Shadow Health – Tina Jones, Health History

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Health History Tips & Tricks:

Student: Hello!

Diana Shadow: 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.

Student: What is the situation?

Diana Shadow: 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.

Student: What are my objectives in this assessment?

Diana Shadow: 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.

Student: What else will this exam involve?

Diana Shadow: 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.

Student: How will I be evaluated?

Diana Shadow: 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.

Student: How does this assignment prepare me for the real world?

Diana Shadow: 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.

Diana Shadow: 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?

Student: So that you understand if there are any problems related to their chief complaint. Also, to help treat their current condition.

Diana Shadow: Time to begin.

Patient Exam – Vital Signs:

Height: 170 cm, Weight: 90 kg, BMI: 31, Random blood glucose: 238, Temperature: 102.4° F, Blood pressure: 138/90 mmHg, Heart rate: 90, Respiratory rate: 18, O2 sat: 98%

Patient Exam – Interview:

Student: Hello, my name is Catlain, I am your nurse today.

Tina Jones: Hey.

Student: Can you confirm your name?

Tina Jones: Tina Jones:.

Student: Why did you come in today?

Tina Jones: I got this scrape on my foot a while ago, and it got really infected. It’s killing me.

Student: What additional symptoms have you experienced?

Tina Jones: 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.

Student: Can you rate your current pain level on a scale of 0 to 10?

Tina Jones: …Like a 7. It hurts a lot, but whatever pain med the ER gave me is helping a little bit.

Student: Please describe the pain.

Tina Jones: It’s throbbing and like, sharp if I try to put weight on it.

Student: How did you hurt your foot?

Tina Jones: 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!

Student: Has your foot been draining any liquids?

Tina Jones: Yeah, there’s definitely pus.

Student: What color was the pus?

Tina Jones: It’s… white or maybe off-white.

Student: How have you treated the wound?

Tina Jones: I’ve been taking Advil for my foot for a few days.

Student: What did you do to treat your foot after your accident?

Tina Jones: I made sure to clean it and keep it bandaged. And I put Neosporin on it.

Student: How effective was the Neosporin?

Tina Jones: Well, I’m here, so I guess it didn’t do its job.

Student: Can you walk with your foot being injured?

Tina Jones: No, I can’t. I can’t put any weight on it without like, shooting pain.

Student: What preexisting medical conditions do you have?

Tina Jones: I mean, I have asthma and diabetes, but right I now I just care about my foot!

Student: I understand your foot hurts, but I need to know this information to make sure I take care of the problem correctly.

Tina Jones: Thanks.

Student: When were you diagnosed with diabetes?

Tina Jones: I was diagnosed when I was 24.

Student: What do you do to manage your asthma?

Tina Jones: I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler.

Student: What medications did you take for your diabetes?

Tina Jones: It was metformin.

Student: Do you currently take medicine for your diabetes?

Tina Jones: No, I don’t take anything for my diabetes anymore.

Student: What made you stop taking medication for your diabetes?

Tina Jones: I guess I just got sick of feeling sick and gassy all the time, and it was overwhelming, remembering to take pills and check my sugar. I feel a lot better now that I’m just eating healthier than I did when I was taking the pills.

Student: Do you monitor your blood glucose?

Tina Jones: I have a monitor at home, but to be honest I don’t really use it that often.

Student: How frequently do you urinate?

Tina Jones: I don’t know. Every hour or two when I’m awake?

Student: What is your current diet?

Tina Jones: It’s pretty good, I think. I’m not a huge health nut or anything.

Student: Have you had any change in appetite?

Tina Jones: Yeah, lately I’ve definitely been much hungrier than usual.

Student: Has your weight changed?

Tina Jones: Yeah, I’ve lost some weight recently.

Student: Do you know why you lost weight?

Tina Jones: I don’t know what caused it, I just lost weight.

Student: How often do you have asthma exacerbations?

Tina Jones: I haven’t had a full attack in years. But my breathing definitely acts up. . .not always. Max twice a week.

Student: What asthma symptoms have you experienced?

Tina Jones: My chest and throat get tight, and I start to wheeze. It feels like I can’t take in air, like I can’t get enough air into my lungs.

Student: How many puffs do you take when using your asthma inhaler?

Tina Jones: I usually use two puffs from my inhaler, but sometimes I need three. [Nurse confirmed with Pharmacy: albuterol 90mcg/spray MDI]

Student: What are some things that trigger your asthma?

Tina Jones: Being around cats is the worst, but dust and running up stairs can make my breathing bad, too.

Student: What allergies do you have?

Tina Jones: I’m allergic to cats.

Student: When did you realize you were allergic to cats?

Tina Jones: For as long as I’ve been around.

Student: How effective was your pain medication at home?

Tina Jones: 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.

Student: What medication allergies do you have?

Tina Jones: I’m allergic to penicillin.

Student: What food allergies do you have?

Tina Jones: I don’t have any food allergies that I know of.

Student: Are you allergic to dust, mold, or pollen?

Tina Jones: Well. . . I don’t know if it’s allergies, but sometimes my asthma acts up around dust.

Student: What immunizations have you received?

Tina Jones: I got a tetanus booster for work about a year ago. For the other kinds, I got all the required ones when I was a kid, and for college…I’m sure I have a record somewhere at home.

Student: Have you received a flu vaccine?

Tina Jones: No.

Student: Have you had any prior hospitalizations?

Tina Jones: 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.

Student: Have you had any gastrointestinal problems?

Tina Jones: No. I’ve never really had stomach or bowel problems.

Student: Do you have a family history of psychiatric illness?

Tina Jones: No. They’re crazy, but nobody’s diagnosed with anything.

Student: Do you have any neck, throat or gland problems?

Tina Jones: No, not that I noticed.

Student: Do you have any problems with your head?

Tina Jones: I don’t think I have any problems. I get headaches sometimes, but that’s all.

Student: Any problems with your ears?

Tina Jones: No.

Student: Any problems with your eyes and vision?

Tina Jones: I’ve actually been noticing problems lately. When I’m reading or studying I’ll notice that things start to get kind of blurry.

Student: Any problems with your nose?

Tina Jones: My nose is fine right now. Sometimes it runs, but not very often.

Student: Do you have problems with your mouth?

Tina Jones: No.

Student: Do you have a history of cardiovascular problems?

Tina Jones: My heart’s fine, thank God!

Student: Any problems with your heart?

Tina Jones: No, my heart’s always been fine.

Student: Have you had any problems with your breasts?

Tina Jones: I haven’t noticed any pain there.

Student: Have you had any reproductive problems?

Tina Jones: I don’t think I have problems in that area. I just get really bad periods, that’s all.

Student: Have you had any neurological problems?

Tina Jones: No, I haven’t.

Student: Have you had any musculoskeletal problems?

Tina Jones: No.

Student: Do you have a history of skin disease?

Tina Jones: Um, I have acne, if that counts.

Student: Does your paternal grandfather have any health problems?

Tina Jones: Grandpa Jones had colon cancer, and that caused all kinds of problems for him. Plus, he had high blood pressure, and…I’m pretty sure he had diabetes. And high cholesterol like everyone else in my family.

Student: Does your mother have any health problems?

Tina Jones: Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though.

Student: Does your father have any health problems?

Tina Jones: Well, he passed away. But he had a couple things… Type 2 diabetes, like me, and high cholesterol and blood pressure.

Student: How did your father die?

Tina Jones: He died in a car accident.

Student: Where is your wound located?

Tina Jones: It’s on the ball of my foot.

Student: Do you get thirsty often?

Tina Jones: You know, I did notice lately that I’ve been really thirsty.

Student: What happened with your father’s car accident?

Tina Jones: It was last year… I guess a little over a year ago.

Student: How long ago was your dad’s car accident?

Tina Jones: It was last year… I guess a little over a year ago.

Student: How did you cope with your fathers death?

Tina Jones: 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 kind of depressed. So, I guess at first I just focused on getting things done–groceries, laundry, insurance papers and stuff. Knowing that Mom needed me kind of 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.

Student: What caused your dads accident?

Tina Jones: He was driving to work, and it was raining…and his car hydroplaned. And hit a tree. So, it was really sudden.

Student: How is your paternal grandmother’s health?

Tina Jones: 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.

Student: How is your paternal grandfather’s health?

Tina Jones: Grandpa Jones passed away when I was really little.

Student: How is your maternal grandfather’s health?

Tina Jones: Well, Poppa died about five years ago.

Student: How is your maternal grandmother’s health?

Tina Jones: Nana was 73 when she died of a stroke about five years ago. I think she had high blood pressure and cholesterol, too.

Student: How is your brother’s health?

Tina Jones: He’s a healthy guy. Kind of big like me.

Student: How is your sister’s health?

Tina Jones: She’s pretty healthy. She has asthma too, but she almost never has attacks.

Student: Does your family have a history of obesity?

Tina Jones: 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.

Student: Does your family have a history thyroid issue?

Tina Jones: No, I don’t think so.

Student: Does your family have a history of substance abuse?

Tina Jones: One person in the family, my dad’s brother, has an alcohol problem, but we never see him.

Student: Does your family have a history of headaches?

Tina Jones: No, not that I know of.

Student: How much alcohol do you drink?

Tina Jones: I only have a few drinks when I go out.

Student: What is your level of education?

Tina Jones: Well, I’m finishing up my bachelor’s degree right now.

Student: What are stressors?

Tina Jones: I feel really stressed out right now! Honestly, I didn’t realize that I’d be admitted to the hospital for my foot. I don’t want to miss work or school but now it looks like I’ll have to. And I want my foot to stop hurting. I know I need sleep, too.

Student: We are going to take care of everything as quickly as possible.

Tina Jones: Thanks.

Student: Where do you live?

Tina Jones: Right now, I’m living at my mom’s place, which is out in the suburbs a bit. It’s like a half hour from here.

Student: What is your belief system?

Tina Jones: 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.

Student: Have you experienced abuse?

Tina Jones: I’ve never had been in any kind of situation like that… It’s scary to think about.

Student: Have you used illicit drugs?

Tina Jones: Well, I used to smoke pot. . . but I don’t do that anymore.

Student: What type of drugs did you use?

Tina Jones: Um…I’ve smoked pot before. In high school, and after high school… I definitely don’t anymore, though.

Student: Have you used drugs other than marijuana?

Tina Jones: No.

Student: When did you last use drugs?

Tina Jones: I haven’t smoked pot since I was twenty or twenty-one.

Student: Have you ever smoked cigarettes?

Tina Jones: No. I think it’s gross.

Student: Have you been around people that are smoking?

Tina Jones: Some of my friend’s smoke when we go out drinking. But I don’t smoke, and nobody at home smokes.

Student: How old were you when your father died?

Tina Jones: He died last year, so I was 27.

Student: Did your father die from any disease?

Tina Jones: He died in a car accident.

Student: Can you tell me about your father’s health?

Tina Jones: He had high blood pressure and cholesterol. And diabetes — we have diabetes in common.

Student: I can’t even imagine how you feel about losing your father

Tina Jones: Thanks.

Student: Tell me about your father.

Tina Jones: Dad was a little stricter than Mom growing up. . . he would sometimes get kind of mad at us when we did something wrong. But he never hit us or anything. He would just get really calm and quiet and tell us to go to our rooms without supper, or that we were grounded when we were older. Or like, he’d make us rake the yard or wash his car or something. It’s pretty sad to

Student: How old was your father when he died?

Tina Jones: Last year when Dad passed, he was only 58.

Subjective Data Collection – Checklist:

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

Example Question: How has the pain changed over time?

Finding: Reports feeling pain radiating into ankle (Available)Pro Tip: Asking about where else the patient’s pain radiates can help determine the progression of infection.

Example Question: Does the pain radiate anywhere else?

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

Example Question: Which foot is in pain?

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

Example Question: Tell me more about any sugars you consume.

Finding: Reports drinking diet 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 (Found)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 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 (Found)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 (Found)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 (Found)Pro Tip: Asthma can have a profound impact on health, and it is important to discovered 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 discovered the severity of her condition by asking about symptoms during an exacerbation, such as difficulty breathing.

Example Question: Do you have trouble breathing?

Finding: Reports wheezing during exacerbation (Found)Pro Tip: Asthma can have a profound impact on health, and it is important to discovered the severity of her condition by asking about symptoms during an exacerbation, such as wheezing.

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

Example Question: What is your reaction to cats?

Finding: Asked about latex allergy

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

Example Question: Are you allergic to latex?

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

Example Question: What is your reaction to penicillin?

Finding: Reports last penicillin reaction was in childhood (Available)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 chicken pox 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 (Found)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 in to 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 in to 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 herbals 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 (Found)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 (Available)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 (Found)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 (Found)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 (Found)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 father died at age 58 (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 age of death can help you assess the patient’s current risks.

Example Question: How old was your father when he died?

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: 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 addition 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 (Found)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 (Found)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 (Found)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 (Found)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 is 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 (Found)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 (Found)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 (Found)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 perform 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 (Available)Pro Tip: Asking about general breathing problems can provide a comparative baseline for assessing Tina’s current condition and previous breathing concerns.

Example Question: Have you had breathing problems?

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

Example Question: Have you been wheezing?

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

Example Question: Have you had chest tightness?

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

Example Question: Does it hurt when you breathe?

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

Example Question: Do you have any skin discoloration?

Finding: Reports 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.E

xample 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

1.Expression of pain Followed Up

Description: Tina expresses frustration about her level of pain. Student: How effective was the Neosporin? Tina Jones: Well, I’m here, so I guess it didn’t do its job. Student: Can you walk with your foot being injured? Tina Jones: No, I can’t. I can’t put any weight on it without like, shooting pain. Student: What preexisting medical conditions do you have? Tina Jones: I mean, I have asthma and diabetes, but right I now I just care about my foot! Student: I understand your foot hurts, but I need to know this information to make sure I take care of the problem correctly. Tina Jones: Thanks. Model Statement: "I’m sorry to hear that your pain is returning. We want you to be in as little pain as possible. I can give you some Advil at this time, and in a few hours, you can have more tramadol. I can also walk through some pain management exercises with you that don’t involve medication, if you are interested."

2.Impact of injury on daily life Followed Up

Description: Tina brings up her pain and frustration at how being unable to bear weight on her foot impacts her life. Student: What are stressors? Tina Jones: I feel really stressed out right now! Honestly, I didn’t realize that I’d be admitted to the hospital for my foot. I don’t want to miss work or school but now it looks like I’ll have to. And I want my foot to stop hurting. I know I need sleep, too. Student: We are going to take care of everything as quickly as possible. Tina Jones: Thanks. Model Statement: "This sounds like a challenging time for you. I understand your frustration at having your life interrupted by foot pain. Please let me know if there is anything I can help you with, such as contacting your employer or asking a family member to bring your schoolwork. We’ll do our best to get you feeling better and, on your way, home as soon as possible."

3.Gaps in health literacy around diabetic diet Not Encountered

Description: Tina describes controlling her diabetes by avoiding "sweets." Model Statement: "Staying away from sugar is a great start. I can give you some more information on what a balanced diet looks like for someone with diabetes. For example, many starchy foods break down into glucose in the body, like pasta, and so you can eat those in moderation, too. Most people with diabetes feel better when they limit all starches, eat protein, and take regular medication."

4.Lack of treatment with diabetes medication Not Followed Up

Description: Tina reveals that she does not treat her diabetes with medication. Student: Do you currently take medicine for your diabetes? Tina Jones: No, I don’t take anything for my diabetes anymore. Student: What made you stop taking medication for your diabetes? Tina Jones: I guess I just got sick of feeling sick and gassy all the time, and it was overwhelming, remembering to take pills and check my sugar. I feel a lot better now that I’m just eating healthier than I did when I was taking the pills. Model Statement: "I understand that it can be challenging to keep up with daily medication. But it’s important to keep your blood sugar under control to prevent long-term damage to your health, and medication can really help. I’d like to talk with you more about getting back onto a prescription. We could start you at a low dose, which reduces the side effects."

5. Lack of blood glucose monitoring Not Followed Up

Description: Tina reveals that she does not check her blood sugar. Student: Do you monitor your blood glucose? Tina Jones: I have a monitor at home, but to be honest I don’t really use it that often. Model Statement: "I understand how it can feel like a frustrating chore to check your sugar every day. But it is important to keeping your diabetes under control. When you monitor your sugar, it helps you understand what foods, activities, and times of day contribute to you feeling your best. And keeping your sugar down will help your foot wound heal quickly, too. If you would like, I can help you find a monitor that is as painless as possible. I can also teach you more about what the numbers mean."

6. Gaps in health literacy around asthma control Not Followed Up

Description: Tina describes increased inhaler use and decreased effectiveness, indicating that her asthma is uncontrolled. Student: How many puffs do you take when using your asthma inhaler? Tina Jones: I usually use two puffs from my inhaler, but sometimes I need three. [Nurse confirmed with Pharmacy: albuterol 90mcg/spray MDI] Student: What are some things that trigger your asthma? Tina Jones: Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. Student: What allergies do you have? Tina Jones: I’m allergic to cats. Model Statement: "It sounds like your asthma is giving you some problems, and you’re not getting full relief from your inhaler. I would like to talk with you about changing your medication and your regimen, to reduce your frequent breathing problems, so that you feel better day-to-day. Most patients find that using a daily inhaler is an easy way to reduce your asthma symptoms even more."

7. Loss of a family member Not Followed Up

Description: Tina shares information about her father dying. Student: Why don’t you have your dad’s income? Tina Jones: Um…well, my dad died in a car accident, about a year ago. Model Statement: "I’m sorry to hear about your father’s passing. That sounds like a difficult situation."

8. Counseling around past drug use Not Followed Up

Description: Tina discusses her past history of marijuana smoking. Student: Have you used illicit drugs? Tina Jones: Well, I used to smoke pot. . . but I don’t do that anymore. Student: What type of drugs did you use? Tina Jones: Um…I’ve smoked pot before. In high school, and after high school… I definitely don’t anymore, though. Student: Have you used drugs other than marijuana? Tina Jones: No. Student: When did you last use drugs? Tina Jones: I haven’t smoked pot since I was twenty or twenty-one. Model Statement: "Thank you for sharing that information. It’s good to hear that you no longer smoke pot. It’s better for your asthma and your overall health."

Information Processing:

1. Acute pain

Priority: High Priority Pro Tip: Managing acute pain is an immediate high priority, because other health concerns cannot be effectively addressed while a patient experiences severe pain. Evidence – Relevant: "…Like a 7. It hurts a lot, but whatever pain med the ER gave me is helping a little bit." "It’s throbbing and like, sharp if I try to put weight on it." Evidence Pro Tip: Tina expresses pain, which is the strongest evidence for this problem. She reports intense pain on a numerical scale and describes pain characteristics. The presence of a physical injury supports her susceptibility to acute pain. Planning – Relevant: Assess – Pain: Assess the patient’s pain at regular intervals and with each assessment of vital signs. Assess – Pain: Assess the patient’s response to pain medication. Educate – Medication: Educate the patient on medications used for pain relief. Educate – Pain: Educate the patient on non-pharmaceutical methods to reduce pain intensity. Intervene – Pain: Administer non-pharmacologic interventions to reduce pain. Intervene – Pain: Administer prescribed analgesics to provide optimal pain relief. Planning Pro Tip: To reduce the patient’s pain, assess her current rating. Provide an appropriate intervention (pharmaceutical or otherwise) and educate the patient. After an appropriate time interval, assess pain levels again to see how the intervention affected the pain.

2. Impaired skin integrity

Priority: High Priority Pro Tip: This is a high priority. The infection is the most immediate threat to the patient’s health, and the wound is at risk for delayed healing because of the patient’s uncontrolled blood glucose. Evidence – Relevant: Evidence Pro Tip: As Tina discusses symptoms of her wound, including symptoms such as discharge, redness, warmth, and swelling, she reports strong evidence of impaired skin integrity. Planning – Relevant: Planning Pro Tip: Because wound infections impact the patient’s overall health, it’s important to assess perfusion, hydration, and swelling. Assess the status of the wound itself and ensure proper cleaning and dressing per the physician’s order. Prevent worsening infection by educating the patient about wound care and self-monitoring.

3. Impaired walking

Priority – High Priority Pro Tip: This is a high priority. The patient is unable to bear weight on her affected leg, which prevents walking. This impacts her daily life and increases her risk for falls and deep-vein thrombosis. Evidence – Relevant: "I mean, it’s all red and swollen, and there’s pus, it feels hot, it hurts like hell… It’s got all that going on." "I got this scrape on my foot a while ago, and it got really infected. It’s killing me." "No, I can’t. I can’t put any weight on it without like, shooting pain." Evidence Pro Tip: The strongest evidence of impaired walking is that Tina directly reports she can’t bear weight or walk on her affected foot. Other supporting data points are the presence of her foot wound and her general reports of pain. Planning – Relevant: Assess – Musculoskeletal: Assess the patient’s ability to bear weight and gait. Assess – Musculoskeletal: Assess the patient’s mobility. Consult / Refer: Consult with physical therapist to develop a plan to improve the patient’s mobility. Intervene – Mobility: Assist the patient as needed with mobility. Intervene – Mobility: Provide assistive devices to facilitate mobility (crutches, therapeutic boot to minimize pressure on plantar surface, wheelchair). Planning Pro Tip: Assess how well the patient can bear weight and walk. While the patient is in your care, work with other healthcare professionals to keep the pain managed and improve the patient’s mobility. Provide assistance with activities such as toileting and ensure that the patient can access and use assistive devices.

4. Ineffective diabetes management

Priority – High Priority Pro Tip: Poorly managed diabetes and uncontrolled blood glucose complicate wound healing. As the underlying cause for delayed healing and infection, they must be addressed. Evidence – Relevant: "No, I don’t take anything for my diabetes anymore." "I guess I just got sick of feeling sick and gassy all the time, and it was overwhelming, remembering to take pills and check my sugar. I feel a lot better now that I’m just eating healthier than I did when I was taking the pills." "I have a monitor at home, but to be honest I don’t really use it that often." Evidence Pro Tip: Tina directly reports ineffective diabetes management when discussing her lack of treatment. She expresses gaps in health literacy about the risk of ceasing prescribed medication and blood glucose monitoring. Supporting evidence comes from her inability to incorporate meaningful dietary changes or increase her exercise. Planning – Relevant: Assess – Health Literacy and Patterns: Assess the patient’s knowledge related to diabetic disease process, assess personal/social supports. Assess – Health Literacy and Patterns: Assess the patient’s perceived barriers to adherence to the prescribed regimen (cost, adverse effects, lack of knowledge). Assess – Health Literacy and Patterns: Assess the patient’s readiness for change/education. Educate – Disease Process: Educate the patient on diabetes pathophysiology, risks of morbidity and mortality, importance of self-care. Planning Pro Tip: To gain a deep understanding of your patient’s situation, determine her level of health literacy, her feelings and beliefs about the disease, and the motivation behind her choices. Educate the patient about what risks are, and what good diabetes care looks like. Most importantly, ask about her goals and changes she may be willing to make.

5. Risk for falls

Priority – High Priority Pro Tip: The patient’s foot wound impairs her walking, which in turn increases her risk for falls while she is an admitted patient. Her past history of injury also adds to this risk. Evidence – Relevant: Evidence Pro Tip: The strongest evidence of Tina’s fall risk is reports of being unable to bear weight or walk on her foot. Other supporting evidence is her recent injury caused by falling. Planning – Relevant: Planning Pro Tip: Protect your patient by taking all fall precautions, and educate your patient about how to be safe as she goes through her daily activities at the hospital. Make sure that the patient feels comfortable asking for your assistance.

6. Risk for unstable blood glucose level

Priority – High Priority Pro Tip: Uncontrolled blood glucose levels delay or prevent wound healing, and must be addressed to resolve the infection. Unstable blood glucose levels could increase the patient’s risk for falls. Evidence – Relevant: "Random blood glucose: 238" Evidence Pro Tip: Tina reports infrequent blood glucose monitoring and a general lack of diabetes management, which increases her risk for fluctuating blood glucose levels. Infection can contribute to poorer glycemic control, and so Tina is likely to experience blood glucose levels that are significantly higher than her baseline. Planning – Relevant: Assess – Vitals: Assess the patient’s blood glucose levels according to orders. Educate – Disease Process: Educate the patient on the signs and symptoms of hyper- and hypoglycemia. Intervene – Diet: Provide the patient a diet without concentrated sweets. Intervene – Hypoglycemia: Administer insulin and/or oral hypoglycemics, per physician orders. Planning Pro Tip: First, gauge your patient’s current status by checking hydration, vital signs, and perfusion. Measure the patient’s blood glucose and provide medication as per the physician’s orders. While the patient is in your care, ensure that their meals align with a low glycemic diet, and educate the patient on monitoring her own health status.

7. Obesity

Priority – Low Priority Pro Tip: A BMI greater than 30 indicates obesity, but this diagnosis is a low priority at present. Obesity is a long-term health concern that cannot be addressed in a single visit. Evidence – Relevant: "BMI: 31" Evidence Pro Tip: Tina’s BMI is 31, which is in the obese range. This numerical evidence is required to establish obesity. Other contributing factors are her family history of diabetes mellitus and a lack of physical exercise. Planning – Relevant: Educate – Diet: Educate the patient on balanced nutritional intake. Educate – Disease Process: Educate the patient on health risks related to obesity. Educate – Exercise: Educate the patient about the benefits of exercise. Planning Pro Tip: To help your patient address her obesity, which is often a sensitive topic, use therapeutic communication techniques. First, gain a deep understanding of your patient’s situation. Determine her level of health literacy, her feelings and beliefs related to the disease, and the motivation behind their choices. Then educate the patient on risks of obesity, recommended dietary changes, and healthy exercise.

8. Risk for ineffective respiratory function

Priority – Low Priority Pro Tip: When caring for a patient diagnosed with asthma, it’s important to be aware of the possibility of emerging respiratory symptoms. However, for a patient with no active respiratory complaints, this problem does not need to be addressed immediately. Evidence – Relevant: Evidence Pro Tip: Tina’s asthma puts her at general risk for breathing problems. She also reports sometimes needing more puffs to resolve symptoms. Contributing factors are a past history of hospitalization and asthma attacks, as well as sedentary lifestyle and obesity. Planning – Relevant: Planning Pro Tip: Take a general survey of the patient for changes in skin color, and assess respiratory rate, rhythm, depth, and quality to confirm there are no acute breathing issues. Gather data on the patient’s breathing status by checking pulse and blood pressure. Auscultate the lungs to listen for abnormal sounds. While the patient is in your care, educate her on the cause and symptoms of shortness of breath so that she can let you know about emerging problems. Empower the patient to take part in her own care by educating her on controlled breathing techniques.

9. Sedentary lifestyle

Priority – Low Priority Pro Tip: A patient’s sedentary lifestyle compromises her overall health and problems such as diabetes. However, this issue is low priority for a patient with acute pain and a wound that prevents her from walking. Evidence – Relevant: Evidence Pro Tip: Tina directly reports that she doesn’t exercise, which is the primary evidence for a sedentary lifestyle. She describes being too busy to exercise and reports that her primary activity is being on her feet at work, a belief which demonstrates her misunderstanding of exercise. Planning – Relevant: Planning Pro Tip: Interview the patient to determine her level of health literacy, and her attitudes and beliefs toward exercise. Educate the patient about the benefits to overall health and blood sugar control and finding an appropriate form of exercise. Ask the patient questions about what changes she may be willing to make.

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