Salem State University - NURSING 361 HH Notes| Health History Notes Shadow Health Subjecti

Health History Notes Shadow Health Subjective Ask the patient to describe the pain and how it started. Is it related to a site of injury, movement, or time of day? What is the quality of the pain—sharp, dull, burning? Ask if the pain radiates or follows a particular pattern. What makes the pain better or worse? Pursue the seven features of pain, as you would with any symptom. Ask the patient to point to the pain because verbal descriptions can be imprecise. Ask about treatments that the patient has tried, including medications, physical therapy, and alternative medicines. A comprehensive medication history identif ies drugs that interact with analgesics and reduce their efficacy . OLD CARTS, or Onset, Location, Duration, Character, Aggravating/ Alleviating Factors, Radiation, and Define and describe Diabetes using your textbook. (Include risk factors for development of the disease such as race, gender, age social/family history, etc. that may make some people more prone to development; If a surgical patient, why did they need surgery and describe surgical procedure) Diabetes is known as a disturbance of the metabolism of carbohydrates and the use of glucose by the body. There are two different types, and they are Type I and Type II diabetes. Type I is when the beta cells of the pancreas stop secreting insulin. This can develop very early in life. Type II is when glucose receptors on the cell membrane lose their sensitivity to insulin. It use to appear in people typically over the age of 40, but not is becoming prevalent in younger people as well. Diabetes is common in African Americans and Hispanics, but is greatest in Pima Indians. People with diabetes are at a greater risk of cardiovascular diseases, hypertension, kidney disease, blindness, and even stroke. Diabetes is known for being genetically linked, but also diet and nutrition of the individual does play a vital role in whether or not the disease occurs in the person. People with diabetes that undergo surgery may be at a greater risk, because the stress from the surgery can cause the blood glucose levels to rise or fall. The patient may then be required to receive insulin through an IV during surgery. People with diabetes may also have slower wound healing after surgery. With a slower wound healing, the higher the risk for infection with the patient. Example Question Tina’s Response What brings you in today? I got this scrape on my foot a while ago, and it got really infected. It’s killing me. Which foot did you scrape? My right foot. Do you have any medical conditions? Yeah…I have asthma and diabetes. What type of diabetes do you have? It’s Type 2. What do you do to manage your diabetes? I just watch what I eat and try to stay away from sweets. Do you have any medical issues in your family? My mom has some issues, and I think some of my grandparents did, too.Health History Notes Shadow Health Subjective List the textbook symptoms for diabetes. 1._____frequent urination_______________________________________________ 2._____excessive thirst__________________________________________________ 3._____increased hunger________________________________________________ 4._____weight loss_____________________________________________________ 5._____tiredness_______________________________________________________ 6._____lack of concentration_____________________________________________ 7._____tingling and numbness in extremities________________________________ 8._____blurres vision___________________________________________________ 9._____frequent infections______________________________________________ 10.____slow healing wounds_____________________________________________ Causes of weight loss include gastrointestinal diseases; endocrine disorders (diabetes mellitus, hyperthyroidism, adrenal insufficiency ); chronic infections, HIV/AIDS; malignancy; chronic cardiac, pulmonary, or renal failure; depression; and anorexia nervosa or bulimia. See Table 4-2, Eating Disorders and Excessively Low BMI, p. 140. Weight loss with relatively high food intake suggests diabetes mellitus, hyperthyroidism, or malabsorption. Consider also binge eating ( bulimia ) with clandestine vomiting. Education: - consuming nutrientdense foods and beverages such as vegetables, fruits, whole grains, fatfree or low-fat milk and milk products, seafood, lean meats and poultry, eggs, beans and peas, and nuts and seeds. - Physical fitness is a key component of both weight control and weight loss. To achieve health benefits, adults should do at least 150 minutes (2 hours and 30 minutes) of moderateintensity cardiorespiratory activity, for example, walking briskly at a pace of 3 to 4.5 miles (4.8 to 7.2 km) per hour, each week Timing The Seven Attributes of a Symptom 1. Location. Where is it? Does it radiate? 2. Quality. What is it like? 3. Quantity or severity. How bad is it? (For pain, ask for a rating on a scale of 1 to 10.) 4. Timing. When did (does) it start? How long does it last? How often does it come? 5. Onset (setting in which symptom occurs). Include environmental factors, personal activities, emotional reactions, or other circumstances that may have contributed to the illness. 6. Remitting or exacerbating factors. Is there anything that makes it better or worse? 7. Associated manifestations. Have you noticed anything else that accompanies it?Health History Notes Shadow Health Subjective 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 Health History Notes Shadow Health Subjective 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:Health History Notes Shadow Health Subjective 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?Health History Notes Shadow Health Subjective  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 (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: Which foot is in pain?  Finding: Reports wound is on the plantar surface of her foot (Found)Health History Notes Shadow Health Subjective 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 (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 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:Health History Notes Shadow Health Subjective 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 (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: 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 injuryHealth History Notes Shadow Health Subjective (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 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 (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 they xray your foot at the ER? Health History Notes Shadow Health Subjective 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 (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 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)Health History Notes Shadow Health Subjective 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 (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 first notice the pus?  Finding:Health History Notes Shadow Health Subjective 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 (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 have an odor?  Finding: Asked about home treatment of foot wound  Finding: Reports wound care regimen of bandagingHealth History Notes Shadow Health Subjective (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 (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 often did you clean the wound?  Finding: Reports cleaning wound with hydrogen peroxide (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 did you use to clean the wound? Health History Notes Shadow Health Subjective Finding: Reports applying bacitracin, neomycin and polymyxin B (Neosporin) (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 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)Health History Notes Shadow Health Subjective 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:Health History Notes Shadow Health Subjective 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 youHealth History Notes Shadow Health Subjective 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:Health History Notes Shadow Health Subjective 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 (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 know what type of diabetes you have?  Finding: Asked about diabetes management through lifestyle changesHealth History Notes Shadow Health Subjective  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 (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 drink sugary drinks?  Finding: Asked about current diabetes medication use  Finding: Reports that she does not currently take medication for diabetes (Found)Health History Notes Shadow Health Subjective 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:Health History Notes Shadow Health Subjective Do you remember what you were prescribed for diabetes?  Finding: Reports last use of medication was 3 years 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 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 ERHealth History Notes Shadow Health Subjective (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 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 (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.Health History Notes Shadow Health Subjective 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:Health History Notes Shadow Health Subjective 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 timelineHealth History Notes Shadow Health Subjective 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 (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 much weight have you lost?Health History Notes Shadow Health Subjective  Finding: Reports weight loss occurred over the past month (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 long did it take you to lose 10 pounds?  Finding: Followed up on reason for weight change  Finding: Reports weight loss was unintentional (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: Was your weight loss intentional?  Finding: Asked about history of asthma exacerbations Health History Notes Shadow Health Subjective Finding: Reports last asthma attack was in high school (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 was your last asthma attack?  Finding: Reports last exacerbation was three 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 have issues with asthma?  Finding: Asked about asthma symptoms  Finding: Reports chest tightness during exacerbation (Available)Health History Notes Shadow Health Subjective 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 (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 ever wheeze?  Finding:Health History Notes Shadow Health Subjective 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 (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: 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 timelineHealth History Notes Shadow Health Subjective 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 diagnosisHealth History Notes Shadow Health Subjective  Finding: Reports specific age of diagnosis is 2.5 years old (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 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)Health History Notes Shadow Health Subjective 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 (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 use your inhaler?  Finding:Health History Notes Shadow Health Subjective 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 timelineHealth History Notes Shadow Health Subjective 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?Health History Notes Shadow Health Subjective  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 (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 seasonal asthma triggers?  Finding: Asked about general allergies  Finding: Reports allergy to cats (Found)Health History Notes Shadow Health Subjective 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)Health History Notes Shadow Health Subjective 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)Health History Notes Shadow Health Subjective 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)Health History Notes Shadow Health Subjective 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 (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 seasonal allergies?  Finding:Health History Notes Shadow Health Subjective Asked about general immunizations received  Finding: Reports being up to date on shots (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: 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 vaccineHealth History Notes Shadow Health Subjective  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 Health History Notes Shadow Health Subjective 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 (Available) Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: What is your 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:Health History Notes Shadow Health Subjective 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 (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 name of the pain medication?  Finding:Health History Notes Shadow Health Subjective 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:Health History Notes Shadow Health Subjective When was your last dose of pain medication?  Finding: Followed up on pain medication dose  Finding: Reports dosage is 50 mg (Available) Pro Tip: A patient's home medications can provide insight into the patient's current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient's background and how it may affect their current situation. Example Question: What is the dose of the pain medication?  Finding: Reports taking 2 pills each time (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 pain pills do you take at a time?  Finding: Followed up on efficacy of pain medication Health History Notes Shadow Health Subjective 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.Health History Notes Shadow Health Subjective 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 (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: Denies vitamin supplementsHealth History Notes Shadow Health Subjective (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.Health History Notes Shadow Health Subjective 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:Health History Notes Shadow Health Subjective Reports disliking metformin side effects (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: 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 (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: Did you have problems affording the diabetes medication?Health History Notes Shadow Health Subjective  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 (Found)Health History Notes Shadow Health Subjective 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:Health History Notes Shadow Health Subjective 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 diet  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.Health History Notes Shadow Health Subjective 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 (Found) Pro Tip: A pat