Chief Complaint
Intermediate Patient Case Results
Edward Carter ShadowHealth
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:
Orientation
,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:
Intermediate Patient Case Results
Edward Carter ShadowHealth
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:
Orientation
,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:
