SHADOW HEALTH COMPREHENSIVE EXAM TINA JONES SOAP NOTE DOCUMENTATION SUBJECTIVE OBJECTIVE DATA COLLECTION

Are you pressed for time and haven’t started working on your assignment yet? Would you like to buy an assignment? Use our custom writing services for better grades. Even if your deadline is approaching fast, our writers can handle your task right when you need it.


Order a Similar Paper Order a Different Paper

Vitals

Student Documentation Model Documentation

128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs

• Height: 170 cm • Weight: 84 kg • BMI: 29.0 • Blood Glucose: 100 • RR: 15 • HR: 78 • BP:128 / 82 • Pulse Ox: 99% • Temperature: 99.0 F

Health History

Student Documentation Model Documentation

Identifying Data & Reliability

The patient is a 28-year-old female who presented for a pre-employment physical exam. She provided the health information freely during the interview. Ms. Jones’ speech is clear and coherent

Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview.

General Survey

Ms. Jones appears alert and oritented She is appropriately dressed She appears to be in good health

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

Reason for Visit

Ms. Jones visited to have a physical exam for the health insurance at her new workplae

“I came in because I’m required to have a recent physical exam for the health insurance at my new job.”

History of Present Illness

Ms. Jones reported that she recently got a job at a new place and she is required to obtain a physical examination. She does not have any acute cincerns She was diagnosed with PCOS and oral contraceptives were prescribed She had type 2 diabetes and asthma She reports positive lifestyle modifications

Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. She needs to obtain a pre-employment physical prior to initiating employment. Today she denies any acute concerns. Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. She has no medication side effects at this time. She states that she feels healthy, is taking better care of herself than in the past, and is looking forward to beginning the new job.

Medications

Metformin 850 PO BID Flovent 2 puffs 88 mcg/spray BID Albuterol 90 mcg/spray MDI 2 puffs Q4H Drospirenone PO QD

• Fluticasone propionate, 110 mcg 2 puffs BID (last use: this morning) • Metformin, 850 mg PO BID (last use: this morning) • Drospirenone and ethinyl estradiol PO QD (last use: this morning) • Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (last use: three months ago) • Acetaminophen 500-1000 mg PO prn (headaches) • Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6 weeks ago)

Allergies

Allergic to cats and dust Allergiic to penicillin Denies any food or latex allergy

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

Medical History

Diagnosed with asthma at 2 1/2 years DIagnosed with diabetes at age 24 years Last asthma exacerbation 3 months ago Diagnosed with PCOS four months ago and take Yaz Has a history of hypertension Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler when she is around cats. Her last asthma exacerbation was three months ago, which she resolved with her inhaler. She was last hospitalized for asthma in high school. Never intubated. Type 2 diabetes, diagnosed at age 24. She began metformin 5 months ago and initially had some gastrointestinal side effects which have since dissipated. She monitors her blood sugar once daily in the morning with average readings being around 90. She has a history of hypertension which normalized when she initiated diet and exercise. No surgeries. OB/GYN: Menarche, age 11. First sexual encounter at age 18, sex with men, identifies as heterosexual. Never pregnant. Last menstrual period 2 weeks ago. Diagnosed with PCOS four months ago. For the past four months (after initiating Yaz) cycles regular (every 4 weeks) with moderate bleeding lasting 5 days. Has new male relationship, sexual contact not initiated. She plans to use condoms with sexual activity. Tested negative for HIV/AIDS and STIs four months ago.

 

 

 

 

Neurological

Student Documentation Model Documentation

Subjective

Denies any dizinness, ligh-headedness, loss of sensation, tingling, numbness Denies any seizures or sense of disequilibrium

Reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium.

Objective

Normal graphesthesia, stereognosis and rapid alternating movements bilaterallly Tests of cerebellar function normal DRTs and equal bilaterally in upper and lower extremities Reduced sensation to monofilament in bilateral plantar surfaces

Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. Tests of cerebellar function normal. DTRs 2+ and equal bilaterally in upper and lower extremities. Decreased sensation to monofilament in bilateral plantar surfaces.

Skin, Hair & Nails

Student Documentation Model Documentation

Subjective

Reports imporved acne due to use of oral contraceptives Facial and body hair imporved Denies any nail or hair changes

Reports improved acne due to oral contraceptives. Skin on neck has stopped darkening and facial and body hair has improved. She reports a few moles but no other hair or nail changes.

Objective

Scattered pustules on face Facial hair on upper lip Acanthos nigricans on posterior neck Nails free of any abnormalities or ridges

Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. Nails free of ridges or abnormalities. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

Vitals

Student Documentation Model Documentation

128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs

• Height: 170 cm • Weight: 84 kg • BMI: 29.0 • Blood Glucose: 100 • RR: 15 • HR: 78 • BP:128 / 82 • Pulse Ox: 99% • Temperature: 99.0 F

Health History

Student Documentation Model Documentation

Identifying Data & Reliability

The patient is a 28-year-old female who presented for a pre-employment physical exam. She provided the health information freely during the interview. Ms. Jones’ speech is clear and coherent

Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview.

General Survey

Ms. Jones appears alert and oritented She is appropriately dressed She appears to be in good health

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

Reason for Visit

Ms. Jones visited to have a physical exam for the health insurance at her new workplae

“I came in because I’m required to have a recent physical exam for the health insurance at my new job.”

History of Present Illness

Ms. Jones reported that she recently got a job at a new place and she is required to obtain a physical examination. She does not have any acute cincerns She was diagnosed with PCOS and oral contraceptives were prescribed She had type 2 diabetes and asthma She reports positive lifestyle modifications

Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. She needs to obtain a pre-employment physical prior to initiating employment. Today she denies any acute concerns. Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. She has no medication side effects at this time. She states that she feels healthy, is taking better care of herself than in the past, and is looking forward to beginning the new job.

Medications

Metformin 850 PO BID Flovent 2 puffs 88 mcg/spray BID Albuterol 90 mcg/spray MDI 2 puffs Q4H Drospirenone PO QD

• Fluticasone propionate, 110 mcg 2 puffs BID (last use: this morning) • Metformin, 850 mg PO BID (last use: this morning) • Drospirenone and ethinyl estradiol PO QD (last use: this morning) • Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (last use: three months ago) • Acetaminophen 500-1000 mg PO prn (headaches) • Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6 weeks ago)

Allergies

Allergic to cats and dust Allergiic to penicillin Denies any food or latex allergy

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

Medical History

Diagnosed with asthma at 2 1/2 years DIagnosed with diabetes at age 24 years Last asthma exacerbation 3 months ago Diagnosed with PCOS four months ago and take Yaz Has a history of hypertension Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler when she is around cats. Her last asthma exacerbation was three months ago, which she resolved with her inhaler. She was last hospitalized for asthma in high school. Never intubated. Type 2 diabetes, diagnosed at age 24. She began metformin 5 months ago and initially had some gastrointestinal side effects which have since dissipated. She monitors her blood sugar once daily in the morning with average readings being around 90. She has a history of hypertension which normalized when she initiated diet and exercise. No surgeries. OB/GYN: Menarche, age 11. First sexual encounter at age 18, sex with men, identifies as heterosexual. Never pregnant. Last menstrual period 2 weeks ago. Diagnosed with PCOS four months ago. For the past four months (after initiating Yaz) cycles regular (every 4 weeks) with moderate bleeding lasting 5 days. Has new male relationship, sexual contact not initiated. She plans to use condoms with sexual activity. Tested negative for HIV/AIDS and STIs four months ago.

 

 

 

 

Neurological

Student Documentation Model Documentation

Subjective

Denies any dizinness, ligh-headedness, loss of sensation, tingling, numbness Denies any seizures or sense of disequilibrium

Reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium.

Objective

Normal graphesthesia, stereognosis and rapid alternating movements bilaterallly Tests of cerebellar function normal DRTs and equal bilaterally in upper and lower extremities Reduced sensation to monofilament in bilateral plantar surfaces

Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. Tests of cerebellar function normal. DTRs 2+ and equal bilaterally in upper and lower extremities. Decreased sensation to monofilament in bilateral plantar surfaces.

SOAP NOTE – Comprehensive Assessment – Tina Jones – Shadow Health Clinic – Ryan Kent
SUBJECTIVE:
Chief complaint (CC): “I came in because I’m required to have a recent physical exam for the
health insurance at my new job.”
History of present illness (HPI): Ms. Jones reports that she recently obtained employment at
Smith, Stevens, Stewart, Silver & Company. She needs to obtain a pre-employment physical
prior to initiating employment. Today she denies any acute concerns. Her last healthcare visit
was 4 months ago, when she received her annual gynecological exam at Shadow Health
General Clinic. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian
syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. She has
type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just
started 5 months ago. She has no medication side effects at this time. She states that she feels
healthy, is taking better care of herself than in the past, and is looking forward to beginning the
new job.
Allergies:
• Penicillin: rash
• Denies food and latex allergies
• Allergic to cats and dust. When she is exposed to allergens she states that she has runny
nose, itchy and swollen eyes, and increased asthma symptoms.
Past medical history (PMH): Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler
when she is around cats. Her last asthma exacerbation was three months ago, which she
resolved with her inhaler. She was last hospitalized for asthma in high school. Never intubated.
Type 2 diabetes, diagnosed at age 24. She began metformin 5 months ago and initially had
some gastrointestinal side effects which have since dissipated. She monitors her blood sugar
once daily in the morning with average readings being around 90. She has a history of
hypertension which normalized when she initiated diet and exercise. No surgeries. OB/GYN:
Menarche, age 11. First sexual encounter at age 18, sex with men, identifies as heterosexual.
Never pregnant. Last menstrual period 2 weeks ago. Diagnosed with PCOS four months ago.
For the past four months (after initiating Yaz) cycles regular (every 4 weeks) with moderate
bleeding lasting 5 days. Has new male relationship, sexual contact not initiated. She plans to
use condoms with sexual activity. Tested negative for HIV/AIDS and STIs four months ago.
Health Maintenance: Last Pap smear 4 months ago. Last eye exam three months ago. Last
dental exam five months ago. PPD (negative) ~2 years ago. Immunizations: Tetanus booster
was received within the past year, influenza is not current, and human papillomavirus has not
been received. She reports that she believes she is up to date on childhood vaccines and
received the meningococcal vaccine for college. Safety: Has smoke detectors in the home,
wears seatbelt in car, and does not ride a bike. Uses sunscreen. Guns, having belonged to her
dad, are in the home, locked in parent’s room.
Social history:
Never married, no children. Lived independently since age 19, currently lives with mother and
This study source was downloaded by 100000778232099 from CourseHero.com on 08-16-2022 20:00:37 GMT -05:00
https://www.coursehero.com/file/74424088/Tina-Jonersdocx/
sister in a single family home, but will move into own apartment in one month. Will begin her
new position in two weeks at Smith, Stevens, Stewart, Silver, & Company. She enjoys spending
time with friends, reading, attending Bible study, volunteering in her church, and dancing. Tina is
active in her church and describes a strong family and social support system. She states that
family and church help her cope with stress. No tobacco. Cannabis use from age 15 to age 21.
Reports no use of cocaine, methamphetamines, and heroin. Uses alcohol when “out with
friends, 2-3 times per month,” reports drinking no more than 3 drinks per episode. Typical
breakfast is frozen fruit smoothie with unsweetened yogurt, lunch is vegetables with brown rice
or sandwich on wheat bread or low-fat pita, dinner is roasted vegetables and a protein, snack is
carrot sticks or an apple. Denies coffee intake, but does consume 1-2 diet sodas per day. No
recent foreign travel. No pets. Participates in mild to moderate exercise four to five times per
week consisting of walking, yoga, or swimming.
Family history:
• Mother: age 50, hypertension, elevated cholesterol
• Father: deceased in car accident one year ago at age 58, hypertension, high cholesterol, and
type 2 diabetes
• Brother (Michael, 25): overweight
• Sister (Britney, 14): asthma
• Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol
• Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol
• Paternal grandmother: still living, age 82, hypertension
• Paternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes
• Paternal uncle: alcoholism
• Negative for mental illness, other cancers, sudden death, kidney disease, sickle cell anemia,
thyroid problems
Current medications:
• Fluticasone propionate, 110 mcg 2 puffs BID (last use: this morning)
• Metformin, 850 mg PO BID (last use: this morning)
• Drospirenone and ethinyl estradiol PO QD (last use: this morning)
• Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (last use: three months ago)
• Acetaminophen 500-1000 mg PO prn (headaches)
• Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6 weeks ago)
Review of systems (ROS):
HEENT:
Reports no current headache and no history of head injury or acute visual changes. Reports no
This study source was downloaded by 100000778232099 from CourseHero.com on 08-16-2022 20:00:37 GMT -05:00
https://www.coursehero.com/file/74424088/Tina-Jonersdocx/
eye pain, itchy eyes, redness, or dry eyes. Wears corrective lenses. Last visit to optometrist 3
months ago. Reports no general ear problems, no change in hearing, ear pain, or discharge.
Reports no change in sense of smell, sneezing, epistaxis, sinus pain or pressure, or rhinorrhea.
Reports no general mouth problems, changes in taste, dry mouth, pain, sores, issues with gum,
tongue, or jaw. No current dental concerns, last dental visit was 5 months ago. Reports no
difficulty swallowing, sore throat, voice changes, or swollen nodes.
Cardiovascular: Reports no palpitations, tachycardia, easy bruising, or edema.
Respiratory: Reports no shortness of breath, wheezing, chest pain, dyspnea, or cough.
Abdominal: Gastrointestinal: Reports no nausea, vomiting, pain, constipation, diarrhea, or
excessive flatulence. No food intolerances. Genitourinary: Reports no dysuria, nocturia,
polyuria, hematuria, flank pain, vaginal discharge or itching.
Musculoskeletal: Reports no muscle pain, joint pain, muscle weakness, or swelling.
Integumentary: Reports improved acne due to oral contraceptives. Skin on neck has stopped
darkening and facial and body hair has improved. She reports a few moles but no other hair or
nail changes.
Neurological: Reports no dizziness, light-headedness, tingling, loss of coordination or sensation,
seizures, or sense of disequilibrium.
Psychiatric: Psychosocial / Mental Health: Reports decreased stress and improved coping
abilities have improved previous sleep difficulties. Denies current feelings of depression, anxiety,
or thoughts of suicide. Alert and oriented to person, place, and time. Well-groomed, easily
engages in conversation and is cooperative. Mood is pleasant. No tics or facial fasciculation.
Speech is fluent, words are clear.
OBJECTIVE:
Vital signs:
• Height: 170 cm
• Weight: 84 kg
• BMI: 29.0
• Blood Glucose: 100
• RR: 15
• HR: 78
• BP:128 / 82
• Pulse Ox: 99%
• Temperature: 99.0 F
Physical exam (PE):
GEN: Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a

Student Documentation Model Documentation

Subjective

Reports imporved acne due to use of oral contraceptives Facial and body hair imporved Denies any nail or hair changes

Reports improved acne due to oral contraceptives. Skin on neck has stopped darkening and facial and body hair has improved. She reports a few moles but no other hair or nail changes.

Objective

Scattered pustules on face Facial hair on upper lip Acanthos nigricans on posterior neck Nails free of any abnormalities or ridges

Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. Nails free of ridges or abnormalities. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

Subjective Data Collection: 0 of 50 (0.0%)

Hover To Reveal…

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

  • Found:

Indicates an item that you found.

  • Available:

Indicates an item that is available to be found.

Category

Scored Items

 

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

Patient Data

Not Scored

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

Current Health Status

Finding:

Confirmed reason for visit

Finding:

Reports needing a pre-employment physical

(Available)

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:

Can I confirm that you are here for a physical?

Finding:

Reports no current acute health problems

(Available)

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 current health problems?

Finding:

Asked about last visit to a healthcare provider

Finding:

Last visit to a healthcare provider was 4 months ago

(Available)

Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history.

Example Question:

When did you see a healthcare provider?

Finding:

Reason for last visit was annual gynecological exam

(Available)

Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. Asking Tina why she saw a healthcare provider might indicate any recent health concerns or problems.

Example Question:

Why did you see a healthcare provider?

Finding:

Last general physical examination was 5 months ago when she was prescribed metformin and daily inhaler

(Available)

Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history.

Example Question:

When was your last physical exam?

Finding:

Asked about current prescription medications

Finding:

Reports taking diabetes medication

(Available)

Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Asking Tina if she has been taking medication for her diabetes will indicate her treatment plan and the degree to which she is following it.

Example Question:

Have you been taking medication for your diabetes?

Finding:

Reports using a daily inhaler

(Available)

Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Asking Tina if she still has her inhaler will indicate her treatment plan and the degree to which she is following it.

Example Question:

Do you use a daily inhaler?

Finding:

Reports taking prescription birth control pills

(Available)

Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans.

Example Question:

Are you taking any form of birth control?

Finding:

Followed up about diabetes medication

Finding:

Medication is metformin

(Available)

Pro Tip: Follow up questions about Tina’s medication history will help you to understand her treatment plan and recent health history.

Example Question:

What is the name of your diabetes medication?

Finding:

Started taking metformin 5 months ago

(Available)

Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history.

Example Question:

How long have you been taking metformin?

Finding:

Reports that eating probiotic yogurt helps with side effects and they have abated over time

(Available)

Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history.

Example Question:

Have you noticed any side effects from the metformin?

Finding:

Followed up on metformin frequency and dose

Finding:

Reports taking metformin twice daily

(Available)

Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history.

Example Question:

How many times a day do you take metformin?

Finding:

Metformin dose is 850 mg

(Available)

Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history.

Example Question:

What is the dose of your metformin?

Finding:

Asked about asthma medication

Finding:

Reports using Flovent inhaler twice daily

(Available)

Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina’s been using her inhaler more frequently since exacerbation can indicate how she’s been treating her symptoms since exacerbation.

Example Question:

How often do you use your daily inhaler?

Finding:

Has a Proventil rescue inhaler

(Available)

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

Example Question:

Do you have a rescue inhaler?

Finding:

Last use of Proventil inhaler was three months ago

(Available)

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

Example Question:

When did you last use your rescue inhaler?

Finding:

Has used Proventil inhaler twice in the last year

(Available)

Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina’s been using her inhaler more frequently since exacerbation can indicate how she’s been treating her symptoms since exacerbation.

Example Question:

How often do you use your rescue inhaler?

Finding:

Followed up about birth control prescription

Finding:

Started taking birth control 4 months ago

(Available)

Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan.

Example Question:

How long ago did you start taking birth control?

Finding:

Reason for birth control was to manage PCOS symptoms

(Available)

Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words.

Example Question:

Why did you decide to start taking birth control?

Finding:

Birth control type is Yaz (drospirenone and ethinyl estradiol)

(Available)

Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Confirming the name of Tina’s birth control pill will solicit information about her health history and current treatment plan.

Example Question:

What type of birth control do you use?

Finding:

Takes birth control pill daily

(Available)

Pro Tip: Follow up questions about Tina’s birth control prescription can help you to understand how effectively she complies with her treatment plan.

Example Question:

How often do you take your birth control pill?

Finding:

Takes birth control pill at the same time every day

(Available)

Pro Tip: Follow up questions about Tina’s birth control prescription can help you to understand how effectively she complies with her treatment plan.

Example Question:

Do you take your pill at the same time every day?

Finding:

Reports no skipped days

(Available)

Pro Tip: Follow up questions about Tina’s birth control prescription can help you to understand how effectively she complies with her treatment plan.

Example Question:

Have you missed any days of your birth control pill?

Finding:

Asked about current non-prescription medications

Finding:

Reports rare Advil use for cramps

(Available)

Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes non prescription drugs will indicate her current treatment plan.

Example Question:

Do you take Advil?

Finding:

Reports no OTC herbal products

(Available)

Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes herbal products will indicate her current treatment plan.

Example Question:

Do you use any herbal products?

Finding:

Reports no OTC vitamins

(Available)

Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes vitamins will indicate her current treatment plan.

Example Question:

Do you take any vitamins?

Finding:

Reports no OTC supplements

(Available)

Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes supplements will indicate her current treatment plan.

Example Question:

Do you take any supplements?

Finding:

Asked about allergies

Finding:

Confirms allergies

(Available)

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

Example Question:

Can you confirm your allergies?

Finding:

Reports no new allergies

(Available)

Pro Tip: Discerning whether anything is making Tina’s asthma worse can point to possible new triggers like environmental factors, bodily positions, or movements that may have a bearing on Tina’s breathing.

Example Question:

Have you noticed any new allergies?

Finding:

Followed up on seasonal allergies

Finding:

Reports no recent seasonal allergy symptoms

(Available)

Pro Tip: Discerning whether anything is making Tina’s asthma worse can point to possible triggers like environmental factors, bodily positions, or movements that may have a bearing on Tina’s breathing.

Example Question:

Have you been having seasonal allergies?

Finding:

Reports no current medication for allergies

(Available)

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

Example Question:

Are you taking any medication for your allergies?

Finding:

Asked about diabetes

Finding:

Reports managing diabetes with diet and exercise in addition to medication

(Available)

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

Example Question:

How are you managing your diabetes?

Finding:

Asked about blood glucose monitoring

Finding:

Reports checking blood sugar once a day

(Available)

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

Example Question:

How often do you monitor your blood glucose?

Finding:

Checks sugar in the morning

(Available)

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

Example Question:

When do you check your blood glucose?

Finding:

Blood sugar number is usually around 90

(Available)

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

Example Question:

What is your average blood sugar number?

Finding:

Reports having adequate supplies

(Available)

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

Example Question:

Do you have enough supplies to monitor your blood glucose?

Finding:

Asked about asthma symptoms

Finding:

Reports no current asthma symptoms

(Available)

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

Example Question:

Do you have any difficulty breathing?

Finding:

Reports no recent asthma exacerbations

(Available)

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

Example Question:

Have you had recent asthma symptoms?

Finding:

Reports last asthma exacerbation was three months ago

(Available)

Pro Tip: Soliciting a shallow history of a patient’s condition can provide a baseline for comparing an attack, exacerbation, and more regular breathing. Asking about breathing problems can elicit a response about recent troubles.

Example Question:

When was your last asthma exacerbation?

Finding:

Asked about headache symptoms

Finding:

Reports no recent headache

(Available)

Pro Tip: Soliciting a shallow history of a patient’s condition can provide a timeline for understanding when a patient experiences a condition. Asking Tina if she’s had a headache recently will allow you to assess the frequency of her headaches.

Example Question:

Have you had a headache recently?

Finding:

Asked about vision

Finding:

Reports optometrist visit

(Available)

Pro Tip: Asking Tina if she has been to an eye doctor will indicate the degree to which she’s seen her vision as something that has needed medical attention.

Example Question:

Have you been to an eye doctor?

Finding:

Optometrist visit 3 months ago

(Available)

Pro Tip: Asking Tina when she last saw an eye doctor will indicate the degree to which she’s seen her vision as something that has needed medical attention.

Example Question:

When did you go to the eye doctor?

Finding:

Reports prescription eyeglasses

(Available)

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

Example Question:

Did you get prescription eyeglasses?

Finding:

Reports that glasses improve overall vision

(Available)

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

Example Question:

Do you like your glasses?

Finding:

Reports reduction in blurry vision

(Available)

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

Example Question:

Is your vision blurry?

Finding:

Asked about palpitations

Finding:

Reports no current palpitations

(Available)

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

Example Question:

Are you having heart palpitations?

Finding:

Reports no recent palpitations

(Available)

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

Example Question:

Have you been having heart palpitations recently?

Finding:

Asked about hypertension treatment

Finding:

Reports that blood pressure responded to diet and exercise changes

(Available)

Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina how she has been treating her hypertension will indicate her treatment plan and the degree to which she complies with it.

Example Question:

How have you been treating your hypertension?

Finding:

Asked about GERD

Finding:

Reports no recent GERD symptoms

(Available)

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

Example Question:

Have you had heartburn recently?

Finding:

Reports no current GERD symptoms

(Available)

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

Example Question:

Are you having any GERD symptoms?

Finding:

Reports no current medication for GERD

(Available)

Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes medication for heartburn will indicate her current treatment plan.

Example Question:

Are you still taking the medication for GERD?

Finding:

Asked about back pain

Finding:

Reports no current back pain

(Available)

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. Asking Tina about her back pain can help you to treat any symptoms she is experiencing.

Example Question:

Are you having back pain?

Finding:

Reports no recent back pain

(Available)

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. Asking Tina about her back pain can help you to treat any symptoms she is experiencing.

Example Question:

Have you had back pain recently?

Finding:

Asked date of last menstrual period

Finding:

Last menstrual period was 2 weeks ago

(Available)

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

Example Question:

When was your last menstrual period?

Finding:

Asked about menstrual patterns

Finding:

Reports a period every 4 weeks

(Available)

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

Example Question:

How often do you get periods?

Finding:

Reports that period lasts 5 days

(Available)

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

Example Question:

How long do your periods last?

Finding:

Reports some cramping

(Available)

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

Example Question:

Do you still have menstrual cramps?

Finding:

Reports a medium flow

(Available)

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

Example Question:

Do you still have a heavy menstrual flow?

Finding:

Asked about weight changes

Finding:

Reports recent weight loss

(Available)

Pro Tip: Weight changes can be indicative of underlying health problems or an unhealthy lifestyle. Asking Tina if she’s lost weight might indicate recent changes in health.

Example Question:

Have you lost weight?

Finding:

Reports weight loss of about 10 pounds

(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 did you lose?

Finding:

Reports that weight loss was result of change in diet and increased exercise

(Available)

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

Example Question:

Was the weight loss intentional?

Psychosocial History

Finding:

Asked about diet

Finding:

Typical breakfast is fruit smoothie with probiotic yogurt or egg on wheat toast with probiotic yogurt

(Available)

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

Example Question:

What is your typical breakfast?

Finding:

Typical lunch is dinner leftovers or tuna or chicken sandwich on wheat bread

(Available)

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

Example Question:

What is your typical lunch?

Finding:

Typical dinner is vegetables with a protein and brown rice or quinoa

(Available)

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

Example Question:

What is your typical dinner?

Finding:

Typical snack is carrot sticks or an apple

(Available)

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

Example Question:

What is a typical snack?

Finding:

Asked about caffeine intake

Finding:

Reports limiting caffeine since heart and sleep problems

(Available)

Pro Tip: Asking Tina if she has limited her caffeine intake will indicate her current nutrition habits and whether or not she sees her caffeine intake as a concern.

Example Question:

Have you limited your caffeine intake?

Finding:

Reports no coffee drinking

(Available)

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

Example Question:

Do you drink coffee?

Finding:

Reports only caffeine is diet Coke

(Available)

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

Example Question:

What caffeinated drinks do you like?

Finding:

Reports drinking 2 diet Cokes per day

(Available)

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

Example Question:

How much soda do you drink a day?

Finding:

Asked about alcohol intake

Finding:

Drinks 2-3 nights per month

(Available)

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

Example Question:

How many nights a week do you drink?

Finding:

Has 2 or 3 drinks when out with friends

(Available)

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

Example Question:

How many drinks do you have in a sitting?

Finding:

Orders single drinks

(Available)

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

Example Question:

What size are your alcoholic drinks?

Finding:

Usually orders rum and diet Coke

(Available)

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

Example Question:

What kind of alcohol do you usually drink?

Finding:

Asked about exercise

Finding:

Reports mild to moderate exercise

(Available)

Pro Tip: Exercise, in addition to diet, is a key part of physical and mental health. Asking Tina how much exercise she gets can help you to assess her current levels of health and nutrition.

Example Question:

How much exercise do you get?

Finding:

Reports walking four or five times a week

(Available)

Pro Tip: Exercise, in addition to diet, is a key part of physical and mental health. Asking Tina how many days a week she exercises can help you to assess her current levels of health and nutrition.

Example Question:

How many days a week do you exercise?

Finding:

Reports that a typical walk is thirty or forty minutes

(Available)

Pro Tip: Exercise, in addition to diet, is a key part of physical and mental health. Asking Tina how long her walks are can help you to assess her current levels of health and nutrition.

Example Question:

How long are your walks?

Finding:

Reports weekly swimming at YMCA

(Available)

Pro Tip: Exercise, in addition to diet, is a key part of physical and mental health. Asking Tina what exercise she does can help you to assess her current levels of health and nutrition.

Example Question:

What exercise do you do?

Finding:

Reports no asthma exacerbation during exercise

(Available)

Pro Tip: Exercise, in addition to diet, is a key part of physical and mental health. Asking Tina how her breathing is when she exercises can help you to assess her current levels of health and nutrition.

Example Question:

How is your breathing when you exercise?

Finding:

Asked about relationship status and current sexual activity

Finding:

Reports no new sexual partners

(Available)

Pro Tip: Asking Tina if she has any new sexual partners will help you to assess whether or not she engages in high-risk sexual practices.

Example Question:

Have you had any new sexual partners?

Finding:

Reports new month-old relationship

(Available)

Pro Tip: Asking about Tina’s relationship status will help you to understand her current sexual activity and practices.

Example Question:

Are you currently in a relationship?

Finding:

Plans to use condoms if sexually active in the future

(Available)

Pro Tip: Asking Tina whether or not she uses condoms will help you to assess whether or not she engages in high-risk sexual practices.

Example Question:

Will you use condoms if you are sexually active?

Social Determinants of Health

Finding:

Asked about education

Finding:

Reports graduated with accounting degree

(Available)

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

Example Question:

Did you graduate from college?

Finding:

Asked about work

Finding:

Reports being hired at Smith, Stevens, Stewart, Silver & Company

(Available)

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

Example Question:

Where do you work?

Finding:

Reports job title is Accounting Clerk

(Available)

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

Example Question:

What is your job title?

Finding:

Reports will start work in 2 weeks

(Available)

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

Example Question:

When do you start working?

Finding:

Asked about living situation

Finding:

Reports currently living at home with mom and sister

(Available)

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

Example Question:

What is your current living situation?

Finding:

Reports moving into her own apartment near work in 1 month

(Available)

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

Example Question:

What are your housing plans?

Finding:

Asked about support system

Finding:

Reports strong friendships

(Available)

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

Example Question:

Do you have close friends?

Finding:

Reports strong familial relationships

(Available)

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

Example Question:

Are you close with family?

Finding:

Reports church remains a strong support system

(Available)

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

Example Question:

Are you still involved with your church?

Mental Health

Finding:

Asked about stress

Finding:

Reports feeling less stress after graduation and passing CPA exam

(Available)

Pro Tip: Follow-up questions about possible causes or aggravating factors will elicit essential information about a patient’s complaint. When Tina says she is stressed out about the future, it is important to follow up in order to determine if her situation could be contributing to, or causing, her feelings of anxiety.

Example Question:

Are you feeling stressed?

Finding:

Reports improved ability to cope with stress

(Available)

Pro Tip: A patient’s experience with and ability to handle stress is important to your understanding of her stress history as well as its current severity. Asking about coping strategies will give you an understanding of Tina’s support system and usual outlets for dealing with stress.

Example Question:

How do you cope with stress?

Finding:

Asked about indicators of depression

Finding:

Reports no depression

(Available)

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

Example Question:

Are you feeling depressed?

Finding:

Reports feeling positive about upcoming life changes

(Available)

Pro Tip: A broad question asking how a patient feels about her life can help you to assess a patient’s level of mental health, anxiety, or depression.

Example Question:

How do you feel about your life?

Finding:

Asked about anxiety

Finding:

Reports anxiety improved with relief of stressors and passing of time

(Available)

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

Example Question:

Are you feeling anxious?

Finding:

Reports coping well with upcoming life changes

(Available)

Pro Tip: A patient’s strategies for coping with stress can indicate her experience with and ability to handle stress. An open question about Tina’s usual stress coping strategies will help you assess how experienced she is with stress and how capable she is of coping with it.

Example Question:

How are you coping with your life changes?

Finding:

Asked about sleep

Finding:

Reports no current difficulties falling asleep

(Available)

Pro Tip: Knowledge of the character of a complaint will aid your diagnosis. In Tina’s case, her sleep quality is important in determining what kind of sleep disturbances she is suffering, as well as possible effects it may have on her daily life.

Example Question:

Do you still have trouble falling asleep?

Finding:

Reports sleeping 8 or 9 hours a night

(Available)

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

Example Question:

How many hours do you sleep a night?

Review of Systems

Finding:

Asked general indicators of health

Finding:

Reports no recent or frequent illness

(Available)

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

Example Question:

Have you been sick recently?

Finding:

Reports no fatigue

(Available)

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

Example Question:

Are you fatigued?

Finding:

Reports no fever

(Available)

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

Example Question:

Have you had fevers?

Finding:

Reports no chills

(Available)

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

Example Question:

Have you had chills?

Finding:

Reports no night sweats

(Available)

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

Example Question:

Have you had night sweats?

Finding:

Asked about review of systems for head

Finding:

Reports no current or recent head problems

(Available)

Pro Tip: Assessing how a patient feels in the current moment can allow you to juxtapose their chief complaint alongside symptoms they experience. Asking Tina if she currently has a headache solicits information about how she is feeling now.

Example Question:

Do you have a headache?

Finding:

Reports no head injury

(Available)

Pro Tip: People who’ve experienced head injuries are at increased risk for sinusitis. Asking Tina whether she’s ever had a head injury solicits health history information that might explain the cause of her symptoms.

Example Question:

Have you had any head injuries?

Finding:

Asked about review of systems for ears

Finding:

Reports no general ear problems

(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 problems?

Finding:

Reports no change in hearing

(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:

Has your hearing changed?

Finding:

Reports no 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:

Reports no 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

Finding:

Reports no eye pain

(Available)

Pro Tip: Sinusitis can create pressure behind the eyes, causing eye pain. Asking Tina whether she is experiencing eye pain solicits information about possible symptoms.

Example Question:

Have you had eye pain?

Finding:

Reports no itchy eyes

(Available)

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

Example Question:

Have you had itchy eyes?

Finding:

Reports no eye redness

(Available)

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

Example Question:

Have you had red eyes?

Finding:

Reports no 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:

Reports no general nose problems

(Available)

Pro Tip: Infected sinuses can manifest as nose problems. Asking Tina about her nasal symptoms solicits information about her sinuses and possible sinus problems.

Example Question:

Have you had nose problems?

Finding:

Reports no change in sense of smell

(Available)

Pro Tip: Changes in sense of smell could be a symptom of acute sinusitis. Asking Tina if she’s had any changes in her sense of smell indicates whether she might be suffering from acute sinusitis.

Example Question:

Has your sense of smell changed?

Finding:

Reports no sneezing

(Available)

Pro Tip: Infected sinuses can manifest as nose problems. Asking Tina about her nasal symptoms solicits information about her sinuses and possible sinus problems.

Example Question:

Have you been sneezing?

Finding:

Reports no nosebleeds

(Available)

Pro Tip: Nosebleeds are often caused by sinusitis. Asking Tina if she ever gets nosebleeds solicits information about her medical history.

Example Question:

Have you had nosebleeds?

Finding:

Reports no sinus pain

(Available)

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

Example Question:

Have you had sinus pain?

Finding:

Reports no sinus pressure

(Available)

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

Example Question:

Have you had sinus pressure?

Finding:

Reports no runny nose

(Available)

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

Example Question:

Have you had a runny nose?

Finding:

Asked about review of systems for mouth and jaw

Finding:

Reports no current dental problems

(Available)

Pro Tip: In some cases, infection can spread to a cheekbone through an infected tooth. Asking Tina if she’s had any dental problems might indicate a problem area that has caused infection.

Example Question:

Have you had any recent dental problems?

Finding:

Reports last dental visit was 5 months ago

(Available)

Pro Tip: Seeing a dentist regularly can assure that among other things, tooth infections, which can cause sinusitis, do not go untreated. Asking Tina when she last saw a dentist will reveal her health literacy and indicate whether or not her mouth is a problem area.

Example Question:

When did you last see a dentist?

Finding:

Reports no general mouth problems

(Available)

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

Example Question:

Do you have any mouth problems?

Finding:

Reports no change in sense of taste

(Available)

Pro Tip: Sinusitis can result in decreased smell or taste. Asking if Tina’s sense of taste has changed lately might indicate a sign of sinusitis.

Example Question:

Has your sense of taste changed?

Finding:

Reports no dry mouth

(Available)

Pro Tip: Sinusitis can result in dry mouth. Asking if Tina’s recently had dry mouth might indicate a sign of sinusitis.

Example Question:

Have you had dry mouth?

Finding:

Reports no mouth pain

(Available)

Pro Tip: In some cases, infection can spread to a cheekbone through an infected tooth. Asking Tina if she’s had mouth pain might indicate a problem area that has caused infection.

Example Question:

Have you had mouth pain?

Finding:

Reports no mouth sores

(Available)

Pro Tip: In some cases, infection can spread to a cheekbone through an infection in the mouth. Asking Tina if she has any mouth sores might indicate a problem area that has caused infection.

Example Question:

Have you had mouth sores?

Finding:

Reports no gum problems

(Available)

Pro Tip: If left untreated, gum problems, like abscesses, can result in sinusitis. Asking Tina if she has problems with her gums solicits information about possible causes of her symptoms.

Example Question:

Have you had gum problems?

Finding:

Reports no tongue problems

(Available)

Pro Tip: If left untreated, tongue problems, like abscesses, can result in sinusitis. Asking Tina if she has problems with her tongue solicits information about possible causes of her symptoms.

Example Question:

Have you had tongue problems?

Finding:

Reports no jaw problems

(Available)

Pro Tip: If left untreated, jaw problems, like abscesses, can result in sinusitis. Asking Tina if she has problems with her jaw solicits information about possible causes of her symptoms.

Example Question:

Have you had jaw problems?

Finding:

Asked about review of systems for neck and throat

Finding:

Reports no difficulty swallowing

(Available)

Pro Tip: Difficulty swallowing can indicate sinusitis. Asking Tina if she’s had difficulty swallowing might suggest sinus troubles that she’s experiencing.

Example Question:

Have you had difficulty swallowing?

Finding:

Reports no sore throat

(Available)

Pro Tip: A sore throat can indicate sinusitis. Asking Tina if she’s had a sore throat might suggest sinus troubles that she’s experiencing.

Example Question:

Have you had a sore throat?

Finding:

Reports no history of throat problems

(Available)

Pro Tip: Throat problems are often linked to sinusitis. Asking Tina if she has a history of throat problems will illustrate her medical history in relation to similar concerns.

Example Question:

Do you have a history of throat problems?

Finding:

Reports no voice changes

(Available)

Pro Tip: Sinusitis can often lead to tonsil problems and voice changes. Asking Tina if she has noticed any changes to her voice would indicate whether her symptoms might be caused by sinus problems.

Example Question:

Have you had voice changes?

Finding:

Reports no general neck problems

(Available)

Pro Tip: Neck pain, soreness, or soft tissue damage might result in sinus pain. Asking Tina if she has neck pain is soliciting information about a possible cause of her symptoms.

Example Question:

Have you had neck pain?

Finding:

Reports no history of lymph node problems

(Available)

Pro Tip: Swollen lymph nodes may appear in the neck when an infection is present. Asking Tina whether she has had any problems with her lymph nodes will solicit a history of her condition.

Example Question:

How are your lymph nodes?

Finding:

Reports no swollen glands

(Available)

Pro Tip: Swollen glands may appear in the neck when an infection is present. Asking Tina whether she has had any problems with her glands will solicit a history of her condition.

Example Question:

Do you have any swollen glands?

Finding:

Asked about review of systems for respiratory

Finding:

Reports no current breathing problems

(Available)

Pro Tip: Asking about how Tina is recently breathing can provide a comparative baseline for assessing Tina’s current condition and previous breathing concerns or conditions.

Example Question:

Have you had breathing problems?

Finding:

Reports no wheezing

(Available)

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

Example Question:

Have you been wheezing?

Finding:

Reports no chest tightness

(Available)

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

Example Question:

Have you had chest tightness?

Finding:

Reports no pain while breathing

(Available)

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

Example Question:

Does it hurt when you breathe?

Finding:

Reports no coughing

(Available)

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

Example Question:

Have you been coughing?

Finding:

Asked about review of systems for cardiovascular

Finding:

Reports no palpitations

(Available)

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

Example Question:

Have you had palpitations?

Finding:

Reports no irregular heartbeat

(Available)

Pro Tip: Soliciting a shallow history of a patient’s condition can provide a baseline for comparing a current condition, concerns, and medical history.

Example Question:

Has your heartbeat been irregular?

Finding:

Reports no easy bruising

(Available)

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

Example Question:

Have you noticed bruising more than usual?

Finding:

Reports no edema

(Available)

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

Example Question:

Have you noticed any swelling in your legs?

Finding:

Reports no 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:

Reports no nausea

(Available)

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

Example Question:

Have you had nausea?

Finding:

Reports no vomiting

(Available)

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

Example Question:

Have you been vomiting?

Finding:

Reports no stomach pain

(Available)

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

Example Question:

Does your stomach hurt?

Finding:

Reports no constipation

(Available)

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

Example Question:

Do you have constipation?

Finding:

Reports no diarrhea

(Available)

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

Example Question:

Do you have diarrhea?

Finding:

Reports no flatulence

(Available)

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

Example Question:

Do you have flatulence?

Finding:

Asked review of systems for genitourinary

Finding:

Reports no dysuria

(Available)

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

Example Question:

Does it hurt when you urinate?

Finding:

Reports reduction in nocturia

(Available)

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

Example Question:

Do you wake up at night to urinate?

Finding:

Reports no polyuria

(Available)

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

Example Question:

Do you urinate frequently?

Finding:

Reports no blood in urine

(Available)

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

Example Question:

Do you ever notice blood in your urine?

Finding:

Reports no flank pain

(Available)

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

Example Question:

Do you have flank pain?

Finding:

Reports no vaginal itching or irritation

(Available)

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

Example Question:

Do you experience vaginal burning?

Finding:

Reports normal vaginal discharge

(Available)

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

Example Question:

What is your vaginal discharge like?

Finding:

Asked review of systems for breasts

Finding:

Reports no general breast problems

(Available)

Pro Tip: Checking breasts for lumps is important in monitoring for signs of breast cancer. Asking Tina if she’s had problems with her breasts will help you to assess whether she is at risk for breast cancer.

Example Question:

Do you have any problems with your breasts?

Finding:

Reports no breast lumps

(Available)

Pro Tip: Checking breasts for lumps is important in monitoring for signs of breast cancer. Asking Tina if she’s noticed any lumps in her breasts will help you to assess whether she is at risk for breast cancer.

Example Question:

Have you noticed any lumps in your breasts?

Finding:

Reports no breast pain

(Available)

Pro Tip: Checking breasts for lumps is important in monitoring for signs of breast cancer. Asking Tina if she’s had any pain in her breasts will help you to assess whether she is at risk for breast cancer.

Example Question:

Have you felt pain in your breasts?

Finding:

Asked review of systems for musculoskeletal

Finding:

Reports no muscle pain

(Available)

Pro Tip: The most common causes of muscle pain are strain, overuse, illness, or infection. Asking Tina if she has any muscle pain allows her to describe any pain or symptoms that she is experiencing.

Example Question:

Do you have muscle pain?

Finding:

Reports no joint pain

(Available)

Pro Tip: Joint pain may suggest a major underlying health concern. Asking Tina if she’s experiencing joint pain will allow you to reach a differential diagnosis.

Example Question:

Do you have joint pain?

Finding:

Reports no muscle weakness

(Available)

Pro Tip: Muscle weakness may suggest a major underlying health concern. Asking Tina if she’s experiencing muscle weakness will allow you to reach a differential diagnosis.

Example Question:

Do you have muscle weakness?

Finding:

Reports no muscle swelling

(Available)

Pro Tip: Muscle swelling may suggest a major underlying health concern. Asking Tina if she’s experiencing muscle swelling will allow you to reach a differential diagnosis.

Example Question:

Do you have muscle swelling?

Finding:

Asked review of systems for neurological

Finding:

Reports no dizziness or lightheadedness

(Available)

Pro Tip: Asking Tina if she’s felt dizzy might indicate whether she is experiencing symptoms of a traumatic brain injury.

Example Question:

Do you get dizzy?

Finding:

Reports no vision disturbance

(Available)

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

Example Question:

Do you ever see spots?

Finding:

Reports no numbness or tingling

(Available)

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

Example Question:

Do you ever get tingling?

Finding:

Reports no loss of coordination

(Available)

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

Example Question:

Do you notice being more clumsy than usual?

Finding:

Reports no loss of sensation

(Available)

Pro Tip: Diabetic patients often struggle with neuropathy, especially in the arms, legs, hands, and feet. Patients should be asked about their sensations.

Example Question:

Do you have a loss of sensation anywhere?

Finding:

Reports no seizures

(Available)

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

Example Question:

Have you ever had a seizure?

Finding:

Reports no problems with balance

(Available)

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

Example Question:

Do you lose your balance often?

Finding:

Asked review of systems for skin, hair and nails

Finding:

Reports no rashes

(Available)

Pro Tip: Chronic or severe skin rashes might require a patient to be seen by a dermatologist. Asking Tina if she has skin rashes will illustrate a skin condition that she might be concerned about.

Example Question:

Do you get skin rashes?

Finding:

Reports using sunscreen while exercising outdoors

(Available)

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

Example Question:

When do you wear sunscreen?

Finding:

Reports no recent slow-healing wounds

(Available)

Pro Tip: Slow healing wounds might suggest an infection that requires medical treatment. Asking Tina if she has any wounds that healed slowly solicits information about her health history.

Example Question:

Have you had any wounds that healed slowly?

Finding:

Reports improving acne

(Available)

Pro Tip: Adult acne can suggest stress or changes in hormone levels. Asking Tina if she still has acne solicits information about her overall health.

Example Question:

Do you still have acne?

Finding:

Reports some male-pattern hair growth

(Available)

Pro Tip: Increases in body hair can suggest changes in hormone levels. Asking Tina if she’s experienced an increase in body hair is good practice in soliciting a health history.

Example Question:

Do you have an increase in body hair?

Finding:

Reports no changes in 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 are health concerns.

Example Question:

Have your moles changed?

Finding:

Reports no sores

(Available)

Pro Tip: Sores are a skin problem that leave the body vulnerable to infection. Asking Tina if she has any sores will help you to assess her general health.

Example Question:

Do you have any sores?

Finding:

Reports no dandruff

(Available)

Pro Tip: Dandruff is a chronic scalp condition characterized by flaking skin. Asking Tina whether she has dandruff will help in your assessment of her skin conditions.

Example Question:

Do you have dandruff?

Finding:

Reports no nail fungus

(Available)

Pro Tip: Nail fungus might cause discoloration and disfigurement of the nails. Asking Tina if she has nail fungus is important in assessing the health of her nails.

Example Question:

Do you have nail fungus?

Finding:

Reports no dry skin

 

Writerbay.net

Most students find it hard to finish papers at some point in their studies. If it ever happens to you, don’t get desperate—we have a service for every writing emergency! Whether you’re stuck with a problem, equation, or a piece of creative writing, we will definitely come to your rescue. Fill in the order form with the details of your paper. Write your personal instructions so we can meet your expectations.


Order a Similar Paper Order a Different Paper