Subjective Data Collection: 98 of 100 (98.0%)
Hover To Reveal…
Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
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Found:
Indicates an item that you found.
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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.
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Chief Complaint
Finding:
Established chief complaint
Finding:
Reports pain
(Found)
Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.Example Question:
How severe is the pain?
Finding:
Reports foot wound
(Found)
Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.Example Question:
What’s causing your pain?
History of Present Illness
Finding:
Asked to rate current pain level on a scale
Finding:
Reports current pain is 7/10
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Can you rate the pain on a scale of 0 to 10?
Finding:
Asked for details about the pain
Finding:
Reports pain is throbbing
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Can you please describe the pain?
Finding:
Reports pain is sharp when she attempts to stand
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
What is the pain like when you stand on your foot?
Finding:
Reports pain has increased in the past 2 days
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
How has the pain changed over time?
Finding:
Reports feeling pain radiating into ankle
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Does the pain radiate anywhere else?
Finding:
Reports pain prevents bearing weight on foot
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Can you bear weight on your foot?
Finding:
Asked location of wound
Finding:
Reports right foot is injured
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Which foot is in pain?
Finding:
Reports wound is on the plantar surface of her foot
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Where is the wound?
Finding:
Asked details of the injury
Finding:
Reports she scraped foot on a cement step
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
How did your injury happen?
Finding:
Reports initial injury occurred 1 week ago
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
When did the pain start?
Finding:
Reports mild ankle injury
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Did you injure anything besides your foot?
Finding:
Reports being barefoot at the time of injury
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Were you wearing shoes when you fell?
Finding:
Asked about the assessment of the injury at the ER
Finding:
Reports going to the ER after sustaining the injury
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
When did you go to the ER?
Finding:
Reports going to the ER because she suspected an ankle sprain
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Why did you go to the ER?
Finding:
Reports receiving an X-ray at the ER
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Did they xray your foot at the ER?
Finding:
Reports X-ray showed no broken bones
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
What did the x-ray show?
Finding:
Reports receiving a prescription for pain pills
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Did you receive any pain medications at the ER?
Finding:
Asked about drainage from the foot wound
Finding:
Reports that the wound bled a little after sustaining the injury
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Did your foot bleed?
Finding:
Reports seeing pus draining from wound
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Did you notice any discharge from the wound?
Finding:
Reports noticing pus 2 days ago
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
When did you first notice the pus?
Finding:
Followed up on drainage
Finding:
Reports pus as white or yellow
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
What color is the drainage from your wound?
Finding:
Denies odor from the wound
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Does the wound have an odor?
Finding:
Asked about home treatment of foot wound
Finding:
Reports wound care regimen of bandaging
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
How did you treat your foot at home?
Finding:
Reports cleaning wound twice a day
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
How often did you clean the wound?
Finding:
Reports cleaning wound with hydrogen peroxide
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
What did you use to clean the wound?
Finding:
Reports applying bacitracin, neomycin and polymyxin B (Neosporin)
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Did you use any ointment on the wound?
Finding:
Asked about other foot wound symptoms
Finding:
Reports swelling around foot wound
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Is there swelling around the wound?
Finding:
Reports swelling worsened in the past 2 days
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
How long have you noticed swelling around the wound?
Finding:
Reports redness around the wound
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Did you notice any redness around the wound?
Finding:
Reports that the wound feels warm
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Does the wound feel warm?
Finding:
Explored impact of patient’s foot injury on activities of daily living
Finding:
Reports pain affects ability to walk
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Does your injury impact your ability to walk?
Finding:
Reports pain affects ability to stand at work for long periods of time
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Does your foot pain affect your work?
Finding:
Reports pain prevented her from being able to walk to class
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Has your injury prevented you from going to class?
Past Medical History
Finding:
Asked about preexisting medical conditions
Finding:
Reports diabetes
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Do you have diabetes?
Finding:
Reports asthma
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Do you have asthma?
Finding:
Followed up on diabetes diagnosis
Finding:
Reports specific age of diagnosis was 24
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
At what age were you diagnosed with diabetes?
Finding:
Reports that her diabetes is Type 2
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Do you know what type of diabetes you have?
Finding:
Asked about diabetes management through lifestyle changes
Finding:
Reports staying away from sweets
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Tell me more about any sugars you consume.
Finding:
Reports drinking diet soda instead of regular
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Do you drink sugary drinks?
Finding:
Asked about current diabetes medication use
Finding:
Reports that she does not currently take medication for diabetes
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Do you take prescribed medication for your diabetes?
Finding:
Asked about past diabetes medication use
Finding:
Reports that she used to take diabetes medication
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Have you ever taken medication for your diabetes?
Finding:
Reports previous medication was prescription metformin
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Do you remember what you were prescribed for diabetes?
Finding:
Reports last use of medication was 3 years ago
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
When was the last time you took your diabetes medication on a regular basis?
Finding:
Asked about blood glucose monitoring
Finding:
Reports infrequent blood glucose monitoring
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Tell me about your blood sugar monitoring.
Finding:
Reports last glucose check was a week ago at the ER
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
How often do you check your blood sugar?
Finding:
Reports confusion about what the numbers mean
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
What are your usual blood sugar levels?
Finding:
Asked about thirst
Finding:
Reports increased thirst
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Have you been more thirsty lately?
Finding:
Reports increased water intake
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Are you drinking more water than normal?
Finding:
Asked about frequency of urination
Finding:
Reports more frequent urination
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Have you been urinating more often than usual?
Finding:
Reports urinating every hour or two during the day
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
How often do you urinate during the day?
Finding:
Reports urinating 2 to 3 times during the night
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
How often do you wake up at night to urinate?
Finding:
Asked about change in appetite
Finding:
Reports increased appetite
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Have you noticed an increase in appetite?
Finding:
Reports change in appetite began a month ago
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
When did you notice the increase in your appetite?
Finding:
Asked about weight change
Finding:
Reports recent loss of 10 lbs
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
How much weight have you lost?
Finding:
Reports weight loss occurred over the past month
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
How long did it take you to lose 10 pounds?
Finding:
Followed up on reason for weight change
Finding:
Reports weight loss was unintentional
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Was your weight loss intentional?
Finding:
Asked about history of asthma exacerbations
Finding:
Reports last asthma attack was in high school
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
When was your last asthma attack?
Finding:
Reports last exacerbation was three days ago
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
When did you last have issues with asthma?
Finding:
Asked about asthma symptoms
Finding:
Reports chest tightness during exacerbation
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
What do your asthma symptoms feel like?
Finding:
Reports difficulty breathing during exacerbation
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Do you have trouble breathing?
Finding:
Reports wheezing during exacerbation
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Do you ever wheeze?
Finding:
Asked about prior hospitalizations
Finding:
Reports past hospitalizations
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Have you been hospitalized in the past?
Finding:
Reports last hospitalization was for asthma
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Why were you hospitalized last time?
Finding:
Reports last hospitalization was age 16
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
When was your last hospitalization?
Finding:
Reports about 5 total hospitalizations for asthma as a child and teen
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
How many times have you been hospitalized?
Finding:
Reports past nebulizer use
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Have you ever used a nebulizer?
Finding:
Asked about asthma diagnosis
Finding:
Reports specific age of diagnosis is 2.5 years old
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
At what age were you diagnosed with asthma?
Finding:
Asked about asthma management
Finding:
Reports using an inhaler
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
How do you manage your asthma?
Finding:
Reports inhaler is albuterol (Proventil)
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
What is the name of the inhaler prescription?
Finding:
Reports last use of inhaler was 3 days ago
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
When did you last use your inhaler?
Finding:
Reports using inhaler no more than 2 times per week
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
How often do you use your inhaler?
Finding:
Asked about number of puffs when using asthma inhaler
Finding:
Reports recommended dose is 1-3 puffs as needed
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
How many puffs of your inhaler are you prescribed?
Finding:
Reports typically taking 2 puffs
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Does your inhaler effectively relieve your symptoms?
Finding:
Reports sometimes needing 3 puffs to control symptoms
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
What’s the most puffs you ever take?
Finding:
Asked about asthma triggers
Finding:
Reports asthma triggered by cats
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
What triggers your asthma problems?
Finding:
Reports asthma triggered by dust
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Does dust trigger your asthma?
Finding:
Reports asthma triggered by running up stairs
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Does physical activity trigger your asthma?
Finding:
Denies seasonal triggers
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Do you have seasonal asthma triggers?
Finding:
Asked about general allergies
Finding:
Reports allergy to cats
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
What allergies do you have?
Finding:
Followed up on cat allergy symptoms
Finding:
Reports sneezing, itchy eyes, and wheezing
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
What is your reaction to cats?
Finding:
Asked about latex allergy
Finding:
Denies latex allergy
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Are you allergic to latex?
Finding:
Asked about medication allergies
Finding:
Reports penicillin allergy
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
What medication allergies do you have?
Finding:
Asked about penicillin reaction
Finding:
Reports that penicillin resulted in hives in childhood
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
What is your reaction to penicillin?
Finding:
Asked about food allergies
Finding:
Denies food allergies
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Do you have any food allergies?
Finding:
Asked if the patient has allergies to dust, mold, or pollen
Finding:
Reports reaction to dust
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Do you have any reaction to dust?
Finding:
Reports dust causes sneezing, itchy eyes, and wheezing
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Do you have any environmental allergies?
Finding:
Denies seasonal allergies
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Do you have any seasonal allergies?
Finding:
Asked about general immunizations received
Finding:
Reports being up to date on shots
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Are your immunizations current?
Finding:
Asked about childhood immunizations
Finding:
Reports receiving all necessary childhood immunizations
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Did you receive childhood vaccinations?
Finding:
Asked if the patient has received a flu vaccine
Finding:
Denies receiving annual flu vaccine
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Did you get a flu shot this year?
Finding:
Asked if the patient received a tetanus immunization
Finding:
Reports last tetanus vaccination was in the past year
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
When was your last tetanus booster?
Finding:
Asked about hypertension
Finding:
Denies past diagnosis of hypertension
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
Have you ever been diagnosed with hypertension?
Finding:
Reports that last BP reading was 140 over 80 or 90
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
What is your usual blood pressure?
Finding:
Denies checking BP regularly
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Example Question:
How often do you check your blood pressure?
Home Medications
Finding:
Asked about use of pain medication
Finding:
Reports taking prescription pain medication
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.Example Question:
Have you taken any prescription pain medications?
Finding:
Reports medication is tramadol
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.Example Question:
What is the name of the pain medication?
Finding:
Followed up on pain medication frequency
Finding:
Reports taking pain medication for 2 days
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.Example Question:
How many days have you needed pain medication?
Finding:
Reports taking tramadol 3 times a day
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.Example Question:
How many times a day do you take pain medication?
Finding:
Reports last dose was this morning
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.Example Question:
When was your last dose of pain medication?
Finding:
Followed up on pain medication dose
Finding:
Reports dosage is 50 mg
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.Example Question:
What is the dose of the pain medication?
Finding:
Reports taking 2 pills each time
(Available)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.Example Question:
How many pain pills do you take at a time?
Finding:
Followed up on efficacy of pain medication
Finding:
Reports that pain pills provide partial relief
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.Example Question:
How effective is the pain medication?
Finding:
Reports pain returns in full every few hours
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.Example Question:
How long does the pain medication last?
Finding:
Asked about other prescription medications
Finding:
Reports a prescription inhaler
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.Example Question:
What prescription medications do you take?
Finding:
Asked about use of OTC medication
Finding:
Reports occasionally taking Advil (ibuprofen) for cramps
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.Example Question:
Do you take any over the counter medications?
Finding:
Reports occasionally taking Tylenol (acetaminophen) for headaches
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.Example Question:
Do you take any over the counter medications?
Finding:
Denies vitamin supplements
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.Example Question:
Do you take any vitamins?
Finding:
Denies herbal supplements
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.Example Question:
Do you take any herbal supplements?
Social Determinants of Health
Finding:
Asked about access to healthcare
Finding:
Denies finances are a barrier to healthcare
(Found)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.Example Question:
Do you have trouble affording healthcare?
Finding:
Denies transportation is a barrier to healthcare
(Available)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.Example Question:
Is transportation a barrier to your healthcare?
Finding:
Followed up on diabetes noncompliance
Finding:
Reports that she got sick of the demands of medication compliance
(Found)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.Example Question:
Why aren’t you taking your diabetes medication?
Finding:
Reports disliking metformin side effects
(Found)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.Example Question:
Did the metformin cause any side effects?
Finding:
Reports disliking checking blood glucose
(Found)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.Example Question:
What’s preventing you from taking your diabetes medication?
Finding:
Denies that cost of metformin was reason for discontinuing medication
(Found)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.Example Question:
Did you have problems affording the diabetes medication?
Finding:
Denies that glucometer-related costs are reason for not checking blood glucose
(Available)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.Example Question:
Do you have problems affording the glucometer?
Finding:
Asked about patient’s level of education
Finding:
Reports currently working toward undergraduate degree
(Found)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.Example Question:
What is your highest level of education?
Finding:
Reports her major is accounting
(Found)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.Example Question:
What do you study?
Finding:
Asked about patient’s living situation
Finding:
Reports living with mother and sister
(Found)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.Example Question:
Does anyone live at home with you?
Finding:
Reports family members will be able to help with activities
(Found)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.Example Question:
Tell me more about living at home.
Social History
Finding:
Asked about stressors
Finding:
Reports she is currently under high stress
(Available)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.Example Question:
Can you tell me about your stress level?
Finding:
Asked about food intake
Finding:
Reports last meal was dinner time the previous night
(Available)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.Example Question:
When was your last meal?
Finding:
Reports last meal consisted of baked chicken and mashed potatoes
(Found)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.Example Question:
What did you eat for your last meal?
Finding:
Reports breakfast is usually a muffin or pumpkin bread
(Found)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.Example Question:
What is your typical breakfast?
Finding:
Reports lunch is usually a sandwich
(Found)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.Example Question:
What is your typical lunch?
Finding:
Reports dinner is usually a home-cooked meat dish and side of vegetables
(Available)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.Example Question:
What is your typical dinner?
Finding:
Reports snacks are pretzels or French fries
(Available)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.Example Question:
What do you typically eat for snacks?
Finding:
Asked about salt intake
Finding:
Denies adding salt to food
(Available)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.Example Question:
Do you add a lot of salt to your food?
Finding:
Asked about caffeine intake
Finding:
Denies drinking coffee
(Found)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.Example Question:
Do you drink coffee?
Finding:
Reports habitual diet soda drinking
(Found)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.Example Question:
Do you drink soda?
Finding:
Reports drinking up to 4 diet sodas per day
(Available)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.Example Question:
How many diet sodas do you drink in a day?
Finding:
Asked about illicit drug use
Finding:
Reports history of recreational marijuana smoking
(Found)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.Example Question:
Have you ever experimented with drugs?
Finding:
Followed up on drug use
Finding:
Reports last use was at age 20 or 21
(Available)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.Example Question:
When did you last smoke marijuana?
Finding:
Reports she stopped because of health reasons and waning interest
(Found)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.Example Question:
What happened to cause you to stop smoking pot?
Finding:
Asked about alcohol intake
Finding:
Reports last alcoholic drink was 3 weeks ago
(Available)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.Example Question:
When was your last alcoholic drink?
Finding:
Reports no more than 2 or 3 alcoholic drinks in one sitting
(Found)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.Example Question:
How many alcoholic drinks do you have in one sitting?
Finding:
Reports no more than 1 or 2 nights a week drinking alcohol
(Found)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.Example Question:
How many nights a week do you drink alcohol?
Finding:
Asked about tobacco use
Finding:
Denies smoking tobacco
(Found)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.Example Question:
Have you ever smoked cigarettes?
Finding:
Denies vaping
(Found)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.Example Question:
Do you vape?
Finding:
Asked about secondhand smoke
Finding:
Denies exposure to secondhand smoke
(Found)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.Example Question:
Are you ever exposed to secondhand smoke?
Family Medical History
Finding:
Asked about mother’s health
Finding:
Reports mother diagnosed with high blood pressure
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.Example Question:
Does your mother have health conditions?
Finding:
Reports mother diagnosed with high cholesterol
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.Example Question:
Does your mother have health conditions?
Finding:
Asked about father’s health
Finding:
Reports father was diagnosed with Type 2 diabetes
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.Example Question:
Does your father have health conditions?
Finding:
Reports father was diagnosed with high blood pressure
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.Example Question:
Does your father have health conditions?
Finding:
Reports father was diagnosed with high cholesterol
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.Example Question:
Does your father have health conditions?
Finding:
Followed up on father’s death
Finding:
Reports father died at age 58
(Available)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.Example Question:
How old was your father when he died?
Finding:
Reports cause of death was a car accident
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.Example Question:
What caused your father’s death?
Finding:
Followed up on coping with father’s death
Finding:
Reports past grief
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.Example Question:
How are you coping with your father’s death?
Finding:
Reports feeling at peace now
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.Example Question:
How are you coping now?
Finding:
Asked about paternal grandfather’s health
Finding:
Reports paternal grandfather diagnosed with Type 2 diabetes
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.Example Question:
Does your paternal grandfather have health conditions?
Finding:
Reports paternal grandfather diagnosed with high blood pressure
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.Example Question:
Does your paternal grandfather have health conditions?
Finding:
Reports paternal grandfather diagnosed with high cholesterol
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.Example Question:
Does your paternal grandfather have health conditions?
Finding:
Reports paternal grandfather died of colon cancer
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.Example Question:
Have you had any family members with cancer?
Finding:
Asked about paternal grandmother’s health
Finding:
Reports paternal grandmother diagnosed with high blood pressure
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.Example Question:
Does your paternal grandmother have health conditions?
Finding:
Reports paternal grandmother diagnosed with high cholesterol
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.Example Question:
Does your paternal grandmother have health conditions?
Finding:
Asked about maternal grandfather’s health
Finding:
Reports maternal grandfather diagnosed with high blood pressure
(Available)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.Example Question:
Does your maternal grandfather have health conditions?
Finding:
Reports maternal grandfather diagnosed with high cholesterol
(Available)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.Example Question:
Does your maternal grandfather have health conditions?
Finding:
Asked about maternal grandmother’s health
Finding:
Reports maternal grandmother diagnosed with high blood pressure
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.Example Question:
Does your maternal grandmother have health conditions?
Finding:
Reports maternal grandmother diagnosed with high cholesterol
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.Example Question:
Does your maternal grandmother have health conditions?
Finding:
Asked about brother’s health
Finding:
Denies brother having diagnosed health problems
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.Example Question:
Does your brother have health conditions?
Finding:
Asked about sister’s health
Finding:
Reports sister diagnosed with asthma
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.Example Question:
Does your sister have health conditions?
Finding:
Asked about family history of obesity
Finding:
Reports that family members are overweight
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.Example Question:
Does obesity run in your family?
Finding:
Asked about family history of thyroid issues
Finding:
Denies family history of thyroid issues
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.Example Question:
Do you have a family history of thyroid problems?
Finding:
Asked about family history of substance abuse
Finding:
Reports 1 uncle has alcoholism
(Available)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.Example Question:
Do you have relatives with addiction problems?
Finding:
Asked about family history of headaches
Finding:
Denies family history of headaches
(Available)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.Example Question:
Do you have a family history of headaches?
Review of Systems
Finding:
Asked about constitutional health
Finding:
Reports occasional tiredness or fatigue
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Are you fatigued?
Finding:
Reports typical sleep pattern
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you noticed changes in your sleep?
Finding:
Reports fever
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Are you feeling feverish right now?
Finding:
Reports chills
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had chills?
Finding:
Denies night sweats
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had night sweats?
Finding:
Asked about review of systems for mental health
Finding:
Denies depression
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have a history of depression?
Finding:
Denies suicidal ideation or attempts
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have a history of suicidal thinking?
Finding:
Asked about review of systems for head
Finding:
Reports occasional headaches
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you ever get headaches?
Finding:
Denies current headache
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have a headache?
Finding:
Denies head injury
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had any head injuries?
Finding:
Asked about review of systems for ears
Finding:
Denies change in hearing
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Has your hearing changed?
Finding:
Denies ringing or tinnitus
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you ever have ringing in your ears?
Finding:
Denies ear pain
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had ear pain?
Finding:
Denies ear discharge
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had ear discharge?
Finding:
Asked about review of systems for eyes and vision
Finding:
Reports periods of blurry vision
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you noticed any changes in your vision?
Finding:
Denies corrective lenses
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you wear glasses or contact?
Finding:
Denies double vision
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you ever get double vision?
Finding:
Reports infrequent itchy eyes
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had itchy eyes?
Finding:
Denies eye redness
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had red eyes?
Finding:
Denies discharge, crusting or wateriness
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had watery eyes?
Finding:
Denies eye pain
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had eye pain?
Finding:
Denies dry eyes
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had dry eyes?
Finding:
Reports last eye exam was in childhood
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
When was your last eye exam?
Finding:
Asked about review of systems for nose
Finding:
Reports infrequent nose problems
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had nose problems?
Finding:
Reports infrequent runny nose
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had a runny nose?
Finding:
Denies frequent sinus problems
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had sinus pain?
Finding:
Denies change in sense of smell
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Has your sense of smell changed?
Finding:
Denies nosebleeds
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had nosebleeds?
Finding:
Asked about review of systems for mouth and jaw
Finding:
Denies dental problems
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had any recent dental problems?
Finding:
Reports last dental visit was several years ago
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
When did you last see a dentist?
Finding:
Denies change in sense of taste
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Has your sense of taste changed?
Finding:
Denies dry mouth
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had dry mouth?
Finding:
Denies mouth pain
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had mouth pain?
Finding:
Denies mouth sores
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had mouth sores?
Finding:
Denies gum problems
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had gum problems?
Finding:
Denies tongue problems
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had tongue problems?
Finding:
Denies jaw problems
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had jaw problems?
Finding:
Asked about review of systems for neck, throat, and glands
Finding:
Denies difficulty swallowing
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had difficulty swallowing?
Finding:
Denies sore throat
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had a sore throat?
Finding:
Denies lymph node problems
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
How are your lymph nodes?
Finding:
Denies frequent sore throat
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have a history of throat problems?
Finding:
Denies swollen glands
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have any swollen glands?
Finding:
Denies voice changes
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had voice changes?
Finding:
Denies general neck problems
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had neck pain?
Finding:
Asked about breast health
Finding:
Reports doing occasional breast exams
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you do regular breast exams?
Finding:
Denies general breast problems
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have any problems with your breasts?
Finding:
Denies breast lumps
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you noticed any lumps in your breasts?
Finding:
Denies breast pain
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you felt pain in your breasts?
Finding:
Denies nipple changes
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you noticed changes in your nipples?
Finding:
Denies nipple discharge
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you noticed any nipple discharge?
Finding:
Denies ever having a mammogram
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you ever had a mammogram?
Finding:
Asked about review of systems for respiratory
Finding:
Denies current breathing problems
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had breathing problems?
Finding:
Denies current wheezing
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you been wheezing?
Finding:
Denies current chest tightness
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had chest tightness?
Finding:
Denies pain while breathing
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Does it hurt when you breathe?
Finding:
Denies frequent coughing
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you been coughing?
Finding:
Asked about review of systems for cardiovascular
Finding:
Denies chest pain or discomfort
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you ever have chest pain?
Finding:
Denies palpitations
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had palpitations?
Finding:
Denies irregular heartbeat
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Has your heartbeat been irregular?
Finding:
Denies easy bruising
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you noticed bruising more than usual?
Finding:
Denies edema
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you noticed any swelling in your legs?
Finding:
Denies circulation problems
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have circulation problems?
Finding:
Denies vascular diseases
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have any vascular diseases?
Finding:
Asked review of systems for gastrointestinal
Finding:
Denies nausea
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had nausea?
Finding:
Denies vomiting
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you been vomiting?
Finding:
Denies stomach pain
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have stomach pain?
Finding:
Denies change in bowel movements
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had changes in your bowel movements?
Finding:
Denies heartburn, GERD, or indigestion
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you ever get heartburn?
Finding:
Denies constipation
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have constipation?
Finding:
Denies diarrhea or loose stool
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have diarrhea?
Finding:
Denies flatulence or bloating
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have flatulence?
Finding:
Denies bloody or tarry stool
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have tarry stools?
Finding:
Asked review of systems for genitourinary
Finding:
Denies painful or difficult urination
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Does it hurt when you urinate?
Finding:
Reports waking up to urinate during the night
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you wake up at night to urinate?
Finding:
Reports large amount of urine
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you urinate frequently?
Finding:
Denies blood in urine
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you ever notice blood in your urine?
Finding:
Denies flank pain
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have flank pain?
Finding:
Denies incontinence
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Are you able to hold your urine?
Finding:
Denies history of urinary tract or bladder infection
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you ever had a urinary infection?
Finding:
Reports normal vaginal discharge
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
What is your vaginal discharge like?
Finding:
Asked review of systems for reproductive
Finding:
Reports last menstrual period was 3 weeks ago
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
When was your last menstrual period?
Finding:
Reports that periods are irregular
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Are your periods regular?
Finding:
Reports menstruating every 6 weeks to 2 months
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
How often do you get your period?
Finding:
Reports typical period lasts 9 days
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
How many days does your period last?
Finding:
Followed up on menstrual flow
Finding:
Reports heavy periods
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have heavy periods?
Finding:
Reports heavy flow for 4 to 5 days
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
How many days is your period heavy?
Finding:
Reports changing tampon every 2 to 3 hours
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
How often do you change your tampon or pad?
Finding:
Reports using super absorbency tampons
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
What absorbency are your tampons?
Finding:
Denies anemia
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you ever been diagnosed with low iron?
Finding:
Followed up on menstrual symptoms
Finding:
Reports heavy cramping
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you get menstrual cramps?
Finding:
Reports cramps for the first 2 days of period
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
How many days do your cramps last?
Finding:
Asked about treatment of menstrual symptoms
Finding:
Reports using a heating pad at home to treat cramps
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you use a heating pad?
Finding:
Reports taking ibuprofen for first 3 days of period
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
How many days do you need Advil for your cramps?
Finding:
Reports ibuprofen effectively reduces pain from cramps
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Does the Advil reduce your cramps?
Finding:
Asked about sexual activity
Finding:
Denies recent sexual activity
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Are you sexually active?
Finding:
Reports past sexual activity
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you ever been sexually active?
Finding:
Reports that she prefers to sleep with men
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you prefer to sleep with men, women, or both?
Finding:
Reports first sexual activity was at age 18
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
When were you first sexually active?
Finding:
Reports last sexual activity was 2 years ago
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
When was your last sexual encounter?
Finding:
Reports total number of partners is 3
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
How many sexual partners have you had?
Finding:
Asked about contraception
Finding:
Reports no current use of any oral or hormonal birth control
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Are you currently taking oral contraception?
Finding:
Reports past use of oral contraception
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you ever taken oral contraception?
Finding:
Reports last taking oral contraception a couple of years ago
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
When did you last take oral contraception?
Finding:
Reports she didn’t see the point in taking contraception while single
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Why did you stop taking birth control?
Finding:
Asked about condom use
Finding:
Reports past condom use
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you ever used a condom?
Finding:
Reports past sexual encounters without condoms
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you ever had sex without using a condom?
Finding:
Reports oral contraceptive use while sexually active
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Were you on oral contraception when you did not use a condom?
Finding:
Asked about STI testing
Finding:
Reports last STI testing was 4 years ago
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
When were you last tested for STIs?
Finding:
Denies STI symptoms
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have STI symptoms?
Finding:
Reports uncertainty about past partners and STI testing
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have your previous partners been tested for STIs?
Finding:
Asked about history of pap smears
Finding:
Reports last pap smear was 4 years ago
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
When was your last pap smear?
Finding:
Reports no abnormal pap smears
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you ever had an abnormal pap smear?
Finding:
Asked about history of pregnancy
Finding:
Denies current pregnancy
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you think you are pregnant?
Finding:
Denies past pregnancies
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you ever tested positive for pregnancy?
Finding:
Asked review of systems for musculoskeletal
Finding:
Denies muscle pain
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have muscle pain?
Finding:
Denies joint pain
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have joint pain?
Finding:
Denies muscle weakness
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have muscle weakness?
Finding:
Denies joint swelling
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you ever have swelling in your joints?
Finding:
Denies back pain
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you ever have back pain?
Finding:
Denies history of fractures or breaks
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you ever broken a bone?
Finding:
Asked review of systems for neurological
Finding:
Denies recent loss of consciousness or fainting
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you ever passed out?
Finding:
Denies dizziness or vertigo
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you get dizzy?
Finding:
Denies lightheadedness
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you get light-headed?
Finding:
Denies vision disturbances
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you ever see spots?
Finding:
Denies tingling
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you ever get tingling?
Finding:
Denies loss of coordination
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you notice being more clumsy than usual?
Finding:
Denies loss of sensation
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have a loss of sensation anywhere?
Finding:
Denies history of seizures
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you ever had a seizure?
Finding:
Denies problems with balance or disequilibrium
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you lose your balance often?
Finding:
Denies memory loss
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you ever experienced memory loss?
Finding:
Asked review of systems for skin, hair, and nails
Finding:
Denies skin rashes
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you get skin rashes?
Finding:
Reports rarely using sunscreen
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
When do you wear sunscreen?
Finding:
Reports acne
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you still have acne?
Finding:
Reports excessive facial or body hair
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have an increase in body hair?
Finding:
Reports changes to neck skin
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have any skin discoloration?
Finding:
Reports moles
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have your moles changed?
Finding:
Reports no body sores (aside from foot wound)
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have any sores?
Finding:
Denies dandruff
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have dandruff?
Finding:
Denies nail abnormalities
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Do you have any problems with your nails?
Finding:
Reports occasional dry skin
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