Unguided Intermediate Patient Case Results.
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
Orientation
,Unguided Intermediate Patient Case Results.
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:
,Unguided Intermediate Patient Case Results.
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.
, Unguided Intermediate Patient Case Results.
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
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
Orientation
,Unguided Intermediate Patient Case Results.
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:
,Unguided Intermediate Patient Case Results.
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.
, Unguided Intermediate Patient Case Results.
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
