Example Question: Do you have a history of suicidal thinking? Finding: Reports cause of death was a car accident (Found)Pro Tip: Following up on the death of an immediate family member is important for gathering details that could be relevant to the patient's case. Diana Shadow: Hi. Intervene - Diet: Provide the patient a diet without concentrated sweets. You should assess her needs to determine if providing any addition resources or support is appropriate. Finding: Asked about history of asthma exacerbations. Tina Jones: Last year when Dad passed, he was only 58. Finding: Reports last hospitalization was age 16 (Available)Pro Tip: Finding out the date of Tina's last hospitalization is important for understanding the timeline of her medical issues, asthma in particular. The patient is unable to bear weight on her affected leg, which prevents walking. Finding: Reports mother diagnosed with high blood pressure (Found)Pro Tip: Family histories might indicate a genetic predisposition. Past illnesses: e.g. Today, he started having chest pain. Priority: High Priority Pro Tip: Managing acute pain is an immediate high priority, because other health concerns cannot be effectively addressed while a patient experiences severe pain. Student: Does your mother have any health problems? Example Question: What caused your father's death? Finding: Reports paternal grandfather died of colon cancer (Found)Pro Tip: Family histories might indicate a genetic predisposition. Tina Jones: Um...I've smoked pot before. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint. Example Question: Have you had voice changes? Tina Jones: Well, right after he died, after the funeral and everything, I just tried to get through that. Example Question: How often do you change your bandage? Counseling around past drug use Not Followed Up, Description: Tina discusses her past history of marijuana smoking. Example Question: What is the name of the inhaler prescription? Example Question: How many pain pills do you take at a time? The patient's response to these questions may uncover neurological problems. Student: Have you had any problems with your breasts? Tina Jones: No, I don't take anything for my diabetes anymore. Finding: Denies ear discharge (Available)Pro Tip: Ear discharge is the leakage of blood, pus, or wax from the ear and can be the result of a ruptured eardrum, eczema, or swimmer's ear. Example Question: Do you ever have chest pain? Tina Jones: I don't know what caused it, I just lost weight. When I'm reading or studying I'll notice that things start to get kind of blurry. She might have high cholesterol too. Evidence - Relevant: "BMI: 31" Evidence Pro Tip: Tina's BMI is 31, which is in the obese range. Finding: Denies dizziness or vertigo (Available)Pro Tip: Asking about dizziness or vertigo is one possible component of a review of systems interview. Finding: Denies dry eyes (Available)Pro Tip: Dry eyes occur when the eyes do not produce enough tears to lubricate them. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint. Example Question: Does the pain radiate anywhere else? So, it was really sudden. Student: How often do you have asthma exacerbations? The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint, such as oral infection. And high cholesterol like everyone else in my family. Finding: Denies odor from the wound (Available)Pro Tip: The odor of discharge from a wound can provide insight into its severity and characteristics. Finding: Reports maternal grandmother diagnosed with high blood pressure (Found)Pro Tip: Family histories might indicate a genetic predisposition. If you find gaps in the patient's literacy, that is your opportunity to provide education. Finding: Denies receiving annual flu vaccine (Found)Pro Tip: The flu virus can be particularly hazardous in a hospital setting. Finding: Followed up on reason for weight change. Example Question: When did your injury occur? Example Question: Are you currently on birth control? Example Question: Do you have constipation? Student: So that you understand if there are any problems related to their chief complaint. Student: Do you know why you lost weight? I don't want to miss work or school but now it looks like I'll have to. 7/22/2020 Health History | Completed | Shadow Health 2/9 Past Medical History Reports seeing pus draining from wound Reports noticing pus 2 days ago Followed up on drainage Reports pus as white or yellow Denies odor from the wound Asked about home treatment of foot wound Reports wound care regimen of bandaging Reports cleaning wound twice a day Reports applying bacitracin, neomycin … Tina Jones: I have a monitor at home, but to be honest I don't really use it that often. Every hour or two when I'm awake? 1, 2 Patients with an acute abdomen represent only a fraction of those with acute abdominal pain. Tina Jones: Right now, I'm living at my mom's place, which is out in the suburbs a bit. When you monitor your sugar, it helps you understand what foods, activities, and times of day contribute to you feeling your best. The most common causes of muscle pain are overuse, and conditions such as arthritis. Example Question: What is your highest level of education? But it is important to keeping your diabetes under control. 7. I definitely don't anymore, though. cancer, heart disease, hypertension, diabetes. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint, such as allergic reactions or infection. Example Question: What color is the drainage from your wound? Your questioning should cover a broad array of the symptoms' characteristics. but I don't do that anymore. Student: When did you realize you were allergic to cats? Example Question: What is your reaction to penicillin? Asking Tina if she's been wheezing illustrates how her asthma is presenting. Danny Rivera reports a history of frequent rhinorrhea and cough. Finding: Denies history of breast cancer (Available)Pro Tip: If a patient has a history of breast cancer, it is important that you look for signs of recurrence and engage in preventative care, as well as patient education. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint, such as allergic reactions, infection, or physical trauma. Throughout the conversation, you should educate and empathize with Ms. Jones when appropriate to increase her health literacy and sense of well-being. Finding: Reports being up to date on shots (Found)Pro Tip: Discovering your patient's immunization history is important to her safety and reveals any susceptibilities she may have to infectious disease. Example Question: Do you ever get tingling? Example Question: Has your injury prevented you from going to class? Example Question: What is your vaginal discharge like? Example Question: Did you receive the measles vaccine? Example Question: How are you coping with your father's death? Example Question: Does obesity run in your family? Finding: Reports last use of inhaler was 3 days ago (Available)Pro Tip: Determining the patient's last use of an inhaler clues you in to any recent breathing problems. Example Question: Have you seen a healthcare provider for this injury? Finding: Reports wound is on the plantar surface of her foot (Found)Pro Tip: Confirming where a wound is located ensures you are aware of your patient's biggest complaint. Example Question: Have you had dry mouth? Contributing factors are a past history of hospitalization and asthma attacks, as well as sedentary lifestyle and obesity. for depression, last dose this morning Losartan 100 mg daily for blood pressure, last … Finding: Asked about patient's living situation. Example Question: Did you receive the polio vaccine? Tina Jones: I was diagnosed when I was 24. 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