Focused Exam: Chest Pain, Brian Foster Shadow health Subjective Data Collection: 30 of 30 (100.0%)
Category: Scored Items
Experts have identified these topics as crucial components of a comprehensive interview with the patient.
Struggling to meet your deadline?
Get your assignment on Focused Exam: Chest Pain, Brian Foster Shadow health Subjective Data Collection: 30 of 30 (100.0%) done by certified MDs and PhDs in the USA. ORDER NOW!
Chief Complaint:
– Patient reports chest pain.
Pro Tip: A patient’s chief complaint is the primary concern they have. Asking about this allows the patient to express their worries and any symptoms they may have.
Example Question: Do you have chest pain?
History of Present Illness:
– Patient mentions chest pain started appearing in the past month.
Pro Tip: Inquiring about the duration of their health issues provides context for their present illness, helping to understand their current condition better.
Example Question: When did your chest pain start?
– The patient notes that the pain is located in the center of the chest and does not radiate.
Pro Tip: Learning about the location of the pain is essential for understanding their current condition.
Juggling Motherhood and Nursing School
Example Question: Where is the pain?
– Patient denies arm, shoulder, back, and neck pain.
Pro Tip: Asking about other areas of discomfort can provide a comprehensive view of their condition.
Example Questions: Are you experiencing arm pain? Are you experiencing shoulder pain? Are you experiencing back pain? Are you experiencing neck pain?
– The patient reports that each pain episode lasts “several” minutes and that there have been three episodes in the past month.
Pro Tip: Inquiring about the duration and frequency of the pain episodes is crucial for understanding the patient’s condition.
Example Questions: How long does your chest pain last? How many times in the last month have you had chest pain?
– The patient indicates that the pain does not seem related to any specific trigger.
Pro Tip: Understanding whether specific factors worsen or alleviate the pain is important for evaluating the patient’s condition.
Example Question: Did the episodes seem associated?
– The patient rates the current pain as 0 out of 10 and the worst pain as 5 out of 10.
Pro Tip: Assessing pain severity is valuable in evaluating the patient’s condition.
Example Questions: How would you rate your pain on a scale of zero to ten?
– The patient describes the pain as tight and uncomfortable.
Pro Tip: Learning about the characteristics of the pain provides additional information for diagnosis.
Example Question: Can you describe your pain?
– The patient denies crushing, gnawing, and burning pain.
Pro Tip: Understanding the type of pain the patient is experiencing can help in diagnosis.
Example Questions: Is the pain crushing? Is the pain gnawing? Is the pain burning?
– The patient reports that the pain is aggravated by activity, such as yard work and taking stairs.
Pro Tip: Identifying what exacerbates the pain is crucial for understanding the patient’s condition.
Example Questions: What makes the pain worse? What activity triggered the pain?
– The patient denies that the pain worsens with eating or after consuming spicy or high-fat foods.
Pro Tip: Understanding how food intake affects the pain is important for diagnosis.
Example Questions: Is the pain worse when you eat? Is the pain worse after you eat spicy food? Is the pain worse after you eat high-fat foods?
– The patient mentions that a brief period of rest provides relief from the pain.
Pro Tip: Knowing what alleviates the pain is important for understanding the patient’s condition.
Example Question: What relieves your pain?
Past Medical History:
– Patient has allergies.
Pro Tip: Inquiring about allergies is essential for understanding the patient’s medical history.
Example Question: Do you have new allergies?
– The patient denies a history of angina and diabetes.
Pro Tip: Inquiring about past medical conditions helps in understanding the patient’s medical history.
Example Questions: Do you have a history of angina? Do you have diabetes?
– The patient reports high blood pressure and high cholesterol.
Pro Tip: Knowing about existing medical conditions is vital for the patient’s medical history.
Example Questions: Do you have high blood pressure? Do you have high cholesterol?
– The patient denies coronary artery disease and previous treatment for chest pain.
Pro Tip: Inquiring about coronary artery disease and past treatments helps in understanding the patient’s medical history.
Example Questions: Do you have coronary artery disease? Have you had previous treatment for chest pain?
– The patient is unsure of their typical blood pressure reading.
Pro Tip: Understanding the patient’s typical blood pressure reading is important for their medical history.
Example Question: What is your typical blood pressure reading?
– The patient reports having a recent EKG test and an annual stress test.
Pro Tip: Knowing about recent tests is vital for understanding the patient’s medical history.
Example Questions: Have you recently had an EKG? Have you recently had a stress test?
– The patient believes the EKG was normal.
Pro Tip: Understanding the results of medical tests is important for the patient’s medical history.
Example Question: What were the results of your last EKG?
– The patient believes the stress test was normal.
Pro Tip: Understanding the results of medical tests is important for the patient’s medical history.
Example Question: What were the results of your last stress test?
Home Medications:
– Patient takes medication for high blood pressure and high cholesterol.
Pro Tip: Inquiring about home medications helps in understanding the patient’s current treatment and its impact.
Example Questions: Do you take medication for high blood pressure? Do you take medication for high cholesterol?
– The patient also takes occasional ibuprofen and fish oil.
Pro Tip: Knowing about other medications and supplements the patient takes is important for their current treatment.
Example Questions: Do you take over-the-counter medications? Do you take any supplements?
– The patient denies an aspirin regimen.
Pro Tip: Understanding whether the patient takes aspirin regularly is important for their treatment.
Example Question: Do you take aspirin?
– The patient reports taking lisinopril for high blood pressure, with a dose of 20 mg once daily.
Pro Tip: Knowing the specific details of medication, including dosage and frequency, is crucial for the patient’s treatment.
Example Questions: What medication do you take for high blood pressure? What dose of medication do you take for high blood pressure? How frequently do you take medication for high blood pressure?
– The patient reports taking atorvastatin for high cholesterol, with a dose of 20 mg once daily at bedtime.
Pro Tip: Knowing the specific details of medication, including dosage and frequency, is crucial for the patient’s treatment.
Example Questions: What medication do you take for high cholesterol? What dose of medication do you take for high cholesterol? How frequently do you take medication for high cholesterol? What time of day do you take your high cholesterol medication? How long have you taken cholesterol medication?
Social Determinants of Health:
– Patient has a primary care provider, and their last visit was 3 months ago. They usually see their healthcare provider every 6 months.
Pro Tip: Understanding the patient’s access to healthcare and their healthcare provider’s visit frequency is crucial for addressing social determinants of health.
Example Questions: Do you have a primary care provider? When was your last visit to a healthcare provider? How often do you measure your blood pressure? When do you measure your blood pressure? What is your typical blood pressure reading?
This comprehensive interview with the patient provides valuable information about their chest pain and medical history, enabling better assessment and care.
Focused Exam: Chest Pain, Brian Foster Shadow health Subjective Data Collection: 30 of 30 (100.0%)
Hover To Reveal…
Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
-
Found:
Indicates an item that you found.
-
Available:
Indicates an item that is available to be found.
Category
Scored Items
Experts selected these topics as essential components of a strong, thorough interview with this patient.
Patient Data
Not Scored
A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case. Focused Exam: Chest Pain, Brian Foster Shadow health Subjective Data Collection: 30 of 30 (100.0%)
Chief Complaint
- Finding:Established chief complaint
- Finding:Reports chest 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:
Do you have chest pain?
History of Present Illness
Finding:
Asked about onset of pain
Finding:
Reports chest pain started appearing in the past month
(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. Focused Exam: Chest Pain, Brian Foster Shadow health Subjective Data Collection: 30 of 30 (100.0%)Example Question:
When did your chest pain start?
Finding:
Asked about location of pain
Finding:
Reports pain is in center of the chest
(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. Focused Exam: Chest Pain, Brian Foster Shadow health Subjective Data Collection: 30 of 30 (100.0%)Example Question:
Where is the pain?
Finding:
Reports pain does not radiate
(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?
Finding:
Denies arm pain
(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:
Are you experiencing arm pain?
Finding:
Denies shoulder pain
(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:
Are you experiencing shoulder pain?
Finding:
Denies back pain
(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:
Are you experiencing back pain?
Finding:
Denies neck pain
(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. Focused Exam: Chest Pain, Brian Foster Shadow health Subjective Data Collection: 30 of 30 (100.0%)Example Question:
Are you experiencing neck pain?
Finding:
Asked about duration of pain episodes
Finding:
Reports each pain episode lasted “several” minutes
(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 long does your chest pain last?
Finding:
Asked about frequency of pain
Finding:
Reports 3 pain episodes in past month
(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 many times in the last month have you had chest pain?
Finding:
Reports that pain episodes did not seem related
(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 the episodes seem associated?
Finding:
Asked about severity of pain
Finding:
Reports current pain is 0 out of 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:
How would you rate your pain on a scale of zero to ten?
Finding:
Reports pain severity at its worst is 5 out of 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:
How would you rate your pain on a scale of zero to ten?
Finding:
Asked about characteristics of pain
Finding:
Describes pain as tight and uncomfortable
(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 describe your pain?
Finding:
Denies crushing pain
(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:
Is the pain crushing?
Finding:
Denies gnawing pain
(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:
Is the pain gnawing?
Finding:
Denies burning pain
(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:
Is the pain burning?
Finding:
Asked about aggravating factors
Finding:
Reports pain is aggravated by activity
(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 makes the pain worse?
Finding:
Reports pain occurred with yard work and taking stairs
(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 activity triggered the pain?
Finding:
Reports pain does not worsen with eating
(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:
Is the pain worse when you eat?
Finding:
Reports pain does not worsen after spicy foods
(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:
Is the pain worse after you eat spicy food?
Finding:
Reports pain does not worsen after high-fat foods
(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:
Is the pain worse after you eat high-fat foods?
Finding:
Asked about relieving factors
Finding:
Reports pain relief with brief period of rest
(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 relieves your pain?
Finding:
Denies taking medication to treat chest pain
(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 take anything for the chest pain?
Past Medical History
Finding:
Confirmed allergies
Finding:
Confirms 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 new allergies?
Finding:
Asked about related medical conditions
Finding:
Denies angina diagnosis
(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 a history of angina?
Finding:
Reports high blood pressure
(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 high blood pressure?
Finding:
Reports high cholesterol
(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 high cholesterol?
Finding:
Denies coronary artery disease
(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 coronary artery disease?
Finding:
Denies diabetes
(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 diabetes?
Finding:
Denies previous treatment for chest pain
(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 had previous treatment for chest pain?
Finding:
Asked about blood pressure monitoring
Finding:
Does not frequently monitor BP at home
(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 measure your blood pressure?
Finding:
Reports infrequent BP checks
(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 do you measure your blood pressure?
Finding:
Denies knowledge of typical BP reading
(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 typical blood pressure reading?
Finding:
Asked about past cardiac tests
Finding:
Reports recent EKG test
(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 recently had an EKG?
Finding:
Reports annual stress test
(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 recently had a stress test?
Finding:
Followed up on results of cardiac tests
Finding:
Reports belief that EKG was normal
(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 were the results of your last EKG?
Finding:
Reports belief that stress test was normal
(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 were the results of your last stress test?
Home Medications
Finding:
Asked about home medications
Finding:
Reports taking high blood pressure 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:
Do you take medication for high blood pressure?
Finding:
Reports taking high cholesterol 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:
Do you take medication for high cholesterol?
Finding:
Reports occasional ibuprofen use
(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:
Do you take over the counter medications?
Finding:
Reports taking fish oil
(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 supplements?
Finding:
Denies aspirin regimen
(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:
Do you take aspirin?
Finding:
Followed up on high blood pressure medication
Finding:
Reports taking lisinopril
(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 medication do you take for high blood pressure?
Finding:
Reports lisinopril dose is 20 mg
(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:
What dose of medication do you take for high blood pressure?
Finding:
Reports taking lisinopril once daily
(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 frequently do you take medication for high blood pressure?
Finding:
Followed up on high cholesterol medication
Finding:
Reports taking atorvastatin
(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 medication do you take for high cholesterol?
Finding:
Reports atorvastatin dose is 20 mg
(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:
What dose of medication do you take for high cholesterol?
Finding:
Reports taking atorvastatin once daily
(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 frequently do you take medication for high cholesterol?
Finding:
Reports taking atorvastatin at bedtime
(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:
What time of day do you take your high cholesterol medication?
Finding:
Reports having taken atorvastatin for one year
(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 long have you taken cholesterol medication?
Social Determinants of Health
Finding:
Asked about access to healthcare
Finding:
Reports a primary care provider
(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 a primary care provider?
Finding:
Reports last visit 3 months ago
(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:
When was your last visit to a healthcare provider?- Finding:Reports usually sees healthcare provider every 6 months
(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:
How often do you see a healthcare provider? - 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:
Do you have difficulty accessing healthcare because of transportation? - Finding:Denies finances are 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:
Do you have trouble affording healthcare?
Social History
Finding:
Asked about stress
Finding:
Reports generally low stress lifestyle
(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 stress level?
Finding:
Asked about exercise
Finding:
Denies regular exercise routine
(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 kind of exercise do you get?
Finding:
Reports last regular exercising was 2 years ago
(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:
When did you last exercise regularly?
Finding:
Asked about typical diet
Finding:
Reports typical breakfast is granola bar and instant breakfast shake
(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 a typical breakfast for you?
Finding:
Reports typical lunch is turkey sub
(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 a typical lunch for you?
Finding:
Reports typical dinner is grilled meat and 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 a typical dinner for you?
Finding:
Denies moderation of salt intake
(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 moderate your salt intake?
Finding:
Asked about fluid intake
Finding:
Reports drinking 4 glasses of water daily
(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 water every day?
Finding:
Reports drinking 2 cups of coffee daily
(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 much coffee do you drink per day?
Finding:
Denies soda drinking
(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 much soda do you drink per day?
- Finding:Asked about substance use
- Finding:Denies current illicit drug use
(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 use illicit drugs?
Finding:
Denies tobacco use
(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 use tobacco?
Finding:
Reports moderate alcohol consumption
(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 consume alcohol?
- Finding:Followed up on alcohol consumption
- Finding:Reports drinking 2-3 alcoholic drinks per week
(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 alcohol? - Finding:Reports 2-3 drinks in one sitting
(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 alcoholic drinks do you have in one sitting? - Finding:Reports drinking only on weekends
(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:
When do you drink alcohol?
Review of Systems
- Finding:Asked about constitutional health
- Finding:Denies fever
(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 fever? - Finding:Denies 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:
Do you have chills?
Finding:
Denies 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:
Do you feel tired?
Finding:
Denies night sweats
(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 night sweats?
Finding:
Denies weight loss
(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 experienced recent weight loss?
Finding:
Denies dizziness or lightheadedness
(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 dizziness?
Finding:
Denies palpitations
(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 palpitations?
- Finding:Asked review of systems for cardiovascular
- Finding:Denies history of angina
(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 angina?
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:
Do you have any swelling?
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 any problems with circulation?
Finding:
Denies blood clots
(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 blood clot?
Finding:
Denies history of rheumatic 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:
Do you have a history of rheumatic fever?
Finding:
Denies history of heart murmur
(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 heart murmur?
Finding:
Denies easy bleeding
(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 unusual bleeding?
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 any unusual bruising?
Finding:
Denies blue 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:
Has your skin ever turned blue?
Finding:
Asked about review of systems for respiratory
Finding:
Denies cough
(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 cough?
Finding:
Denies difficulty 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:
Have you had difficulty breathing?
Finding:
Denies shortness of breath at rest
(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 difficulty breathing when lying down?
- Finding:Asked about review of systems for HEENT
- Finding:Denies change in sense of taste
(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 experienced a change in taste?
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:
Do you have a sore throat?
Finding:
Denies difficulty swallowing
(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 dysphagia?
- Finding:Asked about review of systems for gastrointestinal
- Finding:Denies nausea
(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 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 vomited recently?
Finding:
Denies diarrhea
(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 diarrhea?
Finding:
Denies constipation
(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 constipation?
Finding:
Denies gassiness
(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 gassy?
Finding:
Denies 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 bloating?
Finding:
Denies heartburn or GERD
(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 heartburn or GERD?
Family Medical History
- Finding:Asked about relevant family history
- Finding:Reports family history of heart attack
(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:
Has anyone in your family had a heart attack?
Finding:
Denies family history of stroke
Dont wait until the last minute.
Provide your requirements and let our native nursing writers deliver your assignments ASAP.
(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 stroke?- Finding:Denies family history of pulmonary embolism