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Western Governors University - NURSING BS C492 shadow health Assessment questions Neurological Results | Turned InC492 Physical Assessment - Oct 2019, C492

Neurological Results | Turned InC492 Physical Assessment - Oct 2019, C492 Return to Assignment Your Results Reopen Lab Pass  Overview  Transcript  Subjective Data Collection  Obje... ctive Data Collection  Documentation Subjective Data Collection: 16 of 18 (88.9%) Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.  Found: Indicates an item that you found.  Available: Indicates an item that is available to be found. CategoryScored Items Experts selected these topics as essential components of a strong, thorough interview with this patient. Patient Data Not Scored A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case. Relevant Medical History  Finding: Asked about changes in sensation  Finding: Reports belief that her sensation is normal (Available) Pro Tip: Subjective questions like this one will help you assess Tina's perception of her sensation and pursue the appropriate treatment. Example Question: Do you feel like your sensation is normal?  Finding: Reports belief that she can feel warm and cold normally (Available)Pro Tip: Because symptoms often vary from patient to patient, asking Tina questions about her sensation will allow you to see the ways in which her individual symptoms manifests. Example Question: Can you feel warm and cold normally  Finding: Asked about numbness  Finding: Reports no history of numbness (Found) Pro Tip: Because symptoms often vary from patient to patient, asking Tina questions about her sensation, like if she has a history of numbness, will allow you to see the ways in which her individual symptoms manifests. Example Question: Do you have a history of numbness?  Finding: Reports no current numbness (Found) Pro Tip: Because symptoms often vary from patient to patient, asking Tina questions about her sensation, like if she has numbness, will allow you to see the ways in which her individual symptoms manifests. Example Question: Are you experiencing numbness? Finding: Asked about tingling  Finding: Reports no tingling (Available) Pro Tip: Tingling sensations can suggest a herniated disc. Asking Tina whether she's experiencing tingling sensations might indicate additional musculoskeletal damage. Example Question: Are you experiencing tingling?  Finding: Asked about vision problems  Finding: Reports vision problems (Available) Pro Tip: Eye and vision problems are fairly common after a brain injury. Asking Tina whether she has current visual problems might indicate that she sustained a head injury. Example Question: Are you having vision problems?  Finding: Asked vision problem patterns Finding: Reports vision problems for past few months (Available) Pro Tip: Establishing a timeline of Tina's visual problems will enable you to most effectively treat her symptoms. Example Question: How long have you had vision problems?  Finding: Describes vision problems as "blurry" (Found) Pro Tip: Because symptoms often vary from patient to patient, asking Tina broad, open questions about her vision will allow you to see the ways in which her individual symptoms manifests. Example Question: How would you describe your vision problems?  Finding: Reports vision problems occur only when reading (Found) Pro Tip: Establishing a timeline of Tina's visual problems will enable you to most effectively treat her symptoms. Example Question: When do your vision problems occur? Finding: Reports no double vision (Available) Pro Tip: Because symptoms often vary from patient to patient, asking Tina questions about her vision, like whether or not she has double vision, will allow you to see the ways in which her individual symptoms manifests. Example Question: Do you have double vision?  Finding: Asked about headaches  Finding: Reports occasional headaches (Found) Pro Tip: Because symptoms often vary from patient to patient, asking Tina if she experiences headaches will allow you to see the ways in which her individual symptoms manifests. Example Question: Do you experience headaches?  Finding: Reports no current or recent headache (Found) Pro Tip: Establishing a timeline of Tina's headaches will enable you to most effectively treat her symptoms.Example Question: Have you had a headache recently?  Finding: Asked about headache patterns  Finding: Reports headaches have been occurring for six months (Available) Pro Tip: Establishing a timeline of Tina's headaches will enable you to most effectively treat her symptoms. Example Question: How long have your headaches been occurring?  Finding: Reports headaches occur "a few times a month" (Found) Pro Tip: Establishing a timeline of Tina's headaches will enable you to most effectively treat her symptoms. Example Question: How often do you have headaches?  Finding: Reports headaches last "a few hours" (Available)Pro Tip: Establishing a timeline of Tina's headaches will enable you to most effectively treat her symptoms. Example Question: How long do your headaches last?  Finding: Asked about headache cause  Finding: Reports headaches occur only when reading or studying (Found) Pro Tip: Symptoms often vary from patient to patient. Asking Tina when the headaches begin specifies the way her individual symptoms and pain manifest. Example Question: When do your headaches occur?  Finding: Asked about headache character  Finding: Reports headaches are not severe (Found) Pro Tip: Because symptoms often vary from patient to patient, asking Tina about the character of her headaches will allow you to see the ways in which her individual symptoms manifests. Example Question:Are your headaches severe?  Finding: Reports headaches feel the same on both sides of the head (Found) Pro Tip: Because symptoms often vary from patient to patient, asking Tina about the character of her headaches will allow you to see the ways in which her individual symptoms manifests. Example Question: Do your headaches feel the same on both sides of your head?  Finding: Reports headaches are a "tight, throbbing ache" (Found) Pro Tip: Because symptoms often vary from patient to patient, asking Tina about the character of her headaches will allow you to see the ways in which her individual symptoms manifests. Example Question: What do your headaches feel like?  Finding: Asked headache treatment  Finding: Reports treating headaches with Tylenol (Found)Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina what medication she takes will indicate her treatment plan and the degree to which she complies with it. Example Question: Do you take anything for your headaches?  Finding: Reports taking two regular strength Tylenols for headaches (Available) Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina how much medication she takes will indicate her treatment plan and the degree to which she complies with it. Example Question: How much Tylenol do you take? Review of Systems  Finding: Asked about dizziness  Finding: Reports no dizziness (Found) Pro Tip: Dizziness can have various triggers from stress to low blood sugar, to overeating. Asking Tina if she's been dizzy addresses important health history concerns. Example Question: Have you been experiencing dizziness? Finding: Asked about swallowing  Finding: Reports no difficulty swallowing (Found) Pro Tip: Whiplash from Tina's car accident might result in damage to the soft tissue of her neck. Asking Tina if she is having trouble swallowing might suggest an injury that she sustained in the crash. Example Question: Are you having difficulty swallowing?  Finding: Asked about fainting  Finding: Reports no fainting (Found) Pro Tip: Fainting can be a dramatic and dangerous neurological condition. Asking Tina if she has ever fainted can reveal an underlying neurological condition. Example Question: Have you ever fainted?  Finding:Asked about muscle function  Finding: Reports no weakness (Found) Pro Tip: Feelings of weakness can suggest underlying neurological concerns. Asking Tina if she feels weakness addresses an important health history. Example Question: Are you experiencing weakness?  Finding: Reports no tremors (Found) Pro Tip: Experiencing tremors can be indicative of a severe neurological problem. Asking Tina if she's had any tremors solicits important health information. Example Question: Have you been having tremors?  Finding: Reports no problems with balance (Found) Pro Tip: People with traumatic brain injuries commonly report an inability to maintain their equilibrium. Asking Tina whether she's able to maintain her equilibrium can indicate that she suffered a traumatic brain injury during her accident. Example Question: Have you been having problems with your balance? Finding: Reports no problems with coordination (Found) Pro Tip: People with traumatic brain injuries commonly report poor coordination. Asking Tina whether she's had poor coordination can indicate that she suffered a traumatic brain injury during her accident. Example Question: Have you had poor coordination lately?  Finding: Asked about memory loss  Finding: Reports no problems with memory loss (Found) Pro Tip: One symptom of a concussion is problems with memory. Asking Tina whether she's been experiencing memory problems might reveal that she sustained a concussion. Example Question: Are you having problems with memory loss?  Finding: Asked about behavior changes  Finding:Reports no recent changes in behavior (Available) Pro Tip: Behavior changes can be indicative of a severe neurological problem. Asking Tina if she's had any behavior changes solicits important health information. Example Question: Have you had recent changes in behavior?  Finding: Reports no recent changes in mood (Available) Pro Tip: Mood changes can be indicative of a severe neurological problem. Asking Tina if she's had any mood changes solicits important health information. Example Question: Has your mood changed recently? Risk Factors  Finding: Asked about history of neurological problems  Finding: Reports no history of neurological problems (Available) Pro Tip: A car accident can result in neurological problems. Asking Tina whether she has a family neurological history can separate family history from problems that resulted from the car accident.Example Question: Have you had neurological problems?  Finding: Reports no history of meningitis (Found) Pro Tip: Symptoms of meningitis include many neurological conditions like: double vision, confusion, nausea, headache, fever. Asking Tina if she ever had meningitis solicits important health history information. Example Question: Have you ever had meningitis?  Finding: Reports no history of concussion (Found) Pro Tip: A history of concussion can leave lasting neurological damage. Asking Tina whether she has a history of concussion will allow you to assess whether concussions are a symptom of a neurological condition. Example Question: Do you have a history of concussion?  Finding: Reports no history of seizures (Found) Pro Tip: A car accident can result in a traumatic brain injury (TBI). Asking Tina if she's had seizures might indicate whether or not she is experiencing symptoms of a traumatic brain injury.Example Question: Have you ever had a seizure? Relevant Family History  Finding: Asked family history of migraines  Finding: Reports no family history of migraines (Found) Pro Tip: A car accident can result in migraines. Asking Tina whether she has a family history of migraines can separate family history from problems that resulted from the car accident. Example Question: Do migraines run in your family? Comments If your instructor provides individual feedback on this assignment, it will appear here. Musculoskeletal Results | Turned InC492 Physical Assessment - Oct 2017, C492 Return to Assignment Your Results Reopen Lab Pass Overview  Transcript  Subjective Data Collection  Objective Data Collection  Documentation Subjective Data Collection: 20 of 25 (80.0%) Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.  Found: Indicates an item that you found.  Available: Indicates an item that is available to be found. Category Scored Items Experts selected these topics as essential components of a strong, thorough interview with this patient. Patient Data Not Scored A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case. Relevant Medical History  Finding: Asked joint problems Finding: Reports no joint problems (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 joint problems?  Finding: Asked about walking problems  Finding: Reports no history of walking problems (Available) Pro Tip: People with severe pain might find that they are limited in their movements. Asking Tina whether the pain makes it hard for her to walk would illustrate whether her pain is preventing her from some of the activities that comprise her daily life. Example Question: Have you ever had problems walking?  Finding: Reports improved ability to walk on foot (Found) Pro Tip: People with severe pain might find that they are limited in their movements. Asking Tina whether the pain makes it hard for her to walk would illustrate whether her pain is preventing her from some of the activities that comprise her daily life.Example Question: Does your foot injury make it difficult to walk?  Finding: Asked pain rating when walking  Finding: Rates pain when walking as a 7 or 8 out of 10 (Available) Pro Tip: People with severe pain might find that they are limited in their movements. Asking Tina to rate what the pain is like when she tries to walk would illustrate whether her pain is preventing her from some of the activities that comprise her daily life. Example Question: How would you rate your pain when walking?  Finding: Asked about swelling  Finding: Reports only swelling was on bottom of injured foot, and has now improved (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her injury, like swelling, details the way her individual symptoms and pain manifest. Example Question: Where does the swelling occur? Finding: Asked about standing problems  Finding: Reports no history of standing problems (Available) Pro Tip: Asking Tina if she has a history of standing problems will reveal the severity of her injury and whether her standing problem predated her foot injury. Example Question: Do you have a history of standing problems?  Finding: Reports improved ability to stand on injured foot (Found) Pro Tip: Asking Tina if she can stand on her foot will reveal the severity of her injury and whether or not she is able to put weight on her foot. Example Question: Are you able to stand on your foot?  Finding: Asked pain rating when standing  Finding: Rates pain when standing as a 7 or 8 out of 10(Available) Pro Tip: Asking Tina about the pain if she's standing will reveal the severity of her injury and whether or not standing exacerbates her pain. Example Question: How would you rate your pain on a scale of 1 to 10 when you are standing?  Finding: Asked about muscle soreness  Finding: Reports no history of muscle soreness (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina if she has ever had muscle soreness specifies the way her symptoms and pain manifest. Example Question: Have you ever had muscle soreness?  Finding: Reports no current muscle soreness (Found) Pro Tip: Symptoms often vary from patient to patient. Asking Tina if she is having muscle soreness specifies the way her symptoms and pain manifest. Example Question: Are you having muscle soreness? Finding: Asked about ankle problems  Finding: Reports no current ankle problems (Available) Pro Tip: Ankle problems can greatly affect a patient's mobility. Asking Tina if she has problems with her ankles can reveal a major health concern. Example Question: Are your ankles giving you trouble?  Finding: Reports no difficulty moving ankles (Available) Pro Tip: Ankle problems can greatly affect a patient's mobility. Asking Tina if her ankle movement is restricted can indicate a major health concern. Example Question: Is there restricted movement in your ankle? Review of Systems  Finding: Asked about occupational aggravators  Finding:Reports no general occupational musculoskeletal aggravators (Found) Pro Tip: People with severe pain might find that they are unable to perform all of their daily activities. Asking Tina whether anything at work aggravates her ankle would illustrate whether her pain is preventing her from activities that constitute her daily life. Example Question: What at work makes your ankle worse?  Finding: Reports recent inability to work because she couldn't stand or walk on her foot (Found) Pro Tip: People with severe pain might find that they are unable to perform all of their daily activities. Asking Tina whether she has been able to work in spite of the pain would illustrate whether her pain is preventing her from activities that constitute her daily life. Example Question: Have you been able to work?  Finding: Asked about activities of daily living  Finding: Reports recent inability to perform usual activities of daily living due to injured foot (Available) Pro Tip: People with severe pain might find that they are unable to perform all of their daily activities. Asking Tina whether she is able to perform all of her usual daily activities would illustrate whether her pain is preventing her from activities that comprise her daily life.Example Question: Has your foot injury affected your daily activities?  Finding: Asked about stiffness  Finding: Reports no stiffness (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina to describe what her injury feels like specifies the way her symptoms and pain manifest. Example Question: Do you feel stiff anywhere?  Finding: Asked about back pain  Finding: Reports no history of back pain (Available) Pro Tip: Establishing a timeline of Tina's back pain will help you to most effectively treat any symptoms she's experiencing. Example Question: Have you had back pain before? Finding: Reports no current back 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: Are you having back pain?  Finding: Asked about muscle trauma  Finding: Reports no past muscle trauma (Available) Pro Tip: Establishing a timeline of Tina's muscle trauma will help you to most effectively treat any symptoms she's experiencing. Example Question: Have you ever had muscle trauma?  Finding: Reports no current muscle trauma (Available) Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with. Example Question:Are you experiencing muscle trauma?  Finding: Asked about joint trauma  Finding: Reports no past joint trauma (Available) Pro Tip: Establishing a timeline of Tina's joint trauma will help you to most effectively treat any symptoms she's experiencing. Example Question: Do you have a history of joint trauma?  Finding: Reports no current joint trauma (Available) Pro Tip: Establishing a timeline of Tina's joint trauma will help you to most effectively treat any symptoms she's experiencing. Example Question: Do you have current joint trauma?  Finding: Asked history of fracture  Finding:Reports no past fractures (Found) Pro Tip: Soliciting your patient's medical history can help you to understand the nature of a patient's chief complaint. Asking Tina whether she's ever broken a bone might reveal relevant concerns she'd previously experienced. Example Question: Have you ever broken a bone?  Finding: Asked history of sprains  Finding: Reports no history of sprains (Found) Pro Tip: Soliciting your patient's medical history can help you to understand the nature of a patient's chief complaint. Asking Tina whether she has a history of getting sprains might reveal relevant concerns she'd previously experienced. Example Question: Do you have a history of getting sprains?  Finding: Asked about bone problems  Finding: Reports no past bone problems (Found)Pro Tip: Soliciting your patient's medical history can help you to understand the nature of a patient's chief complaint. Asking Tina whether she ever had bone problems might reveal relevant concerns she'd previously experienced. Example Question: Have you ever had bone problems?  Finding: Reports no current bone problems (Found) Pro Tip: Soliciting your patient's medical history can help you to understand the nature of a patient's chief complaint. Asking Tina whether she has bone problems might reveal relevant concerns she'd previously experienced. Example Question: Do you have bone problems?  Finding: Asked about neck  Finding: Reports no past neck problems (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her injury, like neck problems, details the way her individual symptoms and pain manifest. Example Question: Have you had neck problems? Finding: Reports no neck pain (Found) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her injury, like neck pain, details the way her individual symptoms and pain manifest. Example Question: Have you been having neck pain?  Finding: Reports no difficulty moving neck (Found) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her injury, like difficulty moving her neck, details the way her individual symptoms and pain manifest. Example Question: Are you having difficulty moving your neck?  Finding: Asked about range of motion  Finding: Reports normal range of motion everywhere but right ankle (Found) Pro Tip: People with severe pain might find that they are limited in their movements. Asking Tina whether she is limited in her movements would illustrate whether her pain is preventing her from some of the activities that comprise her daily life.Example Question: Do you have full range of motion?  Finding: Asked about muscle problems  Finding: Reports no past muscle problems (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her injury, like muscle problems, details the way her individual symptoms and pain manifest. Example Question: Have you ever had muscle problems?  Finding: Reports no current muscle problems (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her injury, like muscle problems, details the way her individual symptoms and pain manifest. Example Question: Do you have any problems with your muscles?  Finding: Reports no past muscle cramping(Found) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her injury, like muscle cramps, details the way her individual symptoms and pain manifest. Example Question: Have you had muscle cramps?  Finding: Reports no current muscle cramping (Found) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her injury, like muscle cramping, details the way her individual symptoms and pain manifest. Example Question: Do you have muscle cramping?  Finding: Asked about spine  Finding: Reports no past spine problems (Found) Pro Tip: Asking Tina if she has ever had spine problems solicits information about her health history that can be important in effectively treating her. Example Question: Have you ever had spine problems? Finding: Reports no current spine problems (Found) Pro Tip: Asking Tina if she has any problems with her spine solicits information about her health history that can be important in effectively treating her. Example Question: Do you have any problems with your spine?  Finding: Reports no scoliosis (Available) Pro Tip: Soliciting your patient's medical history can help you to understand the nature of a patient's chief complaint. Asking Tina whether she has scoliosis might reveal relevant concerns she'd previously experienced. Example Question: Do you have scoliosis? Risk Factors  Finding: Asked fall history  Finding: Reports falling one week ago (Found)Pro Tip: Changes in bone composition can leave a patient more at risk for falling. Asking Tina about her history of falling could provide you with information about her bone density. Example Question: When was the last time you fell?  Finding: Reports belief that she is not particularly prone to falls (Found) Pro Tip: Changes in bone composition can leave a patient more at risk for falling. Asking Tina if she is prone to falling could provide you with information about her bone density. Example Question: Are you prone to falling? Relevant Family History  Finding: Asked family history of osteoporosis  Finding: Reports no family history of osteoporosis (Found) Pro Tip: Family histories can suggest a genetic predisposition. Asking Tina if anyone in her family has osteoporosis can indicate a potential predisposition. Example Question: Does anyone in your family have osteoporosis? Finding: Asked family history of joint problems  Finding: Reports no family history of joint problems (Available) Pro Tip: Family histories can suggest a genetic predisposition. Asking Tina if anyone in her family has had joint problems can indicate a potential predisposition. Example Question: Has anyone in your family had joint problems?  Finding: Reports no family history of arthritis (Found) Pro Tip: Family histories can suggest a genetic predisposition. Asking Tina if anyone in her family has arthritis can indicate a potential predisposition. Example Question: Does arthritis run in your family?  Finding: Asked family history of skeletal problems  Finding: Reports no family history of skeletal problems(Found) Pro Tip: Family histories can suggest a genetic predisposition. Asking Tina if skeletal problems run in her family can indicate a potential predisposition. Example Question: Do skeletal problems run in your family? Comments If your instructor provides individual feedback on this assignment, it will appear here. Abdominal Results | Turned InC492 Physical Assessment - Oct 2017, C492 Return to Assignment Your Results Reopen Lab Pass  Overview  Transcript  Subjective Data Collection  Objective Data Collection  Documentation Subjective Data Collection: 15 of 22 (68.2%) Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.  Found: Indicates an item that you found.  Available: Indicates an item that is available to be found.Category Scored Items Experts selected these topics as essential components of a strong, thorough interview with this patient. Patient Data Not Scored A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case. Relevant Medical History  Finding: Asked about general stomach and bowels  Finding: Reports no current abdominal issues (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 abdominal issues?  Finding: Reports no current abdominal 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 abdominal pain?  Finding: Asked about typical bowel habits  Finding: Reports a bowel movement every two days (Available) Pro Tip: GERD and IBS often occur together. Asking Tina about her bowel movements is significant in understanding her gastrointestinal symptoms. Example Question: How often do you have a bowel movement?  Finding: Last bowel movement was yesterday morning (Found) Pro Tip: GERD and IBS often occur together. Asking Tina about her bowel movements is significant in understanding her gastrointestinal symptoms. Example Question: When was your last bowel movement? Finding: Asked about constipation  Finding: Reports no constipation (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like constipation, details the way her individual symptoms and pain manifest. Example Question: Have you been constipated?  Finding: Reports no hard stools (Available) Pro Tip: GERD and IBS often occur together. Asking Tina if there are any abnormalities in her stools is significant in understanding her gastrointestinal symptoms. Example Question: Have you had hard stools?  Finding: Reports no straining during bowel movement (Available) Pro Tip: GERD and IBS often occur together. Asking Tina about her bowel movements is significant in understanding her gastrointestinal symptoms.Example Question: Do you strain during a bowel movement?  Finding: Denies irregular stools (Available) Pro Tip: GERD and IBS often occur together. Asking Tina about her bowel movements is significant in understanding her gastrointestinal symptoms. Example Question: Do you have irregular bowel movements?  Finding: Asked about diarrhea  Finding: Reports no diarrhea (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like diarrhea, details the way her individual symptoms and pain manifest. Example Question: Do you have diarrhea?  Finding: Followed up about characteristics of stool Finding: Describes stools as formed (Available) Pro Tip: GERD and IBS often occur together. Asking Tina about her bowel movements is significant in understanding her gastrointestinal symptoms. Example Question: Are your stools formed?  Finding: Describes color as medium-brown (Found) Pro Tip: GERD and IBS often occur together. Asking Tina if there are any abnormalities in her stools is significant in understanding her gastrointestinal symptoms. Example Question: What color are your stools?  Finding: Reports no blood in stool (Available) Pro Tip: GERD and IBS often occur together. Asking Tina if there are any abnormalities in her stools is significant in understanding her gastrointestinal symptoms. Example Question: Do you notice blood in your stool? Finding: Reports no mucus in stool (Available) Pro Tip: GERD and IBS often occur together. Asking Tina if there are any abnormalities in her stools is significant in understanding her gastrointestinal symptoms. Example Question: Do you notice mucus in your stool?  Finding: Asked about gassiness  Finding: Reports no gassiness (Found) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like gas, details the way her individual symptoms and pain manifest. Example Question: Have you been feeling gassy?  Finding: Reports no bloating (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like feeling bloated, details the way her individual symptoms and pain manifest.Example Question: Have you been experiencing bloating?  Finding: Asked about nausea  Finding: Reports no nausea (Found) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like nausea, details the way her individual symptoms and pain manifest. Example Question: Have you been having nausea?  Finding: Asked about vomiting  Finding: Reports no vomiting (Found) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like vomiting, details the way her individual symptoms and pain manifest. Example Question: Have you been vomiting recently? Finding: Asked about appetite changes  Finding: Reports recent increase in appetite (Available) Pro Tip: Pain can have a substantial effect on diet and appetite. Asking Tina if her appetite has increased will illustrate the ways in which her symptoms are manifesting. Example Question: Has your appetite increased?  Finding: Asked appetite change onset  Finding: Reports appetite increase started about a month ago (Available) Pro Tip: Pain can have a substantial effect on diet and appetite. Asking Tina when her appetite increased will illustrate the ways in which her symptoms are manifesting. Example Question: When did your appetite increase?  Finding: Asked about GERD and heartburn Finding: Reports no heartburn (Found) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like heartburn, details the way her individual symptoms and pain manifest. Example Question: Do you have heartburn?  Finding: Reports no chest pain (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her chest pain, like vomiting, details the way her individual symptoms and pain manifest. Example Question: Do you ever get chest pain?  Finding: Reports no history of GERD (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like GERD, details the way her individual symptoms and pain manifest. Example Question: Have you ever had GERD? Finding: Asked about urinary problems  Finding: Reports increased urination (Available) Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if she has been urinating more than usual can help you to determine the cause of Tina's symptoms. Example Question: Have you been urinating more frequently?  Finding: Reports nocturia (Available) Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if she has to wake up to urinate can help you to determine the cause of Tina's symptoms. Example Question: Are you waking up in the middle of the night to urinate?  Finding: Asked frequency and duration of increased urination  Finding: Reports urinating every hour or two during the day(Available) Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina how many times she urinates during the day can help you to determine the cause of Tina's symptoms. Example Question: How many times do you urinate during the day?  Finding: Reports waking up to pee more than once per night (Available) Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina how frequently she has to wake up to urinate can help you to determine the cause of Tina's symptoms. Example Question: How often do you wake up to urinate in the night?  Finding: Reports frequent urination started a few months ago (Available) Pro Tip: Bladder dysfunction can indicate a GI problem. Establishing a timeline of Tina's change in urinary patterns can help you to determine the cause of Tina's symptoms. Example Question: When did you start urinating more frequently?  Finding: Asked about character of urination Finding: Describes urine color as light yellow or clear (Found) Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina what color her urine is can help you to determine the cause of Tina's symptoms. Example Question: What color is your urine usually?  Finding: Reports no blood in urine (Available) Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if her urine is ever red can help you to determine the cause of Tina's symptoms. Example Question: Have you had blood in your urine?  Finding: Reports no strong or sweet odor (Available) Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if her urine has a strong odor can help you to determine the cause of Tina's symptoms. Example Question: Does your urine have a strong odor?  Finding:Asked about water intake  Finding: Reports increase in water intake (Available) Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if she is drinking more water lately can help you to determine the cause of Tina's symptoms. Example Question: Are you drinking more water lately?  Finding: Reports increased thirst (Available) Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if she has been thirstier lately can help you to determine the cause of Tina's symptoms. Example Question: Have you been thirstier lately?  Finding: Asked 24-hour diet recall  Finding: Breakfast this morning was toast (Found)Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she had for breakfast yesterday will illustrate her recent dietary patterns. Example Question: What did you have for breakfast this morning?  Finding: Lunch was a turkey sandwich (Found) Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she had for lunch yesterday will illustrate her recent dietary patterns. Example Question: What did you have for lunch today?  Finding: Dinner was chicken, baked potato, and a roll (Found) Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she had for dinner yesterday will illustrate her recent dietary patterns. Example Question: What did you have for dinner today?  Finding: Reports no snack today (Found)Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she had for a snack yesterday will illustrate her recent dietary patterns. Example Question: What did you have for a snack today?  Finding: Asked about typical meals  Finding: Typical breakfast is cereal, bread, or a muffin (Available) Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she typically has for breakfast will illustrate her recent dietary patterns. Example Question: What is your typical breakfast?  Finding: Typical lunch is a sandwich and chips (Available) Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she typically has for lunch will illustrate her recent dietary patterns. Example Question: What is your typical lunch? Finding: Typical dinner is chicken, a vegetable or potatoes, and bread (Available) Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she typically has for dinner will illustrate her recent dietary patterns. Example Question: What is your typical dinner?  Finding: Typical snack is pretzels, French fries, crackers or chips (Available) Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she typically has for a snack will illustrate her recent dietary patterns. Example Question: What is a typical snack for you? Review of Systems  Finding: Asked about additional gastrointestinal symptoms  Finding: Reports recent weight loss (Available)Pro Tip: Foundational questions about general health and wellbeing can help you to determine how your patient perceives her health. Asking Tina if her weight changed recently can indicate whether Tina has concerns about changes in weight. Example Question: Have you had any recent changes in your weight?  Finding: Reports no burping (Available) Pro Tip: Increased burping can be a result of heartburn, acid reflux, or indigestion. Asking Tina if she's been burping more would indicate that Tina has been swallowing more air recently. Example Question: Have you been burping?  Finding: Reports no difficulty swallowing (Found) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like difficulty swallowing, details the way her individual symptoms and pain manifest. Example Question: Have you had difficulty swallowing?  Finding: Reports no rectal bleeding (Found)Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like rectal bleeding, details the way her individual symptoms and pain manifest. Example Question: Have you had rectal bleeding?  Finding: Reports no ulcer (Available) Pro Tip: Soliciting a relevant medical history from your patient will aid in effectively treating your patient's symptoms. Asking Tina if she ever had any ulcers will allow her to describe any historical concerns or problems she's had. Example Question: Have you ever had an ulcer?  Finding: Asked about additional urinary symptoms  Finding: Reports no incontinence (Available) Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if she is having bladder control problems can help you to determine the cause of Tina's symptoms. Example Question: Are you having bladder control problems?  Finding:Reports no dysuria (Available) Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if she is having pain or burning with urination can help you to determine the cause of Tina's symptoms. Example Question: Have you felt pain or burning with urination?  Finding: Reports no difficulty urinating (Available) Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if urination has been difficult for her can help you to determine the cause of Tina's symptoms. Example Question: Has urinating been difficult for you?  Finding: Asked about organs of the gastrointestinal system  Finding: Reports no history of gall bladder problems (Found) Pro Tip: Soliciting a relevant medical history from your patient will aid in effectively treating your patient's symptoms. Asking Tina if she has a history of gall bladder problems will allow her to describe any historical concerns or problems she's had. Example Question: Do you have a history of gall bladder problems? Finding: Reports no history of pancreas problems (Found) Pro Tip: Soliciting a relevant medical history from your patient will aid in effectively treating your patient's symptoms. Asking Tina if she has a history of pancreas problems will allow her to describe any historical concerns or problems she's had. Example Question: Do you have a history of pancreas problems?  Finding: Reports no history of liver problems (Found) Pro Tip: Soliciting a relevant medical history from your patient will aid in effectively treating your patient's symptoms. Asking Tina if she has a history of liver problems will allow her to describe any historical concerns or problems she's had. Example Question: Do you have a history of liver problems?  Finding: Reports no history of kidney problems (Found) Pro Tip: Soliciting a relevant medical history from your patient will aid in effectively treating your patient's symptoms. Asking Tina if she has a history of kidney problems will allow her to describe any historical concerns or problems she's had. Example Question: Do you have a history of kidney problems? Finding: Reports no history of bladder problems (Available) Pro Tip: Soliciting a relevant medical history from your patient will aid in effectively treating your patient's symptoms. Asking Tina if she has a history of bladder problems will allow her to describe any historical concerns or problems she's had. Example Question: Do you have a history of bladder problems? Family History  Finding: Asked family history of gastrointestinal issues  Finding: Reports no known family history of gastrointestinal issues (Found) Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking about Tina's relevant family history might reveal a predisposition to gastrointestinal disorders. Example Question: Do gastrointestinal issues run in your family?  Finding: Reports no family history of bowel disease(Available) Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking about Tina's relevant family history might reveal a predisposition to gastrointestinal disorders. Example Question: Does IBS run in your family?  Finding: Reports no family history of liver disease (Available) Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina has a family history of liver cancer might reveal a predisposition to gastrointestinal issues. Example Question: Does liver cancer run in your family?  Finding: Asked family history of gastrointestinal cancer  Finding: Reports family history of colon cancer (Found) Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina has a family history of colon cancer might reveal a predisposition to gastrointestinal issues. Example Question: Does colon cancer run in your family? Finding: Reports paternal grandfather died of colon cancer (Found) Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina has a family history of colon cancer might reveal a predisposition to gastrointestinal issues. Example Question: Has anyone in your family had colon cancer? Comments If your instructor provides individual feedback on this assignment, it will appear here. Cardiovascular Results | Turned InC492 Physical Assessment - Oct 2017, C492 Return to Assignment Your Results Reopen Lab Pass  Overview  Transcript  Subjective Data Collection  Objective Data Collection  Documentation Subjective Data Collection: 12 of 20 (60.0%) Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.  Found: Indicates an item that you found. Available: Indicates an item that is available to be found. Category Scored Items Experts selected these topics as essential components of a strong, thorough interview with this patient. Patient Data Not Scored A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case. Relevant Medical History  Finding: Asked about heart problems  Finding: Reports no known heart problems (Found) Pro Tip: Broad questions like this one enable the patient to establish their chief complaint. Asking Tina if she's had any problems with her heart will allow her to mention any concerns she's recently had regarding her heart. Example Question: Do you experience heart problems? Finding: Asked about heartbeat  Finding: Reports heartbeat is normal (Found) Pro Tip: Broad questions like this one enable the patient to establish their chief complaint. Asking Tina about her heartbeat will allow her to mention any concerns she's recently had regarding her heart. Example Question: Is your heartbeat regular?  Finding: Reports no problems with palpitations (Found) Pro Tip: Symptoms often vary from patient to patient. Asking Tina if she has palpitations specifies the way her individual symptoms manifest. Example Question: Do you have problems with palpitations?  Finding: Reports no problems with slow heart rate (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina if she has a slow heartbeat specifies the way her individual symptoms manifest. Example Question:Do you have problems with a slow heartbeat?  Finding: Reports no arrhythmia (Found) Pro Tip: Symptoms often vary from patient to patient. Asking Tina if she has arrhythmia specifies the way her individual symptoms manifest. Example Question: Do you have arrhythmia?  Finding: Reports heart rate is normal (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina if her heart rate is normal specifies the way her individual symptoms manifest. Example Question: Is your heart rate normal?  Finding: Asked about high blood pressure  Finding: Reports no known history of high blood pressure (Found)Pro Tip: Cardiovascular disease can manifest in various conditions. Inquiring into Tina's relevant history can reveal past diagnoses and previous conditions or concerns. Example Question: Do you have a history of high blood pressure?  Finding: Reports last blood pressure check 140 over 80 or 90 (Available) Pro Tip: Blood pressure might change over time due to such factors as caffeine consumption, stress, diet, and exercise. Asking Tina what her blood pressure was last time it was measured will provide a baseline for comparing her last reading to her blood pressure now. Example Question: What was your blood pressure last time you checked?  Finding: Reports belief that current blood pressure is "fine, or maybe the high side of normal" (Found) Pro Tip: Hypertension is the most important risk factor for stroke. Soliciting a health history from Tina will allow you to assess her risk of cardiovascular disease. Example Question: How is your blood pressure?  Finding: Asked about heart murmur Finding: Reports no problems with heart murmur (Available) Pro Tip: Some heart murmurs can indicate a damaged or overworked heart valve. Asking Tina whether she's experienced a heart murmur allows you to assess whether she's noticed a symptom that indicates a heart condition. Example Question: Do you have problems with a heart murmur?  Finding: Asked about swelling  Finding: Reports no swelling other than foot wound, which seems to be improving (Found) Pro Tip: When the heart weakens and pumps blood less effective, the resulting fluid that accumulates can lead to edema. Asking Tina whether she's experienced edema allows you to assess if her heart is pumping less effectively. Example Question: Have you been experiencing swelling?  Finding: Reports no problems with swollen legs or feet (Found) Pro Tip: When the heart weakens and pumps blood less effective, the resulting fluid that accumulates can lead to edema. Asking Tina whether she's experienced edema allows you to assess if her heart is pumping less effectively.Example Question: Do you have swelling in your legs or feet?  Finding: Reports no problems with swollen arms or hands (Available) Pro Tip: When the heart weakens and pumps blood less effective, the resulting fluid that accumulates can lead to edema. Asking Tina whether she's experienced edema allows you to assess if her heart is pumping less effectively. Example Question: Do you have swelling in your arms or hands? Review of Systems  Finding: Asked about chest pain  Finding: Reports no problems with chest pain (Found) Pro Tip: Chest pain manifests in various ways, from a muted ache to a stabbing pain. Asking Tina whether she's had angina can point to such conditions as angina or heart attack, among others. Example Question: Do you have problems with chest pain? Finding: Reports no history of angina (Available) Pro Tip: Chest pain manifests in various ways, from a muted ache to a stabbing pain. Asking Tina whether she's had angina can point to such conditions as angina or heart attack, among others. Example Question: Have you had problems with angina?  Finding: Asked about chest tightness  Finding: Reports chest only tight during asthma exacerbations (Found) Pro Tip: Chest pain manifests in various ways, from a muted ache to a stabbing pain. Asking Tina when she's had chest tightness can point to such conditions as angina or heart attack, among others. Example Question: When do you have chest tightness?  Finding: Reports no current chest tightness (Found) Pro Tip: Chest pain manifests in various ways, from a muted ache to a stabbing pain. Asking Tina if she currently has chest tightness can point to such conditions as angina or heart attack, among others.Example Question: Do you currently have chest tightness?  Finding: Asked about shortness of breath  Finding: Reports only shortness of breath occurs during asthma exacerbations (Available) Pro Tip: Shortness of breath often indicates a heart condition. Asking Tina when she experiences shortness of breath solicits a relevant health history. Example Question: When do you have shortness of breath?  Finding: Asked shortness of breath follow-up  Finding: Reports only shortness of breath that occurs during activities is due to asthma (Found) Pro Tip: Shortness of breath often indicates a heart condition. Asking Tina what triggers her shortness of breath solicits a relevant health history. Example Question: What triggers your shortness of breath? Finding: Reports no difficulty breathing when lying down (Available) Pro Tip: Shortness of breath often indicates a heart condition. Asking Tina whether she has difficulty of breathing when lying down solicits a relevant health history. Example Question: Do you have difficulty breathing when lying down?  Finding: Reports no sudden waking with shortness of breath (Available) Pro Tip: Shortness of breath often indicates a heart condition. Asking Tina if she wakes suddenly with shortness of breath solicits a relevant health history. Example Question: Do you wake suddenly with shortness of breath?  Finding: Asked about leg pain  Finding: Reports no current or recent leg cramping (Available) Pro Tip: Leg cramping can be a sign of peripheral arterial disease. Asking Tina if she has leg cramping solicits relevant history that might be linked to cardiovascular troubles. Example Question:Have you had recent leg cramping?  Finding: Reports no problems with calf pain when walking (Available) Pro Tip: Calf pain when walking can be a sign of peripheral arterial disease. Asking Tina if she has leg cramping solicits relevant history that might be linked to cardiovascular troubles. Example Question: Do you have calf pain when walking? Risk Factors  Finding: Asked duration of immobility  Finding: Reports immobile for past three days (Available) Pro Tip: Staying immobile for long periods of time can have disastrous effects on the cardiovascular system. Asking Tina how long she's been immobile solicits information relevant to the health of her heart. Example Question: For how long have you been immobile?  Finding:Asked about possible VTE symptoms  Finding: Reports no tender or painful areas other than foot wound (Available) Pro Tip: Tender areas can indicate underlying problems with the heart. Asking Tina whether she has unusual tender or painful areas solicits information about her heart history. Example Question: Do you have tender areas other than your foot wound?  Finding: Reports no unusual redness other than foot wound (Found) Pro Tip: Unusual redness can indicate underlying problems with the heart. Asking Tina whether she has unusual redness solicits information about her heart history. Example Question: Do you have unusual redness other than your foot wound?  Finding: Reports no unusual warmth anywhere (Available) Pro Tip: Unusual warmth can indicate underlying problems with the heart. Asking Tina whether she has unusual warmth solicits information about her heart history. Example Question: Do you have unusual warmth anywhere? Finding: Asked about cholesterol  Finding: Reports no cholesterol problems (Available) Pro Tip: High cholesterol can lead to cardiovascular disease. Asking Tina whether she's had a history of high cholesterol reveals her recent medical history. Example Question: Do you have cholesterol problems?  Finding: Asked history of venous thrombosis  Finding: Reports no history of venous thrombosis (Available) Pro Tip: Many cardiovascular risk factors have been associated with venous thrombosis. Asking Tina if she has ever had venous thrombosis solicits a relevant history. Example Question: Have you ever had venous thrombosis?  Finding:Asked about weight  Finding: Reports that she has "always been on the heavy side" and isn't "built to be skinny," but she is satisfied with her weight (Available) Pro Tip: Weight and body mass are important factors in cardiovascular health. Asking Tina her current weight will help you to assess whether her weight is a risk factor for cardiovascular disease. Example Question: Have you had problems with your weight?  Finding: Is aware of current weight (Available) Pro Tip: Weight and body mass are important factors in cardiovascular health. Asking Tina her current weight will help you to assess whether her weight is a risk factor for cardiovascular disease. Example Question: What is your current weight? Relevant Family History  Finding: Asked family history of hypertension  Finding:Reports family history of hypertension (Found) Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina's family has a history of hypertension might reveal her health literacy and predisposition to heart disease. Example Question: Do you have a family history of hypertension?  Finding: Reports mother has hypertension (Found) Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina's mother had hypertension might reveal a genetic predisposition. Example Question: Does your mother have hypertension?  Finding: Reports father had hypertension (Found) Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina's father had hypertension might reveal a genetic predisposition. Example Question: Did your father have hypertension?  Finding: Reports maternal grandfather had hypertension(Found) Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina's maternal grandfather had hypertension might reveal a genetic predisposition. Example Question: Did your maternal grandmother have hypertension?  Finding: Reports paternal grandfather had hypertension (Found) Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina's paternal grandfather had hypertension might reveal a genetic predisposition. Example Question: Did your paternal grandfather have hypertension?  Finding: Reports maternal grandmother had hypertension (Found) Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina's maternal grandmother had hypertension might reveal a genetic predisposition. Example Question: Did your maternal grandmother have hypertension?  Finding: Reports paternal grandmother has hypertension(Found) Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina's paternal grandmother had hypertension might reveal a genetic predisposition. Example Question: Did your paternal grandmother have hypertension?  Finding: Asked family history of high cholesterol  Finding: Reports family history of high cholesterol (Found) Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if high cholesterol runs in Tina's family might reveal a genetic predisposition. Example Question: Does high cholesterol run in your family?  Finding: Reports mother has high cholesterol (Found) Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina's mother has high cholesterol might reveal a genetic predisposition. Example Question: Does your mother have high cholesterol? Finding: Reports father had high cholesterol (Found) Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina's father has high cholesterol might reveal a genetic predisposition. Example Question: Does your father have high cholesterol?  Finding: Reports maternal grandfather had high cholesterol (Found) Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina's maternal grandfather had high cholesterol might reveal a genetic predisposition. Example Question: Did your maternal grandfather have high cholesterol?  Finding: Reports paternal grandfather had high cholesterol (Found) Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina's paternal grandfather had high cholesterol might reveal a genetic predisposition. Example Question: Did your paternal grandfather have high cholesterol? Finding: Reports maternal grandmother had high cholesterol (Found) Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina's maternal grandmother had high cholesterol might reveal a genetic predisposition. Example Question: Did your maternal grandmother have high cholesterol?  Finding: Reports paternal grandmother has high cholesterol (Found) Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina's paternal grandmother had high cholesterol might reveal a genetic predisposition. Example Question: Did your paternal grandmother have high cholesterol?  Finding: Asked family history of stroke  Finding: Reports maternal grandmother died of stroke (Available) Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina's family has a history of stroke might reveal her health literacy and predisposition to heart disease.Example Question: Does stroke run in your family?  Finding: Asked about family heart history  Finding: Reports maternal grandfather died of heart attack (Found) Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina's family has a history of cardiovascular problems might reveal her health literacy and predisposition to heart disease. Example Question: Do cardiovascular problems run in your family?  Finding: Reports no other family history of heart problems (Found) Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina's family has a history of heart problems might reveal her health literacy and predisposition to heart disease. Example Question: Does your family have a history of heart problems?  Finding: Reports no family history of heart murmur(Available) Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina's family has a history of heart murmur might reveal her health literacy and predisposition to heart disease. Example Question: Does your family have a history of heart murmur?  Finding: Asked about family history of obesity  Finding: Reports some family members are overweight (Available) Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina's family has a history of obesity might reveal her health literacy and predisposition to heart disease. Example Question: Does obesity run in your family? Comments If your instructor provides individual feedback on this assignment, it will appear here. Respiratory Results | Turned InC492 Physical Assessment - Oct 2017, C492 Return to Assignment Your Results Reopen Lab Pass  Overview Transcript  Subjective Data Collection  Objective Data Collection  Documentation Subjective Data Collection: 15 of 24 (62.5%) Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.  Found: Indicates an item that you found.  Available: Indicates an item that is available to be found. Category Scored Items Experts selected these topics as essential components of a strong, thorough interview with this patient. Patient Data Not Scored A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case. Relevant Medical History  Finding: Asked about asthma exacerbations Finding: Reports asthma exacerbations occur but they are "never full attacks" (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 asthma attacks?  Finding: Asked asthma frequency and duration  Finding: Reports asthma exacerbations occur 2-3 times a week (Found) Pro Tip: Establishing a timeline for Tina's asthma attacks will help in treatment and in understanding the severity of her asthma. Example Question: How many times a week do you have an asthma attack?  Finding: Reports asthma exacerbations last "five minutes at most" (Available) Pro Tip: Establishing a timeline for Tina's asthma attacks will help in treatment and in understanding the severity of her asthma.Example Question: How long do your asthma attacks last?  Finding: Asked most recent exacerbation  Finding: Reports last exacerbation three days ago (Available) Pro Tip: Establishing a timeline for Tina's asthma attacks will help in treatment and in understanding the severity of her asthma. Example Question: When is the last time you had an asthma attack?  Finding: Reports last exacerbation around cats at cousin's house (Available) Pro Tip: Tina's answer will reveal the degree to which she is familiar with what factors trigger her asthma. Example Question: What caused your last asthma attack?  Finding: Asked asthma triggers Finding: Reports existence of asthma triggers (Found) Pro Tip: Discerning what's making Tina's asthma worse can point to possible triggers like environmental factors, bodily positions, or movement that may have a bearing on Tina's breathing. Asking Tina what triggers her asthma will indicate, in part, Tina's health literacy. Example Question: Does anything trigger your asthma?  Finding: Reports cat allergy as asthma trigger (Found) Pro Tip: Environmental factors can often be primary allergy triggers. Asking whether Tina has a cat allergy can reveal one such trigger. Example Question: Do cats trigger your asthma?  Finding: Reports dust as asthma trigger (Found) Pro Tip: Environmental factors can often be primary allergy triggers. Asking whether Tina has a dust allergy can reveal one such trigger. Example Question: Does dust trigger your asthma? Finding: Reports running quickly up stairs as asthma trigger (Found) Pro Tip: Shortness of breath or asthma can be exercise-induced. Asking whether climbing stairs can be a trigger for Tina might reveal a possible provocation. Example Question: Does running up stairs trigger your asthma?  Finding: Reports no asthma problems at work (Available) Pro Tip: Environmental factors at home or work can often be primary allergy triggers. Asking Tina about possible allergens at work might indicate a relevant factor in her recent exacerbation. Example Question: Does anything at work make your asthma worse?  Finding: Reports no asthma problems at home (Available) Pro Tip: Environmental factors at home or work can often be primary allergy triggers. Asking Tina about possible allergens at home might indicate a relevant factor in her recent exacerbation. Example Question: Have you had problems with your asthma at home? Finding: Asked asthma management  Finding: Reports inhaler is only form of asthma management (Found) Pro Tip: Tina's response to a question about asthma management will reveal the severity of her symptoms, her health literacy, and the way she's complied with previous treatment plans. Example Question: How do you manage your asthma?  Finding: Asked about inhaler  Finding: Reports inhaler is Proventil (Available) Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina what medication she takes for her asthma will indicate her treatment plan and the degree to which she complies with it. Example Question: What is the name of the inhaler you are currently using?  Finding: Reports dose is "two or three puffs"(Found) Pro Tip: Tina's response to a question about asthma management will reveal the severity of her symptoms, her health literacy, and the way she's complied with previous treatment plans. Example Question: How do you use your inhaler?  Finding: Reports using inhaler "2 or 3 times a week" (Found) Pro Tip: After an asthma exacerbation, patients often will become more reliant on medical tools like inhalers. Asking Tina how many times a week she uses her inhaler will point to the severity of her recent exacerbation. Example Question: How many times a week are you using your inhaler?  Finding: Reports last inhaler use was three days ago (Found) Pro Tip: Soliciting a shallow history of a patient's medication history can reveal recent exacerbation. Asking Tina when she last used her inhaler will indicate when her symptoms most recently required medical treatment. Example Question: When did you last use your inhaler?  Finding: Asked exacerbation symptoms Finding: Reports symptoms during exacerbation as chest tightness, like she "can't take in air" (Found) Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina's had chest tightness since exacerbation can indicate the severity of her symptoms since exacerbation. Example Question: Have you had chest tightness?  Finding: Reports wheezing during exacerbation (Found) Pro Tip: Some people who experience chronic asthma may be accustomed to wheezing and, as a result, might not volunteer this information. Asking Tina if she's been wheezing illustrates how her asthma is presenting. Example Question: Have you been wheezing?  Finding: Reports shortness of breath during exacerbation (Found) Pro Tip: Symptoms often vary from patient to patient. Asking Tina whether she experiences shortness of breath during an attack will indicate how her individual symptoms manifest. Example Question: Do you have shortness of breath during an asthma attack? Finding: Reports no cough during exacerbation (Available) Pro Tip: A shallow history of a patient's condition can provide a comparative baseline for juxtaposing an attack, exacerbation, and more regular breathing. Soliciting this information from Tina allows her to explain any recent developments with her asthma. Example Question: Do you cough during an asthma attack?  Finding: Reports no chest pain during exacerbation (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina whether she experiences chest pain during an attack will indicate how her individual symptoms manifest. Example Question: Do you have chest pains when you have asthma attacks?  Finding: Reports no painful breathing (Available) Pro Tip: Asking about how Tina is currently breathing can provide a comparative baseline for assessing Tina's current condition and previous breathing concerns or conditions. Example Question: Is it painful for you to breathe? Finding: Asked current breathing  Finding: Reports no current shortness of breath (Found) Pro Tip: Asking about how Tina is currently breathing can provide a comparative baseline for assessing Tina's current condition and previous breathing concerns or conditions. Example Question: Do you currently have shortness of breath?  Finding: Reports no current wheezing (Available) Pro Tip: Asking about how Tina is currently breathing can provide a comparative baseline for assessing Tina's current condition and previous breathing concerns or conditions. Example Question: Are you currently wheezing?  Finding: Reports no current coughing (Found)Pro Tip: Asking about how Tina is currently breathing can provide a comparative baseline for assessing Tina's current condition and previous breathing concerns or conditions. Example Question: Are you currently coughing?  Finding: Report no current nose problems (Available) Pro Tip: Asthma symptoms may vary from one attack to the next. Determining which other symptoms Tina has experienced since exacerbation will more specifically illustrate the ways in which Tina's asthma manifests. Example Question: Are you having nose problems right now? Review of Systems  Finding: Asked cough history  Finding: Reports only coughs occur when she has a cold (Available) Pro Tip: Sometimes a condition will change during the course of the day. By asking Tina when she is coughing, you are assessing an important change over time. Example Question: When are you coughing? Finding: Reports no coughing up blood (Available) Pro Tip: Coughing up blood can be indicative of a major health concern. Asking Tina if she has been coughing up blood solicits an important health history. Example Question: Have you been coughing up blood?  Finding: Asked sputum  Finding: Reports no sputum (Available) Pro Tip: Asthma symptoms may vary from one attack to the next. Determining which other symptoms Tina has experienced since exacerbation will more specifically illustrate the ways in which Tina's asthma manifests. Example Question: Are you coughing up phlegm or sputum? Risk Factors  Finding: Asked about respiratory history Finding: Reports history of asthma (Found) Pro Tip: Asking whether Tina has had asthma will elicit information regarding any previous respiratory diagnosis. Example Question: Have you had asthma?  Finding: Reports asthma diagnosis at 2 1/2 (Found) Pro Tip: By determining the onset of asthma you can get a sense for Tina's asthma history, instance, and frequency of exacerbation. Example Question: When were you diagnosed with asthma?  Finding: Reports no history of other respiratory illness (Found) Pro Tip: History of respiratory illness can manifest in various conditions. Inquiring into Tina's relevant history can reveal past diagnoses and previous conditions or concerns. Example Question: Do you have a history of respiratory illness?  Finding:Asked about seeing an asthma specialist  Finding: Reports seeing an "asthma doctor" (Found) Pro Tip: Seeing a specialist, like an asthma doctor, can help patients to manage symptoms. Asking whether Tina is seeing an asthma doctor will allow you to assess her current treatment plan and healthcare access. Example Question: Do you go to an asthma specialist?  Finding: Reports not seeing asthma doctor in two years (Found) Pro Tip: Seeing a specialist, like an asthma doctor, can help patients to manage symptoms. Asking when Tina last saw an asthma doctor will allow you to assess her current treatment plan and healthcare access. Example Question: When did you last see a doctor for asthma?  Finding: Asked about past hospitalizations  Finding: Reports past hospitalizations for asthma (Found)Pro Tip: Hospitalization for a condition, like asthma, can reveal its severity. By asking Tina if she's been hospitalized, you are soliciting information about the history and severity of her condition. Example Question: Have you been hospitalized for asthma in the past?  Finding: Reports five past hospitalizations for asthma (Available) Pro Tip: Hospitalization for a condition, like asthma, can reveal its severity. By asking Tina how many times she was hospitalized, you are soliciting information about the history and severity of her condition. Example Question: How many times have you been hospitalized for asthma?  Finding: Reports most recent hospitalization at age 16 (Available) Pro Tip: Hospitalization for a condition, like asthma, can reveal its severity. By asking Tina when she was last hospitalized, you are soliciting information about the history and severity of her condition. Example Question: When was your most recent hospitalization for asthma?  Finding: Reports hospital treatment was usually "steroids and a nebulizer" (Available)Pro Tip: Hospitalization for a condition, like asthma, can reveal its severity. By asking Tina how she was treated when she was hospitalized, you are soliciting information about the history and severity of her condition. Example Question: How were you treated at the hospital for asthma?  Finding: Asked allergies  Finding: Reports allergies (Found) Pro Tip: In treating your patient, asking if she has allergies can suggest a sensitivity to various environmental triggers. Asking Tina if she has allergies solicits an important health history. Example Question: Are you allergic to anything?  Finding: Reports allergy to cats (Found) Pro Tip: Environmental factors can often be primary allergy triggers. Asking whether Tina has a cat allergy can reveal one such trigger. Example Question: Are you allergic to cats?  Finding:Asked allergy treatment  Finding: Reports avoiding cats when possible (Found) Pro Tip: Tina's response to a question about recent allergy management will reveal the severity of her symptoms, her health literacy, and the way she's complied with previous treatment plans. Example Question: Do you stay away from cats?  Finding: Reports inhaler use and taking a shower as only treatment for cat allergy (Found) Pro Tip: Tina's response to a question about recent allergy management will reveal the severity of her symptoms, her health literacy, and the way she's complied with previous treatment plans. Example Question: How do you treat your cat allergy?  Finding: Asked current tobacco use  Finding: Reports no current tobacco use (Found)Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Asking Tina if she currently smokes can help you to discern whether smoking was a factor in Tina's recent asthma exacerbation. Example Question: Do you use tobacco products?  Finding: Asked history of tobacco use  Finding: Reports no history of tobacco use (Available) Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Asking Tina if she has a history of smoking can help you to discern whether smoking was a factor in Tina's recent asthma exacerbation. Example Question: Have you ever used tobacco?  Finding: Asked marijuana use  Finding: Reports past marijuana use (Available) Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Asking Tina is she ever smoked marijuana can help you to discern whether smoking was an exacerbating factor for Tina's asthma.Example Question: Have you ever smoked marijuana?  Finding: Asked marijuana follow-up  Finding: Reports smoking marijuana for 5 or 6 years (Available) Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Asking Tina how long she smoked marijuana can help you to discern whether smoking exacerbated Tina's asthma. Example Question: How long did you smoke marijuana?  Finding: Reports stopped smoking marijuana 6 or 7 years ago (Available) Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Asking Tina when she quit smoking marijuana can help you to discern whether smoking exacerbated Tina's asthma. Example Question: When did you stop smoking marijuana?  Finding: Reports stopped smoking marijuana because it "wasn't fun anymore" and was bothering her asthma(Available) Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Asking Tina why she quit smoking marijuana can help you to discern whether smoking exacerbated Tina's asthma. Example Question: Why did you stop smoking marijuana?  Finding: Asked second hand smoke  Finding: Reports no second hand smoke exposure (Available) Pro Tip: Secondhand smoke can be particularly triggering for asthmatics. Asking how often Tina is around people who smoke might indicate a proximate environmental trigger. Example Question: Are you exposed to secondhand smoke?  Finding: Asked home environment  Finding: Reports home is clean and free of dust (Available)Pro Tip: Environmental factors at home or work can often be primary allergy triggers. Asking Tina about possible allergens at home might indicate a relevant factor in her recent exacerbation. Example Question: Is there dust in your home?  Finding: Reports mattress is only one year old (Available) Pro Tip: Bedding provides the perfect environment for dust mites and other allergens. By asking Tina how old her mattress is, you're soliciting information about environmental factors that might exacerbate her condition. Example Question: How old is your mattress?  Finding: Reports using hypoallergenic mattress cover (Available) Pro Tip: Hypoallergenic bedding can provide relief to those who suffer from sensitivity to dust mites, allergies, or asthma. Discovering that Tina uses hypoallergenic bedding can indicate a reason why she might feel asthma relief at night. Example Question: Do you use a hypoallergenic mattress cover?  Finding: Reports use of new hypoallergenic pillows (Available)Pro Tip: Hypoallergenic bedding can provide relief to those who suffer from sensitivity to dust mites, allergies, or asthma. Discovering that Tina uses hypoallergenic bedding can indicate a reason why she might feel asthma relief at night. Example Question: What kind of pillows do you have?  Finding: Reports no cats in household (Available) Pro Tip: Environmental factors at home or work can often be primary allergy triggers. Asking Tina if she has a cat might indicate a relevant factor in her recent exacerbation. Example Question: Do you have a cat? Relevant Family History  Finding: Asked family history of asthma  Finding: Reports sister only other family member with asthma (Found) Pro Tip: Soliciting a family history helps you to determine which, if any, conditions are inherited. In asking Tina whether anyone in her family has asthma, you're ascertaining whether Tina's condition is inherited. Example Question: Does anyone else in your family have asthma? Finding: Asked family history of respiratory illness  Finding: Reports no family history of respiratory illness (Found) Pro Tip: People with a family history of respiratory illness are often at a higher risk for asthma. If Tina has a family history of respiratory illness, this could suggest inherited sensitivity. Example Question: Does respiratory illness run in your family?  Finding: Asked family tobacco use  Finding: Reports no family history of tobacco use (Available) Pro Tip: Secondhand smoke can be particularly triggering for asthmatics. Asking whether anyone in Tina's household smokes might indicate a proximate environmental trigger. Example Question: Does anyone in your family use tobacco products? Comments If your instructor provides individual feedback on this assignment, it will appear here.HEENT Results | Turned InC492 Physical Assessment - Oct 2017, C492 Return to Assignment Your Results Reopen Lab Pass  Overview  Transcript  Subjective Data Collection  Objective Data Collection  Documentation Subjective Data Collection: 22 of 32 (68.8%) Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.  Found: Indicates an item that you found.  Available: Indicates an item that is available to be found. Category Scored Items Experts selected these topics as essential components of a strong, thorough interview with this patient. Patient Data Not ScoredA combination of open and closed questions will yield better patient data. The following details are facts of the patient's case. Relevant Medical History  Finding: Asked about history of headache  Finding: Reports occasional headaches (Found) Pro Tip: Sinus problems can result in increased pressure buildup and headaches. Asking Tina if she gets headaches is soliciting information about possible symptoms that she experiences. Example Question: Do you get headaches?  Finding: Asked about frequency and/or duration of headaches  Finding: Headaches occur once a week (Found) Pro Tip: Establishing a timeline for how often Tina gets headaches will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers. Example Question:How frequently do your headaches occur?  Finding: Headaches last "a few hours" (Available) Pro Tip: Establishing a timeline for how long Tina's headaches last will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers. Example Question: For how long do your headaches last?  Finding: Asked about character and location of headaches  Finding: Describes headaches as tight and throbbing (Available) Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Example Question: What do your headaches feel like?  Finding: Describes headache location as behind her eyes (Found)Pro Tip: Specifying the location of pain can narrow and define where Tina's pain is occurring. Soliciting this information allows you to more accurately treat her symptoms. Example Question: Where do you feel your headaches?  Finding: Asked to rate headache pain on a scale  Finding: Rates headaches as a 2 or 3 (Found) Pro Tip: Pain severity might change for a variety of reasons. Asking Tina to rate the severity of her pain on a scale of 1-10 will provide a quantified and relative measurement of her condition. Example Question: On a scale of 1 to 10, how bad are your headaches?  Finding: Asked about headache treatment  Finding: Reports treating headaches with Tylenol (Found) Pro Tip: Tina's response to a question about managing her headaches will reveal the severity of her symptoms, her health literacy, and the way she's complied with previous treatment plans.Example Question: Do you take anything to treat your headaches?  Finding: Reports Tylenol and rest usually resolve symptoms (Found) Pro Tip: Tina's response to a question about managing her headaches will reveal the severity of her symptoms, her health literacy, and the way she's complied with previous treatment plans. Example Question: Does the Tylenol help with your headaches?  Finding: Asked about headache triggers  Finding: Reports headaches only happen when reading or studying (Found) Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Example Question: When do you get headaches?  Finding: Reports that blurry vision and headaches often coincide(Found) Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Example Question: Do your headaches coincide with your blurry vision?  Finding: Asked about vision problems  Finding: Reports occasional blurry vision (Found) Pro Tip: Broad, open questions will allow Tina to describe, in her own words, the specific pain and discomfort that she is experiencing. Example Question: Have you been having problems with your vision?  Finding: Asked about character of blurry vision  Finding: Describes blurry vision as "fuzzy letters" (Available) Pro Tip: Broad, open questions will allow Tina to describe, in her own words, the specific pain and discomfort that she is experiencing.Example Question: What's your blurry vision like?  Finding: Asked about onset and frequency of blurry vision  Finding: Reports worsening vision began within the past year (Available) Pro Tip: Establishing a timeline of when Tina's blurry vision has been worsening will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers. Example Question: When did your vision begin worsening?  Finding: Blurry vision only occurs when reading for long periods (Available) Pro Tip: Establishing a timeline of Tina's blurry vision will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers. Example Question: When does your blurry vision occur?  Finding: Reports noticing it increasing in the past few months(Available) Pro Tip: Establishing a timeline of Tina's blurry vision will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers. Example Question: Have you been getting blurry vision more often?  Finding: Asked about relieving factors for blurry vision  Finding: Reports that resting eyes seems to help (Available) Pro Tip: Tina's response to a question about recent vision management will reveal the severity of her symptoms, her health literacy, and the way she's complied with previous treatment plans. Example Question: What makes your blurry vision go away?  Finding: Asked about vision care  Finding: Reports last vision exam was in childhood (Found) Pro Tip: Asking Tina when her last vision test was will indicate the degree to which she's seen her vision as something that has needed medical attention.Example Question: When was your last vision exam?  Finding: Reports no corrective lens use (Found) Pro Tip: Corrective lenses might indicate a recent change in vision. Asking Tina whether she has glasses or contacts solicits information about her vision history. Example Question: Do you use corrective lenses?  Finding: Asked about current nasal problems  Finding: Reports no current nasal problems (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 ever have a runny nose? Review of Systems  Finding:Asked about eye problems  Finding: Reports occasional itchy eyes (Found) Pro Tip: Environmental factors can often be primary allergy triggers. Asking whether Tina's cat allergy can make her eyes itch can reveal one such trigger. Example Question: Does your cat allergy make your eyes itch?  Finding: Reports no general eye problems other than blurry vision (Found) Pro Tip: Sinusitis can create pressure behind the eyes, causing eye pain. Asking Tina whether she is experiencing eye pain solicits information about possible symptoms. Example Question: Do you have general problems with your eyes?  Finding: Reports no eye pain (Available) Pro Tip: Sinusitis can create pressure behind the eyes, causing eye pain. Asking Tina whether she is experiencing eye pain solicits information about possible symptoms. Example Question: Do you have eye pain? Finding: Reports no eye dryness (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: Do you have eye dryness?  Finding: Reports no eye redness (Available) Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Example Question: Do you have eye redness?  Finding: Asked about triggers for itchy eyes  Finding: Reports cat allergy is trigger for itchy eyes (Available) Pro Tip: Discerning what's making Tina's eyes itch can point to possible triggers like environmental factors, bodily positions, or movements that may have a bearing on Tina's breathing.Example Question: Does being around cats make your eyes itch?  Finding: Asked about treatment of itchy eyes  Finding: Reports not taking medication for itchy eyes (Found) Pro Tip: Tina's response to a question about managing her itchy eyes will reveal the severity of her symptoms, her health literacy, and the way she's complied with previous treatment plans. Example Question: Are you taking medication for your itchy eyes?  Finding: Asked about head problems  Finding: Reports no problems other than occasional headaches (Available) Pro Tip: Broad, open questions will allow Tina to describe, in her own words, the specific pain and discomfort that she is experiencing. Example Question: Other than headaches, are you experiencing head problems? Finding: Reports no current headache (Available) Pro Tip: Assessing how a patient feels in the current moment can allow you to juxtapose their chief complaint alongside symptoms they experience. Asking Tina if she currently has a headache solicits information about how she is feeling now. Example Question: Do you currently have a headache?  Finding: Asked about ear problems  Finding: Reports no general ear problems (Found) Pro Tip: Soliciting a shallow medical history relevant to Tina's chief complaint will allow you to assess her condition relative to past concerns. Example Question: Are you having general ear problems?  Finding: Reports no ear pain (Available) Pro Tip: Ear pain can suggest an ear infection, during which the middle of the ear becomes clogged with fluid and mucous. Asking Tina if she has ear pain might indicate a possible ear infection.Example Question: Do you have ear pain?  Finding: Reports no ear discharge (Available) Pro Tip: Ear discharge is the leakage of blood, pus, or wax from the ear and can be the result of a ruptured eardrum, eczema, or swimmer's ear. Asking whether she's noticed ear discharge could indicate whether she has a ruptured eardrum. Example Question: Do you have ear discharge?  Finding: Asked about changes in hearing  Finding: Reports no hearing changes (Found) 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 changes in your hearing?  Finding: Reports no difficulty hearing(Found) Pro Tip: Soliciting a shallow medical history relevant to Tina's chief complaint will allow you to assess her condition relative to past concerns. Example Question: Do you have difficulty hearing?  Finding: Asked about nasal and sinus problems  Finding: Reports occasional runny nose (Found) Pro Tip: Infected sinuses can manifest as nose problems. Asking Tina about her nasal symptoms solicits information about her sinuses and possible sinus problems. Example Question: Do you have general nose problems?  Finding: Reports no frequent sinus problems (Found) Pro Tip: Infected sinuses can manifest as nose problems. Asking Tina about her nasal symptoms solicits information about her sinuses and possible sinus problems. Example Question: Do you have frequent sinus congestion? Finding: Reports no nosebleeds (Found) Pro Tip: Nosebleeds are often caused by sinusitis. Asking Tina if she ever gets nosebleeds solicits information about her medical history. Example Question: Have you had nosebleeds?  Finding: Asked about triggers of runny nose  Finding: Reports cat allergy is trigger for runny nose (Available) Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Example Question: Do your allergies trigger your runny nose?  Finding: Asked about treatment of runny nose  Finding: Reports not taking medication for runny nose (Available)Pro Tip: Tina's response to a question about managing her runny nose will reveal the severity of her symptoms, her health literacy, and the way she's complied with previous treatment plans. Example Question: Are you taking any medication for your runny nose?  Finding: Reports only treatment is avoiding trigger and showering (Available) Pro Tip: Tina's response to a question about managing her runny nose will reveal the severity of her symptoms, her health literacy, and the way she's complied with previous treatment plans. Example Question: How have you been treating your runny nose?  Finding: Asked about mouth problems  Finding: Reports no general mouth problems (Available) Pro Tip: Broad, open questions will allow Tina to describe, in her own words, the specific pain and discomfort that she is experiencing. Example Question: Have you had general mouth problems?  Finding:Reports no bleeding gums (Available) Pro Tip: If left untreated, gum problems, like abscesses, can result in sinusitis. Asking Tina if she has problems with her gums solicits information about possible causes of her symptoms. Example Question: Have you had bleeding gums?  Finding: Reports no mouth pain (Available) Pro Tip: In some cases, infection can spread to a cheekbone through an infected tooth. Asking Tina if she's had mouth pain might indicate a problem area that has caused infection. Example Question: Have you had mouth pain?  Finding: Reports no mouth sores (Available) Pro Tip: In some cases, infection can spread to a cheekbone through an infection in the mouth. Asking Tina if she has any mouth sores might indicate a problem area that has caused infection. Example Question: Have you had mouth sores?  Finding:Reports no tongue problems (Available) Pro Tip: If left untreated, tongue problems, like abscesses, can result in sinusitis. Asking Tina if she has problems with her tongue solicits information about possible causes of her symptoms. Example Question: Have you had tongue problems?  Finding: Reports no dry mouth (Available) Pro Tip: Sinusitis can result in dry mouth. Asking if Tina's had a dry mouth might indicate a sign of sinusitis. Example Question: Have you had a dry mouth?  Finding: Asked about dentition  Finding: Reports no current dental problems (Available) Pro Tip: In some cases, infection can spread to a cheekbone through an infected tooth. Asking Tina if she's had any dental problems might indicate a problem area that has caused infection. Example Question: Do you have current dental problems? Finding: Reports visit within the last 2 years (Available) Pro Tip: Seeing a dentist regularly can assure that among other things, tooth infections, which can cause sinusitis, do not go untreated. Asking Tina when she last saw a dentist will reveal her health literacy and indicate whether or not her mouth is a problem area. Example Question: When was your last dental visit?  Finding: Reports regular visits in childhood (Available) Pro Tip: Seeing a dentist regularly as a child can lay the foundation for good dental hygiene and prevent infection. Asking Tina how often she saw the dentist as a child will suggest her health and dental history. Example Question: Did you visit the dentist regularly as a child?  Finding: Reports a few cavities in childhood (Available) Pro Tip: In some cases, infection can spread to a cheekbone through an infected tooth. Asking Tina what dental problems she's had might indicate a problem area that has caused infection. Example Question: Did you have cavities as a child? Finding: Asked about throat problems  Finding: Reports no general throat problems (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: Have you been having general throat problems?  Finding: Reports no sore throat (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: Have you had a sore throat?  Finding: Reports no voice changes (Available) Pro Tip: Sinusitis can often lead to tonsil problems and voice changes. Asking Tina if she has noticed any changes to her voice would indicate whether her symptoms might be caused by sinus problems.Example Question: Has your voice changed?  Finding: Asked about lymph node problems  Finding: Reports no general lymph node problems (Found) Pro Tip: Swollen lymph nodes may appear in the neck when an infection is present. Asking Tina whether she has had any problems with her lymph nodes will solicit a history of her condition. Example Question: Have you been having problems with your lymph nodes?  Finding: Reports no painful lymph nodes (Available) Pro Tip: Swollen lymph nodes may appear in the neck when an infection is present. Asking Tina whether her lymph nodes have been painful will solicit a history of her condition. Example Question: Have your lymph nodes been painful?  Finding: Reports no swollen lymph nodes(Found) Pro Tip: Swollen lymph nodes may appear in the neck when an infection is present. Asking Tina whether her lymph nodes have been swollen will solicit a history of her condition. Example Question: Have your lymph nodes been swollen?  Finding: Asked about thyroid problems  Finding: Reports no known thyroid problems (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: Have you been diagnosed with thyroid problems? Relevant Family History  Finding: Asked family history of head problems  Finding: Reports no family history of head problems (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if she has a family history of head problems can reveal generational patterns. Example Question: Do head problems run in your family?  Finding: Reports no family history of migraines (Found) Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if she has a family history of migraines can reveal generational patterns. Example Question: Do you have a family history of migraines?  Finding: Asked family history of eye problems  Finding: Reports no family history of eye problems (Found) Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if she has a family history of eye problems can reveal generational patterns. Example Question: Do you have a family history of eye problems?  Finding:Reports no family history of glaucoma (Available) Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if she has a family history of glaucoma can reveal generational patterns. Example Question: Do you have a family history of glaucoma?  Finding: Asked family history of ear problems  Finding: Reports no family history of ear problems (Found) Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if she has a family history of ear problems can reveal generational patterns. Example Question: Do ear problems run in your family?  Finding: Reports no family history of hearing loss (Found) Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if she has a family history of hearing loss can reveal generational patterns. Example Question: Do you have a family history of hearing loss? Finding: Asked family history of nasal problems  Finding: Reports sister has regular hay fever (Available) Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if she has a family history of hay fever can reveal generational patterns. Example Question: Has anyone in your family had hay fever?  Finding: Asked family history of mouth problems  Finding: Reports no family history of mouth problems (Available) Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if she has a family history of mouth problems can reveal generational patterns. Example Question: Do mouth problems run in your family?  Finding: Reports no family history of dental problems(Available) Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if she has a family history of dental problems can reveal generational patterns. Example Question: Do you have a family history of dental problems?  Finding: Reports no family history of mouth cancer (Available) Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if she has a family history of mouth cancer can reveal generational patterns. Example Question: Do you have a family history of mouth cancer?  Finding: Asked family history of throat and gland problems  Finding: Reports no family history of thyroid problems (Available) Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if she has a family history of thyroid problems can reveal generational patterns. Example Question: Do thyroid problems run in your family? Finding: Reports no family history of lymph node cancers (Available) Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if she has a family history of lymph node cancers can reveal generational patterns. Example Question: Do you have a family history of lymph node cancers?  Finding: Reports no family history of throat cancer (Available) Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if she has a family history of throat cancer can reveal generational patterns. Example Question: Do you have a family history of throat cancer? Comments If your instructor provides individual feedback on this assignment, it will appear here. Skin, Hair, and Nails Results | Turned InC492 Physical Assessment - Oct 2017, C492 Return to Assignment Your Results Reopen Lab Pass  Overview Transcript  Subjective Data Collection  Objective Data Collection  Documentation Subjective Data Collection: 17 of 24 (70.8%) Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.  Found: Indicates an item that you found.  Available: Indicates an item that is available to be found. Category Scored Items Experts selected these topics as essential components of a strong, thorough interview with this patient. Patient Data Not Scored A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case. Relevant Medical History  Finding: Asked about foot wound Finding: Reports wound was swelling, but has improved (Found) Pro Tip: Specific questions about Tina's wound can help you to assess the care that she will need. Asking Tina if her wound has any swelling specifies the symptoms she is experiencing. Example Question: Does your wound have any swelling?  Finding: Reports wound was warm, but has improved (Found) Pro Tip: Specific questions about Tina's wound can help you to assess the care that she will need. Asking Tina if her wound is warm to the touch specifies the symptoms she is experiencing. Example Question: Does your wound feel warm to the touch?  Finding: Reports wound had discharge, but has improved (Found) Pro Tip: Specific questions about Tina's wound can help you to assess the care that she will need. Asking Tina if there is any discharge coming from her wound specifies the symptoms she is experiencing. Example Question: Is discharge coming from your wound? Finding: Reports wound is still a little red (Found) Pro Tip: Specific questions about Tina's wound can help you to assess the care that she will need. Asking Tina if her wound has any redness specifies the symptoms she is experiencing. Example Question: Does your wound have any redness?  Finding: Asked history of slow healing wounds  Finding: Reports no known history of slow healing wounds (Available) Pro Tip: Specific questions about Tina's wounds can help you to assess the care that she will need. Asking Tina if she has a history of slow healing wounds specifies the symptoms she is experiencing. Example Question: Do you have a history of slow healing wounds?  Finding: Asked current wound healing time  Finding:Reports wound was getting worse over the course of a week, but has improved with treatment in the hospital (Available) Pro Tip: Specific questions about Tina's wound can help you to assess the care that she will need. Asking Tina how her foot wound has been healing specifies the symptoms she is experiencing. Example Question: How has your foot wound been healing?  Finding: Asked about history of skin conditions  Finding: Reports acne is only skin condition (Found) Pro Tip: Broad questions like this one enable the patient to establish their chief complaint. Asking Tina about any skin conditions will help to determine any relevant medical history. Example Question: Have you ever had a skin condition?  Finding: Reports no skin cancer (Available) Pro Tip: Soliciting a relevant medical history will help you to more effectively treat your patient. Asking Tina if she has ever been diagnosed with skin cancer solicits important health history information. Example Question:Have you ever been diagnosed with skin cancer?  Finding: Reports no skin rashes (Found) Pro Tip: Soliciting a relevant medical history will help you to more effectively treat your patient. Asking Tina if she has had skin rashes solicits important health history information. Example Question: Have you had skin rashes?  Finding: Reports no sores other than foot wound (Found) Pro Tip: Soliciting a relevant medical history will help you to more effectively treat your patient. Asking Tina if she has sores solicits important health history information. Example Question: Do you have sores?  Finding: Reports skin has only itched in the past due to exposure to cats (Found) Pro Tip: Soliciting a relevant medical history will help you to more effectively treat your patient. Asking Tina if her skin has been itching solicits important health history information. Example Question: Has your skin been itching? Finding: Reports no bruising (Found) Pro Tip: Soliciting a relevant medical history will help you to more effectively treat your patient. Asking Tina if her skin has been bruising solicits important health history information. Example Question: Have you noticed unusual bruising?  Finding: Asked if patient has moles  Finding: Confirms presence of moles (Found) Pro Tip: Monitoring moles is an important step in detecting skin cancer. Asking Tina about her moles solicits important information about her skin. Example Question: Do you have moles anywhere on your body?  Finding: Asked about mole changes  Finding:Reports no known changes in her moles (Found) Pro Tip: Monitoring moles is an important step in detecting skin cancer. Asking Tina about changes in her moles solicits important information about her skin. Example Question: Have your moles changed at all?  Finding: Asked about mole appearance  Finding: Reports moles are "just regular moles" (Available) Pro Tip: Monitoring moles is an important step in detecting skin cancer. Asking Tina what her new moles are like solicits important information about her skin. Example Question: What are your moles like?  Finding: Asked about mole location  Finding: Reports moles are located on her back (Found)Pro Tip: Monitoring moles is an important step in detecting skin cancer. Asking Tina where her moles are located solicits important information about her skin. Example Question: Where are your moles located?  Finding: Asked about acne  Finding: Reports history of acne (Found) Pro Tip: Acne is a skin disorder resulting from hormones and various other substances on the skin's oil glands. Asking Tina if she has a history of acne solicits important information about her health history. Example Question: Do you have a history of acne?  Finding: Reports current acne (Found) Pro Tip: Acne is a skin disorder resulting from hormones and various other substances on the skin's oil glands. Asking Tina if she currently has acne solicits important information about her health history. Example Question: Do you have acne now?  Finding:Reports having acne "since middle school," though it got better for a little while, and then worse again recently (Found) Pro Tip: Acne is a skin disorder resulting from hormones and various other substances on the skin's oil glands. Asking Tina when she developed acne solicits important information about her health history. Example Question: When did you develop acne?  Finding: Asked about acne treatment  Finding: Reports last time seeing doctor about acne was in high school (Found) Pro Tip: Acne is a skin disorder resulting from hormones and various other substances on the skin's oil glands. Asking Tina when she last saw a doctor about her acne solicits important information about her health history and any treatment plan she was following. Example Question: When was the last time you saw a doctor about acne?  Finding: Reports doctor gave her "antibiotics" and other treatments in high school for acne but "nothing helped" (Found) Pro Tip: Acne is a skin disorder resulting from hormones and various other substances on the skin's oil glands. Asking Tina how the doctor treated her acnesolicits important information about her health history and any treatment plan she was following. Example Question: How did the doctor treat your acne?  Finding: Reports antibiotic for acne was tetracycline (Found) Pro Tip: Acne is a skin disorder resulting from hormones and various other substances on the skin's oil glands. Asking Tina what antibiotic she was prescribed for her acne solicits important information about her health history and any treatment plan she was following. Example Question: What antibiotic were you prescribed for your acne?  Finding: Reports only current treatment is washing her face every night (Found) Pro Tip: Acne is a skin disorder resulting from hormones and various other substances on the skin's oil glands. Asking Tina how she treats her acne solicits important information about her health history. Example Question: How do you treat your acne now?  Finding: Asked acne location Finding: Reports acne is located on her face and back (Found) Pro Tip: Acne is a skin disorder resulting from hormones and various other substances on the skin's oil glands. Asking Tina where her acne is located solicits important information about her health history. Example Question: Where is your acne located?  Finding: Asked about changes in skin color  Finding: Confirms skin on her neck "looks a little weird" (Available) Pro Tip: Changes in skin color can be the symptom of various diseases, disorders, or conditions. Asking Tina about changes in skin color solicits relevant information about a symptom she might be experiencing. Example Question: Have there been any changes in your skin color?  Finding: Reports skin on her neck is darker than it used to be (Available) Pro Tip: Changes in skin color can be the symptom of various diseases, disorders, or conditions. Asking Tina about changes in skin color solicits relevant information about a symptom she might be experiencing.Example Question: How has the skin on your neck changed?  Finding: Reports skin is getting darker in the "folds around" her neck (Available) Pro Tip: Changes in skin color can be the symptom of various diseases, disorders, or conditions. Asking Tina about where she is experiencing changes in skin color solicits relevant information about a symptom she might be experiencing. Example Question: Where on your neck is darker?  Finding: Asked about neck skin character  Finding: Reports neck skin is not itchy (Found) Pro Tip: Establishing information about the character of Tina's skin, like whether the skin on her neck is itchy, will allow you to compare her symptoms and assess her condition. Example Question: Is the skin on your neck itchy?  Finding: Reports neck skin does not hurt(Available) Pro Tip: Establishing information about the character of Tina's skin, like whether the skin on her neck hurts, will allow you to compare her symptoms and assess her condition. Example Question: Does the skin on your neck hurt?  Finding: Reports neck skin "could be getting thicker" (Available) Pro Tip: Establishing information about the character of Tina's skin, like whether the skin on her neck is changing, will allow you to compare her symptoms and assess her condition. Example Question: Has the skin on your neck thickened?  Finding: Asked about neck skin change onset  Finding: Reports noticing skin darkening in the "last few months," but skin was darker in a picture from "a few years ago" (Available) Pro Tip: Establishing information about the character of Tina's skin, like when she noticed the skin on her neck changing, will allow you to compare her symptoms and assess her condition. Example Question: When did you notice the skin on your neck change? Finding: Asked about changes in body hair  Finding: Confirms increase in body hair (Found) Pro Tip: Changes in body hair can indicate a change in hormone levels. Asking Tina if her body hair has changed solicits important health history information. Example Question: Have you had changes in your body hair?  Finding: Reports increased hair on face (Found) Pro Tip: Changes in body hair can indicate a change in hormone levels. Asking Tina if the amount of hair on her face has increased solicits important health history information. Example Question: Do you have facial hair?  Finding: Reports increased hair on abdomen (Found) Pro Tip: Changes in body hair can indicate a change in hormone levels. Asking Tina if the amount of hair on her abdomen has increased solicits important health history information.Example Question: Do you have a lot of body hair?  Finding: Reports increased hair around nipples (Available) Pro Tip: Changes in body hair can indicate a change in hormone levels. Asking Tina if the amount of hair around her nipples has increased solicits important health history information. Example Question: Do you have hair around your nipples?  Finding: Asked about body hair onset  Finding: Reports body hair has been increasing "for a really long time" (Found) Pro Tip: Changes in body hair can indicate a change in hormone levels. Asking Tina when the amount of body hair started to increase solicits important health history information. Example Question: When did the amount of body hair start to increase? Review of Systems Finding: Asked about eczema  Finding: Reports no history of eczema (Found) Pro Tip: Establishing information about any skin condition Tina experiences will help you to most effectively treat her symptoms. Asking Tina if she has a history of eczema solicits important health information. Example Question: Do you have a history of eczema?  Finding: Reports no current eczema (Found) Pro Tip: Establishing information about any skin condition Tina experiences will help you to most effectively treat her symptoms. Asking Tina if she currently has eczema solicits important health information. Example Question: Do you have eczema now?  Finding: Asked about hair and scalp problems  Finding: Reports no scalp problems(Found) Pro Tip: Establishing information about any skin condition Tina experiences will help you to most effectively treat her symptoms. Asking Tina if she has scalp problems solicits important health information. Example Question: Do you have scalp problems?  Finding: Reports no problems with her head hair (Available) Pro Tip: Establishing information about any skin condition Tina experiences will help you to most effectively treat her symptoms. Asking Tina if she had problems with the hair on her head solicits important health information. Example Question: Have there been problems with the hair on your head?  Finding: Reports no dandruff (Found) Pro Tip: Establishing information about any skin condition Tina experiences will help you to most effectively treat her symptoms. Asking Tina if she has dandruff solicits important health information. Example Question: Do you have dandruff?  Finding: Asked about nail changes Finding: Reports no nail changes (Found) Pro Tip: Establishing information about any skin condition Tina experiences will help you to most effectively treat her symptoms. Asking Tina if she has had changes in her nails solicits important health information. Example Question: Have you had nail changes?  Finding: Reports no nail fungus (Available) Pro Tip: Establishing information about any skin condition Tina experiences will help you to most effectively treat her symptoms. Asking Tina if she has nail fungus solicits important health information. Example Question: Do you have nail fungus?  Finding: Asked about lumps anywhere on body  Finding: Reports no known lumps currently on her body (Found)Pro Tip: Establishing information about any skin condition Tina experiences will help you to most effectively treat her symptoms. Asking Tina if she has lumps anywhere on her body solicits important health information. Example Question: Do you have lumps anywhere on your body?  Finding: Asked about skin dryness  Finding: Reports skin on her arms and legs gets dry (Found) Pro Tip: Establishing information about any skin condition Tina experiences will help you to most effectively treat her symptoms. Asking Tina if her skin gets dry solicits important health information. Example Question: Does your skin get dry?  Finding: Reports treating dry skin with lotion (Found) Pro Tip: Establishing information about any skin condition Tina experiences will help you to most effectively treat her symptoms. Asking Tina how she treats skin dryness solicits important health information. Example Question: How do you treat skin dryness? Finding: Asked about tanning and sun exposure  Finding: Reports no tanning (Found) Pro Tip: Sun exposure can directly affect a patient's skin. Asking Tina about her sun exposure habits, like whether or not she tans, will help you to determine whether she is at risk for skin cancer. Example Question: Do you tan?  Finding: Reports "almost always" using sun block (Found) Pro Tip: Sun exposure can directly affect a patient's skin. Asking Tina about her sun exposure habits, like how often she uses sun block, will help you to determine whether she is at risk for skin cancer. Example Question: How often do you use sun block? Relevant Family History  Finding: Asked family history of hair problems Finding: Reports no family history of hair problems (Available) Pro Tip: Family histories might indicate a genetic predisposition to certain conditions. Asking Tina if she has a family history of hair problems solicits relevant health history. Example Question: Does your family have a history of hair problems?  Finding: Reports belief that women in family do not have increased body hair (Available) Pro Tip: Example Question: Is increased body hair common for women in your family?  Finding: Asked family history of skin conditions  Finding: Reports no family history of skin conditions (Available) Pro Tip: Example Question: Does your family have a history of skin conditions? Finding: Reports no family history of skin cancer (Available) Pro Tip: Example Question: Does skin cancer run in your family? Comments If your instructor provides individual feedback on this assignment, it will appear here. Health History Results | Turned InC492 Physical Assessment - Oct 2017, C492 Return to Assignment Your Results Reopen Lab Pass  Overview  Transcript  Subjective Data Collection  Objective Data Collection  Education & Empathy  Documentation  Health History Tips and Tricks Subjective Data Collection: 52 of 88 (59.1%) Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.  Found:Indicates an item that you found.  Available: Indicates an item that is available to be found. Category Scored Items Experts selected these topics as essential components of a strong, thorough interview with this patient. Patient Data Not Scored A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case. History of Presenting Illness: Foot Wound  Finding: Established chief complaint  Finding: Reports pain (Found) Pro Tip: Beginning your conversation with your patient by asking an open-ended question is a best practice for gauging your patient's general condition. Example Question: How severe is the pain? Finding: Reports open foot wound (Found) Pro Tip: If a patient mentions pain, it's important to determine what specifically is causing her pain. Example Question: What's causing your pain?  Finding: Asked to rate pain on a scale  Finding: Rates present pain at a 7 out of 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: Describes the pain as throbbing(Available) 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: Describes the pain as sharp when she attempts to stand (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: What is the pain like when you stand on your foot?  Finding: Initial injury occurred 1 week ago (Found) 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 the pain start?  Finding: Pain has increased in the past 2 days (Found)Pro Tip: Finding out how the patient's pain has changed will give you insight into the acceleration of infection. Example Question: How has the pain changed over time?  Finding: Reports feeling pain radiating into ankle (Found) 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: 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: Clarified location of wound  Finding:Confirmed that right foot is injured (Available) 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: Confirmed that wound is on the plantar surface of her foot (Available) 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: Determined details of the injury  Finding: 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 no 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: Was not drinking at the time of the injury (Available) Pro Tip: Finding out if alcohol is involved in an injury can give you insight into a patient's potential substance abuse, and can uncover aggravating factors. Example Question: Did you have any alcoholic drinks before your injury?  Finding: Was not wearing shoes 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: Has not seen a healthcare provider for the injury (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: Began noticing pus 2 days ago (Found) 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 about character of drainage from the foot wound  Finding: Describes pus as white or yellow in color (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: Reports no odor from the wound (Found) 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: Describes wound care regimen of cleaning and bandaging (Found) Pro Tip: Listening to a patient's wound care routine provides insight into the history of the wound, as well as the patient's health literacy. Example Question: How did you treat your foot at home?  Finding: Cleaned 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: Cleaned wound with hydrogen peroxide(Available) Pro Tip: Determining what products a patient used to clean a wound provides insight into the history of the wound, as well as the patient's health literacy. Example Question: What did you use to clean the wound?  Finding: Changed bandage twice a day (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: Applied 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: Asked about other foot wound symptoms Finding: Reports swelling around foot wound (Available) 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: Noticed swelling getting worse 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 (Available) 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 (Available) 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: Pain affects ability to walk (Available) Pro Tip: Learning the impact of your patient's wound on daily activities helps inform your plan for care. Example Question: Does your injury impact your ability to walk?  Finding: Pain affects job performance (Available) Pro Tip: Learning how severely the wound has interfered with an essential aspect of daily life, and can uncover a source of stress for the patient. Example Question: Does your foot pain affect your work? Finding: Pain prevented her from attending 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?  Finding: Asked about recent fever  Finding: Reports recent feverish episode (Found) Pro Tip: The presence or absence of fever can indicate if an infection is approaching sepsis, a life-threatening condition. Example Question: Are you feeling feverish right now? Past Medical History: Diabetes  Finding: Asked details about diabetes diagnosis Finding: Diagnosed as an adult (Available) Pro Tip: Learning the diagnosis date of your patient's illness is an essential element of the illnesses history. Example Question: When were you diagnosed with diabetes?  Finding: Specific age of diagnosis is 24 years old (Available) 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 (Found) 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 diet  Finding: Reports that she tries to manage diabetes with diet (Found) Pro Tip: Understanding how your patient cares for her diabetes is an essential element to learning the history of her illness. Example Question: Do you follow a diabetic diet?  Finding: Reports "staying away from sweets" (Found) Pro Tip: Asking your patient specifically about sugar intake can help you understand the history of her diabetes as well as her health literacy. Example Question: Tell me more about any sugars you consume.  Finding: Reports drinking diet coke instead of regular (Available) Pro Tip: Particularly for diabetic patients, asking about intake of drinks that contain sugar can reveal additional sources of carbohydrates that the patient may not consider. Example Question: Do you drink sugary drinks? Finding: Asked about current diabetes medication use  Finding: Does not currently take medication for diabetes (Available) 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: Used to take diabetes medication (Available) Pro Tip: Asking about diabetes medication is important to understanding if your patient's disease is under control. Example Question: Have you ever taken medication for your diabetes?  Finding: Previous medication was prescription metformin(Available) Pro Tip: Asking about diabetes medication is important to understanding if your patient's disease is under control. Example Question: Do you remember what you were prescribed for diabetes?  Finding: Last use of medication was 3 years ago (Available) Pro Tip: Asking about diabetes medication is important to understanding if your patient's disease is under control. Example Question: When was the last time you took your diabetes medication on a regular basis?  Finding: Explored the reasons the patient stopped her diabetes regimen  Finding: Reports that she "got sick of dealing with it" (Available) Pro Tip: Asking reasons for noncompliance can reveal information about your patient's health literacy, side effects, financial situation, and more. Example Question: Why aren't you taking your diabetes medication? Finding: Reports disliking metformin side effects (Available) Pro Tip: Asking about side effects from medication can provide information about your patient's reaction to treatment. Example Question: Did the metformin cause any side effects?  Finding: Describes that she didn't like checking sugar and taking daily pills (Available) Pro Tip: Asking reasons for noncompliance can reveal information about your patient's health literacy, side effects, financial situation, and more. Example Question: What's preventing you from taking your diabetes medication?  Finding: Asked about blood glucose monitoring  Finding: Does not monitor blood glucose (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: Last checked blood sugar a month ago (Found) 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. Example Question: What are your usual blood sugar levels?  Finding: Asked about increased thirst  Finding: Reports increased thirst (Available)Pro Tip: Your patient's thirst and fluid intake can offer insight into underlying medical conditions. Example Question: Have you been more thirsty lately?  Finding: Reports increased water intake (Available) Pro Tip: Your patient's thirst and fluid intake can offer insight into underlying medical conditions. Example Question: Are you drinking more water than normal?  Finding: Asked about frequency of urination  Finding: Reports more frequent urination (Available) Pro Tip: Your patient's urination habits can offer insight into underlying medical conditions and general health. Example Question: Have you been urinating more often than usual?  Finding:Reports urinating "every hour or so" during the day (Available) Pro Tip: Your patient's urination habits can offer insight into underlying medical conditions and general health. Example Question: How often do you urinate during the day?  Finding: Reports urinating 2 to 3 times during the night (Available) Pro Tip: Your patient's urination habits 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 food intake  Finding: Last meal was dinner at home (Found) Pro Tip: Finding out when 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: When was your last meal? Finding: Last meal consisted of baked chicken and a dinner roll (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: Breakfast is usually a muffin or pumpkin bread (Found) Pro Tip: Asking comprehensive questions about a patient's diet includes finding out what she typically eats for breakfast, which contributes to your understanding of the complete patient's diet and nutrition status. Example Question: What is your typical breakfast?  Finding: Lunch is usually a sandwich (Found) Pro Tip: Asking comprehensive questions about a patient's diet includes finding out what she typically eats for lunch, which contributes to your understanding of the patient's complete diet and nutrition status. Example Question: What is your typical lunch? Finding: Dinner is usually a home-cooked meat dish and side of vegetables (Found) Pro Tip: Asking comprehensive questions about a patient's diet includes finding out what she typically eats for dinner, which contributes to your understanding of the patient's complete diet and nutrition status. Example Question: What is your typical dinner?  Finding: Snacks are pretzels or French fries (Available) Pro Tip: Asking a patient about snacking habits and choices can help you understand additional caloric, fat, and sugar intake that the patient may overlook. Example Question: What do you typically eat for snacks?  Finding: Asked about change in appetite  Finding: Reports an increase in appetite (Available) Pro Tip: Changes in appetite can indicate underlying health conditions.Example Question: Have you noticed an increase in appetite?  Finding: Reports increase in appetite began a month ago (Available) Pro Tip: Determining the onset of a symptom can reveal important details about underlying health conditions. Example Question: When did you notice the increase in your appetite?  Finding: Asked about weight loss  Finding: Reports recent weight loss (Available) Pro Tip: Weight changes can be indicative of underlying health problems or an unhealthy lifestyle. Example Question: Have you had any recent weight changes?  Finding: Lost 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: 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 weight loss by asking if it was intentional  Finding: Weight loss was not caused by intent or lifestyle changes (Available) Pro Tip: Unintentional weight loss can be a sign of underlying medical conditions or a reflection of unhealthy lifestyle choices. Asking your patient about this can inform your care plan. Example Question: Was your weight loss intentional? Past Medical History: Asthma Finding: Asked details about asthma and breathing problems  Finding: Last breathing problem was 3 days ago (Available) Pro Tip: Asthma can have a profound impact on health, and it is important to learn about the characteristics of your patient's condition. Example Question: When did you last have issues with asthma?  Finding: Describes asthma symptoms as chest tightness and inability to "take in air" (Available) Pro Tip: Asthma can have a profound impact on health, and it is important to learn about the characteristics of your patient's condition. Example Question: What do your asthma symptoms feel like?  Finding: Describes wheezing as an asthma symptom (Available) Pro Tip: Asthma can have a profound impact on health, and it is important to learn about the characteristics of your patient's condition. Example Question:Do you ever wheeze?  Finding: Reports last asthma attack was in high school (Available) Pro Tip: Asthma can have a profound impact on health, and it is important to learn about the characteristics of your patient's condition. Example Question: When was your last asthma attack?  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. Example Question: Have you been hospitalized in the past?  Finding: Last hospitalization was for asthma (Found)Pro Tip: Learning the details of your patient's past hospitalizations is crucial to understanding her medical history. Example Question: Why were you hospitalized last time?  Finding: Last hospitalization was age 16 (Available) Pro Tip: Learning the details of your patient's past hospitalizations is crucial to understanding her medical history. Example Question: When was your last hospitalization?  Finding: Estimates 5 total hospitalizations for asthma as a child and teen (Available) Pro Tip: Learning the details of your patient's past hospitalizations is crucial to understanding her medical history. Example Question: How many times have you been hospitalized?  Finding: Reports that she has never been intubated during a hospitalization (Available) Pro Tip: Discovering past intubations can reveal details about the history and severity of your patient's disease.Example Question: Have you ever been intubated for asthma?  Finding: Asked about asthma diagnosis  Finding: Diagnosed with asthma in childhood (Available) Pro Tip: Asthma can have a profound impact on health, and it is important to learn about the characteristics of your patient's condition. Example Question: When were you diagnosed with asthma?  Finding: 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 characteristics of your patient's condition. Example Question: At what age were you diagnosed with asthma?  Finding: Asked about asthma management Finding: Uses 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: Inhaler is Proventil (albuterol) (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: Last use of inhaler was 3 days ago (Found) 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:Uses inhaler 2 or 3 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: Prescribed usage is 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 of your inhaler are you prescribed?  Finding: Sometimes needs more than 2 puffs to control symptoms (Found) Pro Tip: Asking about a medication's efficacy is an important part of planning future care for your patient. Example Question: Does your inhaler effectively relieve your symptoms? Finding: Asked about asthma triggers  Finding: 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: Asthma triggered by dust (Available) 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: Asthma triggered by running up stairs (Available) Pro Tip: Asthma's effect on the lungs can be exacerbated by physical activity. This can impact your patient's quality of life.Example Question: Does physical activity trigger your asthma?  Finding: Reports no 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? Past Medical History: Allergies  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:Asked follow up on cat allergy reaction  Finding: Reports sneezing, itchy eyes, and wheezing (Found) Pro Tip: Determining a patient's reaction to an allergen is essential to gauge if the allergy is life-threatening. Example Question: What is your reaction to cats?  Finding: Asked if the patient is allergic to latex  Finding: Denies latex allergy (Found) Pro Tip: Confirming absence or presence of a latex allergy is essential in a hospital setting, where some instruments have latex parts. Example Question: Are you allergic to latex?  Finding: Asked if the patient is allergic to any medications  Finding:Reports a penicillin allergy (Found) Pro Tip: Asking specifically about allergies to medications is crucial to the patient's safety while she is in your care. Example Question: What medication allergies do you have?  Finding: Asked about penicillin reaction  Finding: Reports that penicillin resulted in hives in childhood (Found) Pro Tip: 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: Asked if the patient has any food allergies  Finding: Denies food allergies (Available)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 (Available) 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: 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? Past Medical History: Immunizations  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 all necessary childhood immunizations(Available) Pro Tip: Discovering information about your patient's childhood vaccinations reveals information about both her medical history and her susceptibility to infectious disease. Example Question: Did you receive childhood vaccinations?  Finding: Asked if the patient has received a flu vaccine  Finding: Has not received annual flu vaccine (Available) 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: 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? Past Medical History: Medication Use  Finding: Asked about use of pain medication  Finding: Has been taking OTC Advil (ibuprofen) 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: 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:Asked about pain medication regimen at home  Finding: Took Advil (ibuprofen) for 2 days (Available) Pro Tip: Discovering how long your patient has been taking pain medication is a crucial part of the history of her condition or injury. Example Question: How many days have you needed pain medication?  Finding: Took 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: Took 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 that Advil (ibuprofen) is "not extra strength" (Found) 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 efficacy of pain medication at home  Finding: Reports that Advil (ibuprofen) "only helped a little" (Available) 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: Pain returned in full every few hours (Available) 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: 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: Occasionally takes Advil (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: Occasionally takes Tylenol (acetaminophen) 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: Does not take vitamin supplements (Found) 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 vitamins?  Finding: Does not take herbal supplements (Found) 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 herbal supplements?PsychoSocial History: Education  Finding: Asked about patient's level of education  Finding: Currently working toward undergraduate degree (Available) 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: Asked what subject the patient is studying in college  Finding: Majoring in 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? Psychosocial History: Daily Life Finding: Discussed the patient's stress level  Finding: Reports stress related to injury, missing work and school, and cost of care (Available) Pro Tip: Stress can cause both physical and mental health problems and complications. Determining your patient's stress level is part of an overall picture of her health. Example Question: Can you tell me about your stress level?  Finding: Asked about patient's living situation  Finding: Lives at home with mother and sister (Found) 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 that family members will be able to help with activities (Found) 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. PsychoSocial History: Substances  Finding: Asked about illicit drug use  Finding: Reports past history of 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 experimented with drugs?  Finding: Followed up on patient's marijuana use  Finding: Last use was at age 20 or 21(Available) Pro Tip: When a patient reports drug use, it's important to determine when exactly when she last took the drug, which, if recent, can interfere with medications. Example Question: When did you last smoke marijuana?  Finding: Stopped because of health reasons and lost 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 the quantity of alcoholic drinks consumed  Finding: 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 their habitual use. Example Question: How many nights a week do you drink alcohol?  Finding: Reports no more than 6 to 10 alcoholic drinks per month (Available) Pro Tip: Finding out the patient's estimate of their number of drinks each month helps you understand their alcohol use patterns over time. Example Question: How many alcoholic drinks do you have in a month?  Finding:Asked about tobacco use  Finding: Denies smoking tobacco (Found) Pro Tip: Finding out if a patient smokes cigarettes is important to understanding her overall health, and is a potential factor in delayed wound healing. Example Question: Have you ever smoked cigarettes?  Finding: Asked about secondhand smoke  Finding: Denies exposure to secondhand smoke (Available) 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 History: 3 Generations  Finding: Asked about mother's health Finding: Mother diagnosed with hypertension (Found) Pro Tip: Asking specifically about each family member's health conditions can help you understand how inherited diseases impact your patient's health history. Example Question: Does your mother have health conditions?  Finding: Mother diagnosed with high cholesterol (Found) Pro Tip: Asking specifically about each family member's health conditions can help you understand how inherited diseases impact your patient's health history. Example Question: Does your mother have health conditions?  Finding: Asked about father's health  Finding: Father diagnosed with Type 2 diabetes (Available) Pro Tip: Asking specifically about each family member's health conditions can help you understand how inherited diseases impact your patient's health history.Example Question: Does your father have health conditions?  Finding: Father diagnosed with hypertension (Available) Pro Tip: Asking specifically about each family member's health conditions can help you understand how inherited diseases impact your patient's health history. Example Question: Does your father have health conditions?  Finding: Father diagnosed with high cholesterol (Available) Pro Tip: Asking specifically about a family member's health conditions can help you understand how inherited diseases impact your patient's health history. Example Question: Does your father have health conditions?  Finding: Asked father's age at death  Finding: Died at age 58 (Available)Pro Tip: Determining the age of death of a family member can provide insight into risk factors for inherited diseases, or can reveal stress caused by premature death. Example Question: How old was your father when he died?  Finding: Asked cause of father's death  Finding: Cause of death: car accident (Available) Pro Tip: Determining the cause of death indicates whether the death was from a health condition that the patient may share, or whether it was accidental. Example Question: What caused your father's death?  Finding: Followed up to ask about coping after father's death  Finding: Reports grief at the time but feeling "at peace" with it now (Available) Pro Tip: Communicating empathetically about grief builds rapport and can provide insight into your patient's lifestyle, stress factors, mental health, and more. Example Question:How are you coping with your father's death?  Finding: Asked about paternal grandfather's health  Finding: Paternal grandfather diagnosed with Type 2 diabetes (Available) Pro Tip: Asking specifically about each family member's health conditions can help you understand how inherited diseases impact your patient's health history. Example Question: Does your paternal grandfather have health conditions?  Finding: Paternal grandfather diagnosed with hypertension (Available) Pro Tip: Asking specifically about each family member's health conditions can help you understand how inherited diseases impact your patient's health history. Example Question: Does your paternal grandfather have health conditions?  Finding: Paternal grandfather diagnosed with high cholesterol (Available)Pro Tip: Asking specifically about each family member's health conditions can help you understand how inherited diseases impact your patient's health history. Example Question: Does your paternal grandfather have health conditions?  Finding: Asked about paternal grandmother's health  Finding: Paternal grandmother diagnosed with hypertension (Available) Pro Tip: Asking specifically about each family member's health conditions can help you understand how inherited diseases impact your patient's health history. Example Question: Does your paternal grandmother have health conditions?  Finding: Asked about maternal grandfather's health  Finding: Maternal grandfather diagnosed with hypertension (Available) Pro Tip: Asking specifically about each family member's health conditions can help you understand how inherited diseases impact your patient's health history. Example Question:Does your maternal grandfather have health conditions?  Finding: Maternal grandfather diagnosed with high cholesterol (Available) Pro Tip: Asking specifically about each family member's health conditions can help you understand how inherited diseases impact your patient's health history. Example Question: Does your maternal grandfather have health conditions?  Finding: Asked about maternal grandmother's health  Finding: Maternal grandmother diagnosed with hypertension (Available) Pro Tip: Asking specifically about each family member's health conditions can help you understand how inherited diseases impact your patient's health history. Example Question: Does your maternal grandmother have health conditions?  Finding: Maternal grandmother diagnosed with high cholesterol (Available)Pro Tip: Asking specifically about each family member's health conditions can help you understand how inherited diseases impact your patient's health history. Example Question: Does your maternal grandmother have health conditions?  Finding: Asked about brother's health  Finding: Reports no diagnosed health problems (Found) Pro Tip: Asking specifically about each family member's health conditions can help you understand how inherited diseases impact your patient's health history. Example Question: Does your brother have health conditions?  Finding: Asked about sister's health  Finding: Sister diagnosed with asthma (Found) Pro Tip: Asking specifically about each family member's health conditions can help you understand how inherited diseases impact your patient's health history. Example Question:Does your sister have health conditions? Family History: Inherited Risk Factors  Finding: Asked about family history of diabetes  Finding: Father and paternal grandfather have diabetes (Available) Pro Tip: Asking about trends 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 anyone else in your family have diabetes?  Finding: Asked about family history of asthma  Finding: Younger sister has asthma (Found) Pro Tip: Asking about trends 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 anyone else in your family have asthma?  Finding: Asked about family history of obesity  Finding: Confirms that family members are overweight (Available) Pro Tip: Asking about trends 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 cancer  Finding: Paternal grandfather died of colon cancer (Found) Pro Tip: Asking about trends 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: Have you had any family members with cancer? Finding: Asked about family history of thyroid issues  Finding: No known family history of thyroid issues (Available) Pro Tip: Asking about trends 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 (Available) 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: No known family history of headaches (Available) Pro Tip: Asking about trends 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 general indicators of health  Finding: Reports no recent or frequent illness (Available) Pro Tip: Asking about recent or frequently presenting illness 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 been sick recently?  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 this topic 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 this topic may uncover additional problems, such as sleep disturbance, not discovered during the discussion of the patient's chief complaint. Example Question: Have you noticed changes in your sleep?  Finding: Reports no 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 this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint. Example Question: Have you had chills?  Finding:Reports no 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: Reports no history of depression (Available) Pro Tip: Asking about 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: Reports no history of suicidal ideation or attempts (Found) Pro Tip: Asking about 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 withthoughts 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: Reports no diagnosed mental health conditions (Available) Pro Tip: Asking about about the patient's mental health history 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: Have you ever been diagnosed with a mental health condition?  Finding: Asked about review of systems for head  Finding: Reports occasional headaches (Found) 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: Reports no current headache (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 have a headache?  Finding: Reports no 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: Reports no general ear problems (Found)Pro Tip: Asking about ear 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 ear problems?  Finding: Reports no change in hearing (Found) 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: Reports no 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: Reports no ear pain(Found) Pro Tip: Ear pain can suggest an ear infection, during which the middle of the ear becomes clogged with fluid and mucous, which can affect hearing. Asking Tina if she has ear pain might indicate a possible ear infection and a reason for changes in her hearing. Example Question: Have you had ear pain?  Finding: Reports no ear discharge (Available) Pro Tip: Ear discharge is the leakage of blood, pus, or wax from the ear and can be the result of a ruptured eardrum, eczema, or swimmer's ear. Asking whether she's noticed ear discharge could indicate whether she has a ruptured eardrum. Example Question: Have you had ear discharge?  Finding: Asked about review of systems for eyes and vision  Finding: Reports changes in 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: Reports no corrective lenses (Found) 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: Reports no 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: Reports no dry eyes (Available)Pro Tip: Dry eyes occur when the eyes do not produce enough tears to lubricate them. Asking Tina if she has dry eyes solicits information about one particular symptom. Example Question: Have you had dry eyes?  Finding: Asked about review of systems for nose  Finding: Reports infrequent 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: Have you had nose problems?  Finding: Reports no current nose problems (Available) Pro Tip: Asking about symptoms, such as nose problems, is one possible component of a review of systems interview. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint, such as allergic reactions, infection, or physical trauma. Example Question: Do you have any recent nose problems? Finding: Reports occasional sneezing around cats and dust (Found) Pro Tip: Asking about symptoms, such as frequent sneezing, 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 additional allergens that could exacerbate existing triggers such as allergies and asthma. Example Question: Have you been sneezing?  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 no frequent sinus problems (Found) 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: Reports no 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: Reports no 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: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: Reports no general mouth problems (Found) Pro Tip: Asking about symptoms, such as general mouth 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 no 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: Reports no 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: Reports no 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: Reports no mouth sores (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 sores? Finding: Reports no 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: Reports no 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: Reports no 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: Reports no current 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 infections that can by the underlying cause of many health issues. Example Question: Have you had any recent dental problems?  Finding: Asked about review of systems for neck, throat and glands  Finding: Reports no difficulty swallowing (Found) 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: Reports no 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: Reports no general 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: Reports no history of frequent throat problems (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: Reports no swollen glands(Available) Pro Tip: Asking about a patient's glands in general could include lymph nodes or thyroid glands. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint. Example Question: Do you have any swollen glands?  Finding: Reports no 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: Reports no general neck pain (Available) Pro Tip: Asking about the presence of neck pain is one possible component of a review of systems interview. The patient’s response to these questions may uncover additional not discovered during discussion of the patient’s chief complaint. Example Question: Have you had neck pain?  Finding: Asked about review of systems for respiratory Finding: Reports no 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: Reports no 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: Reports no current chest tightness (Found) 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: Reports no pain while breathing (Found) 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: Reports no 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: Reports no chest pain or discomfort (Found)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: Reports no 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: Reports no irregular heartbeat (Found) 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: Reports no 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: Reports no 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: Reports no circulation problems (Available) Pro Tip: Poor circulation is the result of other diseases like obesity, diabetes, or cardiac conditions. Asking Tina whether she's experienced poor circulation indicates whether she might suffer from underlying cardiac concerns. Example Question: Do you have circulation problems?  Finding: Asked review of systems for gastrointestinal Finding: Reports no general gastrointestinal problems (Found) Pro Tip: Any gastrointestinal symptom could make the patient uncomfortable, or be a sign of a change in patient status. Starting with a general question allows the patient to prioritize the information herself. Example Question: Do you have a history of gastrointestinal problems?  Finding: Reports no 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: Reports no 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: Reports no stomach pain (Found) 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: Reports no changes 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: Reports no 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: Reports no constipation (Found) 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: Reports no 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: Reports no 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: Reports no dysuria (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 nocturia (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 polyuria (Available) Pro Tip: Frequent urination can be a sign of uncontrolled blood sugar or UTI. As a currently presenting symptom, polyuria could result in a change to the patient's care plan. A history of polyuria could be a symptom of genitourinary or endocrine problems such as diabetes. Example Question: Do you urinate frequently?  Finding: Reports no hematuria (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: Reports no 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:Reports no 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: Reports no history of urinatry 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: Last menstrual period was 3 weeks ago (Found) 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 (Found) 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: Reports no past pregnancies (Found) 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: Reports no 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: Reports no history of STIs (Found) 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: Reports no 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: Reports no muscle pain (Available) Pro Tip: Asking about muscle pain is one possible component of a review of systems interview. The most common causes of muscle pain are strain, overuse, illness, or infection. Example Question: Do you have muscle pain?  Finding: Reports no 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: Reports no 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: Reports no 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: Reports no dizziness or vertigo (Found) 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: Reports no light-headedness (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: Reports no tingling (Found) 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: Reports no 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: Reports no loss of sensation (Found) 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: Reports no problems with balance or disequilibrium (Available) Pro Tip: Problems with balance can indicate neurological problems, or issues with the inner ear. Asking your patient about past fractures may uncover additional problems not discovered during discussion of the patient’s chief complaint. Example Question: Do you lose your balance often?  Finding: Asked review of systems for skin, hair and nails  Finding: Reports acne (Available) Pro Tip: Adult acne can suggest stress or changes in hormone levels. Asking Tina about her present acne and history of acne can help you understand any skin conditions or hormonal changes. Example Question: Do you still have acne?  Finding: Reports excessive facial or body hair (Available) Pro Tip: Increases in body hair can suggest changes in hormone levels. The patient’s response to these questions may uncover additional problems not discovered during discussion of the patient’s chief complaint.Example Question: Do you have facial hair?  Finding: Reports changes to neck skin (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. Example Question: Have your moles changed?  Finding: Reports no 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: Reports no 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: Reports no 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: Reports no rashes (Available) Pro Tip: Chronic or severe skin rashes 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 get skin rashes? Comments If your instructor provides individual feedback on this assignment, it will appear here. [Show More]

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