Assignment 3: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment NURS 6512N-32

OBJECTIVE DATA:

          Physical Exam:

Vital signs: Height: 170 cm, Weight: 84 kg, BMI: 29, Heart Rate: 78, Blood Pressure: 128/82, Respiration Rate: 15, Temperature: 99.0 degrees Fahrenheit, and SpO2: 99 percent

General: The patient looks to be in good health with no indications of concern. Aware and centered in time, place, and person. Very friendly and helpful throughout the interview.

HEENT: Eyes: Anicteric sclera, no lid lag, moist conjunctiva, and mild retinopathy in the right eye. bilaterally PERRLA. Ears, Nose, Mouth & Throat: mucosal membranes of the oropharynx are moist and clear. There are no mucosal ulcerations visible. complete dentition with no indication of gum bleeding. No abnormalities were found, only hard and soft palates.

Neck: without jugular vein distention, soft. Nothing stiff. neither swollen lymph nodes nor lumps.

Chest/Lungs: Auscultation reveals bilateral clarity. a prolonged period of expiration. No rales, rhonchi, or wheezing.

Heart/Peripheral Vascular: Existence of S1 and S2. 2/6 systolic murmur. the regular rhythm of the heartbeat. No rales or gallops were seen.

Abdomen: Bowel sounds were apparent, and the patient had no CVA discomfort and was fat and mushy.

Genital/Rectal: a female who seems typical. No unusually strong or offensive discharge. displays a sacral or right buttock region that is somewhat erythematous and slightly broken.

Musculoskeletal: both upper and lower extremities have a full range of motion. No joint pain or stiffness.

Neurological: Lack of specific neurological impairments. full mental and verbal faculties. minimally intact II through XII cranial nerves. reduced monofilament feeling on both plantar surfaces.

Skin, Hair & Nails: facial hair on the upper lip and a face covered in many pustules. Ankylosis nigricans of the back of the neck. No further anomalies in the hair or nails.

Diagnostic results: The requested laboratory tests include a basic metabolic panel, a thyroid function test, a kidney function test, and a full blood count. Additional tests may include cholesterol testing, pap smears, and screenings for cervix and breast cancer. Imaging modalities, such as computed tomography (CT) and X-rays, are utilized to evaluate the prognosis of polycystic ovary syndrome (PCOS) (Sullivan, 2019).  

 

ASSESSMENT:

1. The patient’s physical findings indicate a high BMI, indicating overweight status (Lebiedowska et al., 2020).
2. The monofilament test indicates reduced sensation in the patient’s feet, indicating peripheral neuropathy as a result of diabetes (Liu et al., 2019).
3. Mild retinopathy, indicating early stages of diabetes, was observed in the right eye (McAnany et al., 2019).
4. Acanthosis nigricans, a skin condition, is commonly linked to systemic diseases such as diabetes and obesity, which are caused by insulin resistance (Das et al., 2020).
5. The presence of upper lip facial hair may be linked to her prior PCOS diagnosis (Shah & Lieman, 2022).

The patient’s care plan will be determined based on an additional assessment of her conditions, including overweight, diabetes, PCOS, and asthma.

Assignment 3: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment NURS 6512N-32

A Sample Answer For the Assignment: Assignment 3 Digital Clinical Experience Comprehensive (Head-to-Toe) Physical Assessment NURS 6512N-32

SUBJECTIVE DATA:

 Chief Complaint (CC):  

“I came in because I’m required to have a recent physical exam for the health insurance at my new job.’’

History of Present Illness (HPI):  

Patient is a 28-year-old African American female who came to the facility for a routine physical examination in preparation for her new position at Smith, Stevens, Silver & Company. Patient reports having no acute health problems.

The patient takes a well-tolerated birth control medication called drospirenone at the exact same time every day. During the yearly gynecological exam a few months ago, the patient received a PCOS diagnosis and was prescribed drospirenone/ethinyl estradiol.

In addition, the patient takes metformin for her diabetes and uses an inhaler for her asthma. In order to improve her vision, the patient saw an eye doctor and received prescription glasses. Also, the patient regularly checks her blood sugar levels and states that the medication metformin is helping in the management of her diabetes and to due to this condition she engages in exercise and has made dietary changes to further help her.

 Medications:

1. 90mcg proventil PRN for wheezing.
2. P.O 200 mg ibuprofen every 8 hours PRN when she has menstrual cramps.
3. 1 tablet of drospirenone pill taken every day.
4. P.O 850 mg metformin two times daily.
5. 88mcg flovent twice daily.

Allergies:

Penicillin

Cats

Patient not allergic to any food.

Patient not allergic to latex.

 Past Medical History (PMH):

Asthma

Type 2 diabetes

Hypertension

PCOS

Past Surgical History (PSH):

Patient has not had a previous surgical procedure.

Sexual/Reproductive History:

Patient had her last menstrual period 2 weeks ago.

Patient is on a birth control pill known as drospirenone

Patient first engaged in sexual intercourse when she was 18 years old.

Patient sexual preference is to males.

Personal/Social History:

Patient lives with her mother and sister.

Patient consumes alcohol on occasion with her friends.

Patient is about to be employed at Smith, Stevens, Silver & Company.

Patient does not use tobacco.

Health Maintenance:

Patient got a pap smear a few months ago.

3 months ago patient underwent an eye exam.

Patient adheres to her prescribed medication.

Patient has made changes to her diet and lifestyle to help manage her diabetes condition

Immunization History:

Patient received a tetanus booster.

Patient has received all expected immunizations.

Significant Family History:

Paternal grandfather: passed away.

Paternal grandmother: hypertensive and with high cholesterol.

Maternal grandfather: died.

Maternal grandmother: 82 and healthy.

Father: died due to a car accident.

Mother: hypertensive and with high cholesterol.

Brother: overweight.

Sister: asthmatic.

Review of Systems:

General:

She has intentionally lost weight.

She has not been recently ill.

She is not fatigued.

HEENT:

She has not had a head injury.

She has not had eye pain.

She has not had ear pain.

She has not had nose problems.

She has not had throat problems.

Respiratory:

She has not had recent breathing problems.

Cardiovascular/Peripheral Vascular:

She has not had palpitations.

She has not had edema.

She has not had chest pain.

Gastrointestinal:

She is not vomiting.

She has not felt nausea.

She is not constipating.

Genitourinary:

She is urinating less at night than before.

She does not have blood in the urine.

She does not feel pain while urinating

Musculoskeletal:

She is not having pain in the muscles.

She is not having pain at the joints.

She is not swelling in the limbs.

Neurological:

She does not get periods when she is dizzy.

She has not had seizures.

She has not experienced loss of coordination.

Psychiatric:

She is not anxious.

She is not depressed.

She is not stressed.

She has no difficulty falling asleep.

 Skin/hair/nails:

She has some male-pattern hair growth,

She has no dry skin.

Her acne is improving.

She has no rashes.

OBJECTIVE DATA:

Physical Exam:

Vital signs:

B.P-128/82mmHg

SPo2-99%

H.R- 78 bpm

R.R-15

Temp.-37.2 C

Weight- 90kg

Height- 5’7”

General:

Patient is alert and oriented. Patient is well groomed. Patient is sitted upright without signs of distress. Patient has appropriate hygiene.

HEENT:

Scattered pustules observed on the face and facial hair noted on upper lip.

Eyes have normal reaction to light.

Visual acuity is at 20/20 while using corrective lenses.

Tympanic membrane is pearly grey.

The nasal mucosa is moist and pink

Nasal mucosa moist.

Oral mucosa is without lesions and moist.

Neck:

Smooth thyroid with no presence of nodules.

No lymphadenopathy detected.

No goiter present.

Chest/Lungs:

No deformities on the chest walls.

Chest wall is resonant on percussion.

The chest wall is symmetric.

In the lungs no adventitious sounds heard

Heart/Peripheral Vascular:

S1 and S2 sounds heard.

No abnormal heart sounds detected.

Capillary refill is less than 3 seconds.

No edema noted in legs.

 Abdomen:

Abdomen is protuberant and symmetric.

Bowel sounds heard to be normoactive.

Abdomen quadrants tympanic on percussion.

Abdomen is non-tender.

No visible masses.

 Musculoskeletal:

Extremities are without swelling or masses.

Extremities have full range of motion.

Extremities strength at 5/5.

Hip has full range of motion.

Neurological:

Patient has decreased sensation in the right and left foot.

Position sense is intact in the toes and fingers.

Heel to shin coordination is smooth and accurate.

Rapid alternating hand movements is smooth.

Skin:

Presence of hair on the upper lip.

Dark discoloration noted on the neck.

Pustules noted scattered on the face.

Fingernails lack clubbing.

 Diagnostic results:

Skin biopsy.

Autonomic testing.

Thyroid function.

Nerve conduction studies (NCS).

ASSESSMENT:

Differential Diagnosis

1. Diabetic neuropathy- this is a possible diagnosis as patient on examination has decreased sensation in the left and right feet. Patient also has diabetes thus it would have complicated and led to this condition. The disease occurs due to prolonged high blood sugar levels that leads to nerve damage (Ziegler, et al., 2021).

2.Guillain Barre’ syndrome- this is a condition that causes numbness, tingling and weakness in the limbs. It could be a possible diagnosis as patient is presenting with some numbness in the feet. However, it progresses rapidly which has not occurred in this patient (Shahrizaila, et al., 2021).

3.Hypothyroidism- a condition that occurs due to low thyroid hormone levels that could lead to peripheral neuropathy symptoms. It could be a possible condition as the patient presents with decreased sensation in the feet in which this disorder presents with such a clinical manifestation (Wilson, et al., 2021).

References

Shahrizaila, N., Lehmann, H. C., & Kuwabara, S. (2021). Guillain-Barré syndrome. The   lancet, 397(10280), 1214-1228.

Wilson, S. A., Stem, L. A., & Bruehlman, R. D. (2021). Hypothyroidism: Diagnosis and   treatment. American family physician, 103(10), 605-613.

Ziegler, D., Keller, J., Maier, C., & Pannek, J. (2021). Diabetic neuropathy. Experimental and      Clinical Endocrinology & Diabetes, 129, S70-S81.

Chief Complaint (CC): ‘I have come for reemployment assessment.’

History of Present Illness (HPI): The client is a 28-year-old African American that has come to the clinic for a reemployment assessment. She is cooperative and offers information needed for the assessment. Her speech is normal and she maintains eye contact during the assessment. She appears alert and oriented to all facets. She has good health and first-class hygiene. She denied any acute concerns as she has come for preemployment assessment. Her significant illnesses include POCS diagnosed four months ago, type 2 diabetes mellitus, and allergy to penicillin, dust, and cars.

Medications: The client currently uses several medications. They include Metformin 850 mg BID, Drospitenone and ethinyl estradiol PO QD, Albuterol spray that she puffs twice and last use was three months ago. She also uses acetaminophen 500-1000 mg PO prn for headaches and ibuprofen for menstrual cramps, which she took six weeks ago. She denies any side effects from these medications.

 Allergies: She reports allergic reaction to penicillin, which causes rashes. She also reports allergies to dust and cars. She denies food and latex allergies.

 Past Medical History (PMH): The client was diagnosed with asthma when she was one and half years old. She reports that last asthma exacerbation was three months ago. Her last asthma hospitalization was when she was in high school. She has not history of intubation. She has type 2 diabetes mellitus that was diagnosed when she was 24 years. She manages it using metformin, with her blood sugar being an average of 90. She monitors blood sugar daily in the morning. She also manages diabetes using exercise and diets. She is also hypertensive. She has no history of surgery.

Past Surgical History (PSH): She denied any history of surgery

Sexual/Reproductive History: She developed her menarche at the age of 11. She has sex with men. She has no history of pregnancy. She had her first sex at the age of 18. She was diagnosed with POCS four months ago when she went for her gynecological exam.

 Personal/Social History: The client just secured an employment. She is not married but has a boyfriend. She lives with her mother and intends to move to her apartment once she starts working. She loves reading, dancing, attending Bible studies, and church functions. She has a strong social support system comprising her family and church.

Health Maintenance: The client does not use tobacco. She used cannabis from ages 15-21 years. She does not abuse any drugs. She occasionally drinks alcohol when with her friends at least 2-3 times monthly. She eats healthily in all her meals from breakfast, lunch, to supper. She takes diet coke. She engages in mild exercise at least four times a week. The client also attends to the doctor’s appointments.

Her last pap smear was four months ago. She had eye examinations three months ago. Her dental examination was 150 days ago. She is negative for PPD, which was done two years ago. She has smoke detectors at home and wears safety belts in the care. She does not ride the bike. She uses sunscreen in the sun. She has her father’s gun locked in their bedroom.

 Immunization History: Her immunization status is current bar HPV and tetanus vaccines. Childhood vaccines are also up to date as well as meningococcal vaccines.

Significant Family History: There is a history of hypertension in all the grandparents from both sides and both parents. Both parents and maternal grandparents have high cholesterol. Stroke killed maternal grandparents. Paternal grandmother is alive and 82 years of age whilst grandfather died of cancer at 65. The deceased grandfather also had a history of type 2 diabetes alongside the patient’s father who died in an accident. The client has an overweight brother and an asthmatic sister. Alcoholism in paternal uncle whilst no other diseases exist in the family as well as her.

Assignment 3: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical

Assessment

Throughout this course, you were encouraged to practice conducting various physical
assessments on multiple areas of the body, ranging from the head to the toes. Each of these assessments, however, was conducted independently of one another. For this
DCE Assignment, you connect the knowledge and skills you gained from each
individual assessment to perform a comprehensive head-to-toe physical examination in
your Digital Clinical Experience.

Week 9: Shadow Health Comprehensive SOAP Note Template

 

Patient Initials: ___T. J____               Age: _____28__                                 Gender: __F_____

 

SUBJECTIVE DATA:

 

Chief Complaint (CC): “I came here because I am required to have a recent physical exam for the health insurance at my new job”

 History of Present Illness (HPI): Ms. Tina Jones states that she is presently going to be employed at Smith, Stevens, Stewart, Silver and Company. As a prerequisite for her employment, Ms. Jones needs to have a preemployment physical. During the interview, she states that she does not have any acute concerns. Ms. Jones last visited a facility, the Shadow Health General Clinic, four months ago for a yearly gynecological assessment.

Consequently, she was diagnosed with POCS at which point the gynecologist prescribed contraceptives for her that were to be taken orally. She states that she is tolerating the contraceptives. The patient also admits to having type 2 diabetes that she manages using exercise, diet and the drug metformin that was prescribed to her some five months ago. She denies having any adverse events with any of the drugs. The patient admits to feeling healthy since she is careful with her body compared to the past and she is excited for the new job.

 Medications: The patient is on Flucotisone propionate 110 mcg that she takes 2 puffs twice daily with the last use occurring in the morning. The patient is also on Metformin 859 mg PO twice daily and its last use was equally in the morning. Moreover, the patient takes Drospirenone and ethinyl estradiol PO four times daily with the last use happening in the morning.

Ms. Jones also uses the Albuterol spray for her asthma and the last use was three months ago. Tina also uses Ibuprofen 600 thrice per day in order to manage her menstrual cramps. The last time she used the medication was six weeks ago.

 Allergies: She is allergic to penicillin which elicits rashes. She however denies latex and food allergies. She admits being allergic to cats and dust. Upon exposure to her allergens, the patient reacts by having runny nose, swollen itchy eyes, as well as exacerbation of her asthma symptoms.

 Past Medical History (PMH): Tina’s asthma was revealed when she was 21/2 years old. When around

allergens such as cats, she uses the Albuterol inhaler. She used the same inhaler to resolve her last asthma exacerbation that occurred three months ago. Her asthma last resulted in hospitalization when she was in high school. She denies ever being intubated. Her type 2 diabetes was diagnosed when she was 24 years old.

Her metformin management of the asthma begun 5 months ago with GI side effects initially, which have since been resolved. The patient ensures to take her blood sugar readings daily in the morning with the average readings standing at 90. She used diet and exercise to manage her hypertension history. She does not have a history of surgeries.

Past Surgical History (PSH): Denies any surgical history

Sexual/Reproductive History: She had menarche at the age of 11. She had her maiden sex at the age of 18. She identifies as heterosexual and only has sex with men. She denies ever being pregnant with her last monthly periods occurring a fortnight ago. She was also diagnosed with PCOS during her last physical exam, which occurred 4 months ago.

After starting on the prescription drug Yaz, her cycles have become regular accompanied with bleeding that is moderate and which lasts five days. She has started a new relationship with a man but they have not had sex yet. She has plans to protect herself when she starts having sex. She does not have any sexually transmitted infections or HIV/AIDS with the last test occurring four months ago.

To Prepare

 Review this week’s Learning Resources, and download and review the Physical
Examination Objective Data Checklist as well as the Student Checklists and Key Points
documents related to neurologic system and mental status.
 Review the Shadow Health Resources provided in this week’s Learning Resources
specifically the tutorial to guide you through the documentation and interpretation with
the Shadow Health platform. Review the examples also provided.
 Review the DCE (Shadow Health) Documentation Template for Comprehensive (Head-
to-Toe) Physical Assessment found in this week’s Learning Resources and use this
template to complete your Documentation Notes for this DCE Assignment.

 Access and login to Shadow Health using the link in the left-hand navigation of the
Blackboard classroom.
 Review the Week 9 DCE Comprehensive Physical Assessment Rubric provided in the
Assignment submission area for details on completing the Assessment in Shadow
Health.

DCE Comprehensive Physical Assessment:
Complete the following in Shadow Health:

 Episodic/Focused Note for Comprehensive Physical Assessment of Tina Jones (180
minutes)
Note: Each Shadow Health Assessment may be attempted and reopened as many
times as necessary prior to the due date to achieve a total of 80% or better (this
includes your DCE and your Documentation Notes), but you must take all attempts by
the Week 9 Day 7 deadline.
Submission and Grading Information

By Day 7 of Week 9

 Complete your Comprehensive (Head-to-Toe) Physical Assessment DCE Assignment
in Shadow Health via the Shadow Health link in Blackboard.
 Once you complete your Assignment in Shadow Health, you will need to download your
lab pass and upload it to the corresponding Assignment in Blackboard for your faculty
review.
 (Note: Please save your lab pass as “LastName_FirstName_AssignmentName”.) You
can find instructions for downloading your lab pass
here: https://link.shadowhealth.com/download-lab-pass
 Once you submit your Documentation Notes to Shadow Health, make sure to copy and
paste the same Documentation Notes into your Assignment submission link below.
 Download, sign, date, and submit your Student Acknowledgement Form found in the
Learning Resources for this week.

Grading Criteria

To access your rubric:
Week 9 Assignment 3 DCE Rubric
Submit Your Assignment by Day 7 of Week 9
To submit your Lab Pass:
Week 9 Lab Pass
To participate in this Assignment:
Week 9 Documentation Notes for Assignment 3
To Submit your Student Acknowledgement Form:
Submit your Week 9 Assignment 3 DCE Student Acknowledgement Form

What's Coming Up in Week 10?

Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images
Next week, you will examine how to assess problems with the breasts, genitalia,
rectum, and prostate while making the patient feel safe, listened to, and cared about
using a non-invasive approach. Once again, you will use a SOAP note format to
complete your Lab Assignment for this week.
Week 10 Required Media
Photo Credit: [fergregory]/[iStock / Getty Images Plus]/Getty Images
Next week, you will need to view several videos and animations in the Seidel’s Guide to
Physical Examination as well as other media, as required, prior to completing your
Discussion. There are several videos of various lengths. Please plan ahead to ensure
you have time to view these media programs to complete your Lab Assignment on
time.
Next Week
To go to the next week:
Week 10

ORDER NOW FOR AN ORIGINAL PAPER ASSIGNMENT: Assignment 3: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment NURS 6512N-32

Learning Resources

Required Readings (click to expand/reduce)
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W.
(2019). Seidel's guide to physical examination: An interprofessional
approach (9th ed.). St. Louis, MO: Elsevier Mosby.

 Chapter 7, “Mental Status”

This chapter revolves around the mental status evaluation of an
individual’s overall cognitive state. The chapter includes a list of mental
abnormalities and their symptoms.

 ·Chapter 23, “Neurologic System”

The authors of this chapter explore the anatomy and physiology of the
neurologic system. The authors also describe neurological examinations
and potential findings.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health
assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO:
Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E.,
Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright
Clearance Center.

Chapter 4, “Affective Changes”

This chapter outlines how to identify the potential cause of affective
changes in a patient. The authors provide a suggested approach to the
evaluation of this type of change, and they include specific tools that can
be used as part of the diagnosis.
Chapter 9, “Confusion in Older Adults”
This chapter focuses on causes of confusion in older adults, with an
emphasis on dementia. The authors include suggested questions for
taking a focused history as well as what to look for in a physical
examination.

Chapter 13, “Dizziness”

Dizziness can be a symptom of many underlying conditions. This chapter
outlines the questions to ask a patient in taking a focused history and
different tests to use in a physical examination.
Chapter 19, “Headache”
The focus of this chapter is the identification of the causes of headaches.
The first step is to ensure that the headache is not a life-threatening
condition. The authors give suggestions for taking a thorough history and
performing a physical exam.

Chapter 31, “Sleep Problems”

In this chapter, the authors highlight the main causes of sleep problems.
They also provide possible questions to use in taking the patient’s history,
things to look for when performing a physical exam, and possible
laboratory and diagnostic studies that might be useful in making the
diagnosis.
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.).
Philadelphia, PA: F. A. Davis.
 Chapter 2, "The Comprehensive History and Physical Exam" ("Cranial
Nerves and Their Function" and "Grading Reflexes") (Previously read in
Weeks 1, 2, 3, and 5)
Note: Download the Physical Examination Objective Data Checklist to use
as you complete the Comprehensive (Head-to-Toe) Physical Assessment
assignment.
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. (2011). Physical examination objective data checklist. In
Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier
Mosby.

Credit Line: Mosby’s Guide to Physical Examination, 7th Edition by Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A.,
Solomon, B. S., & Stewart, R. W. Copyright 2011 by Elsevier. Reprinted by permission of Elsevier via the Copyright Clearance
Center.
Note: Download and review the Student Checklists and Key Points to use
during your practice neurological examination.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W.
(2019). Neurologic system: Student checklist. In Seidel's guide to physical
examination: An interprofessional approach (9th ed.). St. Louis, MO:
Elsevier Mosby.
Credit Line: Seidel's Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the
Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W.
(2019). Neurologic system: Key points. In Seidel's guide to physical
examination: An interprofessional approach (9th ed.). St. Louis, MO:
Elsevier Mosby.
Credit Line: Seidel's Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the
Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W.
(2019). Mental status: Student checklist. In Seidel's guide to physical
examination: An interprofessional approach (9th ed.). St. Louis, MO:
Elsevier Mosby.
Credit Line: Seidel's Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the
Copyright Clearance Center.

Bearden , S. T., & Nay, L. B. (2011). Utility of EEG in differential diagnosis
of adults with unexplained acute alteration of mental status. American
Journal of Electroneurodiagnostic Technology, 51(2), 92–104.
This article reviews the use of electrocenographs (EEG) to
assist in differential diagnoses. The authors provide differential
diagnostic scenarios in which the EEG was useful.

Athilingam, P ., Visovsky, C., & Elliott, A. F. (2015). Cognitive screening in
persons with chronic diseases in primary care: Challenges and
recommendations for practice. American Journal of Alzheimer’s Disease &
Other Dementias, 30(6), 547–558. doi:10.1177/1533317515577127

Sinclair , A. J., Gadsby, R., Hillson, R., Forbes, A., & Bayer, A. J. (2013).
Brief report: Use of the Mini-Cog as a screening tool for cognitive

impairment in diabetes in primary care. Diabetes Research and Clinical
Practice, 100(1), e23–e25. doi:10.1016/j.diabres.2013.01.001

Roalf, D. R., Moberg, P. J., Xei, S. X., Wolk, D. A., Moelter, S. T., &
Arnold, S. E. (2013). Comparative accuracies of two common screening
instruments for classification of Alzheimer’s disease, mild cognitive
impairment, and healthy aging. Alzheimer’s & Dementia, 9(5), 529–537.
doi:10.1016/j.jalz.2012.10.001. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4036230/
Shadow Health Support and Orientation Resources
Use the following resources to guide you through your Shadow Health orientation
as well as other support resources:
Frey, C. [Chris Frey]. (2015, September 4). Student orientation [Video file].
Retrieved from https://www.youtube.com/watch?v=Rfd_8pTJBkY
Shadow Health. (n.d.). Shadow Health help desk. Retrieved
from https://support.shadowhealth.com/hc/en-us
Document: Shadow Health. (2014). Useful tips and tricks (Version 2)
(PDF)
Document: Student Acknowledgement Form (Word document)
Note: You will sign and date this form each time you complete your DCE
Assignment in Shadow Health to acknowledge your commitment to
Walden University’s Code of Conduct.
Document: DCE (Shadow Health) Documentation Template for
Comprehensive (Head-to-Toe) Physical Assessment (Word document)
Use this template to complete your Assignment 3 for this week.
Optional Resources
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s
diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.

 Chapter 14, “The Neurologic Examination” (pp. 683–765)
This chapter provides an overview of the nervous system. The authors
also explain the basics of neurological exams.
 Chapter 15, “Mental Status, Psychiatric, and Social Evaluations” (pp.
766–786)
In this chapter, the authors provide a list of common psychiatric
syndromes. The authors also explain the mental, psychiatric, and social
evaluation process.
Mahlknecht, P., Hotter, A., Hussl, A., Esterhammer, R., Schockey, M., &
Seppi, K. (2010). Significance of MRI in diagnosis and differential
diagnosis of Parkinson’s disease. Neurodegenerative Diseases, 7(5),
300–318.
Required Media (click to expand/reduce)

Online media for Seidel's Guide to Physical Examination
It is highly recommended that you access and view the resources included with the
course text, Seidel's Guide to Physical Examination. Focus on the videos and
animations in Chapters 7 and 23 that relate to the assessment of cognition and the
neurologic system. Refer to the Week 4 Learning Resources area for access instructions
on  https://evolve.elsevier.com/

Patient Information:

Initials: J.K.L

Age: 40 years

Sex: Female

Race: African American

Source: Patient

S.

CC: “I have a headache around my forehead.”

HPI: J.K.L is a 40-year-old African American female who presents with a complaint of a headache across her forehead for a week. The headache is squeezing and feels like pressure behind the eyes. It is non-radiating. The headache is constant and varies in severity ranging from 2/10 at its best to 8/10 at its worst. It is usually worse in the morning and while bending.

Acetaminophen reduces the severity of the headache to 4/10 and occasionally 2/10. It is associated with fever, postnasal drip, nasal congestion, sneezing, and occasional non-productive cough. She takes Sudafed HCL 120 mg every 12 hours to obtain some relief. The symptoms have significantly impaired her concentration at work and made her feel very tired. Finally, she reports a head cold three weeks ago.

Current Medications: Pseudoephedrine 120 mg BID for nasal congestion and acetaminophen for headaches.

Allergies: She has no known food and drug allergies.

Past Medical History: During her last visit to the primary care physician 2 months ago, she was noted to be prehypertensive and was advised on lifestyle modifications. No prior hospitalization. No previous surgeries or blood transfusions.

Social History: She is married with two children both alive and well. She works as a secretary Her husband is a college teacher. She neither drinks alcohol nor smokes tobacco. She does not use marijuana or other illicit drugs. She strictly adheres to dietary advice from her nutritionist and she exercises regularly. Denies caffeine intake.

Family History: Father alive aged 60 years and with hypertension while her mother is 58 years old alive and well. Her brother and sister are 35 and 20 years old respectively, alive and well. Her paternal grandfather died at the age of 80 years due to a heart attack while her paternal grandmother is 78 years and is hypertensive. Her maternal grandfather is 77 years with a history of type 2 diabetes and high cholesterol while her maternal grandmother died at the age of 70 years due to a stroke. No family history of malignancies, mental illness, asthma, sickle cell, or diabetes.

ROS:

GENERAL: Reports fatigue and occasional fever. Denies weight loss, night sweats, and chills.

HEENT:  Reports headaches, nasal congestion, post nasal drip, and sneezing. No blurring of vision, visual loss, hearing loss, tinnitus, nose bleeds, ear pain, mouth sores, or sore throat.

SKIN:  no skin lesion or rashes. No abnormal pigmentation.

CARDIOVASCULAR: Negative for palpitations, chest pain, paroxysmal nocturnal dyspnea, and peripheral limb edema.

RESPIRATORY:  Occasional non-productive cough. No difficulty in breathing, dyspnea, or orthopnea.

GASTROINTESTINAL: Reports loss of appetite and occasional nausea and vomiting. Denies change in bowel habits, abdominal pain, or distention.

GENITOURINARY: No frequency, dysuria, nocturia, and polyuria. No vaginal itchiness or abnormal vaginal discharge.

NEUROLOGICAL: Reports headache. Denies dizziness, lightheadedness, numbness, tingling, loss of sensation, syncope, and convulsion.

MUSCULOSKELETAL: No muscle pain, joint pains, muscle weakness, or muscle swelling.

HEMATOLOGIC:  No anemia, easy bruising, or bleeding.

LYMPHATICS: Normal lymph nodes

PSYCHIATRIC:  Denies anxiety, depression, suicidal ideations, or hallucinations.

ENDOCRINOLOGIC: Denies heat or cold intolerance, polyphagia, and polydipsia.

ALLERGIES:  Reports no allergies.

O.

Physical exam:

VITAL SIGNS: BP 125/78 mmHg, HR 88 b/min, Temp 99. 8 F, RR 20 b/min, saturation 95% on room air, Height 168 cm, weight 76 Kg. Pain level 5/10

GENERAL: A middle-aged African-American female, well kempt, not in any form of respiratory distress but slight discomfort. Maintains eye contact, coherent speech, and a stable mood. Well-hydrated and nourished. No palmar or conjunctival pallor, jaundice, central or peripheral cyanosis, cervical or inguinal lymphadenopathy, and peripheral limb edema.

HEENT: Normocephalic and atraumatic head. Non-tender scalp. Bilateral eyes with pink conjunctiva and white sclera. Pupils equally and bilaterally reacting to light, no ptosis or lid edema. Normal extraocular movements. Bilateral ears present, no impaction or skin lesions, tympanic membrane pearly grey bilaterally, and positive white reflex. Both nares are present and are discharging mucus, midline nasal septum, and pink and soft nasal mucosa. Tender maxillary and frontal sinus. Moist and pink oral mucosa, no oral lesions or ulceration. Normal dentition and teeth alignment.

NECK: Soft neck. The trachea is central. Full range of motion, non-tender, no cervical lymphadenopathy, and no thyroid enlargement.

CARDIOVASCULAR: Regular heart rate. Normoactive precordium. Point of maximal impulse in the 5^th intercostal space in the midclavicular line. S1 and S2 head, no murmurs, thrills, gallops, rubs, or heaves.

RESPIRATORY: Symmetrical chest that moves with respiration. No scars or skin lesions. Equal chest expansion and equal tactile fremitus bilaterally. Equal air entry, vesicular breath sounds, no wheezes, and crackles, and equal vocal fremitus in all lung zones.

NEUROLOGICAL: GCS 15/15, oriented to time, place, and person, intact short-term and long-term memory, good concentration, and a clear coherent speech. Cranial nerves 1 to 12 intact. Normotonic across all joints, normal bulk, and power 5/5 across all muscle groups in upper and lower extremities, deep tendon reflexes 2+ and equal bilaterally in upper and lower limbs. Intact monofilament sensation across all dermatomes, good bowel, and bladder function. No spinal tenderness, normal gait, coordination, graphesthesia, and stereognosis. Normal finger nose, heel to the shin, and rapid alternating movements tests.

Diagnostic results:

J.K.L appears to have an inflammatory/infectious condition. Consequently, complete blood count and inflammatory markers particularly CRP and ESR are paramount. Similarly, bacterial or fungal cultures obtained endoscopically or by direct sinus aspiration are required to identify the possible pathogen. Additionally, a skin prick test is essential to exclude allergic rhinitis. Imaging modalities principally Sinus CT and MRI are recommended to evaluate for rhinosinusitis and intraorbital or intracranial involvement.

A.

Differential Diagnoses

Acute Sinusitis- refers to the inflammation of sinuses lasting less than 4 weeks (DeBoer & Kwon, 2022). The condition is more common in females and particularly during early fall to early spring (DeBoer & Kwon, 2022). It is most commonly caused by viral infection following a common cold although bacteria and fungi are not uncommon etiologies.

J.K.L presents with clinical features that are typical of acute sinusitis including fatigue, fever, headache, facial pain, and pressure worse on bending (DeBoer & Kwon, 2022). Maxillary sinuses and frontal sinuses appear to be the affected sinuses in her as evidenced by pain around the forehead and tenderness of the maxillary and frontal sinuses (DeBoer & Kwon, 2022).

Rhinitis- Refers to the inflammation of the nasal mucosa. J.K.L presents with clinical manifestations suggestive of rhinitis including sneezing, nasal congestion, postnasal drip, and rhinorrhea (Liva et al., 2021). Similarly, she reports a “head cold” three weeks ago. Rhinitis is mostly caused by an upper respiratory infection or type 1 hypersensitivity reaction (Liva et al., 2021). However, an upper respiratory tract infection is likely the cause in her case.

Cluster headache- Cluster headache is a type of primary headache that is usually unilateral retro-orbital and characterized by sharp and stabbing pain (Goadsby et al., 2018). Cluster headache may present with symptoms of lacrimation, nasal congestion, rhinorrhea, ptosis, or miosis (Goadsby et al., 2018). However, it is unlikely the diagnosis in her as cluster headache usually lasts for a brief period. Similarly, cluster headaches mostly awake the patient at night.

Migraine headache- Migraine headache is another type of primary headache that may be preceded with or without aura. It is usually pulsating and moderate to severe (Pescador Ruschel & O, 2022). It is common in young women. However, it is unlikely the diagnosis as migraines last 4 to 72 hours if untreated and are typically associated with nausea, vomiting, photophobia, and phonophobia (Pescador Ruschel & O, 2022).

Rebound headache– Commonly referred to as medication overuse headache. Rebound headache predominantly occurs in individuals with primary headaches who overuse analgesia (Micieli & Robblee, 2018). Rebound headaches are more common in females and individuals less than 50 years. Drugs precipitating this headache include barbiturates, acetaminophen, opioids, ergotamine, and triptans (Micieli & Robblee, 2018). However, this is an unlikely diagnosis in J.K.L as a diagnosis of primary headache hasn’t been established.

References

DeBoer, D. L., & Kwon, E. (2022). Acute Sinusitis. https://pubmed.ncbi.nlm.nih.gov/31613481/

Goadsby, P., Wei, D.-T., & Yuan Ong, J. (2018). Cluster headache: Epidemiology, pathophysiology, clinical features, and diagnosis. Annals of Indian Academy of Neurology, 21(5), 3. https://doi.org/10.4103/aian.aian_349_17

Liva, G. A., Karatzanis, A. D., & Prokopakis, E. P. (2021). Review of rhinitis: Classification, types, pathophysiology. Journal of Clinical Medicine, 10(14), 3183. https://doi.org/10.3390/jcm10143183

Micieli, A., & Robblee, J. (2018). Medication-overuse headache. Journal de l’Association Medicale Canadienne [Canadian Medical Association Journal], 190(10), E296–E296. https://doi.org/10.1503/cmaj.171101

Pescador Ruschel, M., & O, D. J. (2022). Migraine Headache. https://pubmed.ncbi.nlm.nih.gov/32809622/

Patient Information:

Initials: J.K.L             

Age: 40 years

Sex: Female                           

Race: African American

Source: Patient

S.

CC: “I have a headache around my forehead.”

HPI: J.K.L is a 40-year-old African American female who presents with a complaint of a headache across her forehead for a week. The headache is squeezing and feels like pressure behind the eyes. It is non-radiating. The headache is constant and varies in severity ranging from 2/10 at its best to 8/10 at its worst. It is usually worse in the morning and while bending. Acetaminophen reduces the severity of the headache to 4/10 and occasionally 2/10.

It is associated with fever, postnasal drip, nasal congestion, sneezing, and occasional non-productive cough. She takes Sudafed HCL 120 mg every 12 hours to obtain some relief. The symptoms have significantly impaired her concentration at work and made her feel very tired. Finally, she reports a head cold three weeks ago.

Current Medications: Pseudoephedrine 120 mg BID for nasal congestion and acetaminophen for headaches.

Allergies: She has no known food and drug allergies.

Past Medical History: During her last visit to the primary care physician 2 months ago, she was noted to be prehypertensive and was advised on lifestyle modifications. No prior hospitalization. No previous surgeries or blood transfusions.

Social History: She is married with two children both alive and well. She works as a secretary Her husband is a college teacher. She neither drinks alcohol nor smokes tobacco. She does not use marijuana or other illicit drugs. She strictly adheres to dietary advice from her nutritionist and she exercises regularly. Denies caffeine intake.

Family History: Father alive aged 60 years and with hypertension while her mother is 58 years old alive and well. Her brother and sister are 35 and 20 years old respectively, alive and well. Her paternal grandfather died at the age of 80 years due to a heart attack while her paternal grandmother is 78 years and is hypertensive. Her maternal grandfather is 77 years with a history of type 2 diabetes and high cholesterol while her maternal grandmother died at the age of 70 years due to a stroke. No family history of malignancies, mental illness, asthma, sickle cell, or diabetes.

ROS:

GENERAL: Reports fatigue and occasional fever. Denies weight loss, night sweats, and chills.  

HEENT:  Reports headaches, nasal congestion, post nasal drip, and sneezing. No blurring of vision, visual loss, hearing loss, tinnitus, nose bleeds, ear pain, mouth sores, or sore throat.

SKIN:  no skin lesion or rashes. No abnormal pigmentation.

CARDIOVASCULAR: Negative for palpitations, chest pain, paroxysmal nocturnal dyspnea, and peripheral limb edema.

RESPIRATORY:  Occasional non-productive cough. No difficulty in breathing, dyspnea, or orthopnea.

GASTROINTESTINAL: Reports loss of appetite and occasional nausea and vomiting. Denies change in bowel habits, abdominal pain, or distention.

GENITOURINARY: No frequency, dysuria, nocturia, and polyuria. No vaginal itchiness or abnormal vaginal discharge.

NEUROLOGICAL: Reports headache. Denies dizziness, lightheadedness, numbness, tingling, loss of sensation, syncope, and convulsion.

MUSCULOSKELETAL: No muscle pain, joint pains, muscle weakness, or muscle swelling.

HEMATOLOGIC:  No anemia, easy bruising, or bleeding.

LYMPHATICS: Normal lymph nodes

PSYCHIATRIC:  Denies anxiety, depression, suicidal ideations, or hallucinations.

ENDOCRINOLOGIC: Denies heat or cold intolerance, polyphagia, and polydipsia.

ALLERGIES:  Reports no allergies.

O.

Physical exam:

VITAL SIGNS: BP 125/78 mmHg, HR 88 b/min, Temp 99. 8 F, RR 20 b/min, saturation 95% on room air, Height 168 cm, weight 76 Kg. Pain level 5/10

GENERAL: A middle-aged African-American female, well kempt, not in any form of respiratory distress but slight discomfort. Maintains eye contact, coherent speech, and a stable mood. Well-hydrated and nourished. No palmar or conjunctival pallor, jaundice, central or peripheral cyanosis, cervical or inguinal lymphadenopathy, and peripheral limb edema.

HEENT: Normocephalic and atraumatic head. Non-tender scalp. Bilateral eyes with pink conjunctiva and white sclera. Pupils equally and bilaterally reacting to light, no ptosis or lid edema. Normal extraocular movements. Bilateral ears present, no impaction or skin lesions, tympanic membrane pearly grey bilaterally, and positive white reflex. Both nares are present and are discharging mucus, midline nasal septum, and pink and soft nasal mucosa. Tender maxillary and frontal sinus. Moist and pink oral mucosa, no oral lesions or ulceration. Normal dentition and teeth alignment.

NECK: Soft neck. The trachea is central. Full range of motion, non-tender, no cervical lymphadenopathy, and no thyroid enlargement.

CARDIOVASCULAR: Regular heart rate. Normoactive precordium. Point of maximal impulse in the 5^th intercostal space in the midclavicular line. S1 and S2 head, no murmurs, thrills, gallops, rubs, or heaves.

RESPIRATORY: Symmetrical chest that moves with respiration. No scars or skin lesions. Equal chest expansion and equal tactile fremitus bilaterally. Equal air entry, vesicular breath sounds, no wheezes, and crackles, and equal vocal fremitus in all lung zones.

NEUROLOGICAL: GCS 15/15, oriented to time, place, and person, intact short-term and long-term memory, good concentration, and a clear coherent speech. Cranial nerves 1 to 12 intact. Normotonic across all joints, normal bulk, and power 5/5 across all muscle groups in upper and lower extremities, deep tendon reflexes 2+ and equal bilaterally in upper and lower limbs. Intact monofilament sensation across all dermatomes, good bowel, and bladder function. No spinal tenderness, normal gait, coordination, graphesthesia, and stereognosis. Normal finger nose, heel to the shin, and rapid alternating movements tests.

Diagnostic results:

J.K.L appears to have an inflammatory/infectious condition. Consequently, complete blood count and inflammatory markers particularly CRP and ESR are paramount. Similarly, bacterial or fungal cultures obtained endoscopically or by direct sinus aspiration are required to identify the possible pathogen. Additionally, a skin prick test is essential to exclude allergic rhinitis. Imaging modalities principally Sinus CT and MRI are recommended to evaluate for rhinosinusitis and intraorbital or intracranial involvement.

A.

Differential Diagnoses

Acute Sinusitis- refers to the inflammation of sinuses lasting less than 4 weeks (DeBoer & Kwon, 2022). The condition is more common in females and particularly during early fall to early spring (DeBoer & Kwon, 2022). It is most commonly caused by viral infection following a common cold although bacteria and fungi are not uncommon etiologies.

J.K.L presents with clinical features that are typical of acute sinusitis including fatigue, fever, headache, facial pain, and pressure worse on bending (DeBoer & Kwon, 2022). Maxillary sinuses and frontal sinuses appear to be the affected sinuses in her as evidenced by pain around the forehead and tenderness of the maxillary and frontal sinuses (DeBoer & Kwon, 2022).

Rhinitis- Refers to the inflammation of the nasal mucosa. J.K.L presents with clinical manifestations suggestive of rhinitis including sneezing, nasal congestion, postnasal drip, and rhinorrhea (Liva et al., 2021). Similarly, she reports a “head cold” three weeks ago. Rhinitis is mostly caused by an upper respiratory infection or type 1 hypersensitivity reaction (Liva et al., 2021). However, an upper respiratory tract infection is likely the cause in her case.

Cluster headache- Cluster headache is a type of primary headache that is usually unilateral retro-orbital and characterized by sharp and stabbing pain (Goadsby et al., 2018). Cluster headache may present with symptoms of lacrimation, nasal congestion, rhinorrhea, ptosis, or miosis (Goadsby et al., 2018). However, it is unlikely the diagnosis in her as cluster headache usually lasts for a brief period. Similarly, cluster headaches mostly awake the patient at night.

Migraine headache- Migraine headache is another type of primary headache that may be preceded with or without aura. It is usually pulsating and moderate to severe (Pescador Ruschel & O, 2022). It is common in young women. However, it is unlikely the diagnosis as migraines last 4 to 72 hours if untreated and are typically associated with nausea, vomiting, photophobia, and phonophobia (Pescador Ruschel & O, 2022).

Rebound headache– Commonly referred to as medication overuse headache. Rebound headache predominantly occurs in individuals with primary headaches who overuse analgesia (Micieli & Robblee, 2018). Rebound headaches are more common in females and individuals less than 50 years. Drugs precipitating this headache include barbiturates, acetaminophen, opioids, ergotamine, and triptans (Micieli & Robblee, 2018). However, this is an unlikely diagnosis in J.K.L as a diagnosis of primary headache hasn’t been established.

References

DeBoer, D. L., & Kwon, E. (2022). Acute Sinusitis. https://pubmed.ncbi.nlm.nih.gov/31613481/

Goadsby, P., Wei, D.-T., & Yuan Ong, J. (2018). Cluster headache: Epidemiology, pathophysiology, clinical features, and diagnosis. Annals of Indian Academy of Neurology, 21(5), 3. https://doi.org/10.4103/aian.aian_349_17

Liva, G. A., Karatzanis, A. D., & Prokopakis, E. P. (2021). Review of rhinitis: Classification, types, pathophysiology. Journal of Clinical Medicine, 10(14), 3183. https://doi.org/10.3390/jcm10143183

Micieli, A., & Robblee, J. (2018). Medication-overuse headache. Journal de l’Association Medicale Canadienne [Canadian Medical Association Journal], 190(10), E296–E296. https://doi.org/10.1503/cmaj.171101

Pescador Ruschel, M., & O, D. J. (2022). Migraine Headache. https://pubmed.ncbi.nlm.nih.gov/32809622/

SUBJECTIVE DATA:

Chief Complaint (CC): I have come for my pre-employment assessment.

History of Present Illness (HPI): The patient is a 28-year-old African American unmarried female that came to the clinic for pre-employment assessment. She is cooperative and offers information. She maintains normal eye contact and has normal speech. The client reports that she recently got a job that requires her to have a health insurance.

She denies any acute concern. She reports that she had her gynecological exam four months ago where she was diagnosed with POCS and prescribed medications that she tolerates well. She is also diabetic and manages it with metformin and active lifestyle. She tolerates the medication well.

Medications: The patient currently uses Metformin 850 MG po BID Drospitenone and ethinyl estradiol PO QD. She also has Albuterol spay that she puffs twice and last use was three months ago. She occasionally uses Acetaminophen 500-1000 mg PO prn for headaches and Ibuprofen for menstrual cramps and last taken 6 weeks ago.

Allergies: The client reports allergic reaction to penicillin, which causes rashes. She also reports allergic reaction to dust and cats. She denies food and latex allergies.

Past Medical History (PMH): The client reports that she was diagnosed with asthma when 1 1/2 years old. Her last asthma exacerbation occurred three months ago. Last asthma hospitalization was when in high school. She report that she has never been intubated. The client reported that she has type 2 diabetes that was diagnosed at the age of 24.

She has been taking metformin for five months without much side effects. Her average blood sugar is 90 and she monitors it daily in the morning. She also exercises and diets to manage the condition as well as hypertension. She has never undergone any surgery.

Past Surgical History (PSH): She has no history of surgery

Sexual/Reproductive History: She developed menarche at the age of 11. She has sex with men. She has never been pregnant whilst her had first sex at the age of 18. She has a new boyfriend.

Personal/Social History: She graduated with accounting degree and has been hired as an accounting clerk at Smith, Stevens, Steward, Silver & Company. The patient does not have children. She is not married. She lives with her mother alongside sister in a single apartment but planning to move to her own once she starts work. She enjoys reading, attending Bible studies, dancing and attending church functions. She considers her social support to include the church, friends and her family. She does not use tobacco.

She used cannabis from ages 15-21. She does not abuse any other drugs. She uses alcohol in the company of friends at least 2-3 times monthly. She eats healthily in all her meals from breakfast, lunch to supper. She does not take coffee. She takes diet coke. She has not travelled outside recently and does not keep pets. She does mild exercise at least four times per week. She denies being stressed or anxiety.

Health Maintenance: The patient attends to the doctor’s appointment as scheduled. She had a pap smear 4 months ago. She also had an eye exam 3 months ago. The dental exam was last conducted 150 days ago. She is negative for PPD that was done two years ago. Her immunization status is current bar tetanus and HPV vaccines. She swims at YMCA. She reports that she has smoke detectors in the home. She wears safety belts in the car. She does not ride the bike. She uses sunscreen in the sun. She has locked her father’s gun in their bedroom.

Immunization History: Her immunization status is current bar tetanus and HPV vaccines. Childhood vaccines are up to date ad as well as meningococcal vaccine.

Significant Family History: There is history of hypertension in all the grandparents from both sides and both parents. Both parents and maternal grandparents have high cholesterol. Stroke killed maternal grandparents. Paternal grandmother is alive and 82 years of age whilst grandfather died of cancer at 65. The latter also had a history of type 2 diabetes alongside the patient’s father who died in an accident. Has an overweight brother and an asthmatic sister. Alcoholism in paternal uncle. There are no other diseases in the family.

Review of Systems:

General: The client is dressed appropriately for the occasion. She maintains normal eye contact during the assessment. Her speech is of normal rate and tone. She denies, chills, night sweats, headache, fatigue, or weight changes

HEENT: The client denies headache or head injuries. She denies general hearing problems, changes in hearing, ear pain or discharge. She also denies eye pain, itchy eyes, eye redness, or dry eyes. She denies changes in smell, sneezing, runny nose, nose bleeds or sinus pain. Dental visit was five months ago. She denies general mouth problems, changes in sense of taste, dry mouth, mouth pain, gum problems, tongue or jaw problems, and dental problems. She denies difficulty in swallowing, sore throat, voice changes, neck pain, or lymphadenopathy.

Respiratory: She denies any current breathing problems. She chest tightness, wheezing, chest pain, or cough.

Cardiovascular/Peripheral Vascular: She denies palpitations, irregular heartbeat, easy bruising, edema, or circulation problems.

 Gastrointestinal: She denies nausea, vomiting, stomach pain, constipation, diarrhea, or flatulence.

Genitourinary: She denies dysuria, nocturia, polyuria, blood stained urine, flank pain, abnormal vaginal discharge, breast lump or breast pain.

Musculoskeletal: She denies muscle pain, joint pain, muscle weakness, or swelling.

Neurological: She denies dizziness, vision disturbance, numbness or tingling, loss of coordination or sensation, seizures or balance problems.

Psychiatric: Has enhanced coping mechanism to stress. Does not suffer depression, anxiety, or suicidal thoughts. She is alert to all faculties. She is dressed properly and easily converses and cooperatively offers information. Has pleasant mood. Does not have tics or facial fasciculation. Her speech is fluent and words are clear.  Skin/hair/nails: she uses sun-glasses when playing outdoors. She denies slow-healing wounds, with improving acne and some male-pattern hair growth. She denies sores, dandruff, nail fungus, dry skin or rashes.

OBJECTIVE DATA:

Physical Exam:

Vital signs: Height: 170m cm Weight: 84 bmi: 29.00 Blood glucose: 90 RR: 15 HR: 78 BP: 128/82 Pulse Ox: 99% Temperature: 99.0 F

General: She is dressed properly and easily converses and cooperatively offers information. Has pleasant mood. Does not have tics or facial fasciculation. Her speech is fluent and words are clear.

HEENT: Normocephalic head, and atraumatic as well. Bilateral eyes with equal hair distribution on lashes and eye brows, lids without lesions. No ptosis or edema. Conjunctiva pink, no lesions, white sclera. PERRLA bilaterally. OEMS intact bilaterally, no nystagmus. Snellen: 20/20 right eye, 20/20 left eye with corrective lenses. TMS intact and pearly gray bilaterally, positive light reflex. Whispered words bilaterally heard.

Frontal and maxillary sinuses nontender to palpation. Nasal mucosa moist and pink, septum midline. Oral mucosa moist without ulcerations or lesions. Uvula rises midline on phonation. Gag reflex is intact, Dentation minus evidence of carries or infection. Tonsils 2+ bilaterally. Thyroid smooth minus nodules, no goiter. No lymphadenopathy.

Neck: Tonsils 2+ bilaterally. Thyroid smooth minus nodules, no goiter. No lymphadenopathy.

Chest/Lungs: Chest is symmetric. The lung sounds are clear whilst voice occurs in all areas. Percussion produced resonance throughout. In office spirometry: FVC 3.91, FEV1/FVC ratio 80.56%.

Heart/Peripheral Vascular: Heart rate is regular, S1, S2, without murmurs, gallops, or rubs. Bilateral carotids equal bilaterally without bruit. PMI at the midclavicular line, 5th intercostal space, no heaves, lifts or thrills. Bilateral peripheral pulses equal bilaterally, capillary refills less than 3 seconds. No peripheral edema.

Abdomen: Abdomen is protuberant, symmetric without visible masses, scars, or lesions, coarse hair from pubis to umbilicus. Bowel sounds are normoactive in all four quadrants. Tympanic throughout to percussion. No tenderness or guarding to palpation. No organomegaly. No CVA tenderness.

Genital/Rectal:

Musculoskeletal: Strength 5/5 bilateral upper and lower extremities, without swelling, masses, or deformity and with full range of motion. No pain with movement.

Neurological: Graphesthesia, stereognosis, and rapid alternating movements are normal bilaterally. Cerebella function tests produced normal results. DTRs 2+ and equal bilaterally in upper and lower extremities. Decreased sensation to monofilament in bilateral plantar surfaces.

Skin: Pustules on the face are scattered whilst the upper lip ha facial hair. The posterior neck has acanthosis nigricans. Nails are free of ridges or abnormalities.

Diagnostic results: none. The client has come for preemployment physical examination.

ASSESSMENT: The patient is a 28-year-old African American unmarried female that came to the clinic for pre-employment assessment. She is cooperative and offers information. She maintains normal eye contact and has normal speech. The client reports that she recently got a job that requires her to have a health insurance. She denies any acute concern. She reports that she had her gynecological exam four months ago where she was diagnosed with POCS and prescribed medications that she tolerates well.

Subjective Data Collection: 100 of 100 (100.0%)

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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

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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.

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 (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 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 (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: 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 (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 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 (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 you injure anything besides your foot?
• Finding: Reports being barefoot at the time of injury (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: 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 (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 go to the ER?
• Finding: Reports going to the ER because she suspected an ankle sprain (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: Why did you go to the ER?
• Finding: Reports receiving an X-ray at the ER (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 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 (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 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 (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 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 (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 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 (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 often did you clean the wound?
• Finding: Reports cleaning wound with hydrogen peroxide (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 you use to clean the wound?
• Finding: Reports applying bacitracin, neomycin and polymyxin B (Neosporin) (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 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 (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 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 (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: 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 (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 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 (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 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 (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 are your usual blood sugar levels?

• Finding: Asked about thirst

• Finding: Reports increased thirst (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 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 (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 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 (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 much weight have you lost?
• Finding: Reports weight loss occurred over the past month (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 long did it take you to lose 10 pounds?

• Finding: Followed up on reason for weight change

• Finding: Reports weight loss was unintentional (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: 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 (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: Why were you hospitalized last time?
• Finding: Reports last hospitalization was age 16 (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 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 (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: 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 (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 use your inhaler?

• Finding: Asked about number of puffs when using asthma inhaler

• Finding: Reports recommended dose is 1-3 puffs as needed (Found) Pro Tip: 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 (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 your inhaler effectively relieve your symptoms?
• Finding: Reports sometimes needing 3 puffs to control symptoms (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’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 (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 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 (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 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 (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 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 (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 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 (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 pressure?

Home Medications

• Finding: Asked about use of pain medication

• Finding: Reports taking prescription pain medication (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: Have you taken any prescription pain medications?
• Finding: Reports medication is tramadol (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 is the name of the pain medication?

• Finding: Followed up on pain medication frequency

• Finding: Reports taking pain medication for 2 days (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 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 (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: 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 (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 any over the counter medications?
• Finding: Denies vitamin supplements (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 any vitamins?
• Finding: Denies herbal supplements (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 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 (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: 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 (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: 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 (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: 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 (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: Tell me more about living at home.

Social History

• Finding: Asked about stressors

• Finding: Reports she is currently under high stress (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: 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 (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 did you eat for your last meal?
• Finding: Reports breakfast is usually a muffin or pumpkin bread (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 breakfast?
• Finding: Reports lunch is usually a sandwich (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 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 (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 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 (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 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 (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 smoke marijuana?
• Finding: Reports she stopped because of health reasons and waning interest (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 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 (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 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 (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 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 (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 father have health conditions?
• Finding: Reports father was 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 father have health conditions?
• Finding: Reports father was 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 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 (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 paternal grandfather have health conditions?
• Finding: Reports paternal 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 paternal grandfather have health conditions?
• Finding: Reports paternal 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 paternal grandfather have health conditions?
• Finding: Reports paternal grandfather died of colon cancer (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: 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 (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 relatives with addiction problems?

• Finding: Asked about family history of headaches

• Finding: Denies family history of headaches (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 headaches?

Review of Systems

• Finding: Asked about constitutional health

• Finding: Reports occasional tiredness or fatigue (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 fatigued?
• Finding: Reports typical sleep pattern (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 sleep?
• Finding: Reports 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: 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 (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 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 (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 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 (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 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 (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 smell changed?
• Finding: Denies nosebleeds (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 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 (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 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 (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 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 (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 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 (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 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 (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 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 (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 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 (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 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 (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 wheezing?
• Finding: Denies current chest tightness (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 chest tightness?
• Finding: Denies pain while breathing (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 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 (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 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 (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 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 (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 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 (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 it hurt when you urinate?
• Finding: Reports waking up to urinate during the night (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 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 (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 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 (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 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 (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 change your tampon or pad?
• Finding: Reports using super absorbency tampons (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 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 (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 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 (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 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 (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 sex without using a condom?
• Finding: Reports oral contraceptive use while sexually active (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: 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 (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 were you last tested for STIs?
• Finding: Denies STI symptoms (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 STI symptoms?
• Finding: Reports uncertainty about past partners and STI testing (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 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 (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 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 (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 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 (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 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 (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 passed out?
• Finding: Denies dizziness or vertigo (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 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 (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 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

She is also diabetic and manages it with metformin and active lifestyle. She tolerates the medication well. The patient currently uses Metformin 850 MG po BID Drospitenone and ethinyl estradiol PO QD.

She also has Albuterol spay that she puffs twice and last use was three months ago. She occasionally uses Acetaminophen 500-1000 mg PO prn for headaches and Ibuprofen for menstrual cramps and last taken 6 weeks ago. Physical examination findings are unremarkable. She denies any mental health problems such as anxiety or depression. No diagnostic investigations were ordered during this client’s visit.

Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment

Throughout this course, you were encouraged to practice conducting various physical assessments on multiple areas of the body, ranging from the head to the toes. Each of these assessments, however, was conducted independently of one another. For this DCE Assignment, you connect the knowledge and skills you gained from each individual assessment to perform a comprehensive head-to-toe physical examination in your Digital Clinical Experience.

Resources

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources. 

WEEKLY RESOURCES

To Prepare

• Review this week’s Learning Resources, and download and review the Physical Examination Objective Data Checklist as well as the Student Checklists and Key Points documents related to neurologic system and mental status.
• Review the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation with the Shadow Health platform. Review the examples also provided.
• Review the DCE (Shadow Health) Documentation Template for Comprehensive (Head-to-Toe) Physical Assessment found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
• Access and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom.
• Review the Week 9 DCE Comprehensive Physical Assessment Rubric provided in the Assignment submission area for details on completing the Assessment in Shadow Health.
• Also, your Week 9 Assignment 3 should be in the Complete SOAP Note format. Refer to Chapter 2 of the Sullivan text and the Week 4 Complete Physical Exam template and use the template below for your submission.

Week 9 Shadow Health Comprehensive SOAP Note Documentation Template

Download Week 9 Shadow Health Comprehensive SOAP Note Documentation Template

Note: There are 2 parts to this assignment – the lab pass and the documentation. You must achieve a total score of 80% in order to pass this assignment. Carefully review the rubric and video presentation in order to fully understand the requirements of this assignment.

DCE Comprehensive Physical Assessment:

Complete the following in Shadow Health:

• Episodic/Focused Note for Comprehensive Physical Assessment of Tina Jones (180 minutes)

Note: Each Shadow Health Assessment may be attempted and reopened as many times as necessary prior to the due date to achieve a total of 80% or better (this includes your DCE and your Documentation Notes), but you must take all attempts by the Week 9 Day 7 deadline. 

submission information

• Complete your Comprehensive (Head-to-Toe) Physical Assessment DCE Assignment in Shadow Health via the Shadow Health link in Canvas.
• Once you complete your assignment in Shadow Health, you will need to download your lab pass and upload it to the corresponding assignment in Canvas for your faculty review. 
• (Note: Please save your lab pass as “LastName_FirstName_AssignmentName”.) You can find instructions for downloading your lab pass here: https://link.shadowhealth.com/download-lab-pass

• Links to an external site.
• Review the Week 9 DCE Health History Assessment Rubric, provided in the Assignment submission area, for details on completing the Assignment.
• Links to an external site.Complete your documentation using the documentation template in your resources and submit it into your Assignment submission link.
• To submit your completed assignment, save your Assignment as WK9Assgn3+last name+first initial.
• Then, click on Start Assignment near the top of the page.
• Next, click on Upload File and select both files and then Submit Assignment for review.
• Note: You must pass this assignment with a minimum score of 80% in order to pass the class. Once submitted, there are not any opportunities to revise or repeat this assignment.

Rubric

NURS_6512_Week_9_DCE_Assignment_3_Rubric

Criteria	Ratings	Pts
This criterion is linked to a Learning Outcome Student DCE score(DCE percentages will be calculated automatically by Shadow Health after the assignment is completed.)Note: DCE Score – Do not round up on the DCE score.	60 to >55.0 pts ExcellentDCE score>93 55 to >50.0 pts GoodDCE Score 86-92 50 to >45.0 pts FairDCE Score 80-85 45 to >0 pts PoorDCE Score <79… No DCE completed.	60 pts
This criterion is linked to a Learning Outcome Subjective Documentation in Provider Note Template: Subjective narrative documentation in Provider Note Template is detailed and organized and includes: Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS)ROS: covers all body systems that may help you formulate a list of differential diagnoses. You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.	20 to >15.0 pts ExcellentDocumentation is detailed and organized with all pertinent information noted in professional language….Documentation includes all pertinent documentation to include Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). 15 to >10.0 pts GoodDocumentation with sufficient details, some organization and some pertinent information noted in professional language….Documentation provides some of the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). 10 to >5.0 pts FairDocumentation with inadequate details and/or organization; and inadequate pertinent information noted in professional language….Limited or/minimum documentation provided to analyze students critical thinking abilities for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). 5 to >0 pts PoorDocumentation lacks any details and/or organization; and does not provide pertinent information noted in professional language….No information is provided for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS)….or…No documentation provided.	20 pts
This criterion is linked to a Learning Outcome Objective Documentation in Provider Notes – this is to be completed using the documentation template that is provided. Document in a systematic order starting from head-to-toe, include what you see, hear, and feel when doing your physical exam using medical terminology/jargon. Document all normal and abnormal exam findings. Do not use “WNL” or “normal”. You only need to examine the systems that are pertinent to the CC, HPI, and History. Diagnostic result – Include any pertinent labs, x-rays, or diagnostic test that would be appropriate to support the differential diagnoses mentioned. Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list (#1).	20 to >15.0 pts ExcellentDocumentation detailed and organized with all abnormal and pertinent normal assessment information described in professional language….Each system assessed is clearly documented with measurable details of the exam. 15 to >10.0 pts GoodDocumentation with sufficient details and some organization; some abnormal and some normal assessment information described in mostly professional language….Each system assessed is somewhat clearly documented with measurable details of the exam. 10 to >5.0 pts FairDocumentation with inadequate details and/or organization; inadequate identification of abnormal and pertinent normal assessment information described; inadequate use of professional language….Each system assessed is minimally or is not clearly documented with measurable details of the exam. 5 to >0 pts PoorDocumentation with no details and/or organization; no identification of abnormal and pertinent normal assessment information described; no use of professional language….None of the systems are assessed, no documentation of details of the exam….or…No documentation provided.	20 pts
Total Points: 100