Inspected right side chest wall	Exam Action 04/11/25 6:04 AM EDT
	Inspected anterior chest wall	Exam Action 04/11/25 6:04 AM EDT
	Palpated chest expansion: Both sides rise symmetrically	Exam Action 04/11/25 6:05 AM EDT
	Palpated fremitus in anterior upper chest wall: Equal bilaterally, expected vibration	Exam Action 04/11/25 6:05 AM EDT
	Ninety-nine.
	Palpated fremitus in anterior lower chest wall: Equal bilaterally, expected vibration	Exam Action 04/11/25 6:05 AM EDT
	Ninety-nine.
	Palpated fremitus in posterior upper chest wall: Equal bilaterally, expected vibration	Exam Action 04/11/25 6:05 AM EDT
	Ninety-nine.
	Palpated fremitus in posterior middle chest wall: Equal bilaterally, expected vibration	Exam Action 04/11/25 6:05 AM EDT
	Ninety-nine.
	Palpated fremitus in posterior lower chest wall: Equal bilaterally, expected vibration	Exam Action 04/11/25 6:05 AM EDT
	Ninety-nine.
	Percussed anterior right upper lobe	Exam Action 04/11/25 6:06 AM EDT
	Percussed anterior left upper lobe	Exam Action 04/11/25 6:06 AM EDT
	Percussed anterior right middle lobe	Exam Action 04/11/25 6:06 AM EDT
	Percussed anterior left mid-chest (upper lobe)	Exam Action 04/11/25 6:06 AM EDT
	Percussed anterior right lower lobe	Exam Action 04/11/25 6:06 AM EDT
	Percussed anterior left lower lobe	Exam Action 04/11/25 6:06 AM EDT
	Percussed posterior left upper lobe	Exam Action 04/11/25 6:06 AM EDT
	Percussed posterior right upper lobe	Exam Action 04/11/25 6:06 AM EDT
	Percussed posterior left mid-back (lower lobe)	Exam Action 04/11/25 6:06 AM EDT
	Percussed posterior right mid-back (lower lobe)	Exam Action 04/11/25 6:06 AM EDT
	Percussed posterior left lower lobe	Exam Action 04/11/25 6:06 AM EDT
	Percussed posterior right lower lobe	Exam Action 04/11/25 6:06 AM EDT
	Percussed posterior left lower lobe on side	Exam Action 04/11/25 6:06 AM EDT
	Percussed posterior left lower lobe near spine	Exam Action 04/11/25 6:06 AM EDT
	Percussed posterior right lower lobe near spine	Exam Action 04/11/25 6:06 AM EDT
	Percussed posterior right lower lobe on side	Exam Action 04/11/25 6:06 AM EDT
	Auscultated breath sounds in anterior right upper lobe	Exam Action 04/11/25 6:07 AM EDT
	Auscultated breath sounds in anterior left upper lobe	Exam Action 04/11/25 6:07 AM EDT
	Auscultated breath sounds in anterior right middle lobe	Exam Action 04/11/25 6:07 AM EDT
	Auscultated breath sounds in anterior left mid-chest (upper lobe)	Exam Action 04/11/25 6:07 AM EDT
	Auscultated breath sounds in anterior right lower lobe	Exam Action 04/11/25 6:07 AM EDT
	Auscultated breath sounds in anterior left lower lobe	Exam Action 04/11/25 6:07 AM EDT
	Auscultated breath sounds in posterior left upper lobe	Exam Action 04/11/25 6:07 AM EDT
	Auscultated breath sounds in posterior right upper lobe	Exam Action 04/11/25 6:07 AM EDT
	Auscultated breath sounds in posterior left mid-back (lower lobe)	Exam Action 04/11/25 6:07 AM EDT
	Auscultated breath sounds in posterior right mid-back (lower lobe)	Exam Action 04/11/25 6:07 AM EDT
	Auscultated breath sounds in posterior left lower lobe	Exam Action 04/11/25 6:07 AM EDT
	Auscultated breath sounds in posterior right lower lobe	Exam Action 04/11/25 6:07 AM EDT
	Auscultated breath sounds in posterior left lower lobe on side	Exam Action 04/11/25 6:07 AM EDT
	Auscultated breath sounds in posterior left lower lobe near spine	Exam Action 04/11/25 6:07 AM EDT
	Auscultated breath sounds in posterior right lower lobe near spine	Exam Action 04/11/25 6:08 AM EDT
	Auscultated breath sounds in posterior right lower lobe on side	Exam Action 04/11/25 6:08 AM EDT
	Auscultated voice sounds in anterior right upper lobe	Exam Action 04/11/25 6:08 AM EDT
	Ninety-nine.
	Auscultated voice sounds in anterior left upper lobe	Exam Action 04/11/25 6:08 AM EDT
	Ninety-nine.
	Auscultated voice sounds in anterior right middle lobe	Exam Action 04/11/25 6:08 AM EDT
	Ninety-nine.
	Auscultated voice sounds in anterior left mid-chest (upper lobe)	Exam Action 04/11/25 6:08 AM EDT
	Auscultated voice sounds in anterior right lower lobe	Exam Action 04/11/25 6:08 AM EDT
	Auscultated voice sounds in anterior left lower lobe	Exam Action 04/11/25 6:08 AM EDT
	Ninety-nine.
	Ninety-nine.
	Ninety-nine.
	Auscultated voice sounds in anterior right upper lobe	Exam Action 04/11/25 6:13 AM EDT
	Auscultated voice sounds in anterior left upper lobe	Exam Action 04/11/25 6:13 AM EDT
	Auscultated voice sounds in anterior right middle lobe	Exam Action 04/11/25 6:13 AM EDT
	Ninety-nine.
	Auscultated voice sounds in anterior left mid-chest (upper lobe)	Exam Action 04/11/25 6:13 AM EDT
	Auscultated voice sounds in anterior right lower lobe	Exam Action 04/11/25 6:13 AM EDT
	Auscultated voice sounds in anterior left lower lobe	Exam Action 04/11/25 6:13 AM EDT
	Ninety-nine.
	Auscultated voice sounds in posterior left upper lobe	Exam Action 04/11/25 6:14 AM EDT
	Ninety-nine.
	Auscultated voice sounds in posterior right upper lobe	Exam Action 04/11/25 6:14 AM EDT
	Auscultated voice sounds in posterior left mid-back (lower lobe)	Exam Action 04/11/25 6:14 AM EDT
	Ninety-nine.
	Auscultated voice sounds in posterior right mid-back (lower lobe)	Exam Action 04/11/25 6:14 AM EDT
	Ninety-nine.
	Auscultated voice sounds in posterior left lower lobe	Exam Action 04/11/25 6:14 AM EDT
	Auscultated voice sounds in posterior right lower lobe	Exam Action 04/11/25 6:14 AM EDT
	Ninety-nine.
	Auscultated voice sounds in posterior left lower lobe on side	Exam Action 04/11/25 6:14 AM EDT
	Auscultated voice sounds in posterior left lower lobe near spine	Exam Action 04/11/25 6:14 AM EDT
	Ninety-nine.
	Auscultated voice sounds in posterior right lower lobe near spine	Exam Action 04/11/25 6:14 AM EDT
	Ninety-nine.
	Auscultated voice sounds in posterior right lower lobe on side	Exam Action 04/11/25 6:14 AM EDT
	Ninety-nine.
	Auscultated breath sounds in anterior right upper lobe	Exam Action 04/11/25 6:14 AM EDT
	Auscultated breath sounds in anterior left upper lobe	Exam Action 04/11/25 6:14 AM EDT
	Auscultated breath sounds in anterior right middle lobe	Exam Action 04/11/25 6:14 AM EDT
	Auscultated breath sounds in anterior left mid-chest (upper lobe)	Exam Action 04/11/25 6:14 AM EDT
	Auscultated breath sounds in anterior left lower lobe	Exam Action 04/11/25 6:14 AM EDT
	Auscultated breath sounds in anterior right lower lobe	Exam Action 04/11/25 6:14 AM EDT
	Auscultated breath sounds in posterior left upper lobe	Exam Action 04/11/25 6:15 AM EDT
	Auscultated breath sounds in posterior right upper lobe	Exam Action 04/11/25 6:15 AM EDT
	Auscultated breath sounds in posterior left mid-back (lower lobe)	Exam Action 04/11/25 6:15 AM EDT
	Auscultated breath sounds in posterior right mid-back (lower lobe)	Exam Action 04/11/25 6:15 AM EDT
	Auscultated breath sounds in posterior left lower lobe	Exam Action 04/11/25 6:15 AM EDT
	Auscultated breath sounds in posterior right lower lobe	Exam Action 04/11/25 6:15 AM EDT
	Auscultated breath sounds in posterior left lower lobe on side	Exam Action 04/11/25 6:15 AM EDT
	Auscultated breath sounds in posterior left lower lobe near spine	Exam Action 04/11/25 6:15 AM EDT
	Auscultated breath sounds in posterior right lower lobe near spine	Exam Action 04/11/25 6:15 AM EDT
	Auscultated breath sounds in posterior right lower lobe on side	Exam Action 04/11/25 6:15 AM EDT
	Percussed anterior right upper lobe	Exam Action 04/11/25 6:15 AM EDT
	Percussed anterior left upper lobe	Exam Action 04/11/25 6:15 AM EDT
	Percussed anterior right middle lobe	Exam Action 04/11/25 6:15 AM EDT
	Percussed anterior left mid-chest (upper lobe)	Exam Action 04/11/25 6:16 AM EDT
	Percussed anterior right lower lobe	Exam Action 04/11/25 6:16 AM EDT
	Percussed anterior left lower lobe	Exam Action 04/11/25 6:16 AM EDT
	Percussed posterior left upper lobe	Exam Action 04/11/25 6:16 AM EDT
	Percussed posterior left mid-back (lower lobe)	Exam Action 04/11/25 6:16 AM EDT
	Percussed posterior right upper lobe	Exam Action 04/11/25 6:16 AM EDT
	Percussed posterior right mid-back (lower lobe)	Exam Action 04/11/25 6:16 AM EDT
	Percussed posterior left lower lobe	Exam Action 04/11/25 6:16 AM EDT
	Percussed posterior right lower lobe	Exam Action 04/11/25 6:16 AM EDT
	Percussed posterior left lower lobe on side	Exam Action 04/11/25 6:16 AM EDT
	Percussed posterior left lower lobe near spine	Exam Action 04/11/25 6:16 AM EDT
	Percussed posterior right lower lobe near spine	Exam Action 04/11/25 6:16 AM EDT
	Percussed posterior right lower lobe on side	Exam Action 04/11/25 6:17 AM EDT
	Check pulse oximetry using right hand	Exam Action 04/11/25 6:17 AM EDT
	Checked pulse oximetry using left hand	Exam Action 04/11/25 6:17 AM EDT
	Blow into the spirometer?	Question 04/11/25 6:18 AM EDT
	Checked spirometer	Exam Action 04/11/25 6:18 AM EDT
	Checked patient’s inhaler	Exam Action 04/11/25 6:18 AM EDT

Subjective Data Collection: 21 of 21 (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 increased breathing problems and shortness of breath

(Found)

Pro Tip: Foundational questions about general well-being are important in assessing how a patient feels at the current moment. This creates a space for Tina to contextualize her current feeling in relation to a chief complaint.

Example Question:

What brings you in today?

Finding:

Reports decreased effectiveness of inhaler

(Found)

Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.

Example Question:

Why did you decide to seek treatment?

History of Presenting Illness

Finding:

Asked about onset of symptoms

Finding:

Reports symptoms began two days ago

(Found)

Pro Tip: Determining the onset of a health problem is the first step to understanding if the underlying condition is acute or chronic.

Example Question:

How long have you had breathing problems?

Finding:

Asked about frequency and duration of SOB episodes

Finding:

Reports exacerbations lasting several minutes

(Available)

Pro Tip: Knowing the duration of an asthma or shortness of breath episode will give you insight into how effective the patient’s interventions are, and how severe the episode is.

Example Question:

How long do your asthma episodes last?

Finding:

Reports exacerbated breathing about every 4 hours since original episode

(Found)

Pro Tip: The frequency of asthma episodes or shortness of breath might vary over time. Asking Tina about her recent experience will expound upon her current condition.

Example Question:

How many times have you had breathing problems in the past two days?

Finding:

Reports waking up twice a night with asthma the past 2 nights

(Available)

Pro Tip: Many patients with asthma report trouble sleeping. Asking Tina if she has trouble sleeping can indicate the severity of her asthma.

Example Question:

How many times in the past two nights did asthma wake you up?

Finding:

Asked about severity of symptoms

Finding:

Describes asthma severity as “not full attack,” but worse than usual

(Found)

Pro Tip: Asthma severity might change over time for a variety of reasons. Asking Tina about the severity of her asthma will allow her to assess her condition.

Example Question:

How severe is your asthma?

Finding:

Reports asthma has been interfering with activities of daily life

(Available)

Pro Tip: Severe asthma can interfere with daily life. Asking Tina the degree to which asthma impacts her daily life can be illustrative of the relative severity of her asthma.

Example Question:

Is there anything you can’t do because of your asthma?

Finding:

Asked about character of symptoms

Finding:

Reports recent wheezing

(Found)

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

Example Question:

Do you wheeze during an asthma exacerbation?

Finding:

Reports chest tightness

(Found)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina to describe what happens when her asthma acts up will indicate how her individual symptoms manifest.

Example Question:

What happens when your asthma acts up?

Finding:

Denies chest pain

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina whether she experiences chest pain during an attack will indicate how her individual symptoms manifest.

Example Question:

Are the shortness of breath episodes associated with chest pain?

Finding:

Asked about cough

Finding:

Reports cough

(Found)

Pro Tip: A shallow history of a patient’s condition can provide a comparative baseline for juxtaposing an attack, exacerbation, and more regular breathing. Soliciting this information from Tina allows her to explain any recent developments with her asthma.

Example Question:

Have you been coughing?

Finding:

Cough has persisted since original asthma exacerbation 2 days ago

(Available)

Pro Tip: Some people who experience chronic asthma may be accustomed to coughing and thus might not volunteer this information. Asking Tina how long she has been coughing illustrates how her asthma is presenting.

Example Question:

How long have you had a cough?

Finding:

Describes cough as “dry”

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina to describe her cough specifies the way her individual symptoms manifest.

Example Question:

How would you describe your cough?

Finding:

Describes cough as “small” and not severe

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina to describe her cough specifies the way her individual symptoms manifest.

Example Question:

How severe is your cough?

Finding:

Reports cough slightly relieved by drinking water

(Available)

Pro Tip: Coughing can be a symptom of a constricted airway. Assessing what relieves Tina’s cough can open up a conversation about asthma management.

Example Question:

What makes your cough better?

Finding:

Has not treated cough with medication or home remedies

(Available)

Pro Tip: Some people who experience chronic asthma may be accustomed to coughing and thus might not treat this symptom. Asking Tina how she is treating her cough might reveal her current symptom management and health literacy.

Example Question:

Have you tried to treat your cough?

Finding:

Asked about aggravating factors

Finding:

Reports symptoms worse at night

(Available)

Pro Tip: Sometimes a condition will fluctuate during the course of the day. By asking Tina how her asthma differentially impacts her both during the day and at night, you are assessing an important change over time.

Example Question:

Is your asthma worse at night?

Finding:

Reports symptoms increase when lying flat on back

(Available)

Pro Tip: Asthma can be aggravated by movements that constrict the respiratory airways. By asking Tina if lying down causes shortness of breath, you’re assessing which positions might cause exacerbation.

Example Question:

Does lying down make your asthma worse?

Finding:

Reports symptoms aggravated by movement

(Found)

Pro Tip: Asthma can be aggravated by movements that constrict the respiratory airways. Inquiring into what activities make Tina short of breath can indicate possible triggers.

Example Question:

Is there anything you can’t do because of your asthma?

Medical History

Finding:

Confirmed use of medications

Finding:

Confirms medications (no new medications reported)

(Found)

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

Example Question:

What medications do you take?

Finding:

Followed up about inhaler use

Finding:

Uses an inhaler to treat asthma symptoms

(Found)

Pro Tip: It’s essential to ask specifically what medications a patient is using to treat her current complaint or any ongoing medical conditions.

Example Question:

Do you use an inhaler for your asthma?

Finding:

Inhaler is Proventil

(Available)

Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina what medication she takes for her asthma will indicate her treatment plan and the degree to which she complies with it.

Example Question:

What is the name of the inhaler you are currently using?

Finding:

Reports most recent inhaler use was this morning

(Available)

Pro Tip: Soliciting a shallow history of a patient’s medication history can reveal recent exacerbation. Asking Tina when she last used her inhaler will indicate when her symptoms most recently required medical treatment.

Example Question:

When did you last use your inhaler?

Finding:

Reports using inhaler every 4 hours or so since exacerbation

(Found)

Pro Tip: After an asthma exacerbation, patients often will become more reliant on medical tools like inhalers. Asking Tina how many times she’s used her inhaler in the past two days will point to the severity of her recent exacerbation.

Example Question:

How many times have you used your inhaler in the past two days?

Finding:

Prescribed usage is 2 puffs

(Available)

Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina how many puffs of her inhaler she’s prescribed will indicate her treatment plan and the degree to which she complies with it.

Example Question:

How many puffs of your inhaler are you prescribed?

Finding:

Reports needing more than 2 puffs to resolve asthma symptoms

(Available)

Pro Tip: Inhaler effectiveness can vary over time for a variety of reasons. Asking Tina about the number on inhaler puffs she needs to resolve symptoms can indicate whether her asthma has worsened or point to potential problems like poor inhaler technique.

Example Question:

How many inhaler puffs do you need?

Finding:

Confirmed allergies

Finding:

Confirms allergies (no new allergies reported)

(Found)

Pro Tip: It’s best practice to ask a patient about her allergies each visit, even with an established patient, to uncover any new allergy triggers or symptoms.

Example Question:

Do you have any new allergies?

Finding:

Followed up on exposure to allergy and asthma triggers

Finding:

Reports cat allergy triggered recent episodes

(Found)

Pro Tip: Questions about what factors might have caused an illness can point to a patient’s environmental stressors, habits, and general wellbeing. Asking Tina what caused her asthma might indicate her health literacy and understanding of what factors impact her breathing.

Example Question:

What started your recent asthma problems?

Finding:

Reports dust as a known trigger

(Found)

Pro Tip: Environmental factors can often be primary allergy triggers. Asking whether Tina has a dust allergy can reveal one such trigger.

Example Question:

Does being around dust trigger your asthma?

Finding:

Reports activity such as walking up stairs as a known trigger

(Available)

Pro Tip: Shortness of breath or asthma can be exercise-induced. Asking whether climbing stairs can be a trigger for Tina might reveal a possible provocation.

Example Question:

Does climbing stairs trigger your asthma?

Finding:

Denies seasonal pattern

(Found)

Pro Tip: Discerning what’s making Tina’s asthma worse can point to possible triggers like environmental factors, bodily positions, or movement that may have a bearing on Tina’s breathing. Asking Tina whether she has seasonal triggers will indicate, in part, Tina’s health literacy.

Example Question:

Do you have seasonal asthma triggers?

Finding:

Denies changes in weather as a trigger

(Found)

Pro Tip: For some patients, weather changes can be asthma irritants. Asking Tina if the weather impacts her asthma will indicate if weather is an irritant for Tina’s condition.

Example Question:

Do changes in weather make your asthma worse?

Finding:

Reports minimal exposure to asthma triggers at work

(Available)

Pro Tip: Environmental factors at home or work can often be primary allergy triggers. Asking Tina about possible allergens at work might indicate a relevant factor in her recent exacerbation.

Example Question:

Does anything at work make your asthma worse?

Finding:

Asked detailed questions about asthma history

Finding:

No current asthma doctor

(Available)

Pro Tip: Seeing a specialist, like an asthma doctor, can help patients to manage symptoms. Asking whether Tina is seeing an asthma doctor will allow you to assess her current treatment plan and healthcare access.

Example Question:

Do you have an asthma doctor?

Finding:

Diagnosed with asthma in childhood

(Found)

Pro Tip: By determining the onset of asthma you can get a sense for Tina’s asthma history, instance, and frequency of exacerbation.

Example Question:

How long have you had asthma?

Finding:

Age of diagnosis was 2 1/2 years old

(Found)

Pro Tip: By determining the onset of asthma you can get a sense for Tina’s asthma history, instance, and frequency of exacerbation.

Example Question:

How old were you when you were diagnosed with asthma?

Finding:

Asked about hospitalizations for asthma

Finding:

Reports prior hospitalizations for asthma

(Found)

Pro Tip: Hospitalization for a condition, like asthma, can reveal its severity. By asking Tina if she’s been hospitalized, you are soliciting information about the history and severity of her condition.

Example Question:

Have you ever been hospitalized for asthma?

Finding:

Reports last hospitalization was age 16

(Available)

Pro Tip: Hospitalization for a condition, like asthma, can reveal its severity. By asking Tina when she was last hospitalized, you are soliciting information about the history and severity of her condition.

Example Question:

When was your last hospitalization for asthma?

Finding:

Estimates 5 total hospitalizations for asthma

(Available)

Pro Tip: Hospitalization for a condition, like asthma, can reveal its severity. By asking Tina the number of times she’s been hospitalized, you are soliciting information about the history and severity of her condition.

Example Question:

How many times have you been to the hospital?

Finding:

Reports she has never been intubated

(Available)

Pro Tip: Intubation for a condition, like asthma, can reveal its severity. By asking Tina if she’s been intubated, you are soliciting information about the history and severity of her condition.

Example Question:

Have you ever been put on a breathing tube?

Finding:

Followed up about non-medication forms of asthma management

Finding:

Denies record keeping of asthma exacerbation or shortness of breath episodes

(Available)

Pro Tip: For some patients, keeping records of asthma exacerbation allows them to monitor their conditions. Soliciting this information from Tina will show health literacy.

Example Question:

Do you use a chart to monitor your asthma?

Finding:

Denies using peak flow meter

(Available)

Pro Tip: A peak flow meter measures how well a patient’s lungs can expel air. By asking whether Tina uses a peak flow meter, you are asking about her health literacy and what kind of medical tools she uses to manage her asthma.

Example Question:

Do you check your peak flow regularly?

Finding:

Denies nebulizer use

(Available)

Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina if she uses a nebulizer for her asthma will indicate her treatment plan and the degree to which she complies with it.

Example Question:

Do you use a nebulizer?

Social Determinants of Health

Finding:

Asked about environmental control

Finding:

Reports living situation is tidy and free of dust

(Available)

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

Example Question:

Have you noticed anything at home that aggravates your asthma?

Finding:

Reports hypoallergenic bedding hygiene

(Available)

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

Example Question:

Do you change your bedding regularly?

Finding:

Reports avoiding animals and has no pets at home

(Available)

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

Example Question:

Do you have pets at home?

Finding:

Reports avoiding exposure to secondhand smoke

(Found)

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

Example Question:

Does anyone in your house smoke?

Social History

Finding:

Asked about exercise and activity level

Finding:

Reports general low activity level

(Found)

Pro Tip: Learning about a patient’s typical exercise habits helps

Example Question:

Do you exercise?

Finding:

Reports diminished activity due to asthma

(Available)

Pro Tip: Asking a patient if her current complaint affects her exercise level or (vice version) helps you understand if there is a causal relationship in symptoms.

Example Question:

Have you been able to exercise?

Finding:

Asked about possible contributing factors in health history

Finding:

Denies history of eczema

(Found)

Pro Tip: Children with eczema are often at a higher risk of developing asthma. In soliciting a medical history from Tina, you are getting a sense for the history of Tina’s asthma and related conditions.

Example Question:

Have you had eczema?

Finding:

Denies history of sinus problems

(Available)

Pro Tip: People with asthma are likely to also experience sinus problems. It is important to determine whether Tina has sinus problems as they can cause complicating symptoms in patients who also experience asthma.

Example Question:

Do you have a history of sinus problems?

Finding:

Denies history of GERD, heartburn, or indigestion

(Available)

Pro Tip: People with asthma are almost twice as likely to also experience GERD. It is important to determine whether Tina has GERD as GERD can cause shortness of breath in patients who also experience asthma.

Example Question:

Do you have gastroesophageal reflux disease?

Finding:

Denies history of COPD or emphysema

(Available)

Pro Tip: For a patient with a known history of COPD or emphesyma, the symptoms of cough or shortness of breath could be caused by that disease.

Example Question:

Have you ever been diagnosed with COPD?

Finding:

Asked about smoking, inhalants, or tobacco

Finding:

Denies history of tobacco use, including cigarettes

(Found)

Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Asking Tina is she ever smoked cigarettes can help you to discern whether smoking was an exacerbating factor for Tina’s asthma.

Example Question:

Have you ever smoked cigarettes?

Finding:

Reports past history of marijuana use

(Available)

Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Asking Tina is she ever smoked marijuana can help you to discern whether smoking was an exacerbating factor for Tina’s asthma.

Example Question:

Have you ever smoked marijuana?

Finding:

Last use of marijuana was age 20 or 21

(Available)

Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Asking Tina is she ever smoked marijuana can help you to discern whether smoking was an exacerbating factor for Tina’s asthma.

Example Question:

When was the last time you smoked marijuana?

Finding:

Denies inhaling substances

(Available)

Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Asking Tina when she quit smoking marijuana can help you to discern whether smoking recently exacerbated Tina’s asthma.

Example Question:

Have you ever experimented with inhaling substances?

Review of Systems

Finding:

Asked about general symptoms

Finding:

Denies recent respiratory or other illness

(Available)

Pro Tip: Broad, open questions will allow Tina to describe, in her own words, the specific pain and discomfort that she is experiencing.

Example Question:

Have you been sick recently?

Finding:

Denies fever

(Available)

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

Example Question:

Have you had any fever symptoms?

Finding:

Denies nausea or vomiting

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like nausea, details the way her individual symptoms and pain manifest.

Example Question:

Have you had nausea or vomiting?

Finding:

Denies chills

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like getting chills, details the way her individual symptoms and pain manifest.

Example Question:

Have you had chills?

Finding:

Reports low energy level

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like fatigue, details the way her individual symptoms and pain manifest.

Example Question:

Are you fatigued?

Finding:

Denies night sweats

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her injury, like night sweats, details the way her individual symptoms and pain manifest.

Example Question:

Have you had night sweats?

Finding:

Asked review of systems for respiratory

Finding:

Denies phlegm or sputum

(Available)

Pro Tip: A productive asthma cough can expel sputum from the lungs. By asking whether Tina has been coughing up phlegm or sputum you are discovering the nature of Tina’s cough since exacerbation.

Example Question:

Have you been coughing anything up?

Finding:

Denies sore throat, swelling, or difficulty swallowing

(Available)

Pro Tip: Difficulty swallowing could indicate a more severe allergic reaction, or a physical problem with the throat.

Example Question:

Do you have any problems swallowing?

Finding:

Denies nasal drainage

(Available)

Pro Tip: Nasal drainage could suggest that the patient’s symptoms are caused by a viral or bacterial infection, or an allergy attack.

Example Question:

Do you have any nasal drainage?

Family History

Finding:

Asked about relevant family history

Finding:

Reports no recent illnesses with family members at home

(Available)

Pro Tip: For people with asthma, getting sick can increase their risk for exacerbation. If Tina’s had any family members recently sick, that might have caused her recent exacerbation.

Example Question:

Has anyone at home been sick?

Finding:

Reports younger sister as only family with asthma

(Found)

Pro Tip: Soliciting a family history helps you to determine which, if any, conditions are inherited. In asking Tina whether anyone in her family has asthma, you’re ascertaining whether Tina’s condition is inherited.

Example Question:

Does anyone in your family have asthma?

Finding:

Reports younger sister as only family member with allergies

(Available)

Pro Tip: A family history of allergies is an important factor to determine whether a patient is at risk for developing allergies.

Example Question:

Does anyone in your family have allergies?

Finding:

Reports no family history of eczema

(Available)

Pro Tip: People with a family history of eczema are often at a higher risk of developing asthma.

Example Question:

Does anyone in your family have eczema?

Finding:

Reports no family history of chronic nasal or sinus problems

(Available)

Pro Tip: People with a family history of sinus problems are often at a higher risk for asthma. If Tina has a family history of sinus problems, this could suggest inherited sensitivity.

Example Question:

Do you have a family history of sinus problems?

Finding:

Reports no family history of COPD or emphysema

Objective Data Collection: 6 of 6 (100%)

Correct
Partially correct

Incorrect
Missed

Inspected chest

Symmetry (1/2 point)

Symmetric

Appearance (1/2 point)

No visible abnormal findings

Palpated chest expansion

Symmetry (1/1 point)

Equal bilaterally

Palpated tactile fremitus

Symmetry (1/2 point)

Equal bilaterally

Vibration (1/2 point)

Expected fremitus

Percussed chest wall

Observations (1/2 point)

All areas resonant

Location (1/2 point)

No areas of dullness

Breath Sounds (1/3 point)

Present in all areas

Adventitious Sounds (1/3 point)

Wheezing

Location (1/3 point)

Adventitious sounds in posterior right lower lobe
Adventitious sounds in posterior left lower lobe

Auscultated for bronchophony

Bronchophony (1/1 point)

Negative

Education & Empathy : 1 of 4 (25.0%)

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

	Description: Tina describes the symptoms that have been bothering her.
	What brings you here today?	Question 05:21 AM EDT
	I came in because I’ve been having breathing problems, and my inhaler just isn’t working the way it normally does.
	I am sorry for that	Empathize 05:21 AM EDT
	I appreciate you telling me that.
	Model Statement: “Breathing problems can be scary and uncomfortable. I’m sorry you’ve been experiencing these symptoms. Let me learn a little more about your breathing problems, and we will be able to find ways to improve your breathing.”

2 Asthma Triggers

	Description: Tina describes her perceived asthma triggers.
	are you exposed to allergens?	Question 05:53 AM EDT
	Two days ago, at my cousin’s house. She has three of them, and my asthma always goes crazy when I’m there.
	What started your recent asthma problem?	Question 05:53 AM EDT
	This all started at my cousin’s house. She has cats, and I’m allergic, so my asthma always goes crazy when I’m there.
	Does being around dust trigger the asthma?	Question 05:54 AM EDT
	Yeah, being around a lot of dust, especially hanging out in a really dusty house, can make my asthma act up.
	Do changes in weather make your asthma worse?	Question 05:56 AM EDT
	Not that I’ve noticed.
	Do you have seasonal asthma problems?	Question 05:57 AM EDT
	A little while ago, I had some seasonal allergies, but it didn’t really bother my asthma, and it’s better now.
	Do you have environmental exposures at home or at work?	Question 05:58 AM EDT
	No, unless cats count.
	How is your social determinant of health?	Question 05:58 AM EDT
	I’ve known most of my girlfriends since high school. We’ve been a pretty tight group for a long time. I am really close to people at church too, especially the ones in my bible study group. I sometimes get drinks with the other shift-supervisors at work, but we’re not super close.
	Model Statement: “It’s important that I learn about what things may be triggering your asthma, so that we can figure out what you can avoid to improve your breathing.”

	Description: Tina describes her inhaler use and medication regimen.
	Have you been using any medications?	Question 05:25 AM EDT
	I don’t take anything, unless my inhaler counts.
	When did you know you have asthma? (Clarified to: When did your asthma start?)	Question 05:26 AM EDT
	I think I was about two and a half? I used to have a lot of trouble with asthma attacks back then. (Clarified to: when I first got asthma)
	Have you been hospitalized for asthma?	Question 05:26 AM EDT
	I went a bunch of times when I was little, for asthma attacks.
	Model Statement: “Thank you for letting me know that you’re using your inhaler pretty often. It’s important for me to know how you’re using all of your medications.”

4 Inhalants

	Description: Tina describes her lack of exposure to cigarette smoke, secondhand smoke, and other inhalants.
	Are you exposed to secondhand smoke?	Question 06:00 AM EDT
	Some of my friends smoke when we go out drinking. But I don’t smoke, and nobody at home smokes.
	Ninety-nine.
	Ninety-nine.
	Ninety-nine.
	Ninety-nine.
	Ninety-nine.
	Ninety-nine.
	Ninety-nine.
	Ninety-nine.
	Ninety-nine.
	Ninety-nine.
	Ninety-nine.
	Ninety-nine.
	Ninety-nine.
	Ninety-nine.
	Ninety-nine.
	Ninety-nine.
	Ninety-nine.
	Ninety-nine.
	Ninety-nine.
	Ninety-nine.
	Model Statement: “I’m glad to hear that you don’t smoke and avoid smoke in your life. Your lungs are better off for it!”

Documentation / Electronic Health Record

Document: Provider Notes

Document: Provider Notes

Student Documentation	Model Documentation
Subjective Ms. Jones is a 28y/o African American woman who presents to clinic with a complaints of SOB and wheezing. She had a near asthma attack two days ago. She was exposed to cat which triggered the asthma symptoms. She has a 6/10 severity and her SOB was a 8/10 and lasted for five minutes. She did not experience any chest pain or allergic symptoms. She used her albuterol inhaler and her symptoms decreased although they did not completely resolve. She had an episode today morning before coming to clinic. She usually has SOB twice a night.	HPI: Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of shortness of breath and wheezing following a near asthma attack that she had two days ago. She reports that she was at her cousin’s house and was exposed to cats which triggered her asthma symptoms. At the time of the incident she notes that her wheezes were a 6/10 severity and her shortness of breath was a 7-8/10 severity and lasted five minutes. She did not experience any chest pain or allergic symptoms. At that time she used her albuterol inhaler and her symptoms decreased although they did not completely resolve. Since that incident she notes that she has had 10 episodes of wheezing and has shortness of breath approximately every four hours. Her last episode of shortness of breath was this morning before coming to clinic. She notes that her current symptoms seem to be worsened by lying flat and movement and are accompanied by a non-productive cough. She awakens with night-time shortness of breath twice per night. She complains that her current symptoms are beginning to interfere with her daily activities and she is concerned that her albuterol inhaler seems to be less effective than previous. Currently she states that her breathing is normal. Diagnosed with asthma at age 2.5 years. She has no recent use of spirometry, does not use a peak flow, does not record attacks, and does not have a home nebulizer or vaporizer. She has been hospitalized five times for asthma, last at age 16. She has never been intubated for her asthma. She does not have a current pulmonologist or allergist. Social History: She is not aware of any environmental exposures or irritants at her job or home. She changes her sheets weekly and denies dust/mildew at her home. She uses a hypoallergenic pillow cover and her mattress is one year old. She denies current use of tobacco, alcohol, and illicit drugs. She did smoke marijuana for 5 or 6 years, her last use was at age 21 years. She does not exercise. Review of Systems: General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats. • Nose/Sinuses: Denies rhinorrhea with this episode. Denies stuffiness, sneezing, itching, previous allergy, epistaxis, or sinus pressure. • Gastrointestinal: No changes in appetite, no nausea, no vomiting, no symptoms of GERD or abdominal pain • Respiratory: Complains of shortness of breath and cough as above. Denies sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. She has a history of asthma, last hospitalization was age 16, last chest XR was age 16.
Objective She has no acute distress. She is alert and orinted. She maintains eye contact. Chest expansion is symmetrical. Chst resonant to percussion, no dullness. Bilateral expiratory wheezes in posterior lower lobes. Bilaterial muffled words with notable expiratory wheezes in posterior lower lobes. No crackles. Spirometry FVC 3.91L, FEV1/FVC ratio 80.56%, SpO2 97%.	General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented and sitting upright on exam table. She maintains eye contact throughout interview and examination. • Respiratory: Chest expansion is symmetrical with respirations. Normal fremitus, symmetric bilaterally. Chest resonant to percussion; no dullness. Bilateral expiratory wheezes in posterior lower lobes. Bilateral muffled words with notable expiratory wheezes in posterior lower lobes. No crackles. In office spirometry: FVC 1.78 FEV1/FVC ratio 87.02% SpO2: 97%.
Assessment Asthma exacerbation	Asthma exacerbation
Plan Continue monitoring symptoms and log episodes of asthma symptoms. Obtain oxygen saturation Order PFTs after exacerbation Wash beddings regularly Seek emergent care in case of SOB Revisit clinic in 2-4 weeks for check-up	Encourage Ms. Jones to continue to monitor symptoms and log her episodes of asthma symptoms and wheezing with associated factors and bring log to next visit. • Obtain office oxygen saturation. • Order PFTs to be completed after exacerbation to have baseline available for future comparison. • Encourage to wash bedding and consider dust mite covers to decrease allergic nighttime symptoms. • NMT in office x 1. • Educate to increase intake of water and other fluids. • Educate Ms. Jones on when to seek emergent care including episodes of chest pain or shortness of breath unrelieved by rest, worsening asthma symptoms or wheezing, or the sense that rescue inhaler is not helping. • Revisit clinic in 2-4 weeks for follow up and evaluation.

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Tina Jones Mental Health Results

April 30, 2025/in BLOGS /by admin

Tina Jones Mental Health Results

Experience Overview

Patient: Tina Jones

Digital Clinical Experience Score

100%

This score measures your performance on the Student Performance Index in relation to other students in comparable academic programs. Your instructor has chosen to scale your Student Performance Index score so that the average score on the index is a 80.0%. This score may not be your final grade if your instructor chooses to include additional components, such as documentation or time spent.

Student Performance Index

45

out of

48

Proficiency Level:

Proficient

Students rated as “proficient” demonstrate an entry-level expertise in advanced practice competencies and clinical reasoning skills. In comparable programs, the top 25% of students perform at the level of a proficient practitioner.

Subjective Data Collection

44

out of

44

Objective Data Collection

0

out of

0

Education and Empathy

1

out of

4

Time

29 minutes total spent in assignment

Interaction with patient

29 minutes

Transcript

Started: Mar 30, 2025 | Total Time: 29 min

All Lines (45)Interview Questions (44)Statements (1)Exam Actions (0)

	Hello, my name is Mileidy and I will be your nurse today	Greet 03/30/25 7:39 PM EDT
	Hey.
	What brings you here today?	Question 03/30/25 7:40 PM EDT
	I decided to come in because I’m tired all the time now. . . I have this really important exam coming up, and I’m stressed and too foggy to study most of the time. I really need help sleeping so I can focus on preparing for my exam.
	I am sorry for that	Empathize 03/30/25 7:40 PM EDT
	Thanks for understanding.
	When did the symptoms start?	Question 03/30/25 7:40 PM EDT
	Well. . . I’ve known I have a lot coming up for a while, so I was a little worried about stuff starting a few months ago, but it really feels like the stress and the sleeping problems started at around the same time, three and a half weeks ago. . .
	How frequent is the symptoms?	Question 03/30/25 7:40 PM EDT
	It’s happening most nights, I’d say. Four. . . more like five nights a week.
	What makes the symptom worse?	Question 03/30/25 7:41 PM EDT
	Basically, the more I think about what I’m worried about, the worse it is. Sometimes I can distract myself and not let myself start thinking about all the things that stress me out, but that’s been rare.
	What relieves the symptoms? (Clarified to Does anything relieve your symptoms?.)	Question 03/30/25 7:41 PM EDT
	Basically the only way I get to sleep easily is if I manage to feel less stressed out–sometimes I can sort of turn my thoughts away from what I’m worried about by distracting myself with something, like thinking about what I’m going to wear the next day or something like that. I’d rather avoid having to take medication if possible. Taking deep breaths can help a little, too. (Clarified to if anything relieves my symptoms.)
	How does the sleeping problem affect your daily living?	Question 03/30/25 7:42 PM EDT
	Well. . . I’m tired all day, and I feel kind of out of it. That makes it hard to focus and get things done, especially when I try to study for my exam coming up. It’s pretty frustrating.
	How do you feel Out of it?	Question 03/30/25 7:42 PM EDT
	It’s like. . . I just feel slowed down and tired all the time from not sleeping. It’s harder to focus, or get things done efficiently. . . I’m just generally less sharp.
	What are the anxiety symptoms? (Clarified to What are the symptoms of your anxiety?.)	Question 03/30/25 7:42 PM EDT
	When I feel anxious, it’s like. . . I’m kind of on edge and nervous, and my thoughts start racing, and I just think about all the things there are to worry about. (Clarified to what the symptoms of my anxiety are.)
	What is the impact of the anxiety on daily living? (Clarified to Does your anxiety interfere with your daily life?.)	Question 03/30/25 7:43 PM EDT
	Being anxious is mostly just interfering with my sleep, and then not being able to get enough sleep is interfering with my life. (Clarified to if my anxiety interferes with my daily life.)
	How is your sleep quality?	Question 03/30/25 7:43 PM EDT
	Lately I haven’t been getting enough sleep at all. It takes me so long to fall asleep at night–it’s really frustrating.
	How is your sleep habits?	Question 03/30/25 7:44 PM EDT
	Well. . . I usually get into bed around midnight, but at that point I feel too nervous to sleep, so I’ll read to try and wind down for maybe an hour, sometimes longer. Then I turn out the light and try to sleep. If it takes a really long time, then sometimes I’ll turn the light back on and read a little more until I feel sleepier.
	Do you use any medications?	Question 03/30/25 7:44 PM EDT
	All I have is a Proventil inhaler and a Flovent inhaler for my asthma.
	WHich medication do you use for sleep? (Clarified to What depression medication did you take?.)	Question 03/30/25 7:44 PM EDT
	I’ve never taken anything for depression. (Clarified to what medication I take for depression.)
	Do you take medication for sleep?	Question 03/30/25 7:45 PM EDT
	I haven’t tried taking anything to sleep–I would really rather avoid having to take medication if possible.
	Do you have allergies?	Question 03/30/25 7:45 PM EDT
	Yeah, I’m allergic to cats.
	Do you have a history of sleep problems?	Question 03/30/25 7:45 PM EDT
	Well. . . the only other time I’ve had sleep problems was right after Dad died. It felt a little like this, with my mind racing, but honestly, not as bad. Other than that month or two, I’ve always been a really good sleeper. I could fall asleep right away, and then I’d sleep like a log.
	Do you have depression?	Question 03/30/25 7:46 PM EDT
	I don’t think I’m depressed.
	Do you have suicidal tendencies?	Question 03/30/25 7:46 PM EDT
	No, never.
	Do you have a history of self harm	Question 03/30/25 7:47 PM EDT
	No.
	Do you have a past trauma?	Question 03/30/25 7:47 PM EDT
	No, not really.
	Do you have angry outbursts?	Question 03/30/25 7:47 PM EDT
	I don’t really get angry a lot. I try to be patient with people. . . it just makes everything easier that way.
	Are you employed?	Question 03/30/25 7:48 PM EDT
	I’m a supervisor at Mid-American Copy & Ship. I’ve been working there since high school, and I’ve just kept moving up.
	What is your level of education?	Question 03/30/25 7:48 PM EDT
	Well, in about a month I’ll be a college graduate, as long as I manage to get some sleep!
	What are your hobbies?	Question 03/30/25 7:48 PM EDT
	I read a lot, especially since I bought one of those e-book readers. My friends and I have thought about starting a book club actually. Oh, and there’s these free talks at church that I like to go to if I have time. I watch TV, but usually on DVD or streaming. I like to marathon the shows I really like. I’m really interested in documentaries, too.
	How is your legal history?	Question 03/30/25 7:49 PM EDT
	I’ve never been in trouble with the law. [AUDIO COMING SOON]
	Have you been in military service?	Question 03/30/25 7:49 PM EDT
	No, I’ve never been in the military.
	Have you had any legal case?	Question 03/30/25 7:49 PM EDT
	No way.
	How is your living situation?	Question 03/30/25 7:49 PM EDT
	I think moving back home was the best thing for me to do, and I’m really glad I did it, but I’m ready to have my own place again, soon.
	Are you religious?	Question 03/30/25 7:50 PM EDT
	Yeah. We go to First Baptist, and we do a lot with our church community. We socialize before and after church, and I go to Bible study on Wednesdays, too.
	Do you use drugs?	Question 03/30/25 7:50 PM EDT
	No.
	Have you smoked marijuana?	Question 03/30/25 7:50 PM EDT
	Well, I used to smoke pot. . . but I don’t do that anymore.
	When did you last smoke pot?	Question 03/30/25 7:51 PM EDT
	I haven’t smoked pot since I was twenty or twenty-one.
	Do you use alcohol?	Question 03/30/25 7:51 PM EDT
	I do sometimes, yeah, when I go out with my friends.
	How many drinks do you take? (Clarified to How many drinks do you have in a day?.)	Question 03/30/25 7:51 PM EDT
	I don’t drink every day–a couple times a month, I’ll go out on the weekend and have a few drinks. (Clarified to how many alcoholic drinks I have each day.)
	Do you drink and drive?	Question 03/30/25 7:51 PM EDT
	We usually take a cab when we go out.
	Do you use tobacco?	Question 03/30/25 7:51 PM EDT
	No, never.
	Do you abuse prescription drugs?	Question 03/30/25 7:53 PM EDT
	No! I don’t know why I’d want to take someone else’s prescriptions. . . I hate having to take my own medicines.
	Are you married?	Question 03/30/25 7:53 PM EDT
	No, I never have been.
	How is your relationship status?	Question 03/30/25 7:53 PM EDT
	I’m single right now.
	How is your sexual history?	Question 03/30/25 7:53 PM EDT
	Well, I’ve had four boyfriends, and I’ve had sex with three of them.
	Do you have a history of abuse?	Question 03/30/25 7:54 PM EDT
	No.
	What is causing your stress?	Question 03/30/25 7:54 PM EDT
	I’m stressed now because I can’t sleep, but I can’t sleep because I keep worrying about all this other stuff, like graduating, and passing this exam that’s coming up, and getting a job, and finding my own place to live. . . it’s a lot.
	How do you cope with stress?	Question 03/30/25 7:54 PM EDT
	Usually I try to stay organized, you know, make to-do lists, plan my time, that kind of thing. Sometimes I’ll talk to friends or family. . . going to church usually helps, too. Lately, though, none of that is really helping like it should.
	Do you have a family history of stress?	Question 03/30/25 7:55 PM EDT
	I don’t think so. . . I mean everyone gets stressed sometimes, but I don’t think people in my family are more stressed than other people or anything.

Subjective Data Collection: 44 of 44 (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 difficulty sleeping and “feeling nervous”

(Found)

Pro Tip: Foundational questions to open an interview will help the patient tell you what’s bothering her in her own words.

Example Question:

What brings you in today?

Finding:

Reports seeking treatment because she has an upcoming exam and feels “too foggy to study”

(Found)

Pro Tip: Foundational questions will help the patient tell you what’s bothering her in her own words. It is important to ask Tina why she sought treatment to get an understanding of any recent changes with her complaint that could have made it more severe or urgent, prompting her to come in.

Example Question:

Why did you decide to seek treatment?

Finding:

Reports excessive worry and “racing thoughts” before bed

(Available)

Pro Tip: Foundational questions to open an interview will help the patient tell you what’s bothering her in her own words. Tina says that she “feels nervous” before bed, and it is interfering with her sleep. It is important to ask a follow-up question to gain more details about what feeling nervous means to her.

Example Question:

How do you feel just before bed?

History of Present Illness

Finding:

Asked about onset and duration of symptoms

Finding:

Reports difficulty sleeping began 3 1/2 weeks ago

(Found)

Pro Tip: Determining if the onset of a complaint was gradual or acute is important for diagnosis. In Tina’s case, you will need this information to assess what could be causing her sleep disturbance.

Example Question:

How long have you been having trouble sleeping?

Finding:

Reports sleep difficulties have been occurring regularly during past 3 1/2 weeks

(Available)

Pro Tip: Knowledge of the duration of a complaint will help you assess if the issue is recent or chronic. In Tina’s case, you will need this information to assess if she is suffering from chronic insomnia or a more acute sleep disturbance.

Example Question:

How long have your sleeping difficulties lasted?

Finding:

Asked about frequency of symptoms

Finding:

Reports difficulty sleeping at least four or five times a week

(Found)

Pro Tip: A precise question the number of occurrences of the issue in an allotted span of time will give you the most accurate estimation of frequency. In Tina’s case, it is important to know that she is suffering sleep disturbances for the majority of nights in a given week.

Example Question:

How many nights a week do you have trouble sleeping?

Finding:

Asked about aggravating factors

Finding:

Reports sleeping becomes more difficult when she can not redirect her thoughts from the things she is worried about

(Found)

Pro Tip: An open question about aggravating factors can be used to assess what could be exacerbating the patient’s complaint, as well as her knowledge of those factors. For Tina, it is important to understand what she thinks makes it more difficult for her to fall asleep.

Example Question:

What makes it harder to sleep?

Finding:

Denies naps during the day

(Available)

Pro Tip: A closed question about factors that are known to aggravate the complaint will help you to eliminate the most salient possibilities. Though one short nap a day is fine, frequent or extended naps could have been making it more difficult for Tina to fall asleep, and could also indicate an inability to stay awake during her activities of daily living.

Example Question:

Do you take naps?

Finding:

Reports drinking caffeine to stay alert

(Available)

Pro Tip: A closed question about factors that are known to aggravate the complaint will help you to eliminate the most salient possibilities. Though caffeine helps Tina to stay alert, drinking too much caffeine could interfere with her sleep.

Example Question:

Do you drink caffeine?

Finding:

Reports stopping caffeine use after 4 P.M.

(Available)

Pro Tip: This follow-up question is needed to assess how likely it is that caffeine consumption is interfering with sleep. If Tina were drinking caffeine late in the afternoon or at night, it would very likely be aggravating, or even causing, her sleep disturbance.

Example Question:

When do you usually have your last caffeinated drink?

Finding:

Denies alcohol use before bed

(Available)

Pro Tip: A closed question about factors that are known to aggravate the complaint will help you to eliminate the most salient possibilities. Alcohol consumption before bed has been shown to interfere with homeostasis, which regulates sleep, and can even lead to insomnia, so it is important to know if Tina is drinking it to fall asleep.

Example Question:

Do you drink alcohol before bed?

Finding:

Denies drug use before bed

(Available)

Pro Tip: A closed question about factors that are known to aggravate the complaint will help you to eliminate the most salient possibilities. It is important to know if Tina is using drugs to help her fall asleep because they could, in fact, be contributing to her sleep disturbance.

Example Question:

Do you use drugs before bed?

Finding:

Reports respiratory problems are controlled and not interfering with sleep

(Available)

Pro Tip: A closed question about factors that are known to aggravate the complaint will help you to eliminate the most salient possibilities. Tina has asthma, and it is important to rule out respiratory issues as a contributing factor to, or even because of, her sleep disturbance. Tina also has an albuterol prescription, which, if she were using it before bed, could be aggravating or causing her anxiety.

Example Question:

Do you think your sleep problems could be due to breathing issues?

Finding:

Asked about relieving factors

Finding:

Reports sleeping more easily if she can distract herself from her “racing thoughts”

(Found)

Pro Tip: An open question about alleviating factors can be used to assess what brings relief to the patient, as well as her knowledge of those factors. For Tina, it is important to understand what she thinks makes it easier for her to fall asleep.

Example Question:

What helps you sleep?

Finding:

Reports no exercise

(Available)

Pro Tip: A closed question about factors known to alleviate the complaint will help you diagnose and treat the issue. Exercise is known to improve sleep, so it is important to assess Tina’s exercise level.

Example Question:

Do you exercise?

Finding:

Asked about impact of sleeping problems on daily living

Finding:

Reports feeling tired and “out of it” most of the time during the day due to lack of sleep

(Found)

Pro Tip: An open question about the effects of the complaint on a patient’s daily life will help you to get a general idea of the severity of the issue as well as allow you to understand how the patient is dealing with and affected by it. In Tina’s case, though her focus and energy is hampered by her sleep disturbance, she is able to perform all of her usual activities of daily living, meaning her insomnia is not severe, but it is debilitating.

Example Question:

How does your lack of sleep affect your daily life?

Finding:

Reports no increased chance of drifting off during the day despite lack of sleep

(Available)

Pro Tip: A closed question about a specific effect on daily life commonly seen with a patient’s complaint can help you to assess severity, diagnose, and treat it. If Tina were falling asleep without intending to, it could indicate a more severe sleep disorder as well as a more debilitating effect on her daily life.

Example Question:

Have you been falling asleep when you didn’t mean to?

Finding:

Followed up about patient’s experience feeling “out of it”

Finding:

Reports feeling slowed down and tired, having trouble focusing, and generally feeling “less sharp”

(Found)

Pro Tip: When a patient uses phrasing that is unclear or not specific enough, it is important to ask a follow-up to ensure your understanding of the issue. Asking Tina what she means by “out of it” will help you to gain a more detailed idea of her state of mind during the day, and how it is affected by her sleep disturbance.

Example Question:

What do you mean when you say you feel out of it?

Finding:

Asked about anxiety symptoms

Finding:

Reports feelings of anxiety as “thoughts she can’t turn off” and “being on edge”

(Found)

Pro Tip: If a patient may have anxiety, asking about symptoms will aid diagnosis and determine severity. An open question about how Tina’s anxiety feels will help you to get a general idea of its character.

Example Question:

Can you tell me about how your anxiety feels?

Finding:

Reports worry about the future, but no sense of impending doom

(Available)

Pro Tip: If a patient may have anxiety, a sense of impending doom could indicate a panic disorder. Asking Tina about this will help you to come to a diagnosis and to determine severity.

Example Question:

Do you ever have a sense of impending doom?

Finding:

Reports no panic attacks

(Available)

Pro Tip: If a patient may have anxiety, it is important to determine if she is having panic attacks. Asking Tina about this will help you to come to a diagnosis and to determine severity, especially if she is experiencing panic before bed.

Example Question:

Have you been having panic attacks?

Finding:

Reports difficulty concentrating due to fatigue from lack of sleep

(Available)

Pro Tip: Difficulty concentrating is an important indicator of generalized or situational anxiety. Asking Tina about this will help you to come to a diagnosis and to determine severity.

Example Question:

Have you been having trouble concentrating?

Finding:

Reports only restlessness occurs just before bed

(Available)

Pro Tip: Restlessness is an important indicator of generalized or situational anxiety. Asking Tina about this will help you to come to a diagnosis and to determine severity.

Example Question:

Do you feel restless?

Finding:

Reports slight irritability due to fatigue

(Available)

Pro Tip: Irritability is an important indicator of generalized or situational anxiety. Asking Tina about this will help you to come to a diagnosis and to determine severity.

Example Question:

Do you feel irritable?

Finding:

Asked about impact of anxiety on daily living

Finding:

Reports stress only interferes with daily life because it interrupts her sleep

(Found)

Pro Tip: The effects of any complaint on a patient’s daily life are important. Asking Tina about the effects of her anxiety on her daily life will help you to come to a diagnosis and to determine severity.

Example Question:

How does your anxiety interfere with your daily life?

Finding:

Reports stress does not prevent her from completing her usual activities

(Found)

Pro Tip: The effects of any complaint on a patient’s daily life are important. Asking Tina about the effects of her anxiety on her daily life will help you to come to a diagnosis and to determine severity.

Example Question:

Does your anxiety prevent you from completing your usual activities?

Finding:

Asked about sleep quality

Finding:

Reports falling asleep often takes more than an hour

(Available)

Pro Tip: Sleep disorders may manifest in different ways, including difficulty falling asleep. In Tina’s case, it is important to know that falling asleep takes more than an hour, while normal sleep latency is only 15-20 minutes.

Example Question:

How long does it take you to fall asleep?

Finding:

Reports waking up two or three times during the night for “at least ten minutes”

(Available)

Pro Tip: Sleep disorders may manifest in different ways, including frequent awakenings. In Tina’s case, it is important to know how often she is waking often during the night, as well as how long it takes her to fall back asleep.

Example Question:

How often do you wake during the night?

Finding:

Reports waking in the morning feeling “out of it” and not rested

(Available)

Pro Tip: In assessing the severity of a sleep disorder, it is important to determine how rested a patient feels when she wakes up in the morning. Tina is waking up feeling tired and “out of it,” meaning her sleep disturbance is having a noticeable effect on her quality of sleep.

Example Question:

How do you feel when you wake up in the morning?

Finding:

Asked about sleep habits

Finding:

Reports going to bed “around midnight,” but feeling “too nervous” to sleep

(Found)

Pro Tip: A specific question about a patient’s bed time will elicit the information you need about when they try to fall asleep. In Tina’s case, it is important to know that she is getting into bed long before she falls asleep.

Example Question:

When do you go to bed?

Finding:

Reports actually falling asleep at 2 or 3 AM

(Available)

Pro Tip: A specific question about when a patient falls asleep will determine sleep latency as well as how much sleep the patient is actually getting. In Tina’s case, it is important to know that she often falls asleep long after she gets into bed.

Example Question:

When do you fall asleep?

Finding:

Reports reading before bed

(Found)

Pro Tip: A specific question about what a patient does before bed will help you to assess whether something she is doing could be contributing to the sleep disturbance. In Tina’s case, it is important to know that she reads before bed rather than immediately trying to fall asleep.

Example Question:

What do you usually do before bed?

Finding:

Reports no screen use (television or computer) before bed

(Available)

Pro Tip: The use of electronics before bed has been shown to stimulate brain activity, which can disturb sleep, and the artificial light from most screens may also affect melatonin levels, which regulate sleep cycles. It is important to know that Tina does not watch television or use a computer before bed to eliminate screen use as a possible contributing factor to her sleep disorder.

Example Question:

Do you watch television or use the computer before bed?

Finding:

Reports average wake time of 8 AM

(Available)

Pro Tip: A specific question about when a patient wakes up can determine if their sleep disturbance is causing early awakening. It is important to know that Tina is waking up at 8 AM, and that it is due to her schedule, not a result of sleep disturbance.

Example Question:

When do you usually wake up?

Finding:

Reports sleeping an average of 4 or 5 hours a night

(Available)

Pro Tip: Asking for the average number of hours of sleep a patient gets in one night will elicit the specific information you need to assess the severity of her sleep disorder. In Tina’s case, she is getting less sleep per night than is considered healthy.

Example Question:

How many hours of sleep do you get a night?

Finding:

Reports sleeping alone in a quiet room

(Available)

Pro Tip: A patient’s sleep environment can interfere with sleep. It is important to know that Tina has a quiet bedroom to herself to rule out anything from her environment that could be interrupting her sleep with or without her knowledge.

Example Question:

Can you describe where you sleep?

Finding:

Asked about stress quality

Finding:

Reports feeling nervous and worrying about the future, with racing thoughts

(Found)

Pro Tip: Stress can mean different things to different patients, so understanding how a patient experiences stress is essential. In Tina’s case, gathering details about her stress can help you to understand if it is situational or chronic, and how it could be aggravating or causing her sleep disturbance.

Example Question:

How do you feel when you are stressed?

Medical History

Finding:

Confirmed use of medications

Finding:

Confirms medications (no new medications reported)

(Found)

Pro Tip: Even if you have seen a patient before, it is important to ask about medications in case they have changed since the last visit. In Tina’s case, a new medication she is taking could be causing or aggravating her sleep disturbance.

Example Question:

Are you taking any new medications?

Finding:

Followed up about sleep medication use

Finding:

Denies taking OTC sleep medications

(Found)

Pro Tip: Even if you have seen a patient before, it is important to ask about medications in case they have changed since the last visit, especially if they are taking anything to treat their chief complaint. In Tina’s case, asking about over the counter sleep medications is important in understanding possible alleviating factors as well as if an over the counter sleep medication could be contributing to her drowsiness during the day.

Example Question:

Have you been taking over the counter medications to help you sleep?

Finding:

Denies taking prescription sleep medications

(Found)

Pro Tip: Even if you have seen a patient before, it is important to ask about medications in case they have changed since the last visit, especially if they are taking anything to treat their chief complaint. If Tina were taking prescription sleep medication, it could indicate that she has seen someone else about her sleep disturbance or that she has been treated for this problem in the past.

Example Question:

Have you been taking prescribed medication to help you sleep?

Finding:

Confirmed allergies

Finding:

Confirms allergies (no new allergies reported)

(Found)

Pro Tip: It’s best practice to ask a patient about her allergies each visit, even with an established patient, to uncover any new allergy triggers or symptoms.

Example Question:

Have you had any new allergies?

Finding:

Asked about history of sleep problems

Finding:

Reports usually falls asleep very easily and “sleeps like a log”

(Found)

Pro Tip: Assessing the history of a patient’s present illness is essential to diagnosis and treatment of the complaint. Knowing that until recently Tina hadn’t had similar sleep issues will help you narrow down possible causes.

Example Question:

Do you have a history of sleep problems?

Finding:

Reports only past sleep problems occurred for a few months after her father died, but they resolved on their own

(Found)

Pro Tip: Assessing the history of a patient’s present illness is essential to diagnosis and treatment of the complaint. Knowing that Tina had similar sleep problems during a difficult time in her life, and that the problem resolved itself, is integral to diagnosis and treatment.

Example Question:

Have you had difficulty falling asleep before?

Psychological History

Finding:

Asked about history of psychiatric illness

Finding:

Denies history of depression

(Found)

Pro Tip: Differentiating between depression and anxiety can sometimes be difficult, and often a patient will have both. Depression is also often a contributing factor in sleep disturbance, and sleep disturbance can also often contribute to depression. If Tina had a history of depression, it could be contributing to her sleep issues.

Example Question:

Have you ever had depression?

Finding:

Denies history of anxiety

(Available)

Pro Tip: Anxiety is a common cause of sleep disturbance, and lack of sleep can also contribute to anxiety issues. If Tina had a history of anxiety, it could be causing or aggravating her current sleep disturbance.

Example Question:

Do you have a history of anxiety?

Finding:

Denies current psychiatric illness

(Available)

Pro Tip: When performing a mental health assessment, it is essential to do a complete mental status exam. However, asking a patient about possible current psychiatric illness in order to understand her mental health status is also important. In Tina’s case, you should ask her generally about her mental health, and you should also ask about specific psychiatric disorders to rule them out.

Example Question:

Do you have a psychiatric illness?

Finding:

Denies history of psychiatric illness

(Available)

Pro Tip: As with any patient interview, it is important to ask about any relevant medical history. Tina is here for her mental health, so asking about her history of psychiatric illness is essential.

Example Question:

Do you have a history of psychiatric illness?

Finding:

Denies bipolar disorder

(Available)

Pro Tip: When performing a mental health assessment, it is essential to do a complete mental status exam. However, asking a patient about possible current psychiatric illness in order to understand her mental health status is also important. In Tina’s case, you should ask her generally about her mental health, and you should also ask about bipolar disorder to rule it out.

Example Question:

Do you have bipolar disorder?

Finding:

Denies schizophrenia

(Available)

Pro Tip: When performing a mental health assessment, it is essential to do a complete mental status exam. However, asking a patient about possible current psychiatric illness in order to understand her mental health status is also important. In Tina’s case, you should ask her generally about her mental health, and you should also ask about schizophrenia to rule it out.

Example Question:

Do you have schizophrenia?

Finding:

Denies obsessive compulsive disorder

(Available)

Pro Tip: When performing a mental health assessment, it is essential to do a complete mental status exam. However, asking a patient about possible current psychiatric illness in order to understand her mental health status is also important. In Tina’s case, you should ask her generally about her mental health, and you should also ask about obsessive compulsive disorder to rule it out.

Example Question:

Do you have obsessive compulsive disorder?

Finding:

Denies past psychiatric treatment

(Available)

Pro Tip: Even if a patient has not been diagnosed with a psychiatric illness, she could have seen a counselor, therapist, psychologist, or psychiatrist in the past. Asking Tina about past treatment could give you important context for diagnosis.

Example Question:

Do you have a history of psychiatric illness?

Finding:

Denies past psychotropic medications

(Available)

Pro Tip: Knowledge of past medications is integral to the history of the present illness. Tina is here for a mental health assessment, so it is important to ask her about any past medications for psychiatric illness.

Example Question:

Have you ever taken psychotropic medication?

Finding:

Asked about symptoms to determine depression risk

Finding:

Reports belief she does not have depression symptoms

(Found)

Pro Tip: While a patient with depression does not always know she has it, it is important to ask. If Tina had depression, it could be contributing to her sleep disturbance, or her sleep disturbance could be causing or aggravating or depression.

Example Question:

Do you have symptoms of depression?

Finding:

Reports no difficulty making decisions

(Available)

Pro Tip: Difficulty making decisions is an important indicator of depression. Asking Tina about this will help you to come to a differential diagnosis and determine severity.

Example Question:

Do you have difficulty making decisions?

Finding:

Reports slightly decreased energy due to lack of sleep

(Available)

Pro Tip: An uncharacteristic lack of energy is an important indicator of depression. Asking Tina about this will help you to come to a differential diagnosis and determine severity.

Example Question:

Have you had less energy than usual?

Finding:

Denies feelings of guilt or worthlessness

(Available)

Pro Tip: Feelings of guilt or worthlessness are important indicators of depression. Asking Tina about this will help you to come to a differential diagnosis and determine severity.

Example Question:

Have you been feeling guilty for no reason?

Finding:

Denies feelings of hopelessness

(Available)

Pro Tip: Feelings of hopelessness are important indicators of depression. Asking Tina about this will help you to come to a differential diagnosis and determine severity.

Example Question:

Have you been feeling hopeless?

Finding:

Denies loss of enjoyment in activities usually found enjoyable

(Available)

Pro Tip: A loss of enjoyment in activities usually found enjoyable is an important indicator of depression. Asking Tina about this will help you to come to a differential diagnosis and determine severity.

Example Question:

Have you had trouble enjoying your usual activities?

Finding:

Reports slightly less appetite because she feels “a little queasy” from lack of sleep

(Available)

Pro Tip: An unusual increase or decrease in appetite is an important indicator of depression. Asking Tina about this will help you come to a differential diagnosis and determine severity.

Example Question:

Have you had a change in appetite?

Finding:

Denies feelings of sadness

(Available)

Pro Tip: Feeling sad is an important indicator of depression. Asking Tina about this will help you to come to a differential diagnosis and determine severity.

Example Question:

Have you been feeling sad?

Finding:

Asked about suicidal tendencies

Finding:

Denies suicidal thoughts

(Found)

Pro Tip: When assessing mental health risk factors, it is important to rule out your patient as a suicide risk. Tina would be considered a suicide risk if she had been thinking about or planning to commit suicide.

Example Question:

Have you ever had suicidal thoughts?

Finding:

Denies suicidal behaviors

(Available)

Pro Tip: When assessing mental health risk factors, it is important to rule out your patient as a suicide risk. Tina would be considered a suicide risk if she had ever engaged in suicidal behavior.

Example Question:

Have you ever done something that could end your life?

Finding:

Denies past suicide attempts

(Available)

Pro Tip: When assessing mental health risk factors, it is important to rule out your patient as a suicide risk. Tina would be considered a suicide risk if she had attempted suicide recently or in the past.

Example Question:

Have you attempted suicide in the past?

Finding:

Asked about self-harm

Finding:

Denies history of self-harm

(Found)

Pro Tip: Self-harm is an indicator of psychiatric disorders as well as a potential risk for suicide. Knowing if Tina has engaged in self-harm is important to assessing her mental health and her safety.

Example Question:

Have you ever intentionally hurt yourself?

Finding:

Asked about past trauma

Finding:

Denies past trauma

(Found)

Pro Tip: Recurring traumatic memories could indicate post-traumatic stress disorder, a significant aspect of a patient’s mental health and well-being. If Tina had traumatic memories, it would be important to assess PTSD as a risk factor.

Example Question:

Have you ever had repeated, disturbing memories of a stressful experience from the past?

Finding:

Asked about history of violent thoughts

Finding:

Denies angry outbursts

(Found)

Pro Tip: Difficulty controlling anger is an indicator of psychiatric illness as well as a potential risk to others. Asking Tina about anger is important in assessing her mental health and safety.

Example Question:

Have you ever had angry outbursts?

Finding:

Denies past violent behavior

(Available)

Pro Tip: Violence is an indicator of psychiatric illness as well as a potential risk to others. Asking Tina about violence is important in assessing her mental health and safety.

Example Question:

Have you ever behaved violently?

Finding:

Denies desire to harm others

(Available)

Pro Tip: Homicidal ideation or a desire to harm others is an indicator of psychiatric illness as well as a potential risk to others. Asking Tina about any potential desire to harm other people is important in assessing her mental health and safety.

Example Question:

Have you ever wanted to hurt someone else?

Social History – Education and Work

Finding:

Asked about employment status

Finding:

Currently employed

(Found)

Pro Tip: It is important to know whether or not a patient is employed when assessing her mental status. In Tina’s case, a change in her employment status could be a result of her mental health, or could be affecting it. The fact that she is employed lets you know she is financially secure, but it could also mean work is a source of her stress.

Example Question:

Are you employed?

Finding:

Works for a shipping company

(Found)

Pro Tip: A patient’s employment can be an indicator of financial stability, education level, personal interests, and level of responsibility. In Tina’s case, a different workplace could signal instability in her life, which could be a source of her stress. The fact that she is still employed by the same company indicates stability in this area of her life.

Example Question:

Where do you work?

Finding:

Works 32 hours a week

(Available)

Pro Tip: A patient’s work schedule is an indicator of her financial situation, as well as how demanding her employment may be on her time. In Tina’s case, her work schedule could be contributing to her stress levels.

Example Question:

How many hours a week do you work?

Finding:

Reports rarely missing work

(Available)

Pro Tip: Mental health issues can cause a patient to miss work; anxiety and depression, for instance, can make a patient less able to perform her daily responsibilities. If Tina were missing work lately, it could be an important indicator of a change in her mental health status.

Example Question:

How often do you miss work?

Finding:

Asked about education and learning ability

Finding:

About to receive B.A. in Accounting

(Found)

Pro Tip: A patient’s educational history can be an important indicator of economic and mental status, as well as her personal history and interests and any past developmental issues she may have had. In Tina’s case, she is about to achieve an educational milestone, which is a partial source of her stress, so it is especially important to ask her about it.

Example Question:

What is your highest education level?

Finding:

Denies past special education courses

(Available)

Pro Tip: A patient’s past developmental issues can be important indicators of mental status. Asking Tina about past specialized education is an important part of understanding her development.

Example Question:

Did you ever take special education classes?

Finding:

Denies learning disabilities

(Available)

Pro Tip: A patient’s past learning issues can be important indicators of mental status. Asking Tina about learning differences is an important part of understanding her development.

Example Question:

Do you have any learning differences?

Finding:

Denies speech problems

(Available)

Pro Tip: A patient’s speech development can be an important indicator of mental status. Asking Tina about speech difficulties is an important part of understanding her development.

Example Question:

Do you have difficulties with speech?

Finding:

Denies hearing problems

(Available)

Pro Tip: A patient’s hearing ability can be an important indicator of her mental status. Asking Tina about her hearing is an important part of understanding her development.

Example Question:

Do you have hearing difficulties?

Finding:

Asked about hobbies

Finding:

Hobbies are reading and watching television

(Found)

Pro Tip: A patient’s hobbies can help you to get to know her personality and interests better. Any recent change in hobbies, or a loss of interest in them, could indicate a change in mental health. Asking Tina about hobbies is also important in assessing her stress levels and the demands of her current schedule.

Example Question:

What do you do for fun?

Finding:

Asked about legal history

Finding:

Denies past legal issues

(Found)

Pro Tip: Recent or past legal issues are considered a significant indicator of mental status. If Tina had had any recent legal issues, it could indicate an important change in her mental health.

Example Question:

Have you ever had a legal problem?

Finding:

Asked about military service

Finding:

Denies military service

(Found)

Pro Tip: The demands and experiences of military service can have a profound effect on a patient’s mental health. If Tina had a history of military service, it would be an important part of understanding her feelings of stress and anxiety, and would indicate a need to explore the possibility of PTSD and other trauma.

Example Question:

Have you served in the military?

Social History – Housing and Support Network

Finding:

Asked about living situation

Finding:

Lives in a house

(Available)

Pro Tip: A patient’s housing is an indicator of finances and comfort. If Tina had recently undergone a change in housing, it could be contributing to her stress.

Example Question:

Can you tell me about your housing?

Finding:

Lives at home with mother and sister

(Available)

Pro Tip: A patient who lives with friends or family has a definite support system, so it is important to ask her about her living situation. If Tina had recently stopped living with her mother and sister, or if living with family were causing problems, this could be contributing to her stress.

Example Question:

Do you live with anyone?

Finding:

Asked about family dynamics

Finding:

Has a brother and a sister

(Available)

Pro Tip: A patient’s siblings can form part or all of her support network, and her relationship with them can indicate mental health status and/or childhood experiences, so asking about them is important. Tina lives with her sister and sees her brother often, which means they could be a source of support or stress for her.

Example Question:

Do you have siblings?

Finding:

Father died in a car accident almost two years ago

(Available)

Pro Tip: A patient’s parents can form part or all of her support network, and her relationship with them can indicate mental health status and/or child experiences, so asking about them is important. Tina lost her father almost two years ago, so assessing her feelings about that loss is important to assessing her mental health. Tina also lives with her mother, so their relationship could be an important source of support or stress.

Example Question:

Can you tell me about your parents?

Finding:

Reports family is “tight knit” and gets along well

(Available)

Pro Tip: How a patient gets along with family is an important indicator of the existence of a support network, childhood experiences, and/or mental health. Tina sees her family as her responsibility, but also as a source of support, so it is important to ask her about them in order to assess if they could be contributing to her stress.

Example Question:

Does your family get along well?

Finding:

Asked about support network

Finding:

Reports close group of friends from middle and high school as well as from church

(Found)

Pro Tip: It is important to ask a patient about her support network, including her friends. Asking Tina about her relationships with her friends is also important in assessing her stress levels and the demands of her current schedule.

Example Question:

Who are your friends?

Finding:

Spends time with friends “a few times a month,” though less so with her recent schedule

(Available)

Pro Tip: It is important to ask a patient about her support network, including her friends. Asking Tina about her relationships with her friends is also important in assessing her stress levels and the demands of her current schedule.

Example Question:

How often do you spend time with friends?

Finding:

Asked about spirituality

Finding:

Identifies as Baptist

(Found)

Pro Tip: Spirituality can be a significant factor in a patient’s mental status and coping strategies. Tina is a lifelong Baptist and regularly attends church, so it is important to ask her about her spirituality in order to assess her mental health.

Example Question:

What are your religious beliefs?

Finding:

Reports attending Baptist church regularly since childhood

(Found)

Pro Tip: Spirituality can be a significant factor in a patient’s mental status and coping strategies. Tina is a lifelong Baptist and regularly attends church, so it is important to ask her about her spirituality in order to assess her mental health.

Example Question:

Do you attend church regularly?

Social History – Substance Use

Finding:

Asked about substance use

Finding:

Reports past marijuana use

(Found)

Pro Tip: Substance abuse can be an indicator of, or a contributing factor to, psychiatric illness. Assessing Tina’s history of drug use is important to understanding her risk factors.

Example Question:

Have you ever used drugs?

Finding:

Denies current substance use

(Found)

Pro Tip: Substance abuse can be an indicator of, or a contributing factor to, psychiatric illness. Assessing Tina’s current drug use is important to understanding her risk factors.

Example Question:

Do you currently use drugs?

Finding:

Followed up on past marijuana use

Finding:

Reports smoking marijuana for “five or six years”

(Available)

Pro Tip: How long a patient used drugs can help you to assess any possibilities of addiction or relapse, as well as any potential negative effects on her physical or mental health. Asking Tina how long she smoked marijuana could help you to understand how her past drug use fits into her psychiatric history.

Example Question:

How long did you smoke marijuana?

Finding:

Reports last smoked marijuana when she was “20 or 21” years old

(Found)

Pro Tip: Any past substance use can be considered a risk factor, but if a patient had recently stopped using drugs it could indicate a potential for relapse or that drug use could still be affecting her mental health. Asking Tina how long ago she stopped smoking marijuana could help you to understand how her past drug use fits into her psychiatric history.

Example Question:

When did you stop smoking marijuana?

Finding:

Reports quitting marijuana because it “just wasn’t fun anymore” and was bad for her asthma

(Available)

Pro Tip: A patient may have stopped using substances due to adverse effects on her mental and physical wellbeing. Asking Tina why she stopped smoking marijuana could help you to understand how her substance use affected her mentally and physically.

Example Question:

Why did you stop smoking marijuana?

Finding:

Reports marijuana use was for recreation, not to treat or mitigate specific symptoms

(Available)

Pro Tip: A patient may use substances as a form of self-medication for psychiatric illness. Asking Tina why she smoked marijuana could help you to understand how her past drug use fits into her psychiatric history.

Example Question:

Why did you smoke marijuana?

Finding:

Asked about alcohol use

Finding:

Confirms alcohol use

(Found)

Pro Tip: Alcohol abuse can be an indicator of, or a contributing factor to, psychiatric illness. Tina’s alcohol use could be a risk factor, so it is important to assess her alcohol consumption in order to rule out addiction or dependency.

Example Question:

Do you drink alcohol?

Finding:

Reports going out “a couple times a month”

(Found)

Pro Tip: Alcohol abuse can be an indicator of, or a contributing factor to, psychiatric illness. Tina drinks alcohol, so it is important to ask her follow-up questions in order to rule out dependency and addiction when assessing her mental health. Knowing how often she drinks alcohol will help you to asses if her use of it is a risk factor.

Example Question:

How often do you drink alcohol?

Finding:

Reports having “a few drinks” when she goes out

(Available)

Pro Tip: Alcohol abuse can be an indicator of, or a contributing factor to, psychiatric illness. Tina drinks alcohol, so it is important to ask her follow-up questions in order to rule out dependency and addiction when assessing her mental health. Knowing how much alcohol she drinks will help you to asses if her use of it is a risk factor.

Example Question:

How much alcohol do you drink?

Finding:

Reports 10-12 alcoholic drinks per month

(Available)

Pro Tip: Alcohol abuse can be an indicator of, or a contributing factor to, psychiatric illness. Tina drinks alcohol, so it is important to ask her follow-up questions in order to rule out dependency and addiction when assessing her mental health. It is essential, when checking for risk of alcohol dependency, to ask specific questions in order to discern exactly how many drinks she has per month.

Example Question:

How many drinks do you have per month?

Finding:

Reports drinking to “relax and blow off steam”

(Available)

Pro Tip: Alcohol abuse can be an indicator of, or a contributing factor to, psychiatric illness. Asking Tina why she drinks alcohol can help you to rule out self-medication and/or dependency.

Example Question:

Why do you drink alcohol?

Finding:

Denies that anyone has asked her to stop drinking

(Available)

Pro Tip: Alcohol abuse can be an indicator of, or a contributing factor to, psychiatric illness. If people close to Tina had asked her to stop drinking, it would be an important indicator of possible alcohol dependency.

Example Question:

Has anyone asked you to stop drinking?

Finding:

Denies guilt associated with drinking

(Available)

Pro Tip: Alcohol abuse can be an indicator of, or a contributing factor to, psychiatric illness. If Tina felt guilty after drinking, it could indicate she was drinking too much, and/or engaging in risky or uncharacteristic behavior when under the influence, which would be an important indicator of possible alcohol dependency.

Example Question:

Do you ever feel guilty after drinking?

Finding:

Asked about drinking and driving

Finding:

Reports that she and her friends “usually take a cab”

(Found)

Pro Tip: Driving under the influence is dangerous, and it can indicate alcohol dependency. If Tina were driving drunk, or riding in cars with a drunk driver, it would indicate alcohol dependency as a risk factor.

Example Question:

How do you get home when you have been drinking?

Finding:

Asked about tobacco use

Finding:

Denies history of tobacco use

(Found)

Pro Tip: Tobacco can affect mental health, so it is important to ask a patient about her tobacco use. Asking Tina about tobacco is recommended because it can contribute to stress and feelings of anxiety.

Example Question:

Have you ever used tobacco?

Finding:

Denies current tobacco use

(Found)

Pro Tip: Tobacco can affect mental health, so it is important to ask a patient about her tobacco use. Asking Tina about tobacco use is recommended because tobacco can contribute to stress and feelings of anxiety.

Example Question:

Do you use tobacco?

Finding:

Asked about prescription drug abuse

Finding:

Denies prescription drug abuse

(Found)

Pro Tip: Abuse of prescription drugs can be an indicator of, or a contributing factor to, psychiatric illness. If Tina were abusing prescription drugs it would be a definite risk factor for her mental health.

Example Question:

Have you taken drugs not prescribed to you?

Social History – Relationship and Sexual History

Finding:

Asked about relationship status

Finding:

Currently single

(Found)

Pro Tip: Romantic and sexual relationships are an important part of a patient’s support system, but they can also be a source or indicator of stress. If Tina were in a relationship, it would be important to follow-up for more details on the nature and quality of that relationship.

Example Question:

Are you in a relationship?

Finding:

Asked about relationship history

Finding:

Reports past relationships

(Found)

Pro Tip: Understanding a patient’s relationship history is integral to assessing her mental health. In Tina’s case, a change in her relationship status could be a source of her current stress.

Example Question:

Have you been in a relationship in the past?

Finding:

Last relationship ended three years ago

(Available)

Pro Tip: Understanding a patient’s relationship history is integral to assessing her mental health. In Tina’s case, a change in her relationship status could be a source of her current stress.

Example Question:

When was your last relationship?

Finding:

Most recent relationship lasted three years

(Available)

Pro Tip: Understanding a patient’s relationship history is integral to assessing her mental health. In Tina’s case, a change in her relationship status could be a source of her current stress.

Example Question:

How long was your last relationship?

Finding:

Reports she has never been married

(Found)

Pro Tip: Understanding a patient’s marital history is integral to assessing her mental health. If Tina had been married, it could be a current source of her stress.

Example Question:

Have you ever been married?

Finding:

Asked about sexual history

Finding:

Reports past sexual relationships

(Found)

Pro Tip: Understanding a patient’s sexual history and experiences is integral to assessing her mental health. If Tina had anxiety about her sexual history, it could indicate past trauma, or if Tina had a recent change in her sexual pattern it could indicate a change in her mental status.

Example Question:

Have you had sex in the past?

Finding:

Reports three previous sexual partners

(Found)

Pro Tip: Understanding a patient’s sexual history and experiences is integral to assessing her mental health. If Tina had anxiety about her sexual history, it could indicate past trauma, or if Tina had a recent change in her sexual pattern it could indicate a change in her mental status.

Example Question:

How many sexual partners have you had?

Finding:

Reports last sexual encounter was with boyfriend three years ago

(Available)

Pro Tip: Understanding a patient’s sexual history and experiences is integral to assessing her mental health. If Tina had anxiety about her sexual history, it could indicate past trauma, or if Tina had a recent change in her sexual pattern it could indicate a change in her mental status.

Example Question:

When did you last have sex?

Finding:

Asked about abuse history

Finding:

Denies history of abuse

(Found)

Pro Tip: A history of abuse can have an enormous effect on a patient’s mental health. If Tina had suffered abuse, it could mean her feelings of stress and anxiety were related to that past trauma.

Example Question:

Do you have a history of abuse?

Finding:

Denies past physical abuse

(Found)

Pro Tip: Physical abuse can have an enormous effect on a patient’s mental health. If Tina had suffered abuse, it could mean her feelings of stress and anxiety were related to that past trauma.

Example Question:

Have you ever been physically abused?

Finding:

Denies past verbal abuse

(Found)

Pro Tip: Verbal abuse can have an enormous effect on a patient’s mental health. If Tina had suffered abuse, it could mean her feelings of stress and anxiety were related to that past trauma.

Example Question:

Have you ever been verbally abused?

Social Determinants of Health

Finding:

Asked about stress causes

Finding:

Reports feeling stressed about studying and the future

(Found)

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

Example Question:

What seems to be causing your stress?

Finding:

Reports CPA professional qualifying exam in one month

(Found)

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

Example Question:

What test are you trying to study for?

Finding:

Reports upcoming graduation from college and need to secure employment

(Found)

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

Example Question:

What about the future is causing you stress?

Finding:

Asked about stress coping

Finding:

Reports coping with stress by going to church

(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:

How do you cope with stress?

Finding:

Reports coping with stress by staying organized

(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:

How do you manage stress?

Finding:

Reports coping with stress by talking to friends and family

(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:

Who do you talk to about stress?

Finding:

Reports usual stress coping strategies are less effective

(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 your coping strategies help your stress?

Family History

Finding:

Asked about relevant family history

Finding:

Denies psychiatric illness in the family

(Available)

Pro Tip: Many psychiatric illnesses are hereditary, so knowing the patient’s family psychiatric history is essential to assessing her mental health. In Tina’s case, a family history of anxiety or depression could be significant in reaching a diagnosis.

Example Question:

Has anyone in your family had a psychiatric illness?

Finding:

Reports uncle has a “problem with alcohol”

(Available)

Pro Tip: Substance abuse and addiction often runs in families, so knowing the patient’s family history of substance abuse is essential to assessing her mental health. In Tina’s case, a significant family history of addiction could be considered a risk factor.

Example Question:

Do you have a family history of alcohol dependency?

Finding:

Denies family history of drug addiction

(Available)

Pro Tip: Substance abuse and addiction often runs in families, so knowing the patient’s family history of substance abuse is essential to assessing her mental health. In Tina’s case, a significant family history of addiction could be considered a risk factor.

Example Question:

Do you have a family history of drug addiction?

Finding:

Denies family history of suicide

Education & Empathy : 1 of 4 (25.0%)

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

	Description: Tina describes problems sleeping and stress-symptoms like racing thoughts.
	What brings you here today?	Question 07:40 PM EDT
	I decided to come in because I’m tired all the time now. . . I have this really important exam coming up, and I’m stressed and too foggy to study most of the time. I really need help sleeping so I can focus on preparing for my exam.
	I am sorry for that	Empathize 07:40 PM EDT
	Thanks for understanding.
	Model Statement: “I’m sorry to hear about your trouble sleeping and stress. I’m glad you came in. Let me learn more about what you’re experiencing, and I will try to help.”

2 Stress

	Description: Tina describes how busy she is with school and work.
	What is causing your stress?	Question 07:54 PM EDT
	I’m stressed now because I can’t sleep, but I can’t sleep because I keep worrying about all this other stuff, like graduating, and passing this exam that’s coming up, and getting a job, and finding my own place to live. . . it’s a lot.
	How do you cope with stress?	Question 07:54 PM EDT
	Model Statement: “It sounds like you have a lot on your plate. I’m sorry you’re dealing with so much stress.”

3 Sleep

	Description: Tina describes her sleep hygiene and routine.
	What is causing your stress?	Question 07:54 PM EDT
	I’m stressed now because I can’t sleep, but I can’t sleep because I keep worrying about all this other stuff, like graduating, and passing this exam that’s coming up, and getting a job, and finding my own place to live. . . it’s a lot.
	How do you cope with stress?	Question 07:54 PM EDT
	Model Statement: “It’s hard to function at our best when we don’t get enough sleep. I know you’re very busy with work and school, but let’s talk about some strategies to help you get more sleep and make sure you’re getting good quality sleep.”

4 Coping and Support Systems

	Description: Tina describes her coping mechanisms and support systems.
	How do you cope with stress?	Question 07:54 PM EDT
	Usually I try to stay organized, you know, make to-do lists, plan my time, that kind of thing. Sometimes I’ll talk to friends or family. . . going to church usually helps, too. Lately, though, none of that is really helping like it should.
	Do you have a family history of stress?	Question 07:55 PM EDT
	I don’t think so. . . I mean everyone gets stressed sometimes, but I don’t think people in my family are more stressed than other people or anything.
	Model Statement: “It sounds like you have healthy support systems through your family and friends, which is great. It sounds like you work hard to manage your time effectively, too. Remember to take time out to relax or take a walk.”

Documentation / Electronic Health Record

Document: Provider Notes

Document: Provider Notes

Student Documentation	Model Documentation
Subjective Ms. Jones is a 28 y/o African American woman who visits the clinic due to “difficlut aleeping this past month”. She sleeps on average 4-5hrs. Watches TV and reads book to assist with sleep. She drinks four coke daily. She is stressed by upcoming exam and job search. She has support from family and religion. No tobacco use. No medication use. Has lost appetite, Denies depression, suicidal thoughts. Mood is off	HPI: Ms. Jones presents to the clinic complaining of difficulty sleeping which she notes to have started 1 month ago. She states that her sleep is “shallow and not restful”. She complains of difficulty falling asleep at least 4 or 5 nights per week, but states that she is able to stay asleep without difficulty. On average she sleeps 4 or 5 hours per night and awakens at 8:00am daily. She states that she has a fairly consistent schedule on weekdays and weekends. She does not take any prescription or over the counter sleep aids. She limits screen time prior to bed and does not ingest caffeine after 4pm daily. She endorses decreased feelings of sleepiness over the past month. She denies difficulties awaking, but does not feel rested in the morning and has daytime fatigue (rates 5/10 severity), restlessness, and irritability (rates 2/10 severity). She does not take naps. Social History: She states that she has some stress related to her upcoming examinations and her impending job search upon graduation. She states that she has a strong support system made up of friends and family and she is active in her church. She states that she copes with stress by staying organized. She enjoys reading and watching television (1-2 hours per day). She states that her father died in a car accident a year and a half ago, which was difficult for her and she experienced some difficulties with sleep at that time as well. She denies use of tobacco. She drinks approximately 10-12 alcoholic beverages per month, but never more than 3 per sitting and does not note any impact on her sleep. She has used marijuana in the past, but no current use and denies other illicit drugs. She does not exercise regularly, but states that her job is somewhat active and she walks 5-15 minutes daily. She drinks 1-3 diet colas per day. Family History: Denies any history of known sleep disorders or psychiatric disorders. Review of Systems: • General: Denies changes in weight, weakness, fever, chills, and night sweats. Does complain of increasing daytime fatigue. • Neurologic: Denies loss of sensation, numbness, tingling, tremors, weakness, paralysis, fainting, blackouts, or seizures. Endorses changes in concentration and sleep. Denies changes or difficulties in coordination. • Psychiatric: States that her mood has been “off” and she does not feel like herself. She does complain of increased anxiety related to upcoming exams and job search. She has no history of depression, but does state that she feels helpless and notes that her performance at work and school is beginning to decline. She denies tension or memory loss. No past suicide attempts. Denies suicidal or homicidal ideation.
Assessment Insomnia related to anxiety sleep disturbance related to anxiety	Sleep disturbance related to anxiety
Plan Record episodes of insomnia and anxiety Offer CBT Educate on anxiety reduction strategies Encourage diet and exercise regimen. Decrease caffeine intake Provide signs on when to seek for help Continue monitoring symptoms Increase water consumption Maintain regular sleep and wake schedule Revisit in 2 weeks for follow-up and evaluation	• Encourage Ms. Jones to continue to monitor symptoms and log her episodes of insomnia and anxiety with associated factors and bring log to next visit. • Encourage to decrease caffeine consumption and increase intake of water and other fluids. • Educate on anxiety reduction strategies including deep breathing, relaxation, and guided imagery. Continue to monitor and explore the need for possible referral to social work/psychiatry or pharmacologic intervention. • Discuss need to maintain regular sleep and wake schedule and sleep hygiene techniques including limiting caffeine after 2pm, limiting fluids after dinner, limiting screen time or stimulating activities after 8pm, and to get out of bed if awaken in the middle of the night. • Educate to limit alcohol and depressant medications (including diphenhydramine and Tylenol PM). • Educate on when to seek further or emergent care including feelings of self-harm or hopelessness. • Revisit clinic in 2-4 weeks for follow up and evaluation.

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Tina Jones HEENT Completed

April 30, 2025/in BLOGS, Nursing paper help /by admin

Tina Jones HEENT

Experience Overview

Patient: Tina Jones

Digital Clinical Experience Score

98.2%

This score measures your performance on the Student Performance Index in relation to other students in comparable academic programs. Your instructor has chosen to scale your Student Performance Index score so that the average score on the index is a 80.0%. This score may not be your final grade if your instructor chooses to include additional components, such as documentation or time spent.

Student Performance Index

55

out of

59

Proficiency Level:

Proficient

Students rated as “proficient” demonstrate an entry-level expertise in advanced practice competencies and clinical reasoning skills. In comparable programs, the top 25% of students perform at the level of a proficient practitioner.

Subjective Data Collection

29

out of

29

Objective Data Collection

25

out of

25

Education and Empathy

1

out of

5

Time

52 minutes total spent in assignment

Interaction with patient

52 minutes

Transcript

Started: Mar 27, 2025 | Total Time: 52 min

All Lines (130)Interview Questions (44)Statements (1)Exam Actions (85)

	Hello, my name is Mileidy. I will be your nurse today	Greet 03/27/25 4:31 AM EDT
	Hey.
	WHat brings you here today	Question 03/27/25 4:31 AM EDT
	My throat has been sore… and itchy. And my nose won’t stop running. These symptoms are driving me nuts.
	I am sorry for that	Empathize 03/27/25 4:31 AM EDT
	I appreciate you saying that.
	When did the symptoms start	Question 03/27/25 4:32 AM EDT
	Like a week ago, everything started. Sore, itchy throat, runny nose.
	How severe us thr throat discomfort?	Question 03/27/25 4:32 AM EDT
	It’s not… terrible. I mean, it hurts a little. Like, mild to moderate. The main thing is that it won’t go away.
	What is the frequency and duration of runny nose? (No matching questions found.)	Question 03/27/25 4:32 AM EDT
	What is the frequency of runny nose?	Question 03/27/25 4:33 AM EDT
	It runs all day.
	What nasal symptoms do you have?	Question 03/27/25 4:33 AM EDT
	It’s been running nonstop!
	What does the nasal discharge look like?	Question 03/27/25 4:43 AM EDT
	It’s just clear.
	Do you have eye symptoms?	Question 03/27/25 4:44 AM EDT
	You mean, other than this itchy-eye stuff going on right now? I guess… my eyes get blurry sometimes when I read. It seems like my vision is getting worse over the years.
	Do you have any respiratory symptoms?	Question 03/27/25 4:44 AM EDT
	My breathing’s fine. I haven’t had any asthma problems come up.
	what do you think has caused the symptoms?	Question 03/27/25 4:45 AM EDT
	Well, at first I thought this was a cold, but it’s just sticking around. I’m not getting better or worse, so I’m starting to think it’s allergies or something.
	What relieves the symptoms?	Question 03/27/25 4:45 AM EDT
	All I’ve done is suck on some throat drops. And I’ve been drinking more water, which helps.
	What relieves the nose and eye symptoms	Question 03/27/25 4:46 AM EDT
	All I’ve done is suck on some throat drops. And I’ve been drinking more water, which helps.
	What are the relieving factors for nose and eye symptoms	Question 03/27/25 4:46 AM EDT
	All I’ve done is suck on some throat drops. And I’ve been drinking more water, which helps.
	What makes nose and eye symptoms better? (No matching questions found.)	Question 03/27/25 4:46 AM EDT
	What improves nose and eye symptoms? (No matching questions found.)	Question 03/27/25 4:47 AM EDT
	nose and eye symptoms?	Question 03/27/25 4:47 AM EDT
	Yes, my nose won’t stop running!
	What relieves nose and eye symptoms?	Question 03/27/25 4:47 AM EDT
	All I’ve done is suck on some throat drops. And I’ve been drinking more water, which helps.
	Do you use medications?	Question 03/27/25 4:48 AM EDT
	No, I haven’t done anything to try to make my eyes less itchy.
	Do you use an inhaler	Question 03/27/25 4:48 AM EDT
	Yeah, I use it when my asthma acts up.
	Are you exposed to allergens?	Question 03/27/25 4:48 AM EDT
	Not lately.
	How is your healthcare access	Question 03/27/25 4:49 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.
	Do you have any head problem?	Question 03/27/25 4:49 AM EDT
	Just like in general? I get headaches sometimes.
	What causes the headaches?	Question 03/27/25 4:50 AM EDT
	When I get headaches, it’s usually just from reading. I only get them about once a week and it doesn’t really hurt on one side or the other. The pain is mostly behind both eyes.
	Do you have vision problems?	Question 03/27/25 4:50 AM EDT
	Yeah, maybe so. I’ve noticed my vision getting sort of blurry when I read. It seems like it’s getting a little worse — I notice it more.
	Do you have any ears problem	Question 03/27/25 4:50 AM EDT
	No, my ears are fine right now.
	Do you have any mouth or jaw problem?	Question 03/27/25 4:50 AM EDT
	No, that’s not where I’m having problems. [AUDIO COMING SOON]
	Do you have any dental issue?	Question 03/27/25 4:51 AM EDT
	No, I’ve got good teeth. They don’t give me any problems.
	Do you have any throat issue?	Question 03/30/25 6:54 PM EDT
	Yes, my throat’s sore right now.
	Are there any relevant family history? (Clarified to Can you tell me about your family medical history?.)	Question 03/30/25 6:55 PM EDT
	My mom has some issues, and I think some of my grandparents did, too. (Clarified to to tell you about my family medical history.)
	Are there any family health history related to your condition?	Question 03/30/25 6:55 PM EDT
	My mom has some issues, and I think some of my grandparents did, too.
	Do you have a family member with this issue? (Clarified to Do you have any family history of breathing problems?.)	Question 03/30/25 6:56 PM EDT
	My baby sister has asthma, too, but no one else in the family has lung problems, I don’t think. (Clarified to if my family has a history of breathing problems.)
	Do you have a family history of throat problems?	Question 03/30/25 6:57 PM EDT
	No.
	Inspected general face	Exam Action 03/30/25 7:19 PM EDT
	Inspected forehead and scalp	Exam Action 03/30/25 7:19 PM EDT
	Inspected nose and mouth	Exam Action 03/30/25 7:19 PM EDT
	Inspected right side of face	Exam Action 03/30/25 7:19 PM EDT
	Inspected back of head	Exam Action 03/30/25 7:19 PM EDT
	Inspected right side of face	Exam Action 03/30/25 7:19 PM EDT
	Inspected general face	Exam Action 03/30/25 7:19 PM EDT
	Inspected left side of face	Exam Action 03/30/25 7:19 PM EDT
	Inspected back of head	Exam Action 03/30/25 7:19 PM EDT
	Inspected left side of face	Exam Action 03/30/25 7:19 PM EDT
	Inspected general face	Exam Action 03/30/25 7:19 PM EDT
	Inspected right orbital area and sclera	Exam Action 03/30/25 7:19 PM EDT
	Inspected left orbital area and sclera	Exam Action 03/30/25 7:19 PM EDT
	Inspected lower conjunctiva	Exam Action 03/30/25 7:20 PM EDT
	Inspected upper conjunctiva	Exam Action 03/30/25 7:20 PM EDT
	Performed otoscopic examination of right naris	Exam Action 03/30/25 7:20 PM EDT
	Performed otoscopic examination of left naris	Exam Action 03/30/25 7:20 PM EDT
	Performed otoscopic examination of right naris	Exam Action 03/30/25 7:20 PM EDT
	Performed otoscopic examination of right ear	Exam Action 03/30/25 7:20 PM EDT
	Performed otoscopic examination of left ear	Exam Action 03/30/25 7:20 PM EDT
	Inspected mouth	Exam Action 03/30/25 7:20 PM EDT
	Inspected mouth: pushed tongue left with tongue blade	Exam Action 03/30/25 7:20 PM EDT
	Inspect mouth: pushed tongue right with tongue blade	Exam Action 03/30/25 7:20 PM EDT
	Inspect mouth: lifted tongue with tongue blade	Exam Action 03/30/25 7:20 PM EDT
	Inspected mouth: depressed tongue with tongue blade	Exam Action 03/30/25 7:20 PM EDT
	Inspected front of neck	Exam Action 03/30/25 7:20 PM EDT
	Inspected right side of neck	Exam Action 03/30/25 7:20 PM EDT
	Inspected back of neck	Exam Action 03/30/25 7:20 PM EDT
	Inspected left side of neck	Exam Action 03/30/25 7:20 PM EDT
	Inspected back of neck	Exam Action 03/30/25 7:20 PM EDT
	Inspected right side of neck	Exam Action 03/30/25 7:21 PM EDT
	Inspected front of neck	Exam Action 03/30/25 7:21 PM EDT
	Inspected left side of neck	Exam Action 03/30/25 7:21 PM EDT
	Inspected front of neck	Exam Action 03/30/25 7:21 PM EDT
	Palpated scalp: No balding or thinning hair distribution, no masses, no tenderness reported	Exam Action 03/30/25 7:21 PM EDT
	Palpated frontal sinuses: No tenderness reported	Exam Action 03/30/25 7:21 PM EDT
	Palpated maxillary sinuses: No tenderness reported	Exam Action 03/30/25 7:21 PM EDT
	Palpated temporal arteries bilaterally: Right: no thrill, 2+ / Left: no thrill, 2+	Exam Action 03/30/25 7:21 PM EDT
	Palpated right carotid artery: No thrill, 2+	Exam Action 03/30/25 7:21 PM EDT
	Palpated left carotid artery: No thrill, 2+	Exam Action 03/30/25 7:22 PM EDT
	open and close your mouth	Question 03/30/25 7:22 PM EDT
	Palpated jaw: Full range of motion, no popping or clicking	Exam Action 03/30/25 7:22 PM EDT
	Palpated lymph nodes of head and neck: Not palpable	Exam Action 03/30/25 7:23 PM EDT
	Palpated supraclavicular lymph nodes: Not palpable	Exam Action 03/30/25 7:23 PM EDT
	Palpated axillary lymph nodes: Not palpable	Exam Action 03/30/25 7:23 PM EDT
	Palpated thyroid gland: No nodules, not enlarged, no irregularities, no tenderness reported	Exam Action 03/30/25 7:23 PM EDT
	Auscultated breath sounds in anterior right upper lobe	Exam Action 03/30/25 7:23 PM EDT
	Auscultated breath sounds in anterior left upper lobe	Exam Action 03/30/25 7:23 PM EDT
	Auscultated breath sounds in anterior right middle lobe	Exam Action 03/30/25 7:23 PM EDT
	Auscultated breath sounds in anterior left mid-chest (upper lobe)	Exam Action 03/30/25 7:23 PM EDT
	Auscultated breath sounds in anterior right lower lobe	Exam Action 03/30/25 7:24 PM EDT
	Auscultated breath sounds in anterior left lower lobe	Exam Action 03/30/25 7:24 PM EDT
	Auscultated breath sounds in posterior left upper lobe	Exam Action 03/30/25 7:24 PM EDT
	Auscultated breath sounds in posterior right upper lobe	Exam Action 03/30/25 7:24 PM EDT
	Auscultated breath sounds in posterior left mid-back (lower lobe)	Exam Action 03/30/25 7:24 PM EDT
	Auscultated breath sounds in posterior right mid-back (lower lobe)	Exam Action 03/30/25 7:24 PM EDT
	Auscultated breath sounds in posterior left lower lobe	Exam Action 03/30/25 7:24 PM EDT
	Auscultated breath sounds in posterior right lower lobe	Exam Action 03/30/25 7:24 PM EDT
	Auscultated breath sounds in posterior left lower lobe on side	Exam Action 03/30/25 7:24 PM EDT
	Auscultated breath sounds in posterior left lower lobe near spine	Exam Action 03/30/25 7:24 PM EDT
	Auscultated breath sounds in posterior right lower lobe near spine	Exam Action 03/30/25 7:24 PM EDT
	Auscultated breath sounds in posterior right lower lobe on side	Exam Action 03/30/25 7:24 PM EDT
	Auscultated right temporal pulse	Exam Action 03/30/25 7:25 PM EDT
	Auscultated left temporal pulse	Exam Action 03/30/25 7:25 PM EDT
	Auscultated right carotid pulse	Exam Action 03/30/25 7:25 PM EDT
	Auscultated left carotid pulse	Exam Action 03/30/25 7:25 PM EDT
	Tested left pupillary reaction with penlight	Exam Action 03/30/25 7:25 PM EDT
	Tested right pupillary reaction with penlight	Exam Action 03/30/25 7:25 PM EDT
	Follow my fingers with just your eyes	Question 03/30/25 7:25 PM EDT
	Ok.
	Tested EOM to the upper left	Exam Action 03/30/25 7:26 PM EDT
	Tested EOM to the upper center	Exam Action 03/30/25 7:26 PM EDT
	Tested EOM to the upper right	Exam Action 03/30/25 7:26 PM EDT
	Tested convergence to the center	Exam Action 03/30/25 7:26 PM EDT
	Tested EOM to the lower right	Exam Action 03/30/25 7:26 PM EDT
	Tested EOM to the lower center	Exam Action 03/30/25 7:26 PM EDT
	Tested EOM to the lower left	Exam Action 03/30/25 7:26 PM EDT
	Tell me when you can no longer see my finger	Question 03/30/25 7:26 PM EDT
	Ok, I will.
	Tested peripheral vision	Exam Action 03/30/25 7:26 PM EDT
	Now.
	Examined fundus of right eye with ophthalmoscope	Exam Action 03/30/25 7:26 PM EDT
	Examined fundus of left eye with ophthalmoscope	Exam Action 03/30/25 7:27 PM EDT
	Um, that one’s kind of blurry.
	E D E O X F
	Um, that one’s kind of blurry.
	F E L O P Z D
	D E F P O T E C
	Tested visual acuity of left eye (right eye covered)	Exam Action 03/30/25 7:28 PM EDT
	I can’t read that line. It’s too little.
	I can’t read that line. It’s too little.
	That’s… I can’t really tell.
	Um, that one’s kind of blurry.
	E D E O X F
	P E C F D
	Tested visual acuity of right eye (left eye covered)	Exam Action 03/30/25 7:29 PM EDT
	P E C F D
	E D F C Z P
	F E L O P Z D
	D E F P O T E C
	Tested visual acuity with both eyes	Exam Action 03/30/25 7:30 PM EDT
	is the volume the same in both ears or louder in one ear?	Question 03/30/25 7:31 PM EDT
	Ok.
	Same in both ears.
	Performed Weber test with tuning fork	Exam Action 03/30/25 7:31 PM EDT
	Tell me when you no longer hear the ringing	Question 03/30/25 7:31 PM EDT
	Ok, I will.
	Now.
	Tell me when you no longer hear the ringing	Question 03/30/25 7:32 PM EDT
	Ok, I will.
	Now.
	Performed Rinne test on right ear with tuning fork	Exam Action 03/30/25 7:32 PM EDT
	Now.
	Four	Question 03/30/25 7:32 PM EDT
	Four.
	R.	Question 03/30/25 7:32 PM EDT
	R.
	Nine.	Question 03/30/25 7:33 PM EDT
	Nine.
	Performed whisper test in left ear	Exam Action 03/30/25 7:33 PM EDT
	F.	Question 03/30/25 7:33 PM EDT
	F.
	Eight	Question 03/30/25 7:33 PM EDT
	Eight.
	W.	Question 03/30/25 7:33 PM EDT
	W.
	Performed whisper test in right ear	Exam Action 03/30/25 7:33 PM EDT
	Tested gag reflex with tongue blade	Exam Action 03/30/25 7:33 PM EDT

Subjective Data Collection: 29 of 29 (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 sore throat

(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:

Is your throat sore?

Finding:

Reports itchy throat

(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:

Is your throat itchy?

Finding:

Reports itchy eyes

(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:

Are your eyes itchy?

Finding:

Reports runny nose

(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:

Do you have a runny nose?

History of Present Illness

Finding:

Asked about onset of symptoms

Finding:

Reports sore throat began 1 week ago

(Found)

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

Example Question:

How long has your throat been sore?

Finding:

Reports runny nose began 1 week ago

(Found)

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

Example Question:

When did your nose start running?

Finding:

Reports itchy eyes began 1 week ago

(Found)

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

Example Question:

When did your eyes start itching?

Finding:

Asked about aggravating factors for throat symptoms

Finding:

Reports throat pain is constant

(Found)

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

Example Question:

Is the throat pain constant?

Finding:

Reports throat pain is worse in the morning

(Available)

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

Example Question:

When does your sore throat feel the worst?

Finding:

Reports some soreness with swallowing

(Available)

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

Example Question:

Does it hurt when you swallow?

Finding:

Asked severity of throat discomfort

Finding:

Reports sore throat discomfort as mild to moderate

(Available)

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

Example Question:

Can you rate your sore throat on a scale of 0 to 10?

Finding:

Asked about frequency and duration of runny nose

Finding:

Reports runny nose is constant

(Found)

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

Example Question:

How often does your nose run?

Finding:

Followed up on nasal symptoms

Finding:

Denies itchy nose

(Available)

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

Example Question:

Does your nose itch?

Finding:

Denies sinus pain

(Available)

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

Example Question:

Do you feel any sinus pain?

Finding:

Denies sinus pressure

(Available)

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

Example Question:

Do you feel any sinus pressure?

Finding:

Denies sneezing

(Available)

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

Example Question:

Have you been sneezing?

Finding:

Followed up about character of nasal discharge

Finding:

Reports clear discharge

(Found)

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

Example Question:

What color is your mucus?

Finding:

Reports thin discharge

(Available)

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

Example Question:

Is the mucus thick?

Finding:

Denies pus

(Found)

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

Example Question:

Does your mucus have pus in it?

Finding:

Asked about eye symptoms

Finding:

Reports eye itching is constant

(Available)

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

Example Question:

Do your eyes constantly itch?

Finding:

Reports eye redness

(Available)

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

Example Question:

Are your eyes red?

Finding:

Asked related respiratory symptoms

Finding:

Reports breathing isn’t affected

(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:

Have you had any changes in your breathing?

Finding:

Denies cough

(Available)

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

Example Question:

Do you have a cough?

Finding:

Denies chest tightness

(Available)

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

Example Question:

Does your chest feel tight?

Finding:

Asked about related asthma symptoms

Finding:

Denies recent wheezing

(Available)

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

Example Question:

Have you been wheezing?

Finding:

Denies increase in recent asthma symptoms

(Found)

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

Example Question:

Has your asthma been worse lately?

Finding:

Asked about perceived cause of symptoms

Finding:

Reports symptoms are similar to allergies

(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:

Do you know what’s causing your symptoms?

Finding:

Reports symptoms don’t seem like a common cold

(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:

Do you think you have a cold?

Finding:

Reports similarity to her sister’s hay fever symptoms

(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:

Do you think you are having an allergic reaction?

Finding:

Asked about relieving factors for nose and eye symptoms

Finding:

Denies treatment for itchy eyes

(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:

Have you treated your eyes with anything?

Finding:

Denies treatment for nasal symptoms

(Available)

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

Example Question:

Have you done anything for your runny nose?

Finding:

Denies taking antihistamine

(Available)

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

Example Question:

Have you taken any antihistamines?

Finding:

Denies taking decongestant

(Available)

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

Example Question:

Have you taken any decongestants?

Finding:

Asked about relieving factors for throat symptoms

Finding:

Reports lozenges as treatment

(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:

Have you taken anything for your sore throat?

Finding:

Reports lozenges reduce symptoms

(Available)

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

Example Question:

Do the lozenges help?

Finding:

Reports ingesting lozenges every few hours

(Available)

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

Example Question:

How often do you have a lozenge?

Finding:

Reports drinking water reduces symptoms

(Found)

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

Example Question:

Does drinking water help?

Home Medications

Finding:

Confirmed home medications

Finding:

Reports no new medications

(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 started taking any new medications?

Finding:

Followed up about inhaler use

Finding:

Reports using an inhaler to treat asthma symptoms

(Found)

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

Example Question:

Do you use an inhaler for your asthma?

Finding:

Reports inhaler is albuterol (Proventil)

(Available)

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

Example Question:

What is the name of the inhaler you are currently using?

Finding:

Reports last use of inhaler was 1 week ago

(Available)

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

Example Question:

When did you last use your inhaler?

Finding:

Reports typical inhaler use is 2 – 3 times a week

(Available)

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

Example Question:

How often do you use your inhaler?

Finding:

Reports using 2 – 3 puffs of inhaler when used

(Available)

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

Example Question:

How many puffs of your inhaler do you use?

Finding:

Reports prescribed dosage is 2 puffs

(Available)

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

Example Question:

How many puffs of your inhaler are you supposed to do?

Social Determinants of Health

Finding:

Asked about environmental exposure to allergens

Finding:

Denies exposure to cats

(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:

Have you been recently exposed to any allergens?

Finding:

Denies exposure to mold or mildew

(Available)

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

Example Question:

Do you have mold in your house?

Finding:

Denies exposure to dust

(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 dust in your house?

Finding:

Denies exposure to irritants in work environment

(Available)

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

Example Question:

Are you allergic to anything at work?

Finding:

Reports changing bedding once a week

(Available)

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

Example Question:

How often do you change your bedding?

Finding:

Denies history of cigarette smoking

(Available)

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

Example Question:

Have you smoked cigarettes recently?

Finding:

Denies recent exposure to secondhand smoke

(Available)

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

Example Question:

Have you been exposed to secondhand smoke recently?

Finding:

Asked about healthcare access

Finding:

Reports last vision exam was in childhood

(Available)

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

Example Question:

When was your last vision test?

Finding:

Reports last hearing test was in childhood

(Available)

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

Example Question:

When was your last hearing test?

Finding:

Reports dental visit within the last 2 years

(Available)

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

Example Question:

When did you last see the dentist?

Finding:

Reports regular dental visits in childhood

(Available)

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

Example Question:

How often did you see the dentist when you were a child?

Finding:

Denies vision insurance

(Available)

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

Example Question:

Do you have vision insurance?

Finding:

Denies dental insurance

(Available)

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

Example Question:

Do you have dental insurance?

Relevant Medical History

Finding:

Confirmed allergies

Finding:

Reports known allergy to cats

(Available)

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

Example Question:

Can you confirm that you’re allergic to cats?

Finding:

Reports known allergy to dust

(Available)

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

Example Question:

Are you allergic to dust?

Finding:

Denies seasonal allergies

(Available)

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

Example Question:

Do you have seasonal allergies?

Review of Systems

Finding:

Asked about constitutional health

Finding:

Denies recent or frequent illnesses

(Available)

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

Example Question:

Have you been sick recently?

Finding:

Denies chills

(Available)

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

Example Question:

Have you had any chills?

Finding:

Denies fever

(Available)

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

Example Question:

Have you had a fever?

Finding:

Reports low energy level

(Available)

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

Example Question:

Have you felt fatigued?

Finding:

Denies nausea or vomiting

(Available)

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

Example Question:

Have you felt nauseous?

Finding:

Asked about review of systems for head

Finding:

Reports occasional headaches

(Found)

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

Example Question:

Do you ever get headaches?

Finding:

Denies current headache

(Available)

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

Example Question:

Do you have a headache currently?

Finding:

Denies history of head injury

(Available)

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

Example Question:

Have you ever had a head injury?

Finding:

Denies lightheadedness

(Available)

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

Example Question:

Do you ever get lightheaded?

Finding:

Followed up on headaches

Finding:

Reports headaches occur once a week

(Found)

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

Example Question:

How often do you get headaches?

Finding:

Reports headaches last a few hours

(Available)

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

Example Question:

How long do your headaches last?

Finding:

Reports headaches feel tight and throbbing

(Available)

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

Example Question:

How would you describe your headaches?

Finding:

Reports headache location is behind her forehead

(Found)

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

Example Question:

Where do you feel your headaches?

Finding:

Reports headache pain as a 3 or 4

(Available)

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

Example Question:

How would you rate your headache pain on a scale of 0 to 10?

Finding:

Reports treating headaches with acetaminophen (Tylenol)

(Available)

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

Example Question:

How do you treat your headaches?

Finding:

Reports reading and studying seem to cause headaches

(Found)

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

Example Question:

What seems to cause your headaches?

Finding:

Asked about review of systems for eyes

Finding:

Reports occasional blurry vision

(Found)

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

Example Question:

Do you have blurry vision?

Finding:

Reports worsening vision

(Found)

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

Example Question:

Has your vision gotten worse?

Finding:

Denies eye pain

(Available)

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

Example Question:

Have you had eye pain?

Finding:

Denies dry eyes

(Available)

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

Example Question:

Have you had dry eyes?

Finding:

Denies corrective lenses

(Available)

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

Example Question:

Do you have glasses or contacts?

Finding:

Followed up on vision problems

Finding:

Reports blurry vision as fuzzy letters

(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:

Can you describe your blurry vision?

Finding:

Reports blurry vision occurs when reading for long periods

(Found)

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

Example Question:

When do you get blurry vision?

Finding:

Reports blurry vision occurs after 2+ hours of reading

(Available)

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

Example Question:

How long have you been reading when your vision gets blurry?

Finding:

Reports that blurry vision and headaches often coincide

(Available)

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

Example Question:

Do you get headaches when you have blurry vision?

Finding:

Asked about review of systems for ears

Finding:

Denies general ear problems

(Found)

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

Example Question:

Have you had ear problems?

Finding:

Denies change in hearing

(Available)

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

Example Question:

Have you had any changes in your hearing?

Finding:

Denies ear pain

(Available)

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

Example Question:

Have you had ear pain?

Finding:

Denies ear discharge

(Available)

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

Example Question:

Have you noticed ear discharge?

Finding:

Asked about review of systems for nose

Finding:

Denies change in sense of smell

(Available)

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

Example Question:

Have you had any changes in your sense of smell?

Finding:

Denies nasal or sinus surgeries

(Available)

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

Example Question:

Have you ever had a nasal surgery?

Finding:

Denies nosebleeds

(Available)

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

Example Question:

Do you ever get nosebleeds?

Finding:

Asked about review of systems for mouth and jaw

Finding:

Denies general mouth problems

(Found)

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

Example Question:

Have you ever had problems with your mouth?

Finding:

Denies change in sense of taste

(Available)

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

Example Question:

Has your sense of taste changed?

Finding:

Denies dry mouth

(Available)

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

Example Question:

Have you had dry mouth recently?

Finding:

Denies history of oral surgery

(Available)

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

Example Question:

Have you ever had oral surgery?

Finding:

Denies mouth pain

(Available)

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

Example Question:

Do you have mouth pain?

Finding:

Denies mouth sores

(Available)

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

Example Question:

Do you have any mouth sores?

Finding:

Denies gum problems

(Available)

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

Example Question:

Do you have any problems with your gums?

Finding:

Denies tongue problems

(Available)

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

Example Question:

Do you have any problems with your tongue?

Finding:

Denies jaw problems

(Found)

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

Example Question:

Do you have any problems with your jaw?

Finding:

Asked about review of systems for dentation

Finding:

Denies current dental problems

(Found)

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

Example Question:

Do you have any current dental problems?

Finding:

Reports a few cavities in childhood

(Available)

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

Example Question:

What dental problems have you had?

Finding:

Asked about review of systems for neck, throat and glands

Finding:

Denies history of recurrent strep throat

(Available)

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

Example Question:

Do you get strep throat often?

Finding:

Denies lymph node problems

(Available)

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

Example Question:

Do you have any problems with your lymph nodes?

Finding:

Denies history of general throat problems

(Available)

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

Example Question:

Do you have a history of throat problems?

Finding:

Denies voice changes

(Available)

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

Example Question:

Have you noticed any changes to your voice?

Finding:

Denies history of tonsil problems

(Available)

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

Example Question:

Do you have any history of tonsil problems?

Finding:

Denies general neck pain

(Available)

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

Example Question:

Do you have neck pain?

Relevant Family History

Finding:

Asked about relevant family history

Finding:

Reports sister with hay fever

(Available)

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

Example Question:

Do you have any family members with allergies?

Finding:

Denies family history of vision problems

(Available)

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

Example Question:

Do vision problems run in your family?

Finding:

Denies family history of sinus problems

(Available)

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

Example Question:

Do sinus problems run in your family?

Finding:

Denies family history of ear or hearing problems

(Available)

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

Example Question:

Do hearing problems run in your family?

Finding:

Denies family history of mouth, throat, or gland problems

(Found)

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

Example Question:

Do you have any family history of throat problems?

Finding:

Denies family history of headache or migraine

Objective Data Collection: 25 of 25 (100%)

Correct
Partially correct

Incorrect
Missed

Inspected head and face

Skull Symmetry (1/3 point)

Symmetric

Facial Feature Symmetry (1/3 point)

Symmetric

Appearance (1/3 point)

Papules, pustules, or comedones
Excessive hair growth
Red, chapped nose

Inspected eyes and orbital area

Orbital Area (1/4 point)

No visible abnormal findings

Sclera (1/4 point)

Injection

Conjunctiva (1/4 point)

Moist and pink

Conjunctival Discharge (1/4 point)

No discharge

Inspected nasal cavities

Color (1/4 point)

Pale
Bluish

Discharge (1/4 point)

Clear discharge

Turbinate Patency (1/4 point)

Patent

Observations (1/4 point)

No additional visible abnormal findings

Inspected ears

Right: Auditory Canal Color (1/10 point)

Pink

Right: Tympanic Membrane Color (1/10 point)

Pearly gray

Right: Tympanic Membrane Appearance (1/10 point)

No visible abnormal findings

Right: Cone Of Light (1/10 point)

5:00

Right: Discharge (1/10 point)

No discharge

Left: Auditory Canal Color (1/10 point)

Pink

Left: Tympanic Membrane Color (1/10 point)

Pearly gray

Left: Tympanic Membrane Appearance (1/10 point)

No visible abnormal findings

Left: Cone Of Light (1/10 point)

7:00

Left: Discharge (1/10 point)

No discharge

Inspected mouth and throat

Oral Mucosa (1/6 point)

Moist and pink

Tonsils (1/6 point)

Edema

Tonsil Grade (1/6 point)

1+: Tonsils <25% of space between pillars

Posterior Oropharynx Color (1/6 point)

Erythemic

Posterior Oropharynx Texture (1/6 point)

Cobblestoning

Post Nasal Drip (1/6 point)

Clear discharge

Inspected neck

Symmetry (1/2 point)

Symmetric

Appearance (1/2 point)

Discoloration

Palpated scalp

Tenderness (1/2 point)

None reported

Observations (1/2 point)

No additional abnormal findings

Palpated sinuses

Frontal (1/2 point)

None reported

Maxillary (1/2 point)

None reported

Palpated temporal arteries

Right: Vibration (1/4 point)

No thrill

Right: Intensity (1/4 point)

2+ Expected

Left: Vibration (1/4 point)

No thrill

Left: Intensity (1/4 point)

2+ Expected

Palpated carotid arteries

Right: Vibration (1/4 point)

No thrill

Right: Intensity (1/4 point)

2+ Expected

Left: Vibration (1/4 point)

No thrill

Left: Intensity (1/4 point)

2+ Expected

Palpated jaw

Observations (1/1 point)

No palpable abnormal findings

Palpated lymph nodes

Head And Neck (1/3 point)

No palpable nodes

Supraclavicular (1/3 point)

No palpable nodes

Axillary (1/3 point)

No palpable nodes

Palpated thyroid gland

Observations (1/2 point)

No palpable abnormal findings

Tenderness (1/2 point)

None reported

Breath Sounds (1/3 point)

Present in all areas

Adventitious Sounds (1/3 point)

No adventitious sounds

Location (1/3 point)

All areas clear

Auscultated temporal arteries

Right (1/2 point)

No bruit

Left (1/2 point)

No bruit

Auscultated carotid arteries

Right (1/2 point)

No bruit

Left (1/2 point)

No bruit

Tested pupillary reaction

Observations With Penlight (1/1 point)

No visible abnormal findings (PERRL)

Tested extraocular eye movements

Cardinal Fields (1/2 point)

No visible abnormal findings

Convergence (1/2 point)

No visible abnormal findings

Tested peripheral vision

Observations (1/1 point)

No abnormal findings

Examined fundus with ophthalmoscope

Right: Retina (1/4 point)

Cotton wool bodies

Right: Disc Margin (1/4 point)

Sharp

Left: Retina (1/4 point)

No visible abnormal findings

Left: Disc Margin (1/4 point)

Sharp

Tested visual acuity

Right (1/2 point)

20/40

Left (1/2 point)

20/20

Performed Weber test

Results (1/1 point)

Normal

Performed Rinne test

Right (1/2 point)

Normal

Left (1/2 point)

Normal

Performed whisper test

Right (1/2 point)

Normal

Left (1/2 point)

Normal

Tested gag reflex

Observations (1/1 point)

Intact

Education & Empathy : 1 of 5 (20.0%)

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

	Description: Tina describes the symptoms that have been bothering her.
	WHat brings you here today	Question 04:31 AM EDT
	My throat has been sore… and itchy. And my nose won’t stop running. These symptoms are driving me nuts.
	I am sorry for that	Empathize 04:31 AM EDT
	I appreciate you saying that.
	Model Statement: “I’m sorry to hear you don’t feel well. I’ll ask you some questions to learn more about your symptoms, and we will make a plan to help you feel better.”

2 Cause of Symptoms

	Description: Tina describes her symptoms as being similar to allergies.
	what do you think has caused the symptoms?	Question 04:45 AM EDT
	Well, at first I thought this was a cold, but it’s just sticking around. I’m not getting better or worse, so I’m starting to think it’s allergies or something.
	What relieves the symptoms?	Question 04:45 AM EDT
	Model Statement: “It is possible to develop new allergies as an adult, and so I will take that into consideration as I try to determine the cause of your symptoms.”

	Description: Tina describes her medication regimen.
	What relieves nose and eye symptoms?	Question 04:47 AM EDT
	All I’ve done is suck on some throat drops. And I’ve been drinking more water, which helps.
	Do you use medications?	Question 04:48 AM EDT
	No, I haven’t done anything to try to make my eyes less itchy.
	Do you use an inhaler	Question 04:48 AM EDT
	Yeah, I use it when my asthma acts up.
	Are you exposed to allergens?	Question 04:48 AM EDT
	Not lately.
	How is your healthcare access	Question 04:49 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.
	Model Statement: “Thank you for letting me know that you’re using throat drops in addition to the medications you usually take. I will ask you a few questions about how you’re using each medication.”

4 Headaches

	Description: Tina reports occasional headaches.
	Do you have any head problem?	Question 04:49 AM EDT
	Just like in general? I get headaches sometimes.
	What causes the headaches?	Question 04:50 AM EDT
	When I get headaches, it’s usually just from reading. I only get them about once a week and it doesn’t really hurt on one side or the other. The pain is mostly behind both eyes.
	Do you have vision problems?	Question 04:50 AM EDT
	Model Statement: “It sounds like you’re getting frequent headaches. I’m sorry you have to deal with those. I think we can determine more about what’s causing them, and try to relieve those for you.”

5 Vision

	Description: Tina describes her vision problems and lack of eye care.
	Do you have vision problems?	Question 04:50 AM EDT
	Yeah, maybe so. I’ve noticed my vision getting sort of blurry when I read. It seems like it’s getting a little worse — I notice it more.
	Do you have any ears problem	Question 04:50 AM EDT
	No, my ears are fine right now.
	Do you have any mouth or jaw problem?	Question 04:50 AM EDT
	No, that’s not where I’m having problems. [AUDIO COMING SOON]
	Model Statement: “Blurry vision can be a frustrating symptom. Taking steps toward better eye care, like seeing an eye doctor, could improve your vision and prevent blurriness when you read.”

Documentation / Electronic Health Record

Document: Provider Notes

Document: Provider Notes

Student Documentation	Model Documentation
Subjective Ms. Jones is a 28 y/o African American woman who visits the clinic due to sore and itchy throat, itchy eyes and runny nose which has lasted for one week. No aggravating symptoms but sore throat is worse in the morning. She rates the pain as 4/10. She relieves pain with throat lozenges. Has soreness while swallowing. She has a clear nose discharge. Not had any treatment. No cough or other illness. No fever, chills or sweats. Social History: Not exposed to irritants. does not use tobacco, alcohol or drugs. ROS Head: Occasional headaches Eyes: Vision worsening Ears: no discharge or pain Mouth/throat: Sore, itchy Nose/sinuses: Pain outside of nose Respiratory: No shortness of breath	HPI: Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of sore, itchy throat, itchy eyes, and runny nose for the last week. She states that these symptoms started spontaneously and have been constant in nature. She does not note any specific aggravating symptoms, but states that her throat pain seems to be worse in the morning. She rates her throat pain as 4/10 and her throat itchiness as 5/10. She has treated her throat pain with occasional throat lozenges which has “helped a little”. She states that she has some soreness when swallowing, but otherwise no other associated symptoms. She states that her nose “runs all day” and is clear discharge. She has not attempted any treatment for her nasal symptoms. She states that her eyes are constantly itchy and she has not attempted any eye specific treatment. She denies cough and recent illness. She has had no exposures to sick individuals. She denies changes in her hearing, vision, and taste. She denies fevers, chills, and night sweats. She has never been diagnosed with seasonal allergies, but does note that her sister has “hay fever”. Social History: She is not aware of any environmental exposures or irritants at her job or home. She changes her sheets weekly and denies dust/mildew at her home. She denies use of tobacco, alcohol, and illicit drugs. She does not exercise. Review of Systems: General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats. • Head: Denies history of trauma. Reports headaches while studying. • Eyes: She does not wear corrective lenses, but notes that her vision has been worsening over the past few years. She complains of blurry vision after reading for extended periods. Denies increased tearing or itching prior to this past week. • Ears: Denies hearing loss, tinnitus, vertigo, discharge, or earache. • Nose/Sinuses: Denies rhinorrhea prior to this episode. Denies stuffiness, sneezing, itching, previous allergy, epistaxis, or sinus pressure. • Mouth/Throat: Denies bleeding gums, hoarseness, swollen lymph nodes, or wounds in mouth. No sore throat prior to this episode. • Respiratory: She denies shortness of breath, wheezing, cough, sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. She has a history of asthma, last hospitalization was age 16 for asthma, last chest XR was age 16. Her current inhaler use has been her baseline of 2-3 times per week.
Objective She is alert and well oriented Head: Symmetric, no scalps Eyes: Bilateral eyes Ears: No inflammation, whisper normal Nose: Nosal mucosa is boggy and pale Mouse/Throat: Moist buccal mucosa Neck: Thyroid is smooth Respiratory: Symmetrical chest	General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented. She maintains eye contact throughout interview and examination. • Head: Head is normocephalic and atraumatic. Scalp with no masses, normal hair distribution. • Eyes: Bilateral eyes with equal hair distribution, no lesions, no ptosis, no edema, conjunctiva clear and injected. Extraocular movements intact bilaterally. Pupils equal, round, and reactive to light bilaterally. Normal convergence. Left fundoscopic exam reveals sharp disc margins, no hemorrhages. Right fundoscopic exam reveals mild retinopathic changes. Left eye vision: 20/20. Right eye vision: 20/40. • Ears: Ear shape equal bilaterally. External canals without inflammation bilaterally. Tympanic membranes pearly grey and intact with positive light reflex bilaterally. Rinne, Weber, and Whisper tests normal bilaterally. • Nose: Septum is midline, nasal mucosa is boggy and pale bilaterally. No pain with palpation of frontal or maxillary sinuses. • Mouth/Throat: Moist buccal mucosa, no wounds visualized. Adequate dental hygiene. Uvula midline. Tonsils 1+ and without evidence of inflammation. Posterior pharynx is slightly erythematous with mild cobblestoning. •Neck: No cervical, infraclavicular lymphadenopathy. Thyroid is smooth without nodules or goiter. Acanthosis nigricans present. Carotid pulses 2+, no thrills. Jaw with no clicks, full range of motion. Bilateral carotid artery auscultation without bruit. • Respiratory: Chest is symmetrical with respirations. Lung sounds clear to auscultation without wheezes, crackles, or cough.
Assessment Allergic Rhinitis	Allergic Rhinitis
Plan Continue monitoring symptoms Initiate loratadine 10mg by mouth daily Increase intake of water Avoid triggers Seek care in case of uncontrollable episodes Come for check up in 2 weeks	Encourage Ms. Jones to continue to monitor symptoms and log her episodes of allergic symptoms with associated factors and bring log to next visit. • Initiate trial of loratadine (Claritin) 10 mg by mouth daily. • Encourage to increase intake of water and other fluids and educate on frequent handwashing. • Educate on avoidance of triggers and known allergens • Educate Ms. Jones on when to seek care including episodes of uncontrollable epistaxis, worsening headache, or fever. • Revisit clinic in 2-4 weeks for follow up and evaluation.

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Tina Jones Health History Completed

April 30, 2025/in BLOGS, Nursing paper help /by admin

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)

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

Example Question:

What’s causing your pain?

History of Present Illness

Finding:

Asked to rate current pain level on a scale

Finding:

Reports current pain is 7/10

(Found)

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

Example Question:

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

Finding:

Asked for details about the pain

Finding:

Reports pain is throbbing

(Available)

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

Example Question:

Can you please describe the pain?

Finding:

Reports pain is sharp when she attempts to stand

(Available)

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

Example Question:

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

Finding:

Reports pain has increased in the past 2 days

(Found)

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

Example Question:

How has the pain changed over time?

Finding:

Reports feeling pain radiating into ankle

(Available)

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

Example Question:

Does the pain radiate anywhere else?

Finding:

Reports pain prevents bearing weight on foot

(Found)

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

Example Question:

Can you bear weight on your foot?

Finding:

Asked location of wound

Finding:

Reports right foot is injured

(Available)

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

Example Question:

Which foot is in pain?

Finding:

Reports wound is on the plantar surface of her foot

(Found)

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

Example Question:

Where is the wound?

Finding:

Asked details of the injury

Finding:

Reports she scraped foot on a cement step

(Available)

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

Example Question:

How did your injury happen?

Finding:

Reports initial injury occurred 1 week ago

(Found)

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

Example Question:

When did the pain start?

Finding:

Reports mild ankle injury

(Available)

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

Example Question:

Did you injure anything besides your foot?

Finding:

Reports being barefoot at the time of injury

(Available)

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

Example Question:

Were you wearing shoes when you fell?

Finding:

Asked about the assessment of the injury at the ER

Finding:

Reports going to the ER after sustaining the injury

(Available)

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

Example Question:

When did you go to the ER?

Finding:

Reports going to the ER because she suspected an ankle sprain

(Available)

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

Example Question:

Why did you go to the ER?

Finding:

Reports receiving an X-ray at the ER

(Available)

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

Example Question:

Did they xray your foot at the ER?

Finding:

Reports X-ray showed no broken bones

(Available)

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

Example Question:

What did the x-ray show?

Finding:

Reports receiving a prescription for pain pills

(Available)

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

Example Question:

Did you receive any pain medications at the ER?

Finding:

Asked about drainage from the foot wound

Finding:

Reports that the wound bled a little after sustaining the injury

(Available)

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

Example Question:

Did your foot bleed?

Finding:

Reports seeing pus draining from wound

(Found)

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

Example Question:

Did you notice any discharge from the wound?

Finding:

Reports noticing pus 2 days ago

(Available)

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

Example Question:

When did you first notice the pus?

Finding:

Followed up on drainage

Finding:

Reports pus as white or yellow

(Found)

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

Example Question:

What color is the drainage from your wound?

Finding:

Denies odor from the wound

(Available)

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

Example Question:

Does the wound have an odor?

Finding:

Asked about home treatment of foot wound

Finding:

Reports wound care regimen of bandaging

(Found)

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

Example Question:

How did you treat your foot at home?

Finding:

Reports cleaning wound twice a day

(Available)

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

Example Question:

How often did you clean the wound?

Finding:

Reports cleaning wound with hydrogen peroxide

(Available)

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

Example Question:

What did you use to clean the wound?

Finding:

Reports applying bacitracin, neomycin and polymyxin B (Neosporin)

(Found)

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

Example Question:

Did you use any ointment on the wound?

Finding:

Asked about other foot wound symptoms

Finding:

Reports swelling around foot wound

(Found)

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

Example Question:

Is there swelling around the wound?

Finding:

Reports swelling worsened in the past 2 days

(Available)

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

Example Question:

How long have you noticed swelling around the wound?

Finding:

Reports redness around the wound

(Found)

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

Example Question:

Did you notice any redness around the wound?

Finding:

Reports that the wound feels warm

(Found)

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

Example Question:

Does the wound feel warm?

Finding:

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

Finding:

Reports pain affects ability to walk

(Found)

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

Example Question:

Does your injury impact your ability to walk?

Finding:

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

(Available)

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

Example Question:

Does your foot pain affect your work?

Finding:

Reports pain prevented her from being able to walk to class

(Available)

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

Example Question:

Has your injury prevented you from going to class?

Past Medical History

Finding:

Asked about preexisting medical conditions

Finding:

Reports diabetes

(Found)

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

Example Question:

Do you have diabetes?

Finding:

Reports asthma

(Found)

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

Example Question:

Do you have asthma?

Finding:

Followed up on diabetes diagnosis

Finding:

Reports specific age of diagnosis was 24

(Available)

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

Example Question:

At what age were you diagnosed with diabetes?

Finding:

Reports that her diabetes is Type 2

(Available)

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

Example Question:

Do you know what type of diabetes you have?

Finding:

Asked about diabetes management through lifestyle changes

Finding:

Reports staying away from sweets

(Found)

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

Example Question:

Tell me more about any sugars you consume.

Finding:

Reports drinking diet soda instead of regular

(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 drink sugary drinks?

Finding:

Asked about current diabetes medication use

Finding:

Reports that she does not currently take medication for diabetes

(Found)

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

Example Question:

Do you take prescribed medication for your diabetes?

Finding:

Asked about past diabetes medication use

Finding:

Reports that she used to take diabetes medication

(Found)

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

Example Question:

Have you ever taken medication for your diabetes?

Finding:

Reports previous medication was prescription metformin

(Available)

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

Example Question:

Do you remember what you were prescribed for diabetes?

Finding:

Reports last use of medication was 3 years ago

(Found)

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

Example Question:

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

Finding:

Asked about blood glucose monitoring

Finding:

Reports infrequent blood glucose monitoring

(Found)

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

Example Question:

Tell me about your blood sugar monitoring.

Finding:

Reports last glucose check was a week ago at the ER

(Available)

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

Example Question:

How often do you check your blood sugar?

Finding:

Reports confusion about what the numbers mean

(Available)

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

Example Question:

What are your usual blood sugar levels?

Finding:

Asked about thirst

Finding:

Reports increased thirst

(Found)

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

Example Question:

Have you been more thirsty lately?

Finding:

Reports increased water intake

(Found)

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

Example Question:

Are you drinking more water than normal?

Finding:

Asked about frequency of urination

Finding:

Reports more frequent urination

(Found)

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

Example Question:

Have you been urinating more often than usual?

Finding:

Reports urinating every hour or two during the day

(Available)

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

Example Question:

How often do you urinate during the day?

Finding:

Reports urinating 2 to 3 times during the night

(Available)

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

Example Question:

How often do you wake up at night to urinate?

Finding:

Asked about change in appetite

Finding:

Reports increased appetite

(Found)

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

Example Question:

Have you noticed an increase in appetite?

Finding:

Reports change in appetite began a month ago

(Available)

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

Example Question:

When did you notice the increase in your appetite?

Finding:

Asked about weight change

Finding:

Reports recent loss of 10 lbs

(Available)

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

Example Question:

How much weight have you lost?

Finding:

Reports weight loss occurred over the past month

(Available)

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

Example Question:

How long did it take you to lose 10 pounds?

Finding:

Followed up on reason for weight change

Finding:

Reports weight loss was unintentional

(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:

Was your weight loss intentional?

Finding:

Asked about history of asthma exacerbations

Finding:

Reports last asthma attack was in high school

(Available)

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

Example Question:

When was your last asthma attack?

Finding:

Reports last exacerbation was three days ago

(Available)

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

Example Question:

When did you last have issues with asthma?

Finding:

Asked about asthma symptoms

Finding:

Reports chest tightness during exacerbation

(Found)

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

Example Question:

What do your asthma symptoms feel like?

Finding:

Reports difficulty breathing during exacerbation

(Found)

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

Example Question:

Do you have trouble breathing?

Finding:

Reports wheezing during exacerbation

(Found)

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

Example Question:

Do you ever wheeze?

Finding:

Asked about prior hospitalizations

Finding:

Reports past hospitalizations

(Found)

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

Example Question:

Have you been hospitalized in the past?

Finding:

Reports last hospitalization was for asthma

(Available)

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

Example Question:

Why were you hospitalized last time?

Finding:

Reports last hospitalization was age 16

(Found)

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

Example Question:

When was your last hospitalization?

Finding:

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

(Available)

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

Example Question:

How many times have you been hospitalized?

Finding:

Reports past nebulizer use

(Available)

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

Example Question:

Have you ever used a nebulizer?

Finding:

Asked about asthma diagnosis

Finding:

Reports specific age of diagnosis is 2.5 years old

(Found)

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

Example Question:

At what age were you diagnosed with asthma?

Finding:

Asked about asthma management

Finding:

Reports using an inhaler

(Found)

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

Example Question:

How do you manage your asthma?

Finding:

Reports inhaler is albuterol (Proventil)

(Found)

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

Example Question:

What is the name of the inhaler prescription?

Finding:

Reports last use of inhaler was 3 days ago

(Available)

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

Example Question:

When did you last use your inhaler?

Finding:

Reports using inhaler no more than 2 times per week

(Available)

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

Example Question:

How often do you use your inhaler?

Finding:

Asked about number of puffs when using asthma inhaler

Finding:

Reports recommended dose is 1-3 puffs as needed

(Found)

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

Example Question:

How many puffs of your inhaler are you prescribed?

Finding:

Reports typically taking 2 puffs

(Found)

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

Example Question:

Does your inhaler effectively relieve your symptoms?

Finding:

Reports sometimes needing 3 puffs to control symptoms

(Found)

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

Example Question:

What’s the most puffs you ever take?

Finding:

Asked about asthma triggers

Finding:

Reports asthma triggered by cats

(Found)

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

Example Question:

What triggers your asthma problems?

Finding:

Reports asthma triggered by dust

(Found)

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

Example Question:

Does dust trigger your asthma?

Finding:

Reports asthma triggered by running up stairs

(Found)

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

Example Question:

Does physical activity trigger your asthma?

Finding:

Denies seasonal triggers

(Available)

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

Example Question:

Do you have seasonal asthma triggers?

Finding:

Asked about general allergies

Finding:

Reports allergy to cats

(Found)

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

Example Question:

What allergies do you have?

Finding:

Followed up on cat allergy symptoms

Finding:

Reports sneezing, itchy eyes, and wheezing

(Found)

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

Example Question:

What is your reaction to cats?

Finding:

Asked about latex allergy

Finding:

Denies latex allergy

(Found)

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

Example Question:

Are you allergic to latex?

Finding:

Asked about medication allergies

Finding:

Reports penicillin allergy

(Found)

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

Example Question:

What medication allergies do you have?

Finding:

Asked about penicillin reaction

Finding:

Reports that penicillin resulted in hives in childhood

(Found)

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

Example Question:

What is your reaction to penicillin?

Finding:

Asked about food allergies

Finding:

Denies food allergies

(Found)

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

Example Question:

Do you have any food allergies?

Finding:

Asked if the patient has allergies to dust, mold, or pollen

Finding:

Reports reaction to dust

(Found)

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

Example Question:

Do you have any reaction to dust?

Finding:

Reports dust causes sneezing, itchy eyes, and wheezing

(Available)

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

Example Question:

Do you have any environmental allergies?

Finding:

Denies seasonal allergies

(Available)

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

Example Question:

Do you have any seasonal allergies?

Finding:

Asked about general immunizations received

Finding:

Reports being up to date on shots

(Found)

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

Example Question:

Are your immunizations current?

Finding:

Asked about childhood immunizations

Finding:

Reports receiving all necessary childhood immunizations

(Found)

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

Example Question:

Did you receive childhood vaccinations?

Finding:

Asked if the patient has received a flu vaccine

Finding:

Denies receiving annual flu vaccine

(Found)

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

Example Question:

Did you get a flu shot this year?

Finding:

Asked if the patient received a tetanus immunization

Finding:

Reports last tetanus vaccination was in the past year

(Found)

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

Example Question:

When was your last tetanus booster?

Finding:

Asked about hypertension

Finding:

Denies past diagnosis of hypertension

(Found)

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

Example Question:

Have you ever been diagnosed with hypertension?

Finding:

Reports that last BP reading was 140 over 80 or 90

(Available)

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

Example Question:

What is your usual blood pressure?

Finding:

Denies checking BP regularly

(Available)

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

Example Question:

How often do you check your blood pressure?

Home Medications

Finding:

Asked about use of pain medication

Finding:

Reports taking prescription pain medication

(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)

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

Example Question:

What is the name of the pain medication?

Finding:

Followed up on pain medication frequency

Finding:

Reports taking pain medication for 2 days

(Available)

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

Example Question:

How many days have you needed pain medication?

Finding:

Reports taking tramadol 3 times a day

(Found)

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

Example Question:

How many times a day do you take pain medication?

Finding:

Reports last dose was this morning

(Available)

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

Example Question:

When was your last dose of pain medication?

Finding:

Followed up on pain medication dose

Finding:

Reports dosage is 50 mg

(Found)

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

Example Question:

What is the dose of the pain medication?

Finding:

Reports taking 2 pills each time

(Available)

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

Example Question:

How many pain pills do you take at a time?

Finding:

Followed up on efficacy of pain medication

Finding:

Reports that pain pills provide partial relief

(Found)

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

Example Question:

How effective is the pain medication?

Finding:

Reports pain returns in full every few hours

(Found)

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

Example Question:

How long does the pain medication last?

Finding:

Asked about other prescription medications

Finding:

Reports a prescription inhaler

(Found)

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

Example Question:

What prescription medications do you take?

Finding:

Asked about use of OTC medication

Finding:

Reports occasionally taking Advil (ibuprofen) for cramps

(Found)

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

Example Question:

Do you take any over the counter medications?

Finding:

Reports occasionally taking Tylenol (acetaminophen) for headaches

(Found)

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

Example Question:

Do you take any over the counter medications?

Finding:

Denies vitamin supplements

(Available)

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

Example Question:

Do you take any vitamins?

Finding:

Denies herbal supplements

(Available)

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

Example Question:

Do you take any herbal supplements?

Social Determinants of Health

Finding:

Asked about access to healthcare

Finding:

Denies finances are a barrier to healthcare

(Found)

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

Example Question:

Do you have trouble affording healthcare?

Finding:

Denies transportation is a barrier to healthcare

(Available)

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

Example Question:

Is transportation a barrier to your healthcare?

Finding:

Followed up on diabetes noncompliance

Finding:

Reports that she got sick of the demands of medication compliance

(Available)

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

Example Question:

Why aren’t you taking your diabetes medication?

Finding:

Reports disliking metformin side effects

(Available)

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

Example Question:

Did the metformin cause any side effects?

Finding:

Reports disliking checking blood glucose

(Found)

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

Example Question:

What’s preventing you from taking your diabetes medication?

Finding:

Denies that cost of metformin was reason for discontinuing medication

(Available)

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

Example Question:

Did you have problems affording the diabetes medication?

Finding:

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

(Available)

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

Example Question:

Do you have problems affording the glucometer?

Finding:

Asked about patient’s level of education

Finding:

Reports currently working toward undergraduate degree

(Found)

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

Example Question:

What is your highest level of education?

Finding:

Reports her major is accounting

(Available)

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

Example Question:

What do you study?

Finding:

Asked about patient’s living situation

Finding:

Reports living with mother and sister

(Found)

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

Example Question:

Does anyone live at home with you?

Finding:

Reports family members will be able to help with activities

(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:

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)

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

Example Question:

When was your last meal?

Finding:

Reports last meal consisted of baked chicken and mashed potatoes

(Available)

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

Example Question:

What did you eat for your last meal?

Finding:

Reports breakfast is usually a muffin or pumpkin bread

(Available)

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

Example Question:

What is your typical breakfast?

Finding:

Reports lunch is usually a sandwich

(Available)

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

Example Question:

What is your typical lunch?

Finding:

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

(Available)

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

Example Question:

What is your typical dinner?

Finding:

Reports snacks are pretzels or French fries

(Available)

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

Example Question:

What do you typically eat for snacks?

Finding:

Asked about salt intake

Finding:

Denies adding salt to food

(Found)

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

Example Question:

Do you add a lot of salt to your food?

Finding:

Asked about caffeine intake

Finding:

Denies drinking coffee

(Found)

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

Example Question:

Do you drink coffee?

Finding:

Reports habitual diet soda drinking

(Found)

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

Example Question:

Do you drink soda?

Finding:

Reports drinking up to 4 diet sodas per day

(Found)

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

Example Question:

How many diet sodas do you drink in a day?

Finding:

Asked about illicit drug use

Finding:

Reports history of recreational marijuana smoking

(Found)

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

Example Question:

Have you ever experimented with drugs?

Finding:

Followed up on drug use

Finding:

Reports last use was at age 20 or 21

(Found)

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

Example Question:

When did you last smoke marijuana?

Finding:

Reports she stopped because of health reasons and waning interest

(Available)

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

Example Question:

What happened to cause you to stop smoking pot?

Finding:

Asked about alcohol intake

Finding:

Reports last alcoholic drink was 3 weeks ago

(Available)

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

Example Question:

When was your last alcoholic drink?

Finding:

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

(Available)

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

Example Question:

How many alcoholic drinks do you have in one sitting?

Finding:

Reports no more than 1 or 2 nights a week drinking alcohol

(Available)

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

Example Question:

How many nights a week do you drink alcohol?

Finding:

Asked about tobacco use

Finding:

Denies smoking tobacco

(Found)

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

Example Question:

Have you ever smoked cigarettes?

Finding:

Denies vaping

(Available)

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

Example Question:

Do you vape?

Finding:

Asked about secondhand smoke

Finding:

Denies exposure to secondhand smoke

(Found)

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

Example Question:

Are you ever exposed to secondhand smoke?

Family Medical History

Finding:

Asked about mother’s health

Finding:

Reports mother diagnosed with high blood pressure

(Found)

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

Example Question:

Does your mother have health conditions?

Finding:

Reports mother diagnosed with high cholesterol

(Found)

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

Example Question:

Does your mother have health conditions?

Finding:

Asked about father’s health

Finding:

Reports father was diagnosed with Type 2 diabetes

(Available)

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

Example Question:

Does your father have health conditions?

Finding:

Reports father was diagnosed with high blood pressure

(Available)

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

Example Question:

Does your father have health conditions?

Finding:

Reports father was diagnosed with high cholesterol

(Available)

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

Example Question:

Does your father have health conditions?

Finding:

Followed up on father’s death

Finding:

Reports father died at age 58

(Available)

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

Example Question:

How old was your father when he died?

Finding:

Reports cause of death was a car accident

(Found)

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

Example Question:

What caused your father’s death?

Finding:

Followed up on coping with father’s death

Finding:

Reports past grief

(Found)

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

Example Question:

How are you coping with your father’s death?

Finding:

Reports feeling at peace now

(Found)

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

Example Question:

How are you coping now?

Finding:

Asked about paternal grandfather’s health

Finding:

Reports paternal grandfather diagnosed with Type 2 diabetes

(Available)

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

Example Question:

Does your paternal grandfather have health conditions?

Finding:

Reports paternal grandfather diagnosed with high blood pressure

(Available)

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

Example Question:

Does your paternal grandfather have health conditions?

Finding:

Reports paternal grandfather diagnosed with high cholesterol

(Available)

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

Example Question:

Does your paternal grandfather have health conditions?

Finding:

Reports paternal grandfather died of colon cancer

(Available)

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

Example Question:

Have you had any family members with cancer?

Finding:

Asked about paternal grandmother’s health

Finding:

Reports paternal grandmother diagnosed with high blood pressure

(Found)

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

Example Question:

Does your paternal grandmother have health conditions?

Finding:

Reports paternal grandmother diagnosed with high cholesterol

(Found)

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

Example Question:

Does your paternal grandmother have health conditions?

Finding:

Asked about maternal grandfather’s health

Finding:

Reports maternal grandfather diagnosed with high blood pressure

(Available)

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

Example Question:

Does your maternal grandfather have health conditions?

Finding:

Reports maternal grandfather diagnosed with high cholesterol

(Available)

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

Example Question:

Does your maternal grandfather have health conditions?

Finding:

Asked about maternal grandmother’s health

Finding:

Reports maternal grandmother diagnosed with high blood pressure

(Found)

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

Example Question:

Does your maternal grandmother have health conditions?

Finding:

Reports maternal grandmother diagnosed with high cholesterol

(Found)

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

Example Question:

Does your maternal grandmother have health conditions?

Finding:

Asked about brother’s health

Finding:

Denies brother having diagnosed health problems

(Found)

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

Example Question:

Does your brother have health conditions?

Finding:

Asked about sister’s health

Finding:

Reports sister diagnosed with asthma

(Found)

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

Example Question:

Does your sister have health conditions?

Finding:

Asked about family history of obesity

Finding:

Reports that family members are overweight

(Found)

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

Example Question:

Does obesity run in your family?

Finding:

Asked about family history of thyroid issues

Finding:

Denies family history of thyroid issues

(Found)

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

Example Question:

Do you have a family history of thyroid problems?

Finding:

Asked about family history of substance abuse

Finding:

Reports 1 uncle has alcoholism

(Found)

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

Example Question:

Do you have relatives with addiction problems?

Finding:

Asked about family history of headaches

Finding:

Denies family history of headaches

(Found)

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

Example Question:

Do you have a family history of headaches?

Review of Systems

Finding:

Asked about constitutional health

Finding:

Reports occasional tiredness or fatigue

(Available)

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

Example Question:

Are you fatigued?

Finding:

Reports typical sleep pattern

(Available)

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

Example Question:

Have you noticed changes in your sleep?

Finding:

Reports fever

(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 feeling feverish right now?

Finding:

Reports chills

(Available)

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

Example Question:

Have you had chills?

Finding:

Denies night sweats

(Available)

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

Example Question:

Have you had night sweats?

Finding:

Asked about review of systems for mental health

Finding:

Denies depression

(Available)

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

Example Question:

Do you have a history of depression?

Finding:

Denies suicidal ideation or attempts

(Available)

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

Example Question:

Do you have a history of suicidal thinking?

Finding:

Asked about review of systems for head

Finding:

Reports occasional headaches

(Found)

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

Example Question:

Do you ever get headaches?

Finding:

Denies current headache

(Available)

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

Example Question:

Do you have a headache?

Finding:

Denies head injury

(Available)

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

Example Question:

Have you had any head injuries?

Finding:

Asked about review of systems for ears

Finding:

Denies change in hearing

(Available)

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

Example Question:

Has your hearing changed?

Finding:

Denies ringing or tinnitus

(Available)

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

Example Question:

Do you ever have ringing in your ears?

Finding:

Denies ear pain

(Available)

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

Example Question:

Have you had ear pain?

Finding:

Denies ear discharge

(Available)

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

Example Question:

Have you had ear discharge?

Finding:

Asked about review of systems for eyes and vision

Finding:

Reports periods of blurry vision

(Found)

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

Example Question:

Have you noticed any changes in your vision?

Finding:

Denies corrective lenses

(Available)

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

Example Question:

Do you wear glasses or contact?

Finding:

Denies double vision

(Available)

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

Example Question:

Do you ever get double vision?

Finding:

Reports infrequent itchy eyes

(Available)

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

Example Question:

Have you had itchy eyes?

Finding:

Denies eye redness

(Available)

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

Example Question:

Have you had red eyes?

Finding:

Denies discharge, crusting or wateriness

(Available)

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

Example Question:

Have you had watery eyes?

Finding:

Denies eye pain

(Available)

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

Example Question:

Have you had eye pain?

Finding:

Denies dry eyes

(Available)

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

Example Question:

Have you had dry eyes?

Finding:

Reports last eye exam was in childhood

(Available)

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

Example Question:

When was your last eye exam?

Finding:

Asked about review of systems for nose

Finding:

Reports infrequent nose problems

(Found)

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

Example Question:

Have you had nose problems?

Finding:

Reports infrequent runny nose

(Found)

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

Example Question:

Have you had a runny nose?

Finding:

Denies frequent sinus problems

(Available)

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

Example Question:

Have you had sinus pain?

Finding:

Denies change in sense of smell

(Available)

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

Example Question:

Has your sense of smell changed?

Finding:

Denies nosebleeds

(Available)

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

Example Question:

Have you had nosebleeds?

Finding:

Asked about review of systems for mouth and jaw

Finding:

Denies dental problems

(Available)

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

Example Question:

Have you had any recent dental problems?

Finding:

Reports last dental visit was several years ago

(Available)

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

Example Question:

When did you last see a dentist?

Finding:

Denies change in sense of taste

(Available)

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

Example Question:

Has your sense of taste changed?

Finding:

Denies dry mouth

(Available)

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

Example Question:

Have you had dry mouth?

Finding:

Denies mouth pain

(Available)

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

Example Question:

Have you had mouth pain?

Finding:

Denies mouth sores

(Available)

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

Example Question:

Have you had mouth sores?

Finding:

Denies gum problems

(Available)

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

Example Question:

Have you had gum problems?

Finding:

Denies tongue problems

(Available)

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

Example Question:

Have you had tongue problems?

Finding:

Denies jaw problems

(Available)

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

Example Question:

Have you had jaw problems?

Finding:

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

Finding:

Denies difficulty swallowing

(Available)

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

Example Question:

Have you had difficulty swallowing?

Finding:

Denies sore throat

(Available)

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

Example Question:

Have you had a sore throat?

Finding:

Denies lymph node problems

(Available)

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

Example Question:

How are your lymph nodes?

Finding:

Denies frequent sore throat

(Available)

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

Example Question:

Do you have a history of throat problems?

Finding:

Denies swollen glands

(Available)

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

Example Question:

Do you have any swollen glands?

Finding:

Denies voice changes

(Available)

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

Example Question:

Have you had voice changes?

Finding:

Denies general neck problems

(Found)

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

Example Question:

Have you had neck pain?

Finding:

Asked about breast health

Finding:

Reports doing occasional breast exams

(Available)

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

Example Question:

Do you do regular breast exams?

Finding:

Denies general breast problems

(Found)

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

Example Question:

Do you have any problems with your breasts?

Finding:

Denies breast lumps

(Available)

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

Example Question:

Have you noticed any lumps in your breasts?

Finding:

Denies breast pain

(Available)

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

Example Question:

Have you felt pain in your breasts?

Finding:

Denies nipple changes

(Available)

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

Example Question:

Have you noticed changes in your nipples?

Finding:

Denies nipple discharge

(Available)

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

Example Question:

Have you noticed any nipple discharge?

Finding:

Denies ever having a mammogram

(Available)

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

Example Question:

Have you ever had a mammogram?

Finding:

Asked about review of systems for respiratory

Finding:

Denies current breathing problems

(Available)

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

Example Question:

Have you had breathing problems?

Finding:

Denies current wheezing

(Available)

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

Example Question:

Have you been wheezing?

Finding:

Denies current chest tightness

(Available)

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

Example Question:

Have you had chest tightness?

Finding:

Denies pain while breathing

(Available)

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

Example Question:

Does it hurt when you breathe?

Finding:

Denies frequent coughing

(Available)

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

Example Question:

Have you been coughing?

Finding:

Asked about review of systems for cardiovascular

Finding:

Denies chest pain or discomfort

(Available)

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

Example Question:

Do you ever have chest pain?

Finding:

Denies palpitations

(Available)

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

Example Question:

Have you had palpitations?

Finding:

Denies irregular heartbeat

(Available)

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

Example Question:

Has your heartbeat been irregular?

Finding:

Denies easy bruising

(Available)

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

Example Question:

Have you noticed bruising more than usual?

Finding:

Denies edema

(Available)

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

Example Question:

Have you noticed any swelling in your legs?

Finding:

Denies circulation problems

(Available)

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

Example Question:

Do you have circulation problems?

Finding:

Denies vascular diseases

(Available)

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

Example Question:

Do you have any vascular diseases?

Finding:

Asked review of systems for gastrointestinal

Finding:

Denies nausea

(Available)

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

Example Question:

Have you had nausea?

Finding:

Denies vomiting

(Available)

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

Example Question:

Have you been vomiting?

Finding:

Denies stomach pain

(Available)

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

Example Question:

Do you have stomach pain?

Finding:

Denies change in bowel movements

(Available)

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

Example Question:

Have you had changes in your bowel movements?

Finding:

Denies heartburn, GERD, or indigestion

(Available)

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

Example Question:

Do you ever get heartburn?

Finding:

Denies constipation

(Available)

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

Example Question:

Do you have constipation?

Finding:

Denies diarrhea or loose stool

(Available)

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

Example Question:

Do you have diarrhea?

Finding:

Denies flatulence or bloating

(Available)

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

Example Question:

Do you have flatulence?

Finding:

Denies bloody or tarry stool

(Available)

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

Example Question:

Do you have tarry stools?

Finding:

Asked review of systems for genitourinary

Finding:

Denies painful or difficult urination

(Available)

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

Example Question:

Does it hurt when you urinate?

Finding:

Reports waking up to urinate during the night

(Available)

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

Example Question:

Do you wake up at night to urinate?

Finding:

Reports large amount of urine

(Found)

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

Example Question:

Do you urinate frequently?

Finding:

Denies blood in urine

(Available)

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

Example Question:

Do you ever notice blood in your urine?

Finding:

Denies flank pain

(Available)

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

Example Question:

Do you have flank pain?

Finding:

Denies incontinence

(Available)

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

Example Question:

Are you able to hold your urine?

Finding:

Denies history of urinary tract or bladder infection

(Available)

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

Example Question:

Have you ever had a urinary infection?

Finding:

Reports normal vaginal discharge

(Available)

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

Example Question:

What is your vaginal discharge like?

Finding:

Asked review of systems for reproductive

Finding:

Reports last menstrual period was 3 weeks ago

(Available)

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

Example Question:

When was your last menstrual period?

Finding:

Reports that periods are irregular

(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 your periods regular?

Finding:

Reports menstruating every 6 weeks to 2 months

(Available)

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

Example Question:

How often do you get your period?

Finding:

Reports typical period lasts 9 days

(Available)

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

Example Question:

How many days does your period last?

Finding:

Followed up on menstrual flow

Finding:

Reports heavy periods

(Found)

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

Example Question:

Do you have heavy periods?

Finding:

Reports heavy flow for 4 to 5 days

(Available)

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

Example Question:

How many days is your period heavy?

Finding:

Reports changing tampon every 2 to 3 hours

(Found)

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

Example Question:

How often do you change your tampon or pad?

Finding:

Reports using super absorbency tampons

(Found)

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

Example Question:

What absorbency are your tampons?

Finding:

Denies anemia

(Available)

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

Example Question:

Have you ever been diagnosed with low iron?

Finding:

Followed up on menstrual symptoms

Finding:

Reports heavy cramping

(Found)

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

Example Question:

Do you get menstrual cramps?

Finding:

Reports cramps for the first 2 days of period

(Available)

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

Example Question:

How many days do your cramps last?

Finding:

Asked about treatment of menstrual symptoms

Finding:

Reports using a heating pad at home to treat cramps

(Found)

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

Example Question:

Do you use a heating pad?

Finding:

Reports taking ibuprofen for first 3 days of period

(Available)

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

Example Question:

How many days do you need Advil for your cramps?

Finding:

Reports ibuprofen effectively reduces pain from cramps

(Available)

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

Example Question:

Does the Advil reduce your cramps?

Finding:

Asked about sexual activity

Finding:

Denies recent sexual activity

(Found)

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

Example Question:

Are you sexually active?

Finding:

Reports past sexual activity

(Available)

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

Example Question:

Have you ever been sexually active?

Finding:

Reports that she prefers to sleep with men

(Available)

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

Example Question:

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

Finding:

Reports first sexual activity was at age 18

(Available)

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

Example Question:

When were you first sexually active?

Finding:

Reports last sexual activity was 2 years ago

(Available)

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

Example Question:

When was your last sexual encounter?

Finding:

Reports total number of partners is 3

(Available)

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

Example Question:

How many sexual partners have you had?

Finding:

Asked about contraception

Finding:

Reports no current use of any oral or hormonal birth control

(Found)

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

Example Question:

Are you currently taking oral contraception?

Finding:

Reports past use of oral contraception

(Found)

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

Example Question:

Have you ever taken oral contraception?

Finding:

Reports last taking oral contraception a couple of years ago

(Available)

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

Example Question:

When did you last take oral contraception?

Finding:

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

(Available)

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

Example Question:

Why did you stop taking birth control?

Finding:

Asked about condom use

Finding:

Reports past condom use

(Found)

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

Example Question:

Have you ever used a condom?

Finding:

Reports past sexual encounters without condoms

(Available)

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

Example Question:

Have you ever had sex without using a condom?

Finding:

Reports oral contraceptive use while sexually active

(Available)

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

Example Question:

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

Finding:

Asked about STI testing

Finding:

Reports last STI testing was 4 years ago

(Available)

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

Example Question:

When were you last tested for STIs?

Finding:

Denies STI symptoms

(Available)

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

Example Question:

Do you have STI symptoms?

Finding:

Reports uncertainty about past partners and STI testing

(Available)

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

Example Question:

Have your previous partners been tested for STIs?

Finding:

Asked about history of pap smears

Finding:

Reports last pap smear was 4 years ago

(Available)

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

Example Question:

When was your last pap smear?

Finding:

Reports no abnormal pap smears

(Available)

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

Example Question:

Have you ever had an abnormal pap smear?

Finding:

Asked about history of pregnancy

Finding:

Denies current pregnancy

(Available)

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

Example Question:

Do you think you are pregnant?

Finding:

Denies past pregnancies

(Found)

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

Example Question:

Have you ever tested positive for pregnancy?

Finding:

Asked review of systems for musculoskeletal

Finding:

Denies muscle pain

(Available)

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

Example Question:

Do you have muscle pain?

Finding:

Denies joint pain

(Available)

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

Example Question:

Do you have joint pain?

Finding:

Denies muscle weakness

(Available)

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

Example Question:

Do you have muscle weakness?

Finding:

Denies joint swelling

(Available)

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

Example Question:

Do you ever have swelling in your joints?

Finding:

Denies back pain

(Available)

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

Example Question:

Do you ever have back pain?

Finding:

Denies history of fractures or breaks

(Available)

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

Example Question:

Have you ever broken a bone?

Finding:

Asked review of systems for neurological

Finding:

Denies recent loss of consciousness or fainting

(Available)

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

Example Question:

Have you ever passed out?

Finding:

Denies dizziness or vertigo

(Available)

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

Example Question:

Do you get dizzy?

Finding:

Denies lightheadedness

(Available)

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

Example Question:

Do you get light-headed?

Finding:

Denies vision disturbances

(Available)

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

Example Question:

Do you ever see spots?

Finding:

Denies tingling

(Available)

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

Example Question:

Do you ever get tingling?

Finding:

Denies loss of coordination

(Available)

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

Example Question:

Do you notice being more clumsy than usual?

Finding:

Denies loss of sensation

(Available)

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

Example Question:

Do you have a loss of sensation anywhere?

Finding:

Denies history of seizures

(Available)

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

Example Question:

Have you ever had a seizure?

Finding:

Denies problems with balance or disequilibrium

(Available)

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

Example Question:

Do you lose your balance often?

Finding:

Denies memory loss

(Available)

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

Example Question:

Have you ever experienced memory loss?

Finding:

Asked review of systems for skin, hair, and nails

Finding:

Denies skin rashes

(Available)

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

Example Question:

Do you get skin rashes?

Finding:

Reports rarely using sunscreen

(Available)

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

Example Question:

When do you wear sunscreen?

Finding:

Reports acne

(Found)

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

Example Question:

Do you still have acne?

Finding:

Reports excessive facial or body hair

(Available)

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

Example Question:

Do you have an increase in body hair?

Finding:

Reports changes to neck skin

(Available)

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

Example Question:

Do you have any skin discoloration?

Finding:

Reports moles

(Available)

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

Example Question:

Have your moles changed?

Finding:

Reports no body sores (aside from foot wound)

(Available)

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

Example Question:

Do you have any sores?

Finding:

Denies dandruff

(Available)

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

Example Question:

Do you have dandruff?

Finding:

Denies nail abnormalities

(Available)

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

Example Question:

Do you have any problems with your nails?

Finding:

Reports occasional dry skin

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

	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

3 Gaps in health literacy around diabetic diet

	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.”

4 Lack of treatment with diabetes medication

	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.”

	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

6 Gaps in health literacy around asthma control

	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.”

	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

	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

	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

	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

11 Describes problematic menstrual cycle and symptoms

	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.”

	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

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

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

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

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

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

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

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

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

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.

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Newborn Skincare and Hygiene

December 22, 2023/in BLOGS, Nursing paper help, Nursing Questions with Sample Answers /by vivian

Newborn Skincare and Hygiene

Overview

The birth of a newborn is a delightful event, and parents prioritize safeguarding the health of their sensitive skin. This guide will thoroughly examine the intricacies of newborn skin, cover necessary skincare routines, tackle frequent issues, and offer useful advice to maintain the health and happiness of your baby’s skin.

Analyzing the Characteristics of Infant Skin:

The skin of a newborn is a remarkable example of nature’s ingenuity, characterized by its fragility and exceptional sensitivity. Parents must prioritize comprehending the unique characteristics of their child and acquiring knowledge on how to adequately provide for their needs. Now, let’s explore the complexities of infant skin:

1. Newborn Skin Characteristics

Newborn skin is considerably thinner than adult skin, rendering it more susceptible to environmental influences. The epidermis, which is the outer layer, is currently undergoing development, resulting in increased skin permeability.

Restricted Oil Production: In contrast to the skin of adults, neonates have a reduced capacity to produce oil. The sebaceous glands, which are accountable for the production of oil, are still in the process of maturing, resulting in dryness and heightened sensitivity.

Vernix Caseosa: Vernix caseosa is a waxy and cheese-like material that is present before birth and serves to protect the skin while in the womb. Although it is often removed shortly after birth, traces of it may persist, offering a certain degree of inherent defense.

Newborn skin exhibits exceptional flexibility as a result of its elevated collagen levels. This increases its susceptibility to developing temporary skin disorders such as milia and mottling.

2. Prevalent Dermatological Conditions in Neonates

Milia are little, pale or yellowish pimples that can develop on a newborn’s face as a result of keratin becoming stuck. Milia are benign and usually self-resolve.

Erythema Toxicum, commonly known as “newborn rash,” is a prevalent rash distinguished by red patches with a central whitish, pimple-like elevation. The condition is often benign and tends to resolve spontaneously within a few days.

Mottling refers to the presence of a lacy pattern of reddish-blue or purple dots on the skin, which is frequently observed in neonates. It frequently occurs as a consequence of the maturing circulatory system effectively managing the circulation of blood.

3. Determinants of Neonatal Skin Health

Weather Conditions: Infants are susceptible to severe temperatures. Safeguard your infant from intense sunshine and guarantee suitable attire to avoid overheating or excessive cooling.

Attire Selection: Choose textiles that are gentle and allow air to pass through, such as cotton. Refrain from wearing garments that have bothersome seams or tags that could create friction on the sensitive skin.

Environmental factors, including as humidity levels, might affect the condition of a newborn’s skin. Employing a humidifier in arid regions aids in preserving the ideal humidity levels.

Skin-to-skin contact is direct physical contact between the baby’s skin and another person’s skin. This contact is beneficial as it helps to regulate the baby’s body temperature, promotes a strong emotional connection, and contributes to the proper development of the baby’s skin.

Gaining knowledge of these attributes and variables empowers parents to deliver the most effective care for their infant’s skin. When you are experiencing the initial stages of parenthood, remember that simplicity is frequently crucial. Ensuring the general health and well-being of your baby’s fragile skin involves employing a gentle cleansing routine, refraining from using harsh chemicals, and creating a pleasant environment. It is advisable to get guidance from your pediatrician if you have any concerns or inquiries regarding your newborn’s skin.

Foundational Skincare Regimen for Newborns

Bathing Protocol :

Offering a comprehensive, detailed procedure for bathing a baby, with precise instructions on water temperature, frequency, and suggested bathing materials.

Selecting Appropriate Skincare Products (H2): Identifying crucial components to steer clear of in baby goods and providing suggestions for reputable skincare companies that are appropriate for infants.

Diapering Best Practices :

Recommendations for correct diapering techniques, mitigating diaper rash, and selecting suitable diapers to ensure your baby’s comfort.

Clothing Tips for Newborns :

Advice on choosing breathable fabrics, dressing appropriately for the weather, and avoiding clothing options that may cause irritation.

Responding to Frequently Raised Issues:

Diaper Rash and Prevention: Explaining the typical reasons behind diaper rash and providing prevention strategies and treatments.

Understanding and Caring for Baby Acne: Elucidating the etiology of infantile acne and offering recommendations for delicate management.

Cradle Cap Remedies: Providing strategies for effectively controlling and treating cradle cap, a prevalent scalp ailment in infants.

Practices for Maintaining Hygiene in Newborns:

Umbilical Cord Care: Offering guidance on how to care for the umbilical cord stump until it detaches spontaneously.
Guidelines for Cleaning the Ears and Nose : Ensuring proper hygiene by safely cleansing a newborn’s ears and nose without causing any discomfort.
Nail Care for Newborns: Guidelines for carefully clipping your baby’s nails to avoid scratching and irritation.

Selecting Optimal Skincare Products:

Choosing the suitable skincare products for your infant is vital to maintain the health and prevent any irritation of their fragile skin.

1. Harmful Ingredients in Baby Products:

Fragrances: Fragrances may cause irritation to the delicate skin of a baby. Choose fragrance-free or hypoallergenic products to reduce the likelihood of irritation.

Parabens: These are preservatives that have the potential to interfere with the endocrine system. To avoid these chemicals, seek out items that are labeled as “paraben-free”.

Sulfates, such as sodium lauryl sulfate, have the potential to be abrasive and remove the skin’s natural oils. Opt for cleansers that are free of sulfates in order to preserve the skin’s inherent hydration.

Phthalates are chemical compounds that are utilized to augment the scent of certain products. Given that perfumes are best to be avoided, opting for goods that do not contain phthalates is a more secure option.

Dyes: Colored items may contain dyes that have the potential to induce skin irritation. Choose goods that are free from synthetic dyes to reduce the likelihood of experiencing allergic reactions.

2. Top Skincare Brands for Newborns:

1. Cetaphil Baby products are renowned for their mild cleansers and moisturizers, making them a popular choice among pediatricians. Their product selection encompasses shampoo, lotion, and diaper cream.

2. Aveeno Baby: Aveeno is renowned for its utilization of organic components. Their infant merchandise is developed using colloidal oatmeal, offering alleviating comfort for delicate skin.

3. Mustela: Mustela provides a selection of hypoallergenic and fragrance-free products specifically developed for newborns. Their products are frequently appropriate for infants with skin that is prone to eczema.

4. Earth Mama: Earth Mama products are composed of organic ingredients and are devoid of any detrimental chemicals. Their product range encompasses a diverse selection of baby care items, such as balms and oils.

The Honest Company, established by Jessica Alba, manufactures a range of baby care items that are devoid of harmful chemicals. Their product selection encompasses diapers, wipes, and skincare products.

3. Recommendations for Selecting Skincare Products:

Examine Labels: It is imperative to carefully review the list of ingredients. Seek out items containing a limited number of natural ingredients, while avoiding possibly hazardous compounds.

Select Hypoallergenic: Opt for products that are specifically labeled as hypoallergenic, as these are less prone to triggering allergic responses or skin irritation.

Prior to applying a novel product, perform a patch test on a small section of your infant’s skin to verify the absence of any unfavorable reactions.

Seek advice from a pediatrician: If your infant has certain skin issues or conditions, it is advisable to consult a pediatrician before using new products. They are capable of offering customized suggestions based on the specific requirements of your infant.

Frequently Asked Questions Regarding Newborn Skincare and Hygiene

Q1.What is the recommended frequency for bathing a newborn?

Initially, a frequency of 2-3 baths per week is adequate. since your infant develops, you can progressively augment the frequency of bathing, but exercise caution to avoid excessive bathing, since it might deplete the skin’s natural oils.

Q2: What should I do if my baby has a diaper rash?

If your kid is experiencing a diaper rash, you should take certain steps to address the issue.

Diaper rash is a prevalent condition that can be both prevented and managed. Ensure timely diaper changes, apply a diaper cream containing zinc oxide, and provide brief intervals of diaper-free time to facilitate skin ventilation.

Q3.Are all infant items deemed safe for newborns?

No, not all products possess equal quality or characteristics. Refrain from using products that contain abrasive chemicals, strong scents, and alcohol. Choose hypoallergenic and fragrance-free products that are specifically formulated for newborns with sensitive skin.

Q4.What is the most effective method for cleaning my baby’s nasal passages while minimizing discomfort?

Administer saline drops to facilitate the loosening of mucus, followed by the careful extraction of nasal secretions using a bulb syringe. Ensure that the environment is adequately humidified to prevent the occurrence of nose dryness. If the feeling of unease continues, get advice from your pediatrician.

Q5.Is it permissible to utilize conventional soap for bathing my infant?

It is optimal to utilize a gentle, unscented baby soap or cleaner. Adult soaps has strong properties that can potentially cause irritation to the sensitive skin of a baby.

Q6.What is the most suitable attire for my newborn?

Opt for textiles that are soft and allow for proper air circulation, such as cotton. To maintain optimal temperature, clothe your infant in multiple layers and refrain from using tight garments that may cause skin irritation or discomfort.

Q7.At what age is it appropriate to commence clipping my infant’s nails?

It is advisable to clip your baby’s nails during the initial weeks of their life. Utilize nail scissors or clippers that are specifically designed for infants, ensuring their safety. Trim your baby’s nails when they are in a peaceful state or when they are sleeping to minimize the risk of unintentional cuts.

Q8.What is the proper method for cleaning my infant’s ears?

Employ a moistened washcloth to delicately cleanse the external part of the ear, refraining from introducing any objects into the ear canal. If you observe an abundance of earwax or have any concerns, seek advice from your physician.

Q9.Is it typical for neonates to experience infantile acne?

Indeed, infantile acne is a prevalent occurrence that often manifests itself throughout the initial weeks of an infant’s life. Refrain from utilizing abrasive substances and instead cleanse the facial area alone with water. Typically, it resolves spontaneously.

Q10.What is the most effective method for tending to the umbilical cord stump?

Ensure that the stump remains free from dirt and moisture. Position the diaper beneath the stump to facilitate proper airflow. If you observe any signs of redness, discharge, or an unpleasant odor, it is advisable to get in touch with your pediatrician.

Conclusion

Ultimately, tending to the skin of your infant necessitates a careful equilibrium of understanding and fostering. To ensure optimal care for your infant, it is important to comprehend the distinctive attributes of newborn skin, develop a fundamental skincare regimen, and effectively tackle common issues. It is important to keep in mind that every baby is distinct, hence it is crucial to customize these rules to meet the specific requirements of your child. By dedicating time to sensitive care and making well-informed decisions, you are establishing the basis for a lifetime of optimal skin health for your child.

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Strategies to Reduce the Spread of Infectious Diseases

December 22, 2023/in BLOGS, Nursing paper help /by vivian

Strategies to Reduce the Contraction and Spread of Infectious Diseases by Nurses

Introduction

Nurses, who are at the forefront of patient care within the dynamic and challenging healthcare system, face the ongoing risk of contracting and spreading infectious diseases. Nurses must prioritize the implementation of efficient strategies to mitigate these risks, since they bear the responsibility of safeguarding health in hospital settings. This blog post thoroughly examines techniques that nurses can employ to reduce the probability of acquiring and transmitting infectious diseases, for the benefit of all individuals involved in patient care.

Understanding the Hazards

Prior to analyzing solutions, it is crucial to acknowledge the inherent dangers that nurses face in their day-to-day duties. The likelihood of transmitting infectious agents is higher when there is direct contact with patients, exposure to bodily fluids, and contact with contaminated surfaces. To establish effective prevention measures, it is crucial to identify and acknowledge these potential dangers.

Essential Strategies Employed by Nurses

1. Comprehensive Hand Hygiene Protocols
Hand hygiene is the fundamental basis of infection prevention. Practicing adequate hand hygiene is crucial for nurses. It is recommended that individuals cleanse their hands meticulously using soap and water for a minimum duration of 20 seconds. Alternatively, if this is not feasible, they may opt to utilize an alcohol-based hand sanitizer. Consistently practicing proper hand hygiene significantly reduces the probability of transmitting infectious pathogens among patients and healthcare staff.

2.The proper method of donning and utilizing Personal Protective Equipment (PPE)
Nurses must possess a comprehensive comprehension of the significance of personal protective equipment (PPE) and possess the knowledge to employ it responsibly. This entails wearing personal protective equipment such as goggles, gloves, masks, and gowns. It is imperative for nursing students to acquire the skill of properly donning and doffing personal protective equipment (PPE) during their training in order to minimize the likelihood of infection.

3. Adhering to all essential safety protocols.
Adherence to standard measures is essential in every interaction between healthcare practitioners and their patients, as these measures serve as the fundamental principles of infection prevention. Every patient is seen as a potential origin of infection. Consequently, these precautions encompass practices such as employing safe injection methods, properly managing patient care equipment, and upholding a hygienic environment.

4. Protocols for Isolating Affected Patients

Isolation precautions must be rigorously adhered to by nurses when caring for patients who are confirmed or suspected to be infected with contagious illnesses. Utilizing specialist instruments, maintaining cleanliness in the vicinity, and implementing additional precautions to prevent the transmission of disease are integral components of this procedure.

5. Continuous Training on Preventing Infections in Healthcare Settings
Continuing education is crucial in the healthcare sector, given its rapid and constant evolution. Nurses should engage in continuous education on infection control protocols to stay abreast of the dynamic nature of infectious diseases and the most effective strategies for preventing their transmission. Through the practice of lifelong learning, nurses may ensure that they remain well-informed on the latest strategies and resources for infection prevention.

6. Fostering a Culture of Reporting
Having a culture that encourages the reporting of infection control incidents, violations, or concerns is of utmost importance. Nurses must have the ability to openly and without fear of repercussions, engage in discussions regarding potential dangers. To enhance the overall structure for preventing infections, it is crucial to promote a culture of open reporting that facilitates prompt remedial measures.

7. Techniques for Surface Cleaning
Contagious illnesses can be transmitted between individuals via polluted surfaces. Nurses should adhere diligently to authorized criteria for the thorough cleanliness and disinfection of commonly handled surfaces, patient care equipment, and the immediate work space.

8. Techniques for Optimal Waste Management
To halt the transmission of diseases, it is imperative to appropriately discard infectious waste. Nurses must adhere to all waste management guidelines to ensure the safe and secure disposal of potentially hazardous materials.

FAQ’S

1. What are some strategies that nurses might employ to ensure their personal safety?

Precise Hand Sanitization

Maintaining proper hand hygiene is crucial in order to prevent the transmission of illnesses. Nurses must frequently cleanse their hands using either soap and water or alcohol-based hand sanitizers. Implementing this simple procedure significantly reduces the likelihood of disease transmission.

Correct Utilization of Personal Protective Equipment (PPE)

Nurses must possess the knowledge and skills to appropriately employ critical equipment such as protective glasses, masks, gowns, and gloves. Properly donning and doffing personal protective equipment (PPE) is crucial to prevent the transmission of infectious microorganisms while delivering patient care.

2. What measures may nurses implement to mitigate the spread of infections while providing patient care?

Adhering to all essential safety protocols,
Regardless of whether an infection is suspected or confirmed, all patient care must strictly adhere to conventional precautions. This word refers to the implementation of safe injection protocols, meticulous management of medical equipment, and the maintenance of a hygienic work environment.

Isolation Protocols
Nurses are legally obligated to strictly adhere to isolation protocols whenever they encounter patients who may be harboring a contagious illness. This method involves employing specialized tools, maintaining cleanliness in the region, and implementing additional precautions to prevent the transmission of disease.

3. What strategies can be employed to foster a proactive culture among nurses?

Academic Advancement Projects
Continuously educating individuals is necessary to foster a culture that prioritizes infection prevention. Nurses should engage in continuous education on infection control protocols to effectively adapt to the dynamic nature of infectious diseases and optimize prevention strategies.

Presenting oneself to the media with assurance
Nurses should be encouraged to report any concerns, incidents, or violations related to infection control. To foster transparency and facilitate prompt corrective measures, it is crucial to cultivate a culture of reporting.

4. Can Nurses Contribute to Maintaining a Safe Environment Free from Infection?

Surface Sanitization
To prevent the survival and transmission of germs, it is crucial to regularly clean surfaces and patient care equipment. Nurses must rigorously adhere to established criteria for cleaning and disinfecting commonly handled surfaces.

Waste Management Strategies
Effective containment of infectious diseases necessitates the appropriate disposal of infectious waste. Nurses must adhere to all relevant waste management regulations when disposing of potentially dangerous materials.

Summary

The commitment of nurses to infection control is crucial in establishing secure and sanitary environments, as they form the basis of healthcare. Nurses can significantly contribute to the prevention of infectious disease transmission by implementing comprehensive strategies, such as rigorous adherence to hand hygiene protocols, continuous education, and fostering a culture of reporting. Nurses not only protect themselves in this manner, but they also contribute to enhancing the safety of the healthcare system for all individuals. No matter how healthcare evolves, one enduring aspect is the significance of stringent infection control protocols in delivering superior medical care to patients.

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