Unguided Intermediate Patient Case Results EDWARD CARTER SHADOWHEALTH

Intermediate Patient Case Results Edward Carter ShadowHealth Chief Complaint Finding: Established chief complaint Finding: Reports pain ( ) Pro Tip: Beginning your conversation with your patient by asking an open-ended question about their hospital visit is a best practice for gauging your patient's general condition. Example Question: What brings you to the hospital? Finding: Reports blood in urine ( ) Pro Tip: Beginning your conversation with your patient by asking an open-ended question about their symptoms is a best practice for gauging your patient's general condition. Example Question: What are your symptoms? Finding: Reports increased frequency of urination ( ) Pro Tip: A patient with flank pain and blood in urine may have kidney stones, a bladder infection, or another serious complaint that may affect urinary patterns. Example Question: Have you had urinary symptoms? Orientation Unguided Intermediate Patient Case Results EDWARD CARTER SHADOWHEALTH Finding: Asked about orientation Finding: Oriented to own person (Available) Pro Tip: You should ask patients, especially geriatric ones or those on a potentially mind-altering medication, to state their name so you can determine their cognitive functioning. Example Question: Can you tell me who you are? Finding: Oriented to place (Available) Pro Tip: You should ask patients, especially geriatric ones or those on a potentially mind-altering medication, to identify where they are so you can determine their cognitive functioning. Example Question: Do you know where you are right now? Finding: Oriented to situation ( ) Pro Tip: You should ask patients, especially geriatric ones or those on a potentially mind-altering medication, to identify their reason for being here so you can determine their cognitive functioning. Example Question: Do you know why you are here today? Finding: Oriented to time (Available) Pro Tip: You should ask patients, especially geriatric ones or those on a potentially mind-altering medication, to identify the date and year so you can determine their cognitive functioning. Example Question: What is the date and year? History of Present Illness Finding: Asked about onset and duration of symptoms Finding: Reports pain began 3 days ago ( ) Pro Tip: Discovering how long ago the pain began is the first step in understanding whether the pain is chronic or acute. Example Question: When did your pain begin? Finding: Reports pain has gradually increased since onset (Available) Pro Tip: The way that pain changes over time can help you understand its causes and how to treat it. Example Question: Has your pain changed since the onset? Finding: Reports increased urinary frequency began 3 days ago (Available) Pro Tip: Polyuria and increased urinary urgency can be symptoms of several diseases, including kidney stones, bladder infections, or even uncontrolled diabetes. Example Question: How long have you had to urinate more? Finding: Reports pinkish urine starting early this morning (Available) Pro Tip: Asking about the onset of the blood in the patient's urine helps you understand its development as an emerging health problem. Example Question: When did you start seeing blood in your urine? Finding: Reports pain has been constant (Available) Pro Tip: Determining patterns of pain helps you understand patient context; constant pain can affect a patient's ability to answer questions or make decisions. Example Question: Is your pain constant? Finding: Followed up on urinary frequency Finding: Reports urinating about once an hour ( ) Pro Tip: Asking a patient with increased urinary frequency how often they use the bathroom allow you to assess the condition's potential causes and its affect on the patient. Example Question: How often do you urinate? Finding: Reports waking up to use the bathroom (Available) Pro Tip: Asking a patient with increased urinary frequency if they use the bathroom at night allow you to assess the condition's potential causes and its affect on the patient. Example Question: Do you have to wake up to urinate? Finding: Reports waking up four to five times a night to use the bathroom (Available) Pro Tip: Asking a patient with increased urinary frequency how often they use the bathroom at night allow you to assess the condition's potential causes and its affect on the patient. Example Question: How many times a night do you have to wake up to urinate? Finding: Asked about location of pain Finding: Reports pain is in lower left side (flank pain) ( ) Pro Tip: Establishing the location of a patient's pain can provide insight into its cause, and help you determine if the pain progresses or migrates. Example Question: Where is your pain? Finding: Denies radiating pain (Available) Pro Tip: Determining if a patient's pain radiates can indicate its cause or the course of an infection. Example Question: Does the pain radiate? Finding: Asked about characteristics of pain Finding: Describes pain as sharp and shooting ( ) Pro Tip: Determining how your patient describes the characteristics of the pain can be important data to support the cause of the pain. Example Question: How would you describe your pain? Finding: Asked about aggravating factors of pain Finding: Reports nothing makes the pain worse ( ) Pro Tip: Aggravating factors are conditions that worsen a patient's pain, such as activities of living like eating or movement. Identifying these conditions helps you avoid them while the patient is in your care. Example Question: Does anything make your pain wors