Health History – Tina Jones Health Assessment – January 2023
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Digital Clinical Experience Orientation
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Conversation Concept Lab
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Introduction and Medical History
Finding:
Established reason for visit
Finding:
Reports needing an annual physical
(Found)
Pro Tip: Asking the patient’s reason for their visit is a practical way to establish a chief complaint.
Example Question:
What brings you in today?
Finding:
Asked about past medical history
Finding:
Denies medical conditions
(Found)
Pro Tip: A broad question about the patient’s past medical history may prompt a more comprehensive answer.
Example Question:
What medical conditions do you have?
Medications
Finding:
Asked about general medication use
Finding:
Reports taking occasional ibuprofen
(Found)
Pro Tip: Asking a patient what medications they take may prompt a broader response that does not capture a complete picture of their medication use.
Example Question:
What medications do you take?
Finding:
Denies taking prescription medication
(Available)
Pro Tip: Asking the patient what medications are prescribed to him or her may prompt the patient to report medications taken daily or on an as-needed basis.
Example Question:
Do you take any prescription medications?
Finding:
Only OTC medication is ibuprofen (no others reported)
(Found)
Pro Tip: Asking specifically about a patient’s use of the over-the-counter medications may prompt a more definitive response and yield greater insight into their medication use.
Example Question:
Do you take any other over the counter medications?
Finding:
Followed up about reason for ibuprofen use
Finding:
Takes ibuprofen to relieve menstrual cramps
(Found)
Pro Tip: When a patient reports taking any type of medication, it is important to gather information about the reasons it is used.
Example Question:
For what reason do you take ibuprofen?
Finding:
Followed up on frequency and dosage of ibuprofen use
Finding:
Takes ibuprofen monthly
(Found)
Pro Tip: When a patient reports taking any type of medication, it is important to gather information about the frequency of its use. A broader question may prompt a broader response from the patient.
Example Question:
How often do you take ibuprofen?
Finding:
Takes 2 at a time
(Available)
Pro Tip: When a patient reports taking any type of medication, it is important to gather information about the quantity of its use.
Example Question:
How many ibuprofen do you take at a time?
Finding:
Typically takes 2 doses on first day of period
(Available)
Pro Tip: When a patient reports taking any type of medication, it is important to gather information about the frequency of its use.
Example Question:
How many days do you take ibuprofen?
Finding:
Unsure of the dosage, but reports they are “regular strength”
(Available)
Pro Tip: When a patient reports taking any type of medication, it is important to gather information about the quantity of its use.
Example Question:
What dosage of ibuprofen do you take?
Finding:
Last dose was 2 weeks ago
(Available)
Pro Tip: When a patient reports taking any type of medication, it is important to gather information about the frequency of its use. Asking specifically about the last time the patient took the medication may prompt a response that speaks to the medications day to day use.
Example Question:
When did you last take Advil?
Finding:
Asked about supplements
Finding:
Denies vitamins
(Found)
Pro Tip: Asking a patient a specific question about their use of vitamins will prompt a definitive answer and provide insight into their supplement use.
Example Question:
Do you take any vitamins?
Finding:
Denies herbal supplements
(Found)
Pro Tip: Asking a patient a specific question about their use of herbal supplements will prompt a definitive answer and provide insight into their supplement use.
Example Question:
Do you take any herbal supplements?
Allergies
Finding:
Asked about general allergies
Finding:
Reports allergy to peanuts
(Found)
Pro Tip: Beginning an interview with a broad question is a good entry into the topic.
Example Question:
What allergies do you have?
Finding:
Followed up on peanut allergy symptoms
Finding:
Discovered at age 4
(Available)
Pro Tip: When a patient reports an allergy, it is important to establish its onset.
Example Question:
How old were you when had your first reaction to peanuts?
Finding:
Symptoms are itchy mouth and throat
(Found)
Pro Tip: When a patient reports an allergy, it’s necessary to determine the type and extent of his or her allergic reaction. For example, if a patient reports a bee-sting allergy, the provider must determine whether the patient has experienced localized allergic reactions or anaphylaxis.
Example Question:
What are the symptoms of your peanut allergy?
Finding:
Followed up on peanut allergy severity
Finding:
Describes allergy as not severe
(Found)
Pro Tip: When a patient reports an allergy, it is important ascertain the severity of their reaction to the allergen. A broad question about this topic, while a good starting point, may prompt a broad response that lacks the specifics of the reaction type.
Example Question:
How severe do you think your peanut allergy is?
Finding:
Denies breathing problems after exposure
(Available)
Pro Tip: Asking a patient about specific life-threatening reactions to their allergy, such as breathing problems, will prompt a response that characterizes the severity of the allergy.
Example Question:
Do you experience breathing problems when you eat peanuts?
Finding:
Denies hospitalization for reaction to peanuts
(Available)
Pro Tip: Asking a patient about past, allergy-related hospitalizations will prompt a response that characterizes the severity of the allergy.
Example Question:
Have you ever been hospitalized for a reaction to peanuts?
Finding:
Followed up on peanut allergy treatment
Finding:
Treated with Benadryl
(Found)
Pro Tip: When a patient reports an allergy, it is important to ask about the patient’s ability and willingness to treat allergic reactions. The patient’s response may provide insight into their health literacy and impact the allergy has had on their daily life.
Example Question:
How do you treat your peanut allergy?
Finding:
Reports avoiding peanuts and peanut oil
(Found)
Pro Tip: When a patient reports an allergy, it is important to ask about the patient’s ability and willingness to avoid the allergen. The patient’s response may provide insight into their health literacy and impact the allergy has had on their daily life.
Example Question:
How do you avoid eating peanuts?
Finding:
Denies use of epi-pen
(Available)
Pro Tip: When a patient reports an allergy, it is important to ask about access to specific resources that may treat an allergic reaction in the event of an emergency.
Example Question:
Do you have an epi pen?
Finding:
Asked about medication allergies
Finding:
Denies known medication allergies
(Found)
Pro Tip: While general questions about allergies may elicit important information, the patient may not spontaneously report all allergies. For example, medication allergies may be overlooked by the patient because he or she considers adverse reactions to medications separate from more common allergies, such as hay fever or allergic reactions to animal dander. In addition, if the patient experienced an allergic reaction to medication long ago, he or she may not immediately recall it. Therefore, it is important to ask specifically about medication allergies.
Example Question:
Are you allergic to any medications?
Finding:
Asked about other allergies
Finding:
Denies latex allergy
(Available)
Pro Tip: While general questions about allergies may elicit important information, the patient may not spontaneously report all allergies. For example, a latex allergy may be overlooked by a patient who rarely comes into contact with latex, or who has only experienced a mild allergic reaction. Therefore, it is important to ask specifically about latex allergy.
Example Question:
Are you allergic to latex?
Finding:
Denies food allergies or sensitivities (other than peanuts)
(Available)
Pro Tip: While general questions about allergies may elicit important information, the patient may not spontaneously report all allergies. For example, a food allergy may be overlooked by a patient who hasn’t experienced an allergy to things they eat, or to a patient who has already reported known food allergies. To form a more complete picture, it is important to ask specifically about food allergies.
Example Question:
Do you have any food allergies?
Finding:
Denies known environmental allergies
(Available)
Pro Tip: While general questions about allergies may elicit important information, the patient may not spontaneously report all allergies. For example, seasonal allergies may be overlooked by the patient because he or she considers them to be very common or harmless. In addition, if the patient is not currently experiencing an allergic reaction, this information may slip his or her mind. Therefore, it is important to ask specifically about environmental allergies.
Example Question:
Do you have any environmental allergies?
Substance Use
Finding:
Asked about tobacco and nicotine use
Finding:
Reports “some” tobacco use
(Found)
Pro Tip: Tobacco use in all its forms carries risk of adverse health consequences, so it is critical to ask your patient about tobacco use during a health history interview.
Example Question:
What tobacco products have you used?
Finding:
Followed up on type of tobacco or nicotine
Finding:
Reports smoking cigarettes
(Found)
Pro Tip: Smoking is a significant risk factor for many diseases and conditions including lung cancer, emphysema, and heart disease. Therefore, it is essential to ask patients about smoking and other tobacco use during a health history interview.
Example Question:
What do you smoke?
Finding:
Denies other forms of smoking tobacco such as cigars and pipes
(Available)
Pro Tip: Smoking is a significant risk factor for many diseases and conditions including lung cancer, emphysema, and heart disease. Furthermore, different forms of smoked tobacco may carry specific health risks; it is important to ask about other types of smoking tobacco to form a full picture of the patient’s smoking patterns.
Example Question:
Do you smoke cigars?
Finding:
Denies using chew or smokeless forms of tobacco
(Available)
Pro Tip: Smokeless tobacco also carries the risk of adverse health consequences for users, therefore it is important to ask a patient specifically about these products.
Example Question:
Have you ever tried chewing tobacco?
Finding:
Denies vaping or e-cigarettes
(Available)
Pro Tip: While less is known about the specific health consequences of e-cigarettes and personal vaporizers for tobacco use, it is important to to ask a patient about these products to form a more complete picture of their tobacco use patterns.
Example Question:
Have you ever tried an electronic cigarette?
Finding:
Followed up on patterns of tobacco use
Finding:
Reports smoking “really not very many” cigarettes
(Available)
Pro Tip: When a patient reports smoking, it is important to determine the quantity of the patient’s tobacco use in order to assess the patient’s risk level for associated health problems, and also to gauge the degree of the patient’s dependence.
Example Question:
How much do you smoke?
Finding:
Has smoked 3 times (one cigarette each time)
(Found)
Pro Tip: When a patient reports smoking, it is important to determine the frequency and duration of the patient’s tobacco use in order to assess the patient’s risk level for associated health problems, and also to gauge the degree of the patient’s dependence.
Example Question:
How many times have you smoked?
Finding:
Explored patient’s perception of tobacco use
Finding:
Reports understanding of health impacts of smoking
(Available)
Pro Tip: When a patient reports smoking, assessing their knowledge about tobacco use can enable providers to engage in relevant conversation with the patient, and to offer helpful education.
Example Question:
Can you tell me what you know about the health impacts of smoking?
Finding:
Reports negative experiences with smoking
(Found)
Pro Tip: In an adolescent patient, evaluating his or her attitude towards smoking can enable the provider to offer relevant support and education. For example, if the patient communicates that he or she views smoking as a means of relaxing, a provider can offer education and strategies for achieving relaxation in healthy ways.
Example Question:
How do you feel about smoking?
Finding:
Explored reasons that patient experimented with smoking
Finding:
Describes peer pressure related to smoking
(Found)
Pro Tip: When an adolescent patient reports smoking, evaluating the circumstances and social pressure involved may help the provider understand the patient’s motive for smoking. Addressing these motives directly, and exploring their origins, can be essential components of patient education regarding smoking.
Example Question:
Do your friends encourage you to smoke?
Finding:
Reports that she will avoid smoking in the future
(Available)
Pro Tip: When an adolescent patient reports smoking, evaluating the circumstances and social pressure involved may help the provider understand the patient’s motive for smoking. Addressing these motives directly, and exploring their origins, can be essential components of patient education regarding smoking.
Example Question:
What will you say if your friends asked you to smoke again?
Finding:
Asked about alcohol use
Finding:
Denies alcohol use
(Found)
Pro Tip: Asking direct opening questions about alcohol consumption is more likely to prompt a definitive response from a patient.
Example Question:
Have you ever tried alcohol?
Finding:
Denies being around friends who consume alcohol
(Available)
Pro Tip: When asking an adolescent patient about alcohol consumption, it is important to evaluate the circumstances and social pressure involved. Addressing these motives directly, and exploring their origins, can be essential components of patient education regarding drinking.
Example Question:
Do your friends ever drink alcohol?
Finding:
Reports alcohol consumed by parents at home
(Available)
Pro Tip: When asking an adolescent patient about alcohol consumption, it is important to evaluate the circumstances and social pressure involved. Since parents serve as direct models of adult alcohol consumption, asking about drinking patterns in the home may prove insightful.
Example Question:
Does anyone at home drink alcohol?
Finding:
Reports that parents drink “a glass of wine at dinner”
(Available)
Pro Tip: When asking an adolescent patient about alcohol consumption, it is important to evaluate the circumstances and social pressure involved. Since parents serve as direct models of adult alcohol consumption, asking about drinking patterns in the home may prove insightful. A broad question about the quantity of alcohol use in the home is a good starting point.
Example Question:
How much alcohol do your parents drink at home?
Finding:
Asked about drug use
Finding:
Denies previous drug use
(Found)
Pro Tip: Asking direct opening questions about drug use is more likely to prompt a definitive response from a patient.
Example Question:
Have you ever experimented with drugs?
Finding:
Denies being around friends who use drugs
Health History – Patient: Tina Jones
Transcript
| Hello! | Question 02/07/23 2:05 AM MST |
|
| Hi. I’m Preceptor Diana. I will explain the details of this assignment and your objectives, just as a preceptor would in real life. Pay close attention to this information as it will help guide your exam. At the end of this prebrief, you will answer a short question about the upcoming assignment. During the simulation, you may return to these instructions at any time by scrolling to the top of your transcript. | ||
| What is the situation? | Question 02/07/23 2:05 AM MST |
|
| Your patient is Tina Jones, a 28-year-old African American woman who has just been admitted to Shadow General Hospital for a painful foot wound. Your role in this simulation is that of a healthcare provider who will take Ms. Jones’ health history, a key component of her admission process. | ||
| What are my objectives in this assessment? | Question 02/07/23 2:06 AM MST |
|
| A health history requires you to ask questions related to Ms. Jones’ past and present health, from her current foot wound to her pre-existing conditions. You will also want to review Ms. Jones’ systems, psychosocial history, and family medical history. These assessments together will give you a comprehensive picture of Ms. Jones’ overall health. If you discover any disease states, ask about symptoms and the patient’s experiences of them. Your questioning should cover a broad array of the symptoms’ characteristics. Throughout the conversation, you should educate and empathize with Ms. Jones when appropriate to increase her health literacy and sense of well-being. Regardless of whether you have assessed Ms. Jones previously, ask all questions that are necessary for obtaining a complete health history. While you should communicate with patients using accessible, everyday language, it is standard practice to use professional medical terminology everywhere else, such as in documenting physical findings and nursing notes. You may complete the exam activities in any order and move between them as needed. After obtaining Ms. Jones’ health history, you will complete an information processing activity. You will identify and prioritize diagnoses, then create a plan to address the identified diagnoses. | ||
| What else will this exam involve? | Question 02/07/23 2:06 AM MST |
|
| You will complete nursing tasks to protect the patients safety, privacy, and health. You can document your findings, including vital signs, in the Electronic Health Record. This record provides necessary information for healthcare professionals who will continue patient care. Besides Subjective Data Collection, and Education and Empathy, there are activities within the simulation that provide valuable practice for their real-world counterparts, but they are not automatically graded by the simulation. | ||
| How will I be evaluated? | Question 02/07/23 2:06 AM MST |
|
| In this assignment, you will be evaluated on your Subjective Data Collection, as well as your Education and Empathy. Your success in Education and Empathy is based on whether you promptly respond after identifying a moment worthy of therapeutic communication. The evaluation of your interview is dependent on how you word your questions therapeutically and precisely and explore all relevant topics with comprehensive breadth and depth. You will also be evaluated on your ability to collect data and form nursing diagnoses in the information processing activity. This assignment takes on average between 90 and 110 minutes. This exam may take longer than in real life, because in this safe simulation, students of all experience levels can take time to hone and review their skills. You can pause and resume the assignment at any time; your work is always saved automatically. | ||
| How does this assignment prepare me for the real world? | Question 02/07/23 2:07 AM MST |
|
| In this assessment, you will become familiarized with the structure and content of a health history exam so that with real-life patients, you can: º ask effective and comprehensive questions º obtain a thorough health history º evaluate the patient’s risk of disease, infection, injury, and complications º educate and empathize º reflect on your experience and identify areas to improve º identify and prioritize nursing diagnoses º and develop a plan to address nursing diagnoses. | ||
| In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: Why is it important to obtain a patient’s complete health history? | ||
| It is important to obtain a patient’s complete health history in order to make correct diagnosis for the patient. | Statement 02/07/23 2:08 AM MST |
|
| Time to begin. | ||
| Hello, my name is Nukol. I will be your nurse for today. | Greet 02/09/23 1:32 AM MST |
|
| Hello. | ||
| What brings you here today? | Question 02/09/23 1:33 AM MST |
|
| I got this scrape on my foot awhile ago, and it got really infected. It’s killing me. | ||
| I am sorry for that | Empathize 02/09/23 1:33 AM MST |
|
| Thanks a lot. | ||
| WHat is the current pain level on a scale? | Question 02/09/23 1:33 AM MST |
|
| …Like a 7. It hurts a lot, but whatever pain med the ER gave me is helping a little bit. | ||
| What is the pain like? | Question 02/09/23 1:34 AM MST |
|
| It’s throbbing and like, sharp if I try to put weight on it. | ||
| Where is the location of the wound? | Question 02/09/23 1:34 AM MST |
|
| It’s on the ball of my foot. | ||
| How did you injure your leg? | Question 02/09/23 1:34 AM MST |
|
| I was changing a light bulb, and I had to use our little stepstool to reach it. My foot slid off the bottom step and it got all scraped up. I didn’t realize how sharp the edge was! | ||
| Is there drainage on the wound? | Question 02/09/23 1:34 AM MST |
|
| Yeah, there’s definitely pus. | ||
| What is the colour of the drainage? | Question 02/09/23 1:34 AM MST |
|
| It’s… white or maybe off-white. | ||
| How do you treat the wound? (Clarified to How have you cared for the scrape?.) | Question 02/09/23 1:35 AM MST |
|
| I made sure to clean it and keep it bandaged. And I put Neosporin on it. (Clarified to how I have been taking care of the scrape.) | ||
| How effective is the ointment? (Clarified to How did the ointment work?.) | Question 02/09/23 1:35 AM MST |
|
| Well, I’m here, so I guess it didn’t do its job. (Clarified to how the ointment worked.) | ||
| What are the foot wound symptoms? | Question 02/09/23 1:35 AM MST |
|
| 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. | ||
| How has the injury affected your daily living? | Question 02/09/23 1:36 AM MST |
|
| 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 preexisting medical conditions? | Question 02/09/23 1:36 AM MST |
|
| Yeah. . . I have asthma and diabetes. | ||
| When were you diagnosed with diabetes? | Question 02/09/23 1:36 AM MST |
|
| I was diagnosed when I was 24. | ||
| How do you manage the diabetes? | Question 02/09/23 1:36 AM MST |
|
| I just watch what I eat and try to stay away from sweets. | ||
| which medications do you use for diabetes? (Clarified to What medication do you take for diabetes?.) | Question 02/09/23 1:37 AM MST |
|
| I don’t take medicine for it anymore. (Clarified to what medication I take for diabetes.) | ||
| Were you using any diabetes medication in the past? (Clarified to Did you take medication for diabetes?.) | Question 02/09/23 1:37 AM MST |
|
| Yeah, when I was diagnosed they gave me a medicine to try. (Clarified to if I have ever taken something for diabetes.) | ||
| Why did you stop using diabetes medication? | Question 02/09/23 1:38 AM MST |
|
| I just got sick of dealing with it! | ||
| Do you monitor you blood glucose? | Question 02/09/23 1:39 AM MST |
|
| I have a monitor at home, but to be honest I don’t really use it that often. | ||
| Do you feel thirsty? | Question 02/09/23 1:39 AM MST |
|
| No, I just finished a bottle of water not too long ago. | ||
| Do you often feel thirsty? | Question 02/09/23 1:39 AM MST |
|
| You know, I did notice lately that I’ve been really thirsty. | ||
| How frequent do you urinate? | Question 02/09/23 1:39 AM MST |
|
| I don’t know. Every hour or two when I’m awake? | ||
| Have you have any change in appetite? | Question 02/09/23 1:40 AM MST |
|
| Yeah, lately I’ve definitely been much hungrier than usual. | ||
| Have you noticed weight changes? | Question 02/09/23 1:40 AM MST |
|
| Yeah, I’ve lost some weight recently. | ||
| Do you know what is causing weight change? | Question 02/09/23 1:40 AM MST |
|
| I don’t know what caused it, I just lost weight. | ||
| Do you have a history of asthma exacerbation? | Question 02/09/23 1:41 AM MST |
|
| I used to have them a lot growing up, but I haven’t had a full attack in years. It is sometimes difficult to breathe. | ||
| do you often have asthma attack? | Question 02/09/23 1:47 AM MST |
|
| I used to have them a lot growing up, but I haven’t had a full attack in years. It is sometimes difficult to breathe. | ||
| history of asthma exacerbations? (Clarified to What is your history of asthma exacerbations?.) | Question 02/09/23 1:48 AM MST |
|
| I used to have asthma attacks a lot when I was younger, but I haven’t had a full attack in years. I just have some difficulty breathing. (Clarified to what my history of asthma exacerbations is.) | ||
| have you been hospitalized before? | Question 02/09/23 1:49 AM MST |
|
| Well, before this I went a bunch of times when I was little, for asthma attacks. This is the first time I’ve been in the hospital since I was probably sixteen, though. | ||
| how do you manage the asthma? | Question 02/09/23 1:50 AM MST |
|
| I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler. | ||
| How many puffs do you take when on asthma attack? | Question 02/09/23 1:50 AM MST |
|
| I usually use two puffs from my inhaler, but sometimes I need three. I believe the albuterol inhaler is 90 mcg per puff. [AUDIO COMING SOON] | ||
| What triggers the asthma? | Question 02/09/23 1:51 AM MST |
|
| Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. | ||
| Do you have allergies? | Question 02/09/23 1:51 AM MST |
|
| Yeah, I’m allergic to cats. | ||
| How are the cat allergy symptoms? (Clarified to What happens when you are around a cat?.) | Question 02/09/23 1:51 AM MST |
|
| Whenever I’m around cats, I start sneezing, my eyes get itchy. . . and my asthma starts to act up. (Clarified to what the symptoms of my cat allergy are.) | ||
| Do you have latex allergy? | Question 02/09/23 1:52 AM MST |
|
| Nope. | ||
| Do you have medication allergies? | Question 02/09/23 1:52 AM MST |
|
| Yeah, I’m allergic to penicillin. | ||
| how does penicillin affect you? | Question 02/09/23 1:53 AM MST |
|
| 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 02/09/23 1:53 AM MST |
|
| Nope, no food allergies that I know of. | ||
| Do you have dust or mold allergies? (Clarified to Do you have an allergy to pollen, dust, or mold?.) | Question 02/09/23 1:53 AM MST |
|
| Well. . . I don’t know if it’s allergies, but sometimes my asthma acts up around dust. (Clarified to if I have an allergy to pollen dust or mold.) | ||
| Have you been immunized? | Question 02/09/23 1:54 AM MST |
|
| I’m pretty sure my shots are current, yeah. | ||
| Have you had childhood immunizations? | Question 02/09/23 1:54 AM MST |
|
| I am pretty sure I received all my vaccines as a kid, like before registering for school. | ||
| Have you received a flu vaccine? | Question 02/09/23 1:54 AM MST |
|
| No. | ||
| Have you received tetanus immunization? | Question 02/09/23 1:55 AM MST |
|
| I got a tetanus booster about a year ago. | ||
| which home pain medication do you use? | Question 02/09/23 1:55 AM MST |
|
| I took Advil at home, and the ER gave me something, too. | ||
| How effective is home pain medication? | Question 02/09/23 1:55 AM MST |
|
| Whatever pain medication the ER gave me is helping. Before I came in, I was just taking Advil. For the past few days, the Advil wasn’t doing much for me — it would only last a couple of hours. | ||
| What is your level of education | Question 02/09/23 1:56 AM MST |
|
| Well, I’m finishing up my Bachelor’s degree right now. | ||
| Do you have any stressors? | Question 02/09/23 2:01 AM MST |
|
| No, not really. | ||
| Have you taken any OTC medications? | Question 02/10/23 1:42 AM MST |
|
| Yes, I’ve been taking Advil. | ||
| How is your living condition? | Question 02/10/23 1:42 AM MST |
|
| It’s just a regular house. | ||
| How is your belief system? | Question 02/10/23 1:43 AM MST |
|
| I’m Baptist. My faith is a big part of my life–when things get hard like they’ve been this past year, I know I can trust that God’s looking out for me. I’ve been going to the same church since I was a kid, too, so the people at church are practically part of my family. | ||
| Have you ever experienced abuse? | Question 02/10/23 1:43 AM MST |
|
| No, no way. I’ve never been hurt or anything in the way that you’re talking about. | ||
| Have you used illicit drugs? | Question 02/10/23 1:43 AM MST |
|
| Well, I used to smoke pot. . . but I don’t do that anymore. | ||
| When did you last smoke? | Question 02/10/23 1:44 AM MST |
|
| I haven’t smoked pot since I was twenty or twenty-one. | ||
| Do you take alcohol? | Question 02/10/23 1:44 AM MST |
|
| I do sometimes, yeah, when I go out with my friends. | ||
| Do you use tobacco? | Question 02/10/23 1:44 AM MST |
|
| No. I think it’s gross. | ||
| Are you exposed to secondhand smoke? | Question 02/10/23 1:44 AM MST |
|
| Some of my friends smoke when we go out drinking. But I don’t smoke, and nobody at home smokes. | ||
| Exposure to secondhand smoke is as risky as smoking | Educate 02/10/23 1:45 AM MST |
|
| Good to know. | ||
| How is your mother’s health? | Question 02/10/23 1:45 AM MST |
|
| Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though. | ||
| How is your father’s health? | Question 02/10/23 1:45 AM MST |
|
| Dad passed away last year, so…it’s been really hard. | ||
| I am sorry to hear that | Empathize 02/10/23 1:45 AM MST |
|
| I appreciate that. | ||
| What caused your father’s death? | Question 02/10/23 1:46 AM MST |
|
| He died in a car accident. | ||
| How did you cope with father’s death? | Question 02/10/23 1:46 AM MST |
|
| 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 02/10/23 1:48 AM MST |
|
| Grandpa Jones passed away when I was really little. | ||
| how is your paternal grandmother’s health? | Question 02/10/23 1:49 AM MST |
|
| 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 02/10/23 1:49 AM MST |
|
| Well, Poppa died about five years ago. | ||
| how is your maternal grandmother’s health? | Question 02/10/23 1:49 AM MST |
|
| Nana was 73 when she died of a stroke about five years ago. I think she had high blood pressure and cholesterol, too. | ||
| how is your brother’s health? | Question 02/10/23 1:50 AM MST |
|
| He’s a healthy guy. Kinda big like me. | ||
| how is your sister’s health? | Question 02/10/23 1:50 AM MST |
|
| She’s pretty healthy. She has asthma too, but she almost never has attacks. | ||
| Do you have a family history of obesity? | Question 02/10/23 1:50 AM MST |
|
| 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 02/10/23 1:50 AM MST |
|
| No, I don’t think so. | ||
| Do you have a family history of substance abuse? | Question 02/10/23 1:51 AM MST |
|
| One person in the family, my dad’s brother, has an alcohol problem, but we never see him. | ||
| Do you have a family history of headaches? | Question 02/10/23 1:51 AM MST |
|
| No, not that I know of. | ||
| How is your general health? | Question 02/10/23 1:51 AM MST |
|
| 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 any head problem? | Question 02/10/23 1:51 AM MST |
|
| I don’t think I have any problems. I get headaches sometimes, but that’s all. | ||
| Do you have any ear problem? | Question 02/10/23 1:51 AM MST |
|
| No. | ||
| Do you have any eye problem? | Question 02/10/23 1:52 AM MST |
|
| 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 any mouth problem? | Question 02/10/23 1:52 AM MST |
|
| No. | ||
| Do you have any neck problem? | Question 02/10/23 1:52 AM MST |
|
| Fine, I think? I do notice the skin on my neck is looking weird. | ||
| Do you have any breast problem? | Question 02/10/23 1:52 AM MST |
|
| No, they’re fine . . . [AUDIO COMING SOON] | ||
| Do you have any stomach problem? | Question 02/10/23 1:52 AM MST |
|
| I don’t really get stomach problems — I usually have an iron stomach. | ||
| Do you have any reproductive health problem? | Question 02/10/23 1:53 AM MST |
|
| I don’t think I have problems in that area. I just get really bad periods, that’s all. | ||
| Do you have any nerve problem? | Question 02/10/23 1:53 AM MST |
|
| I don’t think so. . .not even sure what that would feel like. | ||
| Vitals measured | Exam Action 02/10/23 1:54 AM MST |
|
| have you been hospitalized before? | Question 02/10/23 2:26 AM MST |
|
| Well, before this I went a bunch of times when I was little, for asthma attacks. This is the first time I’ve been in the hospital since I was probably sixteen, though. | ||
| Vitals measured | Exam Action 02/10/23 2:32 AM MST |
Subjective Data Collection: 88 of 88 (100.0%)
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: 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:
Do you have any pain?
Finding:
Reports foot wound
(Found)
Pro Tip: If a patient mentions pain, it’s important to determine what specifically is causing her pain, if she knows.
Example Question:
What’s causing your pain?
History of Presenting Illness
Finding:
Asked to rate current pain level on a scale
Finding:
Reports current pain is 7/10
(Found)
Pro Tip: Asking your patient to rate her pain on a scale of 0 to 10 is important to gauge how it ebbs and flows while she is in your care.
Example Question:
Can you rate the pain on a scale of 0 to 10?
Finding:
Asked for details about the pain
Finding:
Reports pain is throbbing
(Found)
Pro Tip: Determining how your patient describes the characteristics of the pain can be important data to support the cause of the pain.
Example Question:
Can you please describe the pain?
Finding:
Reports pain is sharp when she attempts to stand
(Found)
Pro Tip: Determining what physical activities and movements exacerbate the patient’s pain can help you better understand the problems and assess treatment needs. This can also alert you if a patient’s activities of daily living are hindered.
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: Finding out how the patient’s pain has changed will give you insight into the acceleration of infection.
Example Question:
How has the pain changed over time?
Finding:
Reports feeling pain radiating into ankle
(Available)
Pro Tip: Asking about where else the patient’s pain radiates can help determine the progression of infection.
Example Question:
Does the pain radiate anywhere else?
Finding:
Reports pain prevents bearing weight on foot
(Found)
Pro Tip: Determining if your patient can bear weight on an injury is important to determine their risk for falls while in your care.
Example Question:
Can you bear weight on your foot?
Finding:
Asked location of wound
Finding:
Reports right foot is injured
(Available)
Pro Tip: Confirming which extremity an injury is located on is a best practice for your patient’s safety.
Example Question:
Which foot is in pain?
Finding:
Reports wound is on the plantar surface of her foot
(Found)
Pro Tip: Confirming where a wound is located ensures you are aware of your patient’s biggest complaint.
Example Question:
Where is the wound?
Finding:
Asked details of the injury
Finding:
Reports she scraped foot on bottom rung of a step stool
(Found)
Pro Tip: Discovering how an injury happened helps to assess your patient’s risk factors for injury.
Example Question:
How did your injury happen?
Finding:
Reports injury occurred 1 week ago
(Available)
Pro Tip: Discovering how long ago the pain began is the first step in understanding whether the pain is chronic or acute.
Example Question:
When did your injury occur?
Finding:
Denies other injuries besides foot wound
(Available)
Pro Tip: Discovering additional injuries can reveal more information about the circumstances that caused the presenting injury.
Example Question:
Did you injure anything besides your foot?
Finding:
Reports being barefoot at the time of injury
(Available)
Pro Tip: Asking about clothing, footwear, and other protective elements being worn at the time of injury helps you discover the totality of the circumstances.
Example Question:
Were you wearing shoes when you fell?
Finding:
Denies seeing a healthcare provider for the injury until now
(Found)
Pro Tip: It’s crucial to ask whether your patient has seen another provider for the injury, because any previous medical intervention will help you understand the progression of the wound.
Example Question:
Have you seen a healthcare provider for this injury?
Finding:
Asked about drainage from the foot wound
Finding:
Reports that the wound bled a little after sustaining the injury
(Available)
Pro Tip: Asking about bleeding helps you determine the characteristics of a wound.
Example Question:
Did your foot bleed?
Finding:
Reports seeing pus draining from wound
(Found)
Pro Tip: Asking about discharge helps you determine the characteristics of a wound.
Example Question:
Did you notice any discharge from the wound?
Finding:
Reports noticing pus 2 days ago
(Available)
Pro Tip: Pinpointing exactly when the patient noticed the arrival of pus gives you an important data point for when an active infection began.
Example Question:
When did you first notice the pus?
Finding:
Followed up on drainage
Finding:
Reports pus as white or yellow
(Found)
Pro Tip: The color of discharge from a wound can provide insight into its severity and characteristics.
Example Question:
What color is the drainage from your wound?
Finding:
Denies odor from the wound
(Available)
Pro Tip: The odor of discharge from a wound can provide insight into its severity and characteristics.
Example Question:
Does the wound have an odor?
Finding:
Asked about home treatment of foot wound
Finding:
Reports wound care regimen of bandaging
(Available)
Pro Tip: Asking specifically how often a patient changed a bandage will let you know if an infection spread through improper hygiene, or for other reasons such as uncontrolled blood sugar.
Example Question:
How often do you change your bandage?
Finding:
Reports cleaning wound twice a day
(Available)
Pro Tip: Asking specifically how often a patient cleaned a wound will let you know if an infection spread through improper hygiene, or for other reasons such as uncontrolled blood sugar.
Example Question:
How often did you clean the wound?
Finding:
Reports applying bacitracin, neomycin and polymyxin B (Neosporin)
(Found)
Pro Tip: Determining what products a patient used to sterilize or treat a wound establishes home care routines and health literacy.
Example Question:
Did you use any ointment on the wound?
Finding:
Followed up on effectiveness of ointment
Finding:
Reports bacitracin, neomycin and polymyxin B (Neosporin) was ineffective
(Found)
Pro Tip: Understanding the effect of a home medication can help you determine the severity of the wound. Tina’s diabetes diagnosis will have a large impact on her body’s healing ability, which should be taken into consideration during your exam.
Example Question:
Did the ointment help?
Finding:
Asked about other foot wound symptoms
Finding:
Reports swelling around foot wound
(Found)
Pro Tip: Asking about the presence of swelling helps you gather information about your patient’s complaint, as well as potential related illnesses.
Example Question:
Is there swelling around the wound?
Finding:
Reports swelling worsened in the past 2 days
(Available)
Pro Tip: Finding out how long swelling appeared will help you understand the timeline for the infection progression.
Example Question:
How long have you noticed swelling around the wound?
Finding:
Reports redness around the wound
(Found)
Pro Tip: Asking about redness will help you understand the timeline for the infection progression.
Example Question:
Did you notice any redness around the wound?
Finding:
Reports that the wound feels warm
(Found)
Pro Tip: Asking about warmth will help you understand the timeline for the infection progression.
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
(Available)
Pro Tip: Understanding the impact of your patient’s wound on daily activities helps inform your plan for care. With a foot wound, it is imperative to discern if a patient can walk or not, as a lack of mobility can compromise quality of life.
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: Understanding the impact of your patient’s wound on daily activities helps inform your plan for care. With a foot wound, it is imperative to discern if a patient can stand or not, as this can compromise quality of life and impact job performance.
Example Question:
Does your foot pain affect your work?
Finding:
Reports pain prevented her from being able to walk to class
(Available)
Pro Tip: For patients who are also students, you can find out what schoolwork they are missing, and help them make accommodations so they don’t fall behind.
Example Question:
Has your injury prevented you from going to class?
Past Medical History
Finding:
Asked about preexisting medical conditions
Finding:
Reports diabetes
(Found)
Pro Tip: It is important to identify any existing medical conditions, as that information is an integral part of a complete health history. Existing conditions can also inform your treatment and understanding of the patient’s current health issues. In Tina’s case, it is important to identify her diabetes diagnosis because that condition has a direct relationship with her current foot infection.
Example Question:
Do you have any existing conditions?
Finding:
Reports asthma
(Found)
Pro Tip: It is important to identify any existing medical conditions, such as Tina’s asthma, because that information is an integral part of her health history. Existing conditions can also inform your treatment and understanding of the patient’s current health issues.
Example Question:
Do you have any other conditions?
Finding:
Followed up on diabetes diagnosis
Finding:
Reports specific age of diagnosis was 24
(Found)
Pro Tip: Learning the diagnosis date of your patient’s illness is an essential element of the illness’s history.
Example Question:
At what age were you diagnosed with diabetes?
Finding:
Reports that her diabetes is Type 2
(Available)
Pro Tip: The type of diabetes your patient has will drastically affect how you care for her.
Example Question:
Do you know what type of diabetes you have?
Finding:
Asked about diabetes management through lifestyle changes
Finding:
Reports staying away from sweets
(Found)
Pro Tip: Asking your patient specifically about sugar intake can help you understand the history of her diabetes as well as her health literacy.
Example Question:
Tell me more about any sugars you consume.
Finding:
Reports drinking diet coke instead of regular
(Available)
Pro Tip: Particularly for diabetic patients, asking about intake of drinks that contain sugar can reveal additional sources of carbohydrates that the patient may not consider.
Example Question:
Do you drink sugary drinks?
Finding:
Asked about current diabetes medication use
Finding:
Reports that she does not currently take medication for diabetes
(Found)
Pro Tip: Asking about diabetes medication is important to understanding if your patient’s disease is under control.
Example Question:
Do you take prescribed medication for your diabetes?
Finding:
Asked about past diabetes medication use
Finding:
Reports that she used to take diabetes medication
(Found)
Pro Tip: Asking about Tina’s medication history for asthma will provide a timeline of treatment. You will be able to see what has been effective and ineffective in the past, which will allow you to make a more informed decision about current treatment.
Example Question:
Have you ever taken medication for your diabetes?
Finding:
Reports previous medication was prescription metformin
(Available)
Pro Tip: Asking about a patient’s medication history for a particular condition, such as Tina’s past prescription for metformin, will provide a timeline of her asthma treatment. You will be able to see what has been effective and ineffective in the past, which will allow you to make a more informed decision about current treatment.
Example Question:
Do you remember what you were prescribed for diabetes?
Finding:
Reports last use of medication was 3 years ago
(Available)
Pro Tip: It is important to discover when Tina stopped taking any medications and what caused her to stop. Discovering her reason for noncompliance will allow you to make a more informed decision about current treatment.
Example Question:
When was the last time you took your diabetes medication on a regular basis?
Finding:
Followed up on stopping diabetes regimen
Finding:
Reports disliking diabetes medication side effects
(Available)
Pro Tip: Asking about side effects from medication can provide information about your patient’s reaction to treatment.
Example Question:
Did the metformin cause any side effects?
Finding:
Reports that she didn’t like checking sugar and taking daily pills
(Available)
Pro Tip: Asking reasons for noncompliance can reveal information about your patient’s health literacy, side effects, financial situation, and more.
Example Question:
What’s preventing you from taking your diabetes medication?
Finding:
Asked about blood glucose monitoring
Finding:
Reports infrequent blood glucose monitoring
(Found)
Pro Tip: Your patient’s blood sugar monitoring habits are an important part of her health literacy and home treatment.
Example Question:
Tell me about your blood sugar monitoring.
Finding:
Reports she last checked blood sugar a month ago
(Available)
Pro Tip: Your patient’s blood sugar monitoring habits are an important part of her health literacy and home treatment.
Example Question:
How often do you check your blood sugar?
Finding:
Reports confusion about what the numbers mean
(Available)
Pro Tip: Your patient’s blood sugar monitoring habits are an important part of her health literacy and home treatment. If you find gaps in the patient’s literacy, that is your opportunity to provide education.
Example Question:
What are your usual blood sugar levels?
Finding:
Asked about thirst
Finding:
Reports increased thirst
(Found)
Pro Tip: Your patient’s thirst can offer insight into underlying medical conditions. Knowing that Tina is diabetic, you will want to explore this classic symptom of the condition.
Example Question:
Have you been more thirsty lately?
Finding:
Reports increased water intake
(Available)
Pro Tip: Your patient’s fluid intake can offer insight into underlying medical conditions. Knowing that Tina is diabetic, you will want to explore this classic symptom of the condition.
Example Question:
Are you drinking more water than normal?
Finding:
Asked about frequency of urination
Finding:
Reports more frequent urination
(Found)
Pro Tip: Your patient’s urination habits can offer insight into underlying medical conditions and general health. Knowing that Tina is diabetic, you will want to explore this classic symptom of the condition.
Example Question:
Have you been urinating more often than usual?
Finding:
Reports urinating every hour or two during the day
(Found)
Pro Tip: Your patient’s urination habits can offer insight into underlying medical conditions and general health. Knowing that Tina is diabetic, you will want to explore this classic symptom of the condition.
Example Question:
How often do you urinate during the day?
Finding:
Reports urinating 2 to 3 times during the night
(Available)
Pro Tip: Discovering if Tina has nocturia can offer insight into underlying medical conditions and general health.
Example Question:
How often do you wake up at night to urinate?
Finding:
Asked about diet
Finding:
Reports eating a bowl of cereal for breakfast yesterday
(Available)
Pro Tip: In a health history, it is important to get an idea of a patient’s typical dietary patterns. This can be achieved by asking for a 24-hour diet recall.
Example Question:
What did you eat for breakfast yesterday?
Finding:
Reports eating mac and cheese for lunch yesterday
(Available)
Pro Tip: In a health history, it is important to get an idea of a patient’s typical dietary patterns. This can be achieved by asking for a 24-hour diet recall.
Example Question:
What did you eat for lunch yesterday?
Finding:
Reports eating chicken and roll for dinner yesterday
(Available)
Pro Tip: Finding out the foods a patient last ate can provide evidence for any current stomach upset and for their current level of hunger and blood sugar status, and can affect medications given while in your care.
Example Question:
What did you eat for your last meal?
Finding:
Asked about change in appetite
Finding:
Reports increased appetite
(Found)
Pro Tip: Identifying if a patient has recently experienced a change in appetite is important, as it could indicate an underlying endocrine or psychiatric condition.
Example Question:
Have you noticed an increase in appetite?
Finding:
Reports change in appetite began a month ago
(Available)
Pro Tip: Determining the onset of appetite change can reveal important details about underlying health conditions.
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: Determining the exact amount of weight loss can indicate whether it’s within expected ranges, or extreme, which may indicate an underlying health problem.
Example Question:
How much weight have you lost?
Finding:
Reports weight loss occurred over the past month
(Available)
Pro Tip: Finding out the timeline for weight loss can indicate if it’s sudden or gradual.
Example Question:
How long did it take you to lose 10 pounds?
Finding:
Followed up on reason for weight change
Finding:
Reports weight loss was unintentional
(Found)
Pro Tip: Unintentional weight loss can be a sign of underlying medical conditions or a reflection of unhealthy lifestyle choices. Asking your patient about this can inform your care plan.
Example Question:
Was your weight loss intentional?
Finding:
Asked about history of asthma exacerbations
Finding:
Reports last asthma attack was in high school
(Available)
Pro Tip: Discovering the patient’s most recent asthma attack can provide a timeline of exacerbations and help you better understand the patient’s condition and effectiveness of any treatments.
Example Question:
When was your last asthma attack?
Finding:
Reports last exacerbation was three days ago
(Available)
Pro Tip: Discovering the patient’s most recent exacerbation can provide a timeline of asthma symptoms and help you better understand the patient’s condition and effectiveness of any treatments.
Example Question:
When did you last have issues with asthma?
Finding:
Asked about asthma symptoms
Finding:
Reports chest tightness during exacerbation
(Available)
Pro Tip: Asthma can have a profound impact on health, and it is important to discover the severity of her condition by asking about symptoms during an exacerbation, such as chest tightness.
Example Question:
What do your asthma symptoms feel like?
Finding:
Reports difficulty breathing during exacerbation
(Found)
Pro Tip: Asthma can have a profound impact on health, and it is important to discover the severity of her condition by asking about symptoms during an exacerbation, such as chest tightness.
Example Question:
Do you have trouble breathing?
Finding:
Reports wheezing during exacerbation
(Available)
Pro Tip: Asthma can have a profound impact on health, and it is important to discover the severity of her condition by asking about symptoms during an exacerbation, such as chest tightness.
Example Question:
Do you ever wheeze?
Finding:
Asked about prior hospitalizations
Finding:
Reports past hospitalizations
(Found)
Pro Tip: Finding out if the patient has any past hospitalizations is the first step in understanding any past serious medical issues. In Tina’s case, it will help you better understand her asthma and create a timeline.
Example Question:
Have you been hospitalized in the past?
Finding:
Reports last hospitalization was for asthma
(Available)
Pro Tip: Finding out if Tina has any past hospitalizations is the first step in understanding any past serious medical issues. In Tina’s case, it will help you better understand her asthma and create a timeline.
Example Question:
Why were you hospitalized last time?
Finding:
Reports last hospitalization was age 16
(Available)
Pro Tip: Finding out the date of Tina’s last hospitalization is important for understanding the timeline of her medical issues, asthma in particular.
Example Question:
When was your last hospitalization?
Finding:
Reports about 5 total hospitalizations for asthma as a child and teen
(Available)
Pro Tip: Finding out the number of Tina’s previous hospitalizations is important for understanding the history of her asthma.
Example Question:
How many times have you been hospitalized?
Finding:
Reports past nebulizer use
(Available)
Pro Tip: Finding out what treatments Tina received during her hospitalizations will give you a fuller picture of the history of her condition.
Example Question:
Have you ever used a nebulizer?
Finding:
Asked about asthma diagnosis
Finding:
Reports specific age of diagnosis is 2.5 years old
(Available)
Pro Tip: Asthma can have a profound impact on health, and it is important to learn about the patient’s history of the condition, including the age of diagnosis.
Example Question:
At what age were you diagnosed with asthma?
Finding:
Asked about asthma management
Finding:
Reports using an inhaler
(Found)
Pro Tip: Asking how your patient treats her asthma can provide important information about her medical history and health literacy.
Example Question:
How do you manage your asthma?
Finding:
Reports inhaler is albuterol (Proventil)
(Found)
Pro Tip: Finding out the specific medication type or brand is essential in understanding whether it’s a maintenance or rescue medication.
Example Question:
What is the name of the inhaler prescription?
Finding:
Reports last use of inhaler was 3 days ago
(Available)
Pro Tip: Determining the patient’s last use of an inhaler clues you in to any recent breathing problems.
Example Question:
When did you last use your inhaler?
Finding:
Reports using inhaler no more than 2 times per week
(Available)
Pro Tip: Discovering the frequency with which your patient uses her inhaler is an important aspect of determining the severity of her condition.
Example Question:
How often do you use your inhaler?
Finding:
Asked about number of puffs when using asthma inhaler
Finding:
Reports recommended dose is 1-3 puffs as needed
(Found)
Pro Tip: Discovering how much your patient uses her inhaler at any given time is a good indicator of the efficacy of her medication.
Example Question:
How many puffs of your inhaler are you prescribed?
Finding:
Reports typically taking 2 puffs
(Found)
Pro Tip: Discovering how much your patient uses her inhaler at any given time is a good indicator of the efficacy of her medication.
Example Question:
How many puffs do you typically take?
Finding:
Reports sometimes needing 3 puffs to control symptoms
(Found)
Pro Tip: Discovering how much your patient uses her inhaler at any given time is a good indicator of the efficacy of her medication.
Example Question:
What’s the most puffs you ever take?
Finding:
Asked about asthma triggers
Finding:
Reports asthma triggered by cats
(Found)
Pro Tip: Discovering occasional environmental triggers, such as animal allergies, gives you insight into exacerbating factors of your patient’s condition.
Example Question:
What triggers your asthma problems?
Finding:
Reports asthma triggered by dust
(Found)
Pro Tip: Dust is a common allergen, and discovering its effect on asthmatic patients is particularly important.
Example Question:
Does dust trigger your asthma?
Finding:
Denies seasonal triggers
(Available)
Pro Tip: Asking about seasonal triggers can help you understand a patient’s complete set of asthma triggers over the course of a year.
Example Question:
Do you have seasonal asthma triggers?
Finding:
Asked about general allergies
Finding:
Reports allergy to cats
(Found)
Pro Tip: Asking general questions about allergies is the first step to a conversation with a patient about her complete set of allergies.
Example Question:
What allergies do you have?
Finding:
Followed up on cat allergy symptoms
Finding:
Reports sneezing, itchy eyes, and wheezing
(Found)
Pro Tip: Determining a patient’s reaction to an allergen is essential to gauge if the allergy is life-threatening.
Example Question:
What is your reaction to cats?
Finding:
Asked about latex allergy
Finding:
Denies latex allergy
(Found)
Pro Tip: Confirming absence or presence of a latex allergy is essential in a hospital setting, where some instruments have latex parts.
Example Question:
Are you allergic to latex?
Finding:
Asked about medication allergies
Finding:
Reports penicillin allergy
(Found)
Pro Tip: Asking specifically about allergies to medications, such as penicillin, is crucial to the patient’s safety while she is in your care, as it affects what medications will be safe and appropriate.
Example Question:
What medication allergies do you have?
Finding:
Asked about penicillin reaction
Finding:
Reports that penicillin resulted in hives
(Found)
Pro Tip: Determining a patient’s reaction to an allergen is essential to gauge if the allergy is life-threatening.
Example Question:
What is your reaction to penicillin?
Finding:
Reports last penicillin reaction was in childhood
(Found)
Pro Tip: Determining a patient’s last reaction to penicillin is part of gathering thorough information about her allergy.
Example Question:
When was your last penicillin reaction?
Finding:
Asked about food allergies
Finding:
Denies food allergies
(Found)
Pro Tip: Inquiring about food allergies is important for an admitted patient, who will be receiving food during her stay.
Example Question:
Do you have any food allergies?
Finding:
Asked if the patient has allergies to dust, mold, or pollen
Finding:
Reports reaction to dust
(Found)
Pro Tip: Dust is a common allergen, and discovering its effect on asthmatic patients is particularly important.
Example Question:
Do you have any reaction to dust?
Finding:
Reports dust causes sneezing, itchy eyes, and wheezing
(Available)
Pro Tip: Dust is a common allergen, and discovering its effect on asthmatic patients is particularly important.
Example Question:
Do you have any environmental allergies?
Finding:
Denies seasonal allergies
(Available)
Pro Tip: Asking about seasonal allergies can help you understand a patient’s complete set of allergies over the course of a year.
Example Question:
Do you have any seasonal allergies?
Finding:
Asked about general immunizations received
Finding:
Reports being up to date on shots
(Found)
Pro Tip: Discovering your patient’s immunization history is important to her safety and reveals any susceptibilities she may have to infectious disease.
Example Question:
Are your immunizations current?
Finding:
Asked about childhood immunizations
Finding:
Reports receiving measles-mumps-rubella shot
(Available)
Pro Tip: Discovering what childhood immunizations a patient has received reveals information about both her medical history and her susceptibility to infectious disease.
Example Question:
Did you receive the measles vaccine?
Finding:
Reports receiving polio shot
(Available)
Pro Tip: Discovering if a patient received a childhood polio vaccination reveals information about both her medical history and her susceptibility to infectious disease.
Example Question:
Did you receive the polio vaccine?
Finding:
Reports receiving varicella shot
(Available)
Pro Tip: Discovering if a patient has received a childhood varicella shot reveals information about both her medical history and her susceptibility to infectious disease.
Example Question:
Did you receive the chickenpox vaccine?
Finding:
Reports receiving Hepatitis A and B shot
(Available)
Pro Tip: Discovering if a patient has received a childhood Hepatitis A and B vaccination reveals information about both her medical history and her susceptibility to infectious disease.
Example Question:
Did you receive the Hepatitis vaccine?
Finding:
Reports receiving meningococcal shot
(Available)
Pro Tip: Discovering if a patient has received a childhood meningococcal vaccination reveals information about both her medical history and her susceptibility to infectious disease.
Example Question:
Did you receive the meningitis vaccine?
Finding:
Reports receiving HPV vaccine series
(Available)
Pro Tip: Discovering if a patient has received the HPV vaccination reveals information about both her medical history and her susceptibility to infectious disease.
Example Question:
Did you receive the HPV vaccine?
Finding:
Asked if the patient has received a flu vaccine
Finding:
Denies receiving annual flu vaccine
(Found)
Pro Tip: The flu virus can be particularly hazardous in a hospital setting. It is important to ask your patient about the flu vaccine.
Example Question:
Did you get a flu shot this year?
Finding:
Asked if the patient received a tetanus immunization
Finding:
Reports last tetanus vaccination was in the past year
(Found)
Pro Tip: For a patient with a recent scrape on a metal surface, confirming the last date of a tetanus shot is essential to prevent any diseases from contact.
Example Question:
When was your last tetanus booster?
Finding:
Asked about use of pain medication
Finding:
Reports taking ibuprofen (Advil) at home
(Found)
Pro Tip: Discovering how a patient has been medicating for pain is a crucial element of understanding and treating her condition or injury.
Example Question:
What pain medication have you been taking?
Finding:
Reports ER administered pain medication
(Found)
Pro Tip: The differences between prescription and over-the-counter pain medications can be vast, and asking about the type of pain medication your patient has been using will help you fully understand her home treatment habits.
Example Question:
Have you taken any prescription pain medications?
Finding:
Followed up on home pain medication
Finding:
Reports taking ibuprofen (Advil) for 2 days
(Available)
Pro Tip: Discovering how long your patient has been taking pain medication is a crucial part of the history of her condition or injury.
Example Question:
How many days have you needed pain medication?
Finding:
Reports taking doses at morning, noon and night
(Available)
Pro Tip: The frequency with which your patient takes pain medication can indicate the severity of her condition or injury.
Example Question:
How many times a day do you take pain medication?
Finding:
Reports taking 2 pills each time
(Available)
Pro Tip: Determining the exact dose of pain medication your patient takes helps determine the severity of her condition or injury and will factor into your care plan.
Example Question:
How many pain pills do you take at a time?
Finding:
Reports ibuprofen is regular strength
(Available)
Pro Tip: Determining the exact dose of pain medication your patient takes helps determine the severity of her condition or injury and will factor into your care plan.
Example Question:
What is the dose of the pain medication?
Finding:
Asked about the effectiveness of pain medication at home
Finding:
Reports ibuprofen helped a little
(Found)
Pro Tip: The efficacy of pain medication varies from patient to patient. Discovering a patient’s individual response to pain medication is an important factor in your overall treatment plan.
Example Question:
How effective is the pain medication?
Finding:
Reports pain returned in full every few hours
(Found)
Pro Tip: The efficacy of pain medication varies from patient to patient. Discovering a patient’s individual response to pain medication is an important factor in your overall treatment plan.
Example Question:
How long does the pain medication last?
Finding:
Asked about prescription medications
Finding:
Reports only prescription is an inhaler
(Available)
Pro Tip: Determining what, if any, prescription medications a patient is taking is a crucial element of a thorough health history and will help you avoid unwanted drug interactions.
Example Question:
What prescription medications do you take?
Finding:
Asked about use of OTC medication
Finding:
Reports occasionally taking ibuprofen for cramps
(Available)
Pro Tip: Finding out about your patient’s use of over-the-counter medications, vitamins, and supplements will help you get a complete health history and avoid unwanted drug interactions.
Example Question:
Do you take any over the counter medications?
Finding:
Reports occasionally taking acetaminophen (Tylenol) for headaches
(Available)
Pro Tip: Finding out about your patient’s use of over-the-counter medications, vitamins, and supplements will help you get a complete health history and avoid unwanted drug interactions.
Example Question:
Do you take any over the counter medications?
Finding:
Denies taking supplements
(Available)
Pro Tip: Finding out about your patient’s use of supplements will help you get a complete health history and avoid unwanted drug interactions.
Example Question:
Do you take any supplements?
Finding:
Denies taking herbals
(Available)
Pro Tip: Finding out about your patient’s use of herbal supplements will help you get a complete health history and avoid unwanted drug interactions.
Example Question:
Do you take any herbal supplements?
Social History
Finding:
Asked about patient’s level of education
Finding:
Reports currently working toward undergraduate degree
(Found)
Pro Tip: Finding out a patient’s level of education can give you a baseline for her health literacy.
Example Question:
What is your highest level of education?
Finding:
Reports her major is accounting
(Available)
Pro Tip: Asking about a patient’s course of study is a good practice to establish rapport with your patient.
Example Question:
What do you study?
Finding:
Asked about stressors
Finding:
Reports she is currently under high stress
(Available)
Pro Tip: Stress can cause both physical and mental health problems and complications. Determining your patient’s stress level is part of an overall picture of her health.
Example Question:
Can you tell me about your stress level?
Finding:
Asked about patient’s living situation
Finding:
Reports living with mother and sister
(Available)
Pro Tip: Learning about your patient’s living situation helps develop rapport and gives you a broad picture of her lifestyle.
Example Question:
Does anyone live at home with you?
Finding:
Reports living in a house
(Found)
Pro Tip: Learning about your patient’s living situation helps develop rapport and gives you a broad picture of her lifestyle.
Example Question:
Do you live in a house?
Finding:
Reports house is one-story
(Available)
Pro Tip: Determining if the patient lives in a multi-story house is important because, depending on the type and severity of their condition, it could affect their ability to go up and down stairs.
Example Question:
How many stories is your house?
Finding:
Reports family members will be able to help with activities
(Available)
Pro Tip: Learning about your patient’s living situation helps develop rapport and gives you a broad picture of her lifestyle.
Example Question:
Tell me more about living at home.
Finding:
Asked about patient belief system
Finding:
Reports her religious affiliation is Baptist
(Found)
Pro Tip: An important part of a health history is developing rapport with the patient and fostering an atmosphere of respect. Learning about the patient’s religious beliefs will allow you to provide the appropriate support and resources.
Example Question:
What is your religious affiliation?
Finding:
Asked if patient has experienced abuse
Finding:
Denies experiencing abuse
(Found)
Pro Tip: Determining if a patient has experienced abuse, whether it be emotional, physical, or financial, is important for understanding the patient’s needs. It is necessary to approach this subject with the utmost respect and sensitivity.
Example Question:
Have you experienced any type of abuse?
Finding:
Asked about illicit drug use
Finding:
Reports history of recreational marijuana smoking
(Found)
Pro Tip: Determining any recent or past history of drug use is essential to revealing any substance abuse issues, and if the patient is likely to seek drugs while admitted.
Example Question:
Have you ever smoked marijuana?
Finding:
Followed up on drug use
Finding:
Reports last use was at age 20 or 21
(Found)
Pro Tip: When a patient reports drug use, it’s important to determine the reason for drug use, as well as the timeline. Depending on when the drug was most recently taken, it could interfere with medications. You also want to identify any potential issues with substance abuse.
Example Question:
When did you last smoke marijuana?
Finding:
Reports she stopped because of health reasons and waning interest
(Available)
Pro Tip: Communicating about why a patient stopped or started drug use gives insight into their attitudes and dependencies on a substance.
Example Question:
What happened to cause you to stop smoking pot?
Finding:
Asked about alcoholic intake
Finding:
Reports last alcoholic drink was 3 weeks ago
(Available)
Pro Tip: Confirming when a patient had her last alcohol intake is important, because she will receive medications while admitted, and alcohol is often contraindicated.
Example Question:
When was your last alcoholic drink?
Finding:
Reports no more than 2 or 3 alcoholic drinks in one sitting
(Available)
Pro Tip: Finding out how many alcoholic drinks a patient has in a single day or sitting is essential to uncover any binge-drinking habits that can be unhealthy for your patient.
Example Question:
How many alcoholic drinks do you have in one sitting?
Finding:
Reports no more than 1 or 2 nights a week drinking alcohol
(Available)
Pro Tip: Finding out how many nights a week your patient has alcohol gives insight into potential habits or abuse.
Example Question:
How many nights a week do you drink alcohol?
Finding:
Asked about tobacco use
Finding:
Denies smoking tobacco
(Found)
Pro Tip: Finding out if a patient uses tobacco products is important to understanding her overall health, and is a potential factor in delayed wound healing.
Example Question:
Have you ever smoked cigarettes?
Finding:
Denies Vaping
(Available)
Pro Tip: Finding out if a patient uses tobacco products is important to understanding her overall health, and is a potential factor in delayed wound healing.
Example Question:
Do you vape?
Finding:
Asked about secondhand smoke
Finding:
Denies exposure to secondhand smoke
(Found)
Pro Tip: Exposure to secondhand smoke can be especially detrimental to an asthmatic patient’s health.
Example Question:
Are you ever exposed to secondhand smoke?
Family Medical History
Finding:
Asked about mother’s health
Finding:
Reports mother diagnosed with high blood pressure
(Found)
Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her mother had high blood pressure can reveal generational patterns.
Example Question:
Does your mother have health conditions?
Finding:
Reports mother diagnosed with high cholesterol
(Found)
Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her mother had high cholesterol can reveal generational patterns.
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: Family histories might indicate a genetic predisposition. Asking Tina if her father had diabetes can reveal generational patterns.
Example Question:
Does your father have health conditions?
Finding:
Reports father was diagnosed with high blood pressure
(Available)
Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her father had high blood pressure can reveal generational patterns.
Example Question:
Does your father have health conditions?
Finding:
Reports father was diagnosed with high cholesterol
(Available)
Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her father had high cholesterol can reveal generational patterns.
Example Question:
Does your father have health conditions?
Finding:
Followed up on father’s death
Finding:
Reports cause of death was a car accident
(Found)
Pro Tip: Following up on the death of an immediate family member is important for gathering details that could be relevant to the patient’s case. Uncovering the cause of death can help you assess the patient’s current risks.
Example Question:
What caused your father’s death?
Finding:
Reports father died at age 58
(Available)
Pro Tip: Following up on the death of an immediate family member is important for gathering details that could be relevant to the patient’s case. Uncovering the age of death can help you assess the patient’s current risks.
Example Question:
How old was your father when he died?
Finding:
Followed up on coping with father’s death
Finding:
Reports past grief
(Found)
Pro Tip: Asking about Tina’s reaction to her father’s death is a vital part of patient-centered care. You may discover that a patient experiencing grief needs additional resources and support.
Example Question:
How are you coping with your father’s death?
Finding:
Reports feeling at peace now
(Found)
Pro Tip: Asking about Tina’s reaction to her father’s death is a vital part of patient-centered care. You should assess her needs to determine if providing any additional resources or support is appropriate.
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: Family histories might indicate a genetic predisposition. Asking Tina if her paternal grandfather had diabetes can reveal generational patterns.
Example Question:
Does your paternal grandfather have health conditions?
Finding:
Reports paternal grandfather diagnosed with high blood pressure
(Available)
Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her paternal grandfather had high blood pressure can reveal generational patterns.
Example Question:
Does your paternal grandfather have health conditions?
Finding:
Reports paternal grandfather diagnosed with high cholesterol
(Available)
Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her paternal grandfather had high cholesterol can reveal generational patterns.
Example Question:
Does your paternal grandfather have health conditions?
Finding:
Reports paternal grandfather died of colon cancer
(Available)
Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if any of her family members had cancer is essential for understanding her risks.
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: Family histories might indicate a genetic predisposition. Asking Tina if her paternal grandmother had high blood pressure can reveal generational patterns.
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: Family histories might indicate a genetic predisposition. Asking Tina if her maternal grandfather had high blood pressure can reveal generational patterns.
Example Question:
Does your maternal grandfather have health conditions?
Finding:
Reports maternal grandfather diagnosed with high cholesterol
(Available)
Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her maternal grandfather had high cholesterol can reveal generational patterns.
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: Family histories might indicate a genetic predisposition. Asking Tina if her maternal grandmother had high blood pressure can reveal generational patterns.
Example Question:
Does your maternal grandmother have health conditions?
Finding:
Reports maternal grandmother diagnosed with high cholesterol
(Found)
Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her maternal grandmother had high cholesterol can reveal generational patterns.
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: Family histories might indicate a genetic predisposition. Asking Tina if her brother has any health problems can reveal potential risks.
Example Question:
Does your brother have health conditions?
Finding:
Asked about sister’s health
Finding:
Reports sister diagnosed with asthma
(Found)
Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her asthma can help you develop a sense of health patterns within her family.
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: Asking about trends such as obesity can help you fill in holes in the history that your patient may have missed, and can allow you insight into other inherited diseases that affect relatives outside of immediate family.
Example Question:
Does obesity run in your family?
Finding:
Asked about family history of thyroid issues
Finding:
Denies family history of thyroid issues
(Found)
Pro Tip: Asking about trends such as thyroid issues can help you fill in holes in the history that your patient may have missed, and can allow you insight into other inherited diseases that affect relatives outside of immediate family.
Example Question:
Do you have a family history of thyroid problems?
Finding:
Asked about family history of substance abuse
Finding:
Reports 1 uncle has alcoholism
(Found)
Pro Tip: Asking about trends in substance abuse can help you understand your patient’s risk for inherited diseases linked to addiction.
Example Question:
Do you have relatives with addiction problems?
Finding:
Asked about family history of headaches
Finding:
Denies family history of headaches
(Found)
Pro Tip: Asking about trends such as headaches can help you fill in holes in the history that your patient may have missed, and can allow you insight into other inherited diseases that affect relatives outside of immediate family.
Example Question:
Do you have a family history of headaches?
Review of Systems
Finding:
Asked about constitutional health
Finding:
Reports occasional tiredness or fatigue
(Available)
Pro Tip: Asking about tiredness or fatigue is one possible component of a review of systems interview. The patient’s response to questions about general, constitutional health may uncover additional problems not discovered during the discussion of the patient’s chief complaint.
Example Question:
Are you fatigued?
Finding:
Reports typical sleep pattern
(Available)
Pro Tip: Asking about the patient’s typical sleep pattern is one possible component of a review of systems interview. The patient’s response to questions about general, constitutional health may uncover additional problems not discovered during the discussion of the patient’s chief complaint.
Example Question:
Have you noticed changes in your sleep?
Finding:
Reports fever
(Available)
Pro Tip: Asking about additional symptoms, such as fever, is one possible component of a review of systems interview. The patient’s response to questions about general, constitutional health may uncover additional problems not discovered during the discussion of the patient’s chief complaint.
Example Question:
Are you feeling feverish right now?
Finding:
Denies chills
(Available)
Pro Tip: Asking about additional symptoms, such as chills, is one possible component of a review of systems interview. The patient’s response to questions about general, constitutional health may uncover additional problems not discovered during the discussion of the patient’s chief complaint.
Example Question:
Have you had chills?
Finding:
Denies night sweats
(Available)
Pro Tip: Asking about additional symptoms, such as night sweats, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint.
Example Question:
Have you had night sweats?
Finding:
Asked about review of systems for mental health
Finding:
Denies depression
(Available)
Pro Tip: Asking about the patient’s history with depression is one possible component of a review of systems interview and may provide insight into their ability to cope in the event of painful physical trauma. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint.
Example Question:
Do you have a history of depression?
Finding:
Denies suicidal ideation or attempts
(Available)
Pro Tip: Asking about the patient’s suicidal ideation one possible component of a review of systems interview and may provide insight into their ability to cope in the event of painful physical trauma. Higher levels of pain have been associated with thoughts of self-harm. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint.
Example Question:
Do you have a history of suicidal thinking?
Finding:
Asked about review of systems for head
Finding:
Reports occasional headaches
(Available)
Pro Tip: Asking about headache frequency is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint.
Example Question:
Do you ever get headaches?
Finding:
Denies current headache
(Available)
Pro Tip: Asking Tina if she currently has a headache is important because it might be contributing to her current discomfort and should be treated promptly.
Example Question:
Do you have a headache?
Finding:
Denies head injury
(Available)
Pro Tip: Asking about the patient’s history of physical trauma, including head injury, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint.
Example Question:
Have you had any head injuries?
Finding:
Asked about review of systems for ears
Finding:
Denies change in hearing
(Available)
Pro Tip: Asking about changes in hearing is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems, such as hearing loss, not discovered during the discussion of the patient’s chief complaint.
Example Question:
Has your hearing changed?
Finding:
Denies ringing or tinnitus
(Available)
Pro Tip: Ringing in the ears can suggest an ear infection, during which the middle of the ear becomes clogged with fluid and mucous, which can affect hearing, or hearing loss. Asking Tina if she has ear pain might indicate a possible ear infection and a reason for changes in her hearing.
Example Question:
Do you ever have ringing in your ears?
Finding:
Denies ear pain
(Available)
Pro Tip: Ear pain can suggest an ear infection, during which the middle of the ear becomes clogged with fluid and mucous, which can affect hearing. Asking Tina if she has ear pain might indicate a possible ear infection and a reason for changes in her hearing.
Example Question:
Have you had ear pain?
Finding:
Denies ear discharge
(Available)
Pro Tip: Ear discharge is the leakage of blood, pus, or wax from the ear and can be the result of a ruptured eardrum, eczema, or swimmer’s ear. Asking whether she’s noticed ear discharge could indicate whether she has a ruptured eardrum.
Example Question:
Have you had ear discharge?
Finding:
Asked about review of systems for eyes and vision
Finding:
Reports periods of blurry vision
(Found)
Pro Tip: Asking about changes in vision is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint, such as vision loss.
Example Question:
Have you noticed any changes in your vision?
Finding:
Denies corrective lenses
(Available)
Pro Tip: Asking about the patient’s use of corrective lenses is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint, such as vision loss.
Example Question:
Do you wear glasses or contacts?
Finding:
Reports infrequent itchy eyes
(Available)
Pro Tip: Asking about symptoms, such as itchy eyes, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint, such as allergic reactions or infection.
Example Question:
Have you had itchy eyes?
Finding:
Reports infrequent eye redness
(Available)
Pro Tip: Asking about symptoms, such as eye redness, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint, such as allergic reactions or infection.
Example Question:
Have you had red eyes?
Finding:
Reports infrequent discharge, crusting or wateriness
(Available)
Pro Tip: Asking about symptoms, such as eye discharge, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint, such as allergic reactions or infection.
Example Question:
Have you had watery eyes?
Finding:
Denies eye pain
(Available)
Pro Tip: Asking about symptoms, such as eye pain, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint, such as allergic reactions, infection, or physical trauma.
Example Question:
Have you had eye pain?
Finding:
Denies dry eyes
(Available)
Pro Tip: Dry eyes occur when the eyes do not produce enough tears to lubricate them. Asking Tina if she has dry eyes solicits information about one particular symptom.
Example Question:
Have you had dry eyes?
Finding:
Asked about review of systems for nose
Finding:
Denies current nose problems
(Available)
Pro Tip: Asking about symptoms, such as nose problems, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint, such as allergic reactions, infection, or physical trauma.
Example Question:
Do you have any nose problems right now?
Finding:
Reports infrequent runny nose
(Available)
Pro Tip: Asking about symptoms, such as runny nose, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint, such as unspecified allergies.
Example Question:
Have you had a runny nose?
Finding:
Reports infrequent sinus problems
(Available)
Pro Tip: Asking about symptoms, such as frequent sinus issues, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint, such as unspecified allergies.
Example Question:
Have you had problems with your sinuses?
Finding:
Denies nosebleeds
(Available)
Pro Tip: Asking about symptoms, such as frequent nosebleeds, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint.
Example Question:
Have you had nosebleeds?
Finding:
Denies change in sense of smell
(Available)
Pro Tip: Asking about symptoms, such as a change in smell, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint.
Example Question:
Has your sense of smell changed?
Finding:
Asked about review of systems for mouth and jaw
Finding:
Denies dental problems
(Found)
Pro Tip: Asking about symptoms, such as dental problems, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint, such as oral infection.
Example Question:
Do you have any mouth problems?
Finding:
Reports last dental visit was several years ago
(Available)
Pro Tip: Asking about a patient’s dental care is one possible component of a review of systems interview. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint.
Example Question:
When did you last see a dentist?
Finding:
Denies change in sense of taste
(Available)
Pro Tip: Asking about symptoms, such as a change in taste, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint.
Example Question:
Has your sense of taste changed?
Finding:
Denies dry mouth
(Available)
Pro Tip: Asking about symptoms, such as dry mouth, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint.
Example Question:
Have you had dry mouth?
Finding:
Denies mouth pain
(Available)
Pro Tip: Asking about symptoms, such as oral pain, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint, such as oral infection or recent trauma.
Example Question:
Have you had mouth pain?
Finding:
Denies mouth sores
(Available)
Pro Tip: Asking about symptoms, such as mouth sores, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint, such as oral infection or recent trauma.
Example Question:
Have you had mouth sores?
Finding:
Denies gum problems
(Available)
Pro Tip: Asking about symptoms, such as gum problems, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint, such as oral infection or recent trauma.
Example Question:
Have you had gum problems?
Finding:
Denies tongue problems
(Available)
Pro Tip: Asking about symptoms, such as tongue pain, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint, such as oral infection or recent trauma.
Example Question:
Have you had tongue problems?
Finding:
Denies jaw problems
(Available)
Pro Tip: Asking about symptoms, such as jaw problems, is one possible component of a review of systems interview. The patient’s response to questions about this topic may uncover additional problems not discovered during the discussion of the patient’s chief complaint.
Example Question:
Have you had jaw problems?
Finding:
Asked about review of systems for neck, throat and glands
Finding:
Denies difficulty swallowing
(Available)
Pro Tip: Asking if a patient has difficulty swallowing is one possible component of a review of systems interview. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint.
Example Question:
Have you had difficulty swallowing?
Finding:
Denies sore throat
(Available)
Pro Tip: Asking if a patient has a sore throat is one possible component of a review of systems interview. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint.
Example Question:
Have you had a sore throat?
Finding:
Denies lymph node problems
(Available)
Pro Tip: Asking about a patient’s lymph nodes is one possible component of a review of systems interview. Swollen lymph nodes may appear in the neck when an infection is present.
Example Question:
How are your lymph nodes?
Finding:
Denies frequent sore throat
(Available)
Pro Tip: Asking if a patient has recurring throat problems is one possible component of a review of systems interview. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint.
Example Question:
Do you have any throat problems?
Finding:
Denies swollen glands
(Available)
Pro Tip: Asking about a patient’s glands in general could include lymph nodes or thyroid glands. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint.
Example Question:
Do you have any swollen glands?
Finding:
Denies voice changes
(Available)
Pro Tip: Asking about changes in a patient’s voice is one possible component of a review of systems interview. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint.
Example Question:
Have you had voice changes?
Finding:
Asked about breast health
Finding:
Reports doing occasional breast exams
(Available)
Pro Tip: Asking if a patient performs breast self-examinations is important because it reveals a patient’s level of health literacy.
Example Question:
Do you perform breast self-examinations?
Finding:
Denies swelling
(Available)
Pro Tip: Asking about abnormal characteristics of a patient’s breasts, such as swelling, is one way of assessing overall breast health.
Example Question:
Do you have any breast swelling?
Finding:
Denies breast rashes
(Available)
Pro Tip: Asking about abnormal characteristics of a patient’s breasts, such as a rash, is one way of assessing overall breast health.
Example Question:
Do you have a rash on your breasts?
Finding:
Denies lumps
(Available)
Pro Tip: Asking about abnormal characteristics of a patient’s breasts, such as lumps, is one way of assessing overall breast health. Lumps have a range of severity, as they could be the result of breast injury or cancerous growths, but any abnormalities should be handled with the highest level of concern.
Example Question:
Do you have any lumps in your breasts?
Finding:
Denies nipple discharge
(Available)
Pro Tip: Asking about abnormal characteristics of a patient’s breasts, such as nipple discharge, is one way of assessing overall breast health.
Example Question:
Have you experienced nipple discharge?
Finding:
Denies ever having a mammogram
(Available)
Pro Tip: Inquiring into what breast screenings Tina has had can lead to a discussion about any test results and their implications for her cardiovascular health. If she has not had any screenings, it provides an opportunity for patient education.
Example Question:
Have you had a mammogram?
Finding:
Denies history of breast cancer
(Available)
Pro Tip: If a patient has a history of breast cancer, it is important that you look for signs of recurrence and engage in preventative care, as well as patient education. You may also need to provide further support and resources to the patient.
Example Question:
Have you had breast cancer?
Finding:
Asked about review of systems for respiratory
Finding:
Denies current breathing problems
(Found)
Pro Tip: Asking about general breathing problems can provide a comparative baseline for assessing Tina’s current condition and previous breathing concerns.
Example Question:
Have you had breathing problems?
Finding:
Denies current wheezing
(Available)
Pro Tip: Patients who experience chronic asthma may be accustomed to wheezing and, as a result, might not volunteer this information. Asking Tina if she’s been wheezing illustrates how her asthma is presenting.
Example Question:
Have you been wheezing?
Finding:
Denies current chest tightness
(Available)
Pro Tip: Asking about chest tightness is one possible component of a review of systems interview. As a currently presenting symptom, it could indicate a change in patient status. If the patient reports a history of chest tightness, it could be a symptom of asthma or another respiratory problem.
Example Question:
Have you had chest tightness?
Finding:
Denies pain while breathing
(Available)
Pro Tip: Asking about pain during breathing is one possible component of a review of systems interview. As a currently presenting symptom, it could indicate a change in patient status. If the patient reports a history of pain during breathing, it could be a symptom of asthma or another respiratory problem.
Example Question:
Does it hurt when you breathe?
Finding:
Denies frequent coughing
(Available)
Pro Tip: Asking about coughing is one possible component of a review of systems interview. As a currently presenting symptom, it could indicate an asthma exacerbation or a new respiratory infection.
Example Question:
Have you been coughing?
Finding:
Asked about review of systems for cardiovascular
Finding:
Denies chest pain or discomfort
(Available)
Pro Tip: Asking about chest pain is one possible component of a review of systems interview. As a currently presenting symptom, it could indicate a change in patient status. If the patient reports a history of chest pain, it could be a symptom of a recurring cardiovascular problem.
Example Question:
Do you ever have chest pain?
Finding:
Denies palpitations
(Available)
Pro Tip: Asking about palpitations is one possible component of a review of systems interview. As a currently presenting symptom, it could indicate a change in patient status. If the patient reports a history of palpitations, it could be a symptom of a recurring cardiovascular problem.
Example Question:
Have you had palpitations?
Finding:
Denies irregular heartbeat
(Available)
Pro Tip: Asking about heartbeat patterns is one possible component of a review of systems interview. As a currently presenting symptom, it could indicate a change in patient status. If the patient reports a history of irregular heartbeat, it could be a symptom of a recurring cardiovascular problem.
Example Question:
Has your heartbeat been irregular?
Finding:
Denies easy bruising
(Available)
Pro Tip: Asking if a patient bruises easily is one possible component of a review of systems interview. Bruising easily can be indicative of anemia or a more serious blood disorder.
Example Question:
Have you noticed bruising more than usual?
Finding:
Denies edema
(Available)
Pro Tip: Asking about edema is one possible component of a review of systems interview. Edema is caused by the presence of excess fluid in the tissues, and it can indicate an infection, weak heart or veins, or other organ problems.
Example Question:
Have you noticed any swelling in your legs?
Finding:
Denies circulation problems
(Available)
Pro Tip: Poor circulation is the result of other diseases like obesity, diabetes, or cardiac conditions. Asking Tina whether she’s experienced poor circulation indicates whether she might suffer from underlying cardiac concerns.
Example Question:
Do you have circulation problems?
Finding:
Asked review of systems for gastrointestinal
Finding:
Denies nausea
(Available)
Pro Tip: Currently presenting nausea can be caused by changes in blood sugar, a reaction to medication, stress, or even spreading infection. If the patient reports a history of nausea, it could be a symptom of a recurring gastrointestinal problem.
Example Question:
Have you had nausea?
Finding:
Denies vomiting
(Available)
Pro Tip: Vomiting can be caused by a pain response, a reaction to medication, stress, or even spreading infection. If the patient reports a history of vomiting, it could be a symptom of a recurring gastrointestinal problem
Example Question:
Have you been vomiting?
Finding:
Denies stomach pain
(Available)
Pro Tip: Asking about stomach pain is one possible component of a review of systems interview. As a currently presenting symptom, it could indicate a change in patient status. If the patient reports recurring stomach pain, it could be a symptom of a gastrointestinal problem.
Example Question:
Do you have stomach pain?
Finding:
Denies change in bowel movements
(Available)
Pro Tip: Asking about changes in bowel movements can help you understand a patient’s baseline patterns. Any recent or abrupt changes could impact the patient’s care plan, such as administering treatment for constipation or diarrhea.
Example Question:
Have you had changes in your bowel movements?
Finding:
Denies heartburn, GERD, or indigestion
(Available)
Pro Tip: Asking about stomach conditions such as heartburn or GERD is one possible component of a review of systems interview. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint.
Example Question:
Do you ever get heartburn?
Finding:
Denies constipation
(Available)
Pro Tip: Asking about constipation is one possible component of a review of systems interview. As a currently presenting symptom, it could impact the patient’s care plan. If the patient reports a history of constipation, it could be a symptom of dietary or gastrointestinal problems.
Example Question:
Do you have constipation?
Finding:
Denies diarrhea or loose stool
(Available)
Pro Tip: Asking about diarrhea is one possible component of a review of systems interview. As a currently presenting symptom, it could impact the patient’s care plan. If the patient reports a history of diarrhea, it could be a symptom of dietary or gastrointestinal problems.
Example Question:
Do you have diarrhea?
Finding:
Denies excessive flatulence or bloating
(Available)
Pro Tip: Asking about gas or bloating is one possible component of a review of systems interview. As a currently presenting symptom, it could impact the patient’s care plan. If the patient reports a history of gas, it could be a symptom of dietary or gastrointestinal problems.
Example Question:
Do you have flatulence?
Finding:
Asked review of systems for urinary
Finding:
Denies painful or difficult urination
(Available)
Pro Tip: Asking about pain during urination is one possible component of a review of systems interview. As a currently presenting symptom, it could result in a change to the patient’s care plan. A history of pain during urination could be a symptom of genitourinary problems.
Example Question:
Does it hurt when you urinate?
Finding:
Reports waking up to urinate during the night
(Available)
Pro Tip: Frequent urination at night can be a sign of uncontrolled blood sugar or UTI. As a currently presenting symptom, nocturia could result in a change to the patient’s care plan. A history of nocturia could be a symptom of genitourinary or endocrine problems such as diabetes.
Example Question:
Do you wake up at night to urinate?
Finding:
Reports large amount of urine
(Found)
Pro Tip: Polyuria is a common symptom of diabetes. Establishing that Tina is producing a large amount of urine is important for understanding the current state of her condition and treatment needs.
Example Question:
Do you urinate frequently?
Finding:
Denies blood in urine
(Available)
Pro Tip: As a currently presenting symptom, blood in the urine is a serious symptom that requires immediate intervention. A history of hematuria could be a symptom of genitourinary problems.
Example Question:
Do you ever notice blood in your urine?
Finding:
Denies flank pain
(Available)
Pro Tip: Flank pain can be a sign of kidney infection. As a currently presenting symptom, flank pain could result in a change to the patient’s care plan. A history of flank pain could be a symptom of genitourinary problems.
Example Question:
Do you have flank pain?
Finding:
Denies incontinence
(Available)
Pro Tip: As a currently presenting symptom, incontinence could result in a change to the patient’s care plan. A history of incontinence could be a symptom of genitourinary or pelvic problems.
Example Question:
Are you able to hold your urine?
Finding:
Denies history of urinary tract or bladder infection
(Available)
Pro Tip: Asking about a history of bladder or urinary tract infections is one possible component of a review of systems interview. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint.
Example Question:
Have you ever had a urinary infection?
Finding:
Asked review of systems for reproductive
Finding:
Reports last menstrual period was 3 weeks ago
(Available)
Pro Tip: Establishing the patient’s last menstrual period will help you determine if the patient could be pregnant. A potential pregnancy impacts important parts of the patient’s care plan, including which medications are administered.
Example Question:
When was your last period?
Finding:
Reports that periods are irregular
(Available)
Pro Tip: Asking about menstrual regularity is one possible component of a review of systems interview. A history of irregular periods could indicate hormonal or endocrine problems.
Example Question:
Are your periods regular?
Finding:
Denies past pregnancies
(Available)
Pro Tip: A patient’s history of pregnancy can shed light on other health conditions, body systems, or risk factors. It’s important to learn about any past pregnancies, live births, or miscarriages.
Example Question:
Have you ever been pregnant?
Finding:
Denies vaginal itching or discomfort
(Available)
Pro Tip: Asking about vaginal discomfort, such as itching or burning, is one possible component of a review of systems interview. Symptoms like these could indicate a yeast or sexually transmitted infection.
Example Question:
Do you experience vaginal burning?
Finding:
Reports normal vaginal discharge
(Available)
Pro Tip: Asking about vaginal discharge is one possible component of a review of systems interview. If a patient reports atypical discharge, it could indicate a yeast or sexually transmitted infection.
Example Question:
What is your vaginal discharge like?
Finding:
Denies history of STIs
(Available)
Pro Tip: Asking about a patient’s history of STIs is one possible component of a review of systems interview. A history of STIs could cause complications with the genitourinary system.
Example Question:
Have you ever been diagnosed with a sexually transmitted infection?
Finding:
Reports past condom use
(Available)
Pro Tip: Asking about a patient’s past condom use is one possible component of a review of systems interview. Sexual activity without condoms increases a patient’s risk of STIs, and can be an indicator of a patient’s health literacy.
Example Question:
Do you use condoms when you are sexually active?
Finding:
Denies current birth control
(Available)
Pro Tip: A patient’s use of birth control can impact the care plan, such as which medications are prescribed. Understanding a patient’s history of birth control can be an indicator of health literacy.
Example Question:
Are you currently on birth control?
Finding:
Asked review of systems for musculoskeletal
Finding:
Denies muscle pain
(Available)
Pro Tip: Asking about muscle pain is one possible component of a review of systems interview. The most common causes of muscle pain are strain, overuse, illness, or infection.
Example Question:
Do you have muscle pain?
Finding:
Denies joint pain
(Available)
Pro Tip: Asking about joint pain is one possible component of a review of systems interview. The most common causes of muscle pain are overuse, and conditions such as arthritis.
Example Question:
Do you have joint pain?
Finding:
Denies muscle weakness
(Available)
Pro Tip: Asking about muscle weakness is one possible component of a review of systems interview. Muscle weakness can be a sign of neurological problems, or a reaction to medication.
Example Question:
Do you have muscle weakness?
Finding:
Denies muscle swelling
(Available)
Pro Tip: Asking about muscle swelling is one possible component of a review of systems interview. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint.
Example Question:
Do you have muscle swelling?
Finding:
Asked review of systems for neurological
Finding:
Denies dizziness or vertigo
(Available)
Pro Tip: Asking about dizziness or vertigo is one possible component of a review of systems interview. Presence of dizziness could indicate a reaction to medication, an inner ear problem, or changes in blood sugar or blood pressure.
Example Question:
Do you get dizzy?
Finding:
Denies lightheadedness
(Available)
Pro Tip: Asking about light-headedness is one possible component of a review of systems interview. Feeling light-headed could indicate a reaction to medication, changes in blood sugar or blood pressure, or a neurological problem.
Example Question:
Do you get light-headed?
Finding:
Denies tingling
(Available)
Pro Tip: Asking about tingling sensations is one possible component of a review of systems interview. The patient’s response to these questions may uncover additional problems, such as nerve damage.
Example Question:
Do you ever get tingling?
Finding:
Denies loss of coordination
(Available)
Pro Tip: Asking if the patient has experienced loss of coordination is one possible component of a review of systems interview. The patient’s response to these questions may uncover neurological problems.
Example Question:
Do you notice being more clumsy than usual?
Finding:
Denies loss of sensation
(Available)
Pro Tip: Diabetic patients often experience numbness due to neuropathy, especially in the arms, legs, hands, and feet. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint.
Example Question:
Do you have a loss of sensation anywhere?
Finding:
Reports no seizures
(Available)
Pro Tip: Asking about seizures is one possible component of a review of systems interview. The patient’s response to these questions may uncover neurological problems.
Example Question:
Have you ever had a seizure?
Finding:
Denies problems with balance or disequilibrium
(Available)
Pro Tip: Problems with balance can indicate neurological problems, or issues with the inner ear. Asking your patient about past fractures may uncover additional problems not discovered during discussion of the patient’s chief complaint.
Example Question:
Do you lose your balance often?
Finding:
Asked review of systems for skin, hair and nails
Finding:
Reports acne
(Available)
Pro Tip: Adult acne can suggest stress or changes in hormone levels. Asking Tina about her present acne and history of acne can help you understand any skin conditions or hormonal changes.
Example Question:
Do you still have acne?
Finding:
Reports excessive facial or body hair
(Available)
Pro Tip: Increases in body hair can suggest changes in hormone levels. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint.
Example Question:
Do you have facial hair?
Finding:
Reports changes to neck skin
(Found)
Pro Tip: Asking about changes in skin color is one possible component of a review of systems interview. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint.
Example Question:
Do you have any skin discoloration?
Finding:
Reports moles
(Available)
Pro Tip: Monitoring moles is key in preventing cancerous growths. Asking Tina if her moles have changed will indicate whether any of her moles should be assessed further.
Example Question:
Have your moles changed?
Finding:
Denies dandruff
(Available)
Pro Tip: Dandruff is a chronic scalp condition characterized by flaking skin. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint.
Example Question:
Do you have dandruff?
Finding:
Denies hair loss
(Available)
Pro Tip: Asking about hair loss or balding is one possible component of a review of systems interview. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint.
Example Question:
Have you noticed any hair loss?
Finding:
Denies nail abnormalities
(Available)
Pro Tip: Nail fungus might cause discoloration and disfigurement of the nails. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint.
Example Question:
Do you have nail fungus?
Finding:
Reports occasional dry skin
(Available)
Pro Tip: Chronic or severe dry skin might require a patient to be seen by a dermatologist. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint.
Example Question:
Do you have dry skin?
Finding:
Denies skin rashes
Education & Empathy : 2 of 6 (33.3%)
During the patient interview, there are a number of opportunities to provide patient education and empathy. The opportunities listed below are those identified by nursing experts to be of particular importance to this patient. A Model Statement is provided as an example of an appropriate response to each opportunity.
- Opportunities marked as Not Encountered are opportunities that were not elicited in the interview
- Opportunities marked as Not Followed Up are missed opportunities that were present in the interview, but where no statements were made
- Opportunities marked as Followed Up were followed up by students, and include the dialogue between student and patient
1 Expression of pain
Followed Up
2 Impact of injury on daily life
Not Followed Up
3 Gaps in health literacy around diabetic diet
Not Followed Up
4 Lack of diabetes management
Not Followed Up
5 Lack of blood glucose monitoring
Not Followed Up
6 Loss of a family member
Followed Up
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