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Shadow Health Tina Jones Respiratory Documentation
Advanced Pathopharmacology & Physical Assessment For The Nurse Educator B (NRSG631B)
Colorado Technical University
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Shadow Health Tina Jones Respiratory Documentation
Documentation / Electronic Health Record
Document: Provider Notes
Student DocumentationModel Documentation
Subjective
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HPI: Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of shortness of breath and wheezing following a near asthma attack that she had two days ago. She reports that she was at her cousin’s house and was exposed to cats which triggered her asthma symptoms. At the time of the incident she notes that her wheezes were a 6/10 severity and her shortness of breath was a 7- 8/10 severity and lasted five minutes. She did not experience any chest pain or allergic symptoms. At that time she used her albuterol inhaler and her symptoms decreased although they did not completely resolve. Since that incident she notes that she has had 10 episodes of wheezing and has shortness of breath approximately every four hours. Her last episode of shortness of breath was this morning before coming to clinic. She notes that her current symptoms seem to be worsened by lying flat and movement and are accompanied by a non-productive cough. She awakens with night- time shortness of breath twice per night. She complains that her current symptoms are beginning to interfere with her daily activities and she is concerned that her albuterol inhaler seems to be less effective than previous. Currently she states that her breathing is normal. Diagnosed with asthma at age 2 years. She has no recent use of spirometry, does not use a peak flow, does not record attacks, and does not have a home nebulizer or vaporizer. She has been hospitalized five times for asthma, last at age 16. She has never been intubated for her asthma. She does not have a current pulmonologist or allergist. Social History: She is not aware of any environmental exposures or irritants at her job or home. She changes her sheets weekly and denies dust/mildew at her home. She uses a hypoallergenic pillow cover and her mattress is one year old. She denies current use of tobacco, alcohol, and illicit drugs. She did smoke marijuana for 5 or 6 years, her last use was at age 21 years. She does not exercise. Review of Systems: General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats. • Nose/Sinuses: Denies rhinorrhea with this episode. Denies stuffiness, sneezing, itching, previous allergy, epistaxis, or sinus pressure. • Gastrointestinal: No changes in appetite, no nausea, no vomiting, no symptoms of GERD or abdominal pain • Respiratory: Complains of shortness of breath and cough as above. Denies sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. She has a history of asthma, last hospitalization was age 16, last chest XR was age 16.
Objective
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General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented and sitting upright on exam table. She maintains eye contact throughout interview and examination. • Respiratory: Chest expansion is symmetrical with respirations. Normal fremitus, symmetric bilaterally. Chest resonant to percussion; no dullness. Bilateral expiratory wheezes in posterior lower lobes. Bilateral muffled words with notable expiratory wheezes in posterior lower lobes. No crackles. In office spirometry: FVC 3 L, FEV1/FVC ratio 80%. SpO2: 97%.
Assessment
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Asthma exacerbation
Plan
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Encourage Ms. Jones to continue to monitor symptoms and log her episodes of asthma symptoms and wheezing with associated factors and bring log to next visit. • Obtain office oxygen saturation. • Order PFTs to be completed after exacerbation to have baseline available for future comparison. • Encourage to wash bedding and consider dust mite covers to decrease allergic nighttime symptoms. • NMT in office x 1. • Educate to increase intake of water and other fluids. • Educate Ms. Jones on when to seek emergent care including episodes of chest pain or shortness of breath unrelieved by rest, worsening asthma symptoms or wheezing, or the sense that rescue inhaler is not helping. • Revisit clinic in 2-4 weeks for follow up and evaluation.
Respiratory Assessment Asked about asthma Reports having asthma Reports asthma exacerbations Asked about severity of asthma Reports asthma exacerbations occur up to 2 times a week Reports asthma exacerbations last around five minutes Asked most recent asthma exacerbation Reports last exacerbation was three days ago Reports last exacerbation around cats at cousin's house Asked about asthma triggers Reports cat allergy as asthma trigger Reports dust as asthma trigger Denies asthma problems at work Denies asthma problems at home Asked asthma management Reports inhaler Asked about asthma medication Reports albuterol inhaler (Proventil) Reports last inhaler use was three days ago Reports using inhaler no more than 2 times per week Asked about number of puffs when using asthma inhaler Reports recommended dose is 1-3 puffs as needed Reports typically taking 2 puffs Reports sometimes needing 3 puffs to control symptoms Asked exacerbation symptoms Reports chest tightness during exacerbation Reports wheezing during exacerbation Reports shortness of breath during exacerbation Denies coughing during exacerbation Denies chest pain during exacerbation Denies painful breathing Asked current breathing Denies current breathing problems
Asked cough history Reports only coughing when she has a cold Denies coughing up blood Asked about sputum Denies sputum Asked about respiratory illness history besides asthma Denies history of bronchitis Denies history of pneumonia Denies history of emphysema Upgrade to remove ads Only $35/year
Followed up on asthma diagnosis Reports specific age of diagnosis is 2 years old Asked about seeing an asthma specialist Reports not seeing asthma doctor in two years Asked about past hospitalizations Reports past hospitalizations for asthma Reports five past hospitalizations for asthma Reports most recent hospitalization at age 16 Reports hospital treatment was usually steroids and a nebulizer Asked about general allergies Reports allergy to cats Followed up on allergy symptoms Reports sneezing, itchy eyes, and wheezing Asked about allergy treatment Reports avoiding cats when possible Reports using inhaler Reports showering Asked about tobacco use Denies currently smoking tobacco Denies history of smoking tobacco Denies vaping Asked about marijuana use Reports past recreational marijuana smoking Followed up on marijuana Reports smoking marijuana for 5 or 6 years Reports stopped smoking marijuana 6 or 7 years ago Reports stopping because of health reasons and waning interest Asked about secondhand smoke Denies secondhand smoke exposure Upgrade to remove ads Only $35/year
Asked family history of asthma Reports sister has asthma Asked family history of other respiratory illness Denies family history of respiratory illness Asked family tobacco use Denies family history of tobacco use Asked about family history of lung cancer Denies family history of lung cancer
Inspected chest Symmetric No visible abnormal findings Palpated chest expansion Equal bilaterally Palpated tactile fremitus Equal bilaterally Expected fremitus Percussed chest wall All areas resonant No areas of dullness Auscultated breath sounds Present in all areas Wheezing - posterior right and left lower lobes Auscultated for bronchophony Negative Patient Exam - Vital Signs: Height: 170 cm, Weight: 90 kg, BMI: 31, Random blood glucose: 238, Temperature: 102° F, Blood pressure: 138/90 mmHg, Heart rate: 90, Respiratory rate: 18, O2 sat: 98% Patient Exam - Interview: ... Student: Hello, my name is Catlain, I am your nurse today. Tina Jones: Hey. Upgrade to remove ads Only $35/year
Student: Can you confirm your name? Tina Jones: Tina Jones:. Student: Why did you come in today? Tina Jones: I got this scrape on my foot a while ago, and it got really infected. It's killing me. Student: What additional symptoms have you experienced? Tina Jones: I mean, it's all red and swollen, and there's pus, it feels hot, it hurts like hell... It's got all that going on. Student: Can you rate your current pain level on a scale of 0 to 10? Tina Jones: .. a 7. It hurts a lot, but whatever pain med the ER gave me is helping a little bit. Student: Please describe the pain. Tina Jones: It's throbbing and like, sharp if I try to put weight on it. Student: How did you hurt your foot? Tina Jones: I was changing a light bulb, and I had to use our little stepstool to reach it. My foot slid off the bottom step and it got all scraped up. I didn't realize how sharp the edge was! Student: Has your foot been draining any liquids? Tina Jones: Yeah, there's definitely pus.
Tina Jones: My heart's fine, thank God! Student: Any problems with your heart? Tina Jones: No, my heart's always been fine. Student: Have you had any problems with your breasts? Tina Jones: I haven't noticed any pain there. Student: Have you had any reproductive problems? Tina Jones: I don't think I have problems in that area. I just get really bad periods, that's all. Student: Have you had any neurological problems? Tina Jones: No, I haven't. Student: Have you had any musculoskeletal problems? Tina Jones: No. Student: Do you have a history of skin disease? Tina Jones: Um, I have acne, if that counts. Student: Does your paternal grandfather have any health problems? Tina Jones: Grandpa Jones had colon cancer, and that caused all kinds of problems for him. Plus, he had high blood pressure, and..'m pretty sure he had diabetes. And high cholesterol like everyone else in my family. Student: Does your mother have any health problems? Tina Jones: Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though. Student: Does your father have any health problems? Tina Jones: Well, he passed away. But he had a couple things... Type 2 diabetes, like me, and high cholesterol and blood pressure. Student: How did your father die? Tina Jones: He died in a car accident. Student: Where is your wound located? Tina Jones: It's on the ball of my foot. Student: Do you get thirsty often? Tina Jones: You know, I did notice lately that I've been really thirsty. Student: What happened with your father's car accident? Tina Jones: It was last year... I guess a little over a year ago. Student: How long ago was your dad's car accident? Tina Jones: It was last year... I guess a little over a year ago. Student: How did you cope with your fathers death? Tina Jones: Well, right after he died, after the funeral and everything, I just tried to get through that. Mom was having such a hard time, crying a lot, everything made her sad, she was kind of depressed. So, I guess at first I just focused on getting things done--groceries, laundry, insurance papers and stuff. Knowing that Mom needed me kind of helped me get through day by day. There was about a month where it was hard for us to get to church. Even getting up and ready for church was too overwhelming. But our church family helped us out and gave us rides to church and brought meals and all that, so they really helped build us back up. Things were only hard like that for a few months. Student: What caused your dads accident? Tina Jones: He was driving to work, and it was raining.. his car hydroplaned. And hit a tree. So, it was really sudden. Student: How is your paternal grandmother's health? Tina Jones: Granny's doing good. She's still living on her own. She's slowing down, but we help her out. She lives down the street from us, and she gets around okay. I think she takes some pills, maybe for blood pressure? She might have high cholesterol too. She seems happy. Student: How is your paternal grandfather's health? Tina Jones: Grandpa Jones passed away when I was really little. Student: How is your maternal grandfather's health? Tina Jones: Well, Poppa died about five years ago. Student: How is your maternal grandmother's health? Tina Jones: Nana was 73 when she died of a stroke about five years ago. I think she had high blood pressure and cholesterol, too. Student: How is your brother's health? Tina Jones: He's a healthy guy. Kind of big like me. Student: How is your sister's health? Tina Jones: She's pretty healthy. She has asthma too, but she almost never has attacks. Student: Does your family have a history of obesity? Tina Jones: No, I don't think so. My brother and my dad are kind of big, but I wouldn't say they were obese or anything. Student: Does your family have a history thyroid issue? Tina Jones: No, I don't think so. Student: Does your family have a history of substance abuse? Tina Jones: One person in the family, my dad's brother, has an alcohol problem, but we never see him. Student: Does your family have a history of headaches? Tina Jones: No, not that I know of. Student: How much alcohol do you drink? Tina Jones: I only have a few drinks when I go out. Student: What is your level of education? Tina Jones: Well, I'm finishing up my bachelor's degree right now. Student: What are stressors? Tina Jones: I feel really stressed out right now! Honestly, I didn't realize that I'd be admitted to the hospital for my foot. I don't want to miss work or school but now it looks like I'll have to. And I want my foot to stop hurting. I know I need sleep, too. Student: We are going to take care of everything as quickly as possible. Tina Jones: Thanks. Student: Where do you live? Tina Jones: Right now, I'm living at my mom's place, which is out in the suburbs a bit. It's like a half hour from here. Student: What is your belief system? Tina Jones: I'm Baptist. My faith is a big part of my life--when things get hard like they've been this past year, I know I can trust that God's looking out for me. I've been going to the same church since I was a kid, too, so the people at church are practically part of my family. Student: Have you experienced abuse? Tina Jones: I've never had been in any kind of situation like that... It's scary to think about. Student: Have you used illicit drugs? Tina Jones: Well, I used to smoke pot... but I don't do that anymore. Student: What type of drugs did you use? Tina Jones: Um..'ve smoked pot before. In high school, and after high school... I definitely don't anymore, though. Student: Have you used drugs other than marijuana? Tina Jones: No. Student: When did you last use drugs? Tina Jones: I haven't smoked pot since I was twenty or twenty-one. Student: Have you ever smoked cigarettes? Tina Jones: No. I think it's gross. Student: Have you been around people that are smoking? Tina Jones: Some of my friend's smoke when we go out drinking. But I don't smoke, and nobody at home smokes. Student: How old were you when your father died? Tina Jones: He died last year, so I was 27. Student: Did your father die from any disease? Tina Jones: He died in a car accident. Student: Can you tell me about your father's health? Tina Jones: He had high blood pressure and cholesterol. And diabetes -- we have diabetes in common.
Student: I can't even imagine how you feel about losing your father Tina Jones: Thanks. Student: Tell me about your father. Tina Jones: Dad was a little stricter than Mom growing up... he would sometimes get kind of mad at us when we did something wrong. But he never hit us or anything. He would just get really calm and quiet and tell us to go to our rooms without supper, or that we were grounded when we were older. Or like, he'd make us rake the yard or wash his car or something. It's pretty sad to Student: How old was your father when he died? Tina Jones: Last year when Dad passed, he was only 58. Subjective Data Collection - Checklist: ... Chief Complaint ... Finding: Established chief complaint ... Finding: Reports pain (Found)Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with. Example Question: Do you have any pain? Finding: Reports foot wound (Found)Pro Tip: If a patient mentions pain, it's important to determine what specifically is causing her pain, if she knows. Example Question: What's causing your pain? History of Presenting Illness ... Finding: Asked to rate current pain level on a scale ... Finding: Reports current pain is 7/10 (Found)Pro Tip: Asking your patient to rate her pain on a scale of 0 to 10 is important to gauge how it ebbs and flows while she is in your care. 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: Determining how your patient describes the characteristics of the pain can be important data to support the cause of the pain. Example Question: Can you please describe the pain? Finding: Reports pain is sharp when she attempts to stand (Found)Pro Tip: Determining what physical activities and movements exacerbate the patient's pain can help you better understand the problems and assess treatment needs. This can also alert you if a patient's activities of daily living are hindered. Example Question: What is the pain like when you stand on your foot? Finding: Reports pain has increased in the past 2 days (Available)Pro Tip:Finding out how the patient's pain has changed will give you insight into the acceleration of infection. Example Question: How has the pain changed over time? Finding: Reports feeling pain radiating into ankle (Available)Pro Tip: Asking about where else the patient's pain radiates can help determine the progression of infection. Example Question: Does the pain radiate anywhere else? Finding: Reports pain prevents bearing weight on foot (Found)Pro Tip: Determining if your patient can bear weight on an injury is important to determine their risk for falls while in your care. Example Question: Can you bear weight on your foot? Finding: Asked location of wound ... Finding: Reports right foot is injured (Found)Pro Tip: Confirming which extremity an injury is located is a best practice for your patient's safety. Example Question: Which foot is in pain? Finding: Reports wound is on the plantar surface of her foot (Found)Pro Tip: Confirming where a wound is located ensures you are aware of your patient's biggest complaint. Example Question: Where is the wound? Finding: Asked details of the injury ... Finding: Reports she scraped foot on bottom rung of a step stool (Found)Pro Tip: Discovering how an injury happened helps to assess your patient's risk factors for injury. Example Question: How did your injury happen? Finding: Reports injury occurred 1 week ago (Available)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 injury occur? Finding: Denies other injuries besides foot wound (Available)Pro Tip: Discovering additional injuries can reveal more information about the circumstances that caused the presenting injury. Example Question: Did you injure anything besides your foot? Finding: Reports being barefoot at the time of injury (Available)Pro Tip: Asking about clothing, footwear, and other protective elements being worn at the time of injury helps you discover the totality of the circumstances. Example Question: Were you wearing shoes when you fell? Finding: Denies seeing a healthcare provider for the injury until now (Available)Pro Tip: It's crucial to ask whether your patient has seen another provider for the injury, because any previous medical intervention will help you understand the progression of the wound. Example Question: Have you seen a healthcare provider for this injury? Finding: Asked about drainage from the foot wound ... Finding: Reports that the wound bled a little after sustaining the injury (Available)Pro Tip: Asking about bleeding helps you determine the characteristics of a wound. Example Question: Did your foot bleed? Finding: Reports seeing pus draining from wound (Found)Pro Tip: Asking about discharge helps you determine the characteristics of a wound. Example Question: Did you notice any discharge from the wound? Finding: Reports noticing pus 2 days ago (Available)Pro Tip: Pinpointing exactly when the patient noticed the arrival of pus gives you an important data point for when an active infection began. Example Question: When did you first notice the pus? Finding: Followed up on drainage ... Finding: Reports pus as white or yellow (Found)Pro Tip: The color of discharge from a wound can provide insight into its severity and characteristics. Example Question: What color is the drainage from your wound? Finding: Denies odor from the wound (Available)Pro Tip: The odor of discharge from a wound can provide insight into its severity and characteristics. Example Question: Does the wound have an odor? Finding: Asked about home treatment of foot wound ... Finding: Reports wound care regimen of bandaging (Available)Pro Tip: Asking specifically how often a patient changed a bandage will let you know if an infection spread through improper hygiene, or for other reasons such as uncontrolled blood sugar. Example Question: How often do you change your bandage? Finding: Reports cleaning wound twice a day (Available)Pro Tip: Asking specifically how often a patient cleaned a wound will let you know if an infection spread through improper hygiene, or for other reasons such as uncontrolled blood sugar. Example Question: How often did you clean the wound? Finding: Reports applying bacitracin, neomycin and polymyxin B (Neosporin) (Found)Pro Tip: Determining what products a patient used to sterilize or treat a wound establishes home care routines and health literacy. Example Question: Did you use any ointment on the wound? Finding: Followed up on effectiveness of ointment ... Finding: Reports bacitracin, neomycin and polymyxin B (Neosporin) was ineffective (Found)Pro Tip: Understanding the effect of a home medication can help you determine the severity of the wound. Tina's diabetes diagnosis will have a large impact on her body's healing ability, which should be taken into consideration during your exam. Example Question: Did the ointment help? Finding: Asked about other foot wound symptoms ...
Finding: Reports more frequent urination (Found)Pro Tip: Your patient's urination habits can offer insight into underlying medical conditions and general health. Knowing that Tina is diabetic, you will want to explore this classic symptom of the condition. Example Question: Have you been urinating more often than usual? Finding: Reports urinating every hour or two during the day (Found)Pro Tip: Your patient's urination habits can offer insight into underlying medical conditions and general health. Knowing that Tina is diabetic, you will want to explore this classic symptom of the condition. Example Question: How often do you urinate during the day? Finding: Reports urinating 2 to 3 times during the night (Available)Pro Tip: Discovering if Tina has nocturia can offer insight into underlying medical conditions and general health. Example Question: How often do you wake up at night to urinate? Finding: Asked about diet ... Finding: Reports eating a bowl of cereal for breakfast yesterday (Available)Pro Tip: In a health history, it is important to get an idea of a patient's typical dietary patterns. This can be achieved by asking for a 24-hour diet recall. Example Question: What did you eat for breakfast yesterday? Finding: Reports eating mac and cheese for lunch yesterday (Available)Pro Tip: In a health history, it is important to get an idea of a patient's typical dietary patterns. This can be achieved by asking for a 24-hour diet recall. Example Question: What did you eat for lunch yesterday? Finding: Reports eating chicken and roll for dinner yesterday (Available)Pro Tip:Finding out the foods a patient last ate can provide evidence for any current stomach upset and for their current level of hunger and blood sugar status and can affect medications given while in your care. Example Question: What did you eat for your last meal? Finding: Asked about change in appetite ... Finding: Reports increased appetite (Found)Pro Tip: Identifying if a patient has recently experienced a change in appetite is important, as it could indicate an underlying endocrine or psychiatric condition. Example Question: Have you noticed an increase in appetite? Finding: Reports change in appetite began a month ago (Available)Pro Tip: Determining the onset of appetite change can reveal important details about underlying health conditions. 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: Determining the exact amount of weight loss can indicate whether it's within expected ranges, or extreme, which may indicate an underlying health problem. Example Question: How much weight have you lost? ... Finding: Reports weight loss occurred over the past month (Available)Pro Tip:Finding out the timeline for weight loss can indicate if it's sudden or gradual. 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: Unintentional weight loss can be a sign of underlying medical conditions or a reflection of unhealthy lifestyle choices. Asking your patient about this can inform your care plan. Example Question: Was your weight loss intentional? Finding: Asked about history of asthma exacerbations ... Finding: Reports last asthma attack was in high school (Available)Pro Tip: Discovering the patient's most recent asthma attack can provide a timeline of exacerbations and help you better understand the patient's condition and effectiveness of any treatments. Example Question: When was your last asthma attack? Finding: Reports last exacerbation was three days ago (Available)Pro Tip: Discovering the patient's most recent exacerbation can provide a timeline of asthma symptoms and help you better understand the patient's condition and effectiveness of any treatments. Example Question: When did you last have issues with asthma? Finding: Asked about asthma symptoms ... Finding: Reports chest tightness during exacerbation (Found)Pro Tip: Asthma can have a profound impact on health, and it is important to discovered the severity of her condition by asking about symptoms during an exacerbation, such as chest tightness. Example Question: What do your asthma symptoms feel like? Finding: Reports difficulty breathing during exacerbation (Found)Pro Tip: Asthma can have a profound impact on health, and it is important to discovered the severity of her condition by asking about symptoms during an exacerbation, such as difficulty breathing. Example Question: Do you have trouble breathing? Finding: Reports wheezing during exacerbation (Found)Pro Tip: Asthma can have a profound impact on health, and it is important to discovered the severity of her condition by asking about symptoms during an exacerbation, such as wheezing. Example Question: Do you ever wheeze? Finding: Asked about prior hospitalizations ... Finding: Reports past hospitalizations (Found)Pro Tip: Finding out if the patient has any past hospitalizations is the first step in understanding any past serious medical issues. In Tina's case, it will help you better understand her asthma and create a timeline. Example Question: Have you been hospitalized in the past? Finding: Reports last hospitalization was for asthma (Available)Pro Tip: Finding out if Tina has any past hospitalizations is the first step in understanding any past serious medical issues. In Tina's case, it will help you better understand her asthma and create a timeline. Example Question: Why were you hospitalized last time? Finding: Reports last hospitalization was age 16 (Available)Pro Tip: Finding out the date of Tina's last hospitalization is important for understanding the timeline of her medical issues, asthma in particular. Example Question: When was your last hospitalization? Finding: Reports about 5 total hospitalizations for asthma as a child and teen (Available)Pro Tip: Finding out the number of Tina's previous hospitalizations is important for understanding the history of her asthma. Example Question: How many times have you been hospitalized? Finding: Reports past nebulizer use (Available)Pro Tip: Finding out what treatments Tina received during her hospitalizations will give you a fuller picture of the history of her condition. Example Question: Have you ever used a nebulizer? Finding: Asked about asthma diagnosis ... Finding: Reports specific age of diagnosis is 2 years old (Available)Pro Tip: Asthma can have a profound impact on health, and it is important to learn about the patient's history of the condition, including the age of diagnosis. Example Question: At what age were you diagnosed with asthma? Finding: Asked about asthma management ... Finding: Reports using an inhaler (Found)Pro Tip: Asking how your patient treats her asthma can provide important information about her medical history and health literacy. Example Question: How do you manage your asthma? Finding: Reports inhaler is albuterol (Proventil) (Found)Pro Tip: Finding out the specific medication type or brand is essential in understanding whether it's a maintenance or rescue medication. Example Question: What is the name of the inhaler prescription? Finding: Reports last use of inhaler was 3 days ago (Available)Pro Tip: Determining the patient's last use of an inhaler clues you in to any recent breathing problems. Example Question: When did you last use your inhaler? Finding: Reports using inhaler no more than 2 times per week (Available)Pro Tip: Discovering the frequency with which your patient uses her inhaler is an important aspect of determining the severity of her condition. 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: Discovering how much your patient uses her inhaler at any given time is a good indicator of the efficacy of her medication. Example Question: How many puffs of your inhaler are you prescribed? Finding: Reports typically taking 2 puffs (Found)Pro Tip: Discovering how much your patient uses her inhaler at any given time is a good indicator of the efficacy of her medication. Example Question: How many puffs do you typically take? Finding: Reports sometimes needing 3 puffs to control symptoms (Found)Pro Tip: Discovering how much your patient uses her inhaler at any given time is a good indicator of the efficacy of her medication. Example Question: What's the most puffs you ever take? Finding: Asked about asthma triggers ... Finding: Reports asthma triggered by cats (Found)Pro Tip: Discovering occasional environmental triggers, such as animal allergies, gives you insight into exacerbating factors of your patient's condition. Example Question: What triggers your asthma problems? Finding: Reports asthma triggered by dust (Found)Pro Tip: Dust is a common allergen, and discovering its effect on asthmatic patients is particularly important. Example Question: Does dust trigger your asthma? Finding: Denies seasonal triggers (Available)Pro Tip: Asking about seasonal triggers can help you understand a patient's complete set of asthma triggers over the course of a year. Example Question: Do you have seasonal asthma triggers? Finding: Asked about general allergies ... Finding: Reports allergy to cats (Found)Pro Tip: Asking general questions about allergies is the first step to a conversation with a patient about her complete set of allergies. Example Question: What allergies do you have? Finding: Followed up on cat allergy symptoms ... Finding: Reports sneezing, itchy eyes, and wheezing (Available)Pro Tip: Determining a patient's reaction to an allergen is essential to gauge if the allergy is life-threatening. Example Question: What is your reaction to cats? Finding: Asked about latex allergy ... Finding: Denies latex allergy (Available)Pro Tip: Confirming absence or presence of a latex allergy is essential in a hospital setting, where some instruments have latex parts. Example Question: Are you allergic to latex? Finding: Asked about medication allergies ... Finding: Reports penicillin allergy (Found)Pro Tip: Asking specifically about allergies to medications, such as penicillin, is crucial to the patient's safety while she is in your care, as it affects what medications will be safe and appropriate. Example Question: What medication allergies do you have? Finding: Asked about penicillin reaction ... Finding: Reports that penicillin resulted in hives (Available)Pro Tip: Determining a patient's reaction to an allergen is essential to gauge if the allergy is life-threatening. Example Question: What is your reaction to penicillin? Finding: Reports last penicillin reaction was in childhood (Available)Pro Tip: Determining a patient's last reaction to penicillin is part of gathering thorough information about her allergy. Example Question: When was your last penicillin reaction? Finding: Asked about food allergies ... Finding: Denies food allergies (Found)Pro Tip: Inquiring about food allergies is important for an admitted patient, who will be receiving food during her stay. 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: Dust is a common allergen and discovering its effect on asthmatic patients is particularly important. Example Question: Do you have any reaction to dust? Finding: Reports dust causes sneezing, itchy eyes, and wheezing (Available)Pro Tip: Dust is a common allergen and discovering its effect on asthmatic patients is particularly important. Example Question: Do you have any environmental allergies? Finding: Denies seasonal allergies (Available)Pro Tip: Asking about seasonal allergies can help you understand a patient's complete set of allergies over the course of a year. 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: Discovering your patient's immunization history is important to her safety and reveals any susceptibilities she may have to infectious disease. Example Question: Are your immunizations current? Finding: Asked about childhood immunizations ... Finding: Reports receiving measles-mumps-rubella shot (Available)Pro Tip: Discovering what childhood immunizations a patient has received reveals information about both her medical history and her susceptibility to infectious disease. Example Question: Did you receive the measles vaccine? Finding: Reports receiving polio shot (Available)Pro Tip: Discovering if a patient received a childhood polio vaccination reveals information about both her medical history and her susceptibility to infectious disease. Example Question: Did you receive the polio vaccine? Finding: Reports receiving varicella shot (Available)Pro Tip: Discovering if a patient has received a childhood varicella shot reveals information about both her medical history and her susceptibility to infectious disease. Example Question: Did you receive the chicken pox vaccine? Finding: Reports receiving Hepatitis A and B shot (Available)Pro Tip: Discovering if a patient has received a childhood Hepatitis A and B vaccination reveals information about both her medical history and her susceptibility to infectious disease. Example Question: Did you receive the Hepatitis vaccine? Finding: Reports receiving meningococcal shot (Available)Pro Tip: Discovering if a patient has received a childhood meningococcal vaccination reveals information about both her medical history and her susceptibility to infectious disease. Example Question: Did you receive the meningitis vaccine? Finding: Reports receiving HPV vaccine series (Available)Pro Tip: Discovering if a patient has received the HPV vaccination reveals information about both her medical history and her susceptibility to infectious disease. Example Question: Did you receive the HPV vaccine? Finding: Asked if the patient has received a flu vaccine ... Finding: Denies receiving annual flu vaccine (Found)Pro Tip: The flu virus can be particularly hazardous in a hospital setting. It is important to ask your patient about the flu vaccine. 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: For a patient with a recent scrape on a metal surface, confirming the last date of a tetanus shot is essential to prevent any diseases from contact. Example Question: When was your last tetanus booster? Finding: Asked about use of pain medication ... Finding: Reports taking ibuprofen (Advil) at home (Found)Pro Tip: Discovering how a patient has been medicating for pain is a crucial element of understanding and treating her condition or injury. Example Question: What pain medication have you been taking?
Finding: Reports last alcoholic drink was 3 weeks ago (Available)Pro Tip: Confirming when a patient had her last alcohol intake is important, because she will receive medications while admitted, and alcohol is often contraindicated. Example Question: When was your last alcoholic drink? Finding: Reports no more than 2 or 3 alcoholic drinks in one sitting (Available)Pro Tip: Finding out how many alcoholic drinks a patient has in a single day or sitting is essential to uncover any binge-drinking habits that can be unhealthy for your patient. 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 (Available)Pro Tip: Finding out how many nights a week your patient has alcohol gives insight into potential habits or abuse. Example Question: How many nights a week do you drink alcohol? Finding: Asked about tobacco use ... Finding: Denies smoking tobacco (Found)Pro Tip: Finding out if a patient uses tobacco products is important to understanding her overall health, and is a potential factor in delayed wound healing. Example Question: Have you ever smoked cigarettes? Finding: Denies Vaping (Available)Pro Tip: Finding out if a patient uses tobacco products is important to understanding her overall health and is a potential factor in delayed wound healing. Example Question: Do you vape? Finding: Asked about secondhand smoke ... Finding: Denies exposure to secondhand smoke (Found)Pro Tip: Exposure to secondhand smoke can be especially detrimental to an asthmatic patient's health. 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: Family histories might indicate a genetic predisposition. Asking Tina if her mother had high blood pressure can reveal generational patterns. Example Question: Does your mother have health conditions? Finding: Reports mother diagnosed with high cholesterol (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her mother had high cholesterol can reveal generational patterns. Example Question: Does your mother have health conditions? Finding: Asked about father's health ... Finding: Reports father was diagnosed with Type 2 diabetes (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her father had diabetes can reveal generational patterns. Example Question: Does your father have health conditions? Finding: Reports father was diagnosed with high blood pressure (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her father had high blood pressure can reveal generational patterns. Example Question: Does your father have health conditions? Finding: Reports father was diagnosed with high cholesterol (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her father had high cholesterol can reveal generational patterns. Example Question: Does your father have health conditions? Finding: Followed up on father's death ... Finding: Reports father died at age 58 (Found)Pro Tip: Following up on the death of an immediate family member is important for gathering details that could be relevant to the patient's case. Uncovering the age of death can help you assess the patient's current risks. Example Question: How old was your father when he died? Finding: Reports cause of death was a car accident (Found)Pro Tip: Following up on the death of an immediate family member is important for gathering details that could be relevant to the patient's case. Uncovering the cause of death can help you assess the patient's current risks. Example Question: What caused your father's death? Finding: Followed up on coping with father's death ... Finding: Reports past grief (Found)Pro Tip: Asking about Tina's reaction to her father's death is a vital part of patient-centered care. You may discover that a patient experiencing grief needs additional resources and support. Example Question: How are you coping with your father's death? Finding: Reports feeling at peace now (Found)Pro Tip: Asking about Tina's reaction to her father's death is a vital part of patient-centered care. You should assess her needs to determine if providing any addition resources or support is appropriate. Example Question: How are you coping now? Finding: Asked about paternal grandfather's health ... Finding: Reports paternal grandfather diagnosed with Type 2 diabetes (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her paternal grandfather had diabetes can reveal generational patterns. Example Question: Does your paternal grandfather have health conditions? Finding: Reports paternal grandfather diagnosed with high blood pressure (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her paternal grandfather had high blood pressure can reveal generational patterns. Example Question: Does your paternal grandfather have health conditions? Finding: Reports paternal grandfather diagnosed with high cholesterol (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her paternal grandfather had high cholesterol can reveal generational patterns. Example Question: Does your paternal grandfather have health conditions? Finding: Reports paternal grandfather died of colon cancer (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if any of her family members had cancer is essential for understanding her risks. 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: Family histories might indicate a genetic predisposition. Asking Tina if her paternal grandmother had high blood pressure can reveal generational patterns. 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: Family histories might indicate a genetic predisposition. Asking Tina if her maternal grandfather had high blood pressure can reveal generational patterns. Example Question: Does your maternal grandfather have health conditions? Finding: Reports maternal grandfather diagnosed with high cholesterol (Available)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her maternal grandfather had high cholesterol can reveal generational patterns. 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: Family histories might indicate a genetic predisposition. Asking Tina if her maternal grandmother had high blood pressure can reveal generational patterns. Example Question: Does your maternal grandmother have health conditions? Finding: Reports maternal grandmother diagnosed with high cholesterol (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her maternal grandmother had high cholesterol can reveal generational patterns. 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: Family histories might indicate a genetic predisposition. Asking Tina if her brother has any health problems can reveal potential risks. Example Question: Does your brother have health conditions? Finding: Asked about sister's health ... Finding: Reports sister diagnosed with asthma (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her asthma can help you develop a sense of health patterns within her family. 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: Asking about trends such as obesity can help you fill in holes in the history that your patient may have missed and can allow you insight into other inherited diseases that affect relatives outside of immediate family. 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: Asking about trends such as thyroid issues can help you fill in holes in the history that your patient may have missed, and can allow you insight into other inherited diseases that affect relatives outside of immediate family. 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: Asking about trends in substance abuse can help you understand your patient's risk for inherited diseases linked to addiction. 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: Asking about trends such as headaches can help you fill in holes in the history that your patient may have missed and can allow you insight into other inherited diseases that affect relatives outside of immediate family. 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: Asking about tiredness or fatigue is one possible component of a review of systems interview. The patient's response to questions about general, constitutional health may uncover additional problems not discovered during the discussion of the patient's chief complaint. Example Question: Are you fatigued? Finding: Reports typical sleep pattern (Available)Pro Tip: Asking about the patient's typical sleep pattern is one possible component of a review of systems interview. The patient's response to questions about general, constitutional health may uncover additional problems not discovered during the discussion of the patient's chief complaint. Example Question: Have you noticed changes in your sleep? Finding: Reports fever (Available)Pro Tip: Asking about additional symptoms, such as fever, is one possible component of a review of systems interview. The patient's response to questions about general, constitutional health may uncover additional problems not discovered during the discussion of the patient's chief complaint Example Question: Are you feeling feverish right now? Finding: Denies chills (Available)Pro Tip: Asking about additional symptoms, such as chills, is one possible component of a review of systems interview. The patient's response to questions about general, constitutional health may uncover additional problems not discovered during the discussion of the patient's chief complaint. Example Question: Have you had chills? Finding: Denies night sweats (Available)Pro Tip: Asking about additional symptoms, such as night sweats, is one possible component of a review of systems interview. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint. Example Question: Have you had night sweats? Finding: Asked about review of systems for mental health ... Finding: Denies depression (Available)Pro Tip: Asking about the patient's history with depression is one possible component of a review of systems interview and may provide insight into their ability to cope in the event of painful physical trauma. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint. Example Question: Do you have a history of depression? Finding: Denies suicidal ideation or attempts (Available)Pro Tip: Asking about the patient's suicidal ideation one possible component of a review of systems interview and may provide insight into their ability to cope in the event of painful physical trauma. Higher levels of pain have been associated with thoughts of self-harm. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint. Example Question: Do you have a history of suicidal thinking? Finding: Asked about review of systems for head ... Finding: Reports occasional headaches (Available)Pro Tip: Asking about headache frequency is one possible component of a review of systems interview. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint. Example Question: Do you ever get headaches? Finding: Denies current headache (Available)Pro Tip: Asking Tina is she currently has a headache is important because it might be contributing to her current discomfort and should be treated promptly. Example Question: Do you have a headache? Finding: Denies head injury (Available)Pro Tip: Asking about the patient's history of physical trauma, including head injury, is one possible component of a review of systems interview. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint. Example Question: Have you had any head injuries? Finding: Asked about review of systems for ears ... Finding: Denies change in hearing (Available)Pro Tip: Asking about changes in hearing is one possible component of a review of systems interview. The patient's response to questions about this topic may uncover additional problems, such as hearing loss, not discovered during the discussion of the patient's chief complaint. Example Question: Has your hearing changed? Finding: Denies ringing or tinnitus (Available)Pro Tip: Ringing in the ears can suggest an ear infection, during which the middle of the ear becomes clogged with fluid and mucous, which can affect hearing, or hearing loss. Asking Tina if she has ear pain might indicate a possible ear infection and a reason for changes in her hearing. Example Question: Do you ever have ringing in your ears? Finding: Denies ear pain (Available)Pro Tip: Ear pain can suggest an ear infection, during which the middle of the ear becomes clogged with fluid and mucous, which can affect hearing. Asking Tina if she has ear pain might indicate a possible ear infection and a reason for changes in her hearing. Example Question: Have you had ear pain? Finding: Denies ear discharge (Available)Pro Tip: Ear discharge is the leakage of blood, pus, or wax from the ear and can be the result of a ruptured eardrum, eczema, or swimmer's ear. Asking whether she's noticed ear discharge could indicate whether she has a ruptured eardrum. 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: Asking about changes in vision is one possible component of a review of systems interview. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint, such as vision loss. Example Question: Have you noticed any changes in your vision? Finding: Denies corrective lenses (Available)Pro Tip: Asking about the patient's use of corrective lenses is one possible component of a review of systems interview. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint, such as vision loss. Example Question: Do you wear glasses or contacts?
Example Question: Do you have any lumps in your breasts? Finding: Denies nipple discharge (Available)Pro Tip: Asking about abnormal characteristics of a patient's breasts, such as nipple discharge, is one way of assessing overall breast health. Example Question: Have you experienced nipple discharge? Finding: Denies ever having a mammogram (Available)Pro Tip: Inquiring into what breast screenings Tina has had can lead to a discussion about any test results and their implications for her cardiovascular health. If she has not had any screenings, it provides an opportunity for patient education. Example Question: Have you had a mammogram? Finding: Denies history of breast cancer (Available)Pro Tip: If a patient has a history of breast cancer, it is important that you look for signs of recurrence and engage in preventative care, as well as patient education. You may also need to provide further support and resources to the patient. Example Question: Have you had breast cancer? Finding: Asked about review of systems for respiratory ... Finding: Denies current breathing problems (Available)Pro Tip: Asking about general breathing problems can provide a comparative baseline for assessing Tina's current condition and previous breathing concerns. Example Question: Have you had breathing problems? Finding: Denies current wheezing (Available)Pro Tip: Patients who experience chronic asthma may be accustomed to wheezing and, as a result, might not volunteer this information. Asking Tina if she's been wheezing illustrates how her asthma is presenting. Example Question: Have you been wheezing? Finding: Denies current chest tightness (Available)Pro Tip: Asking about chest tightness is one possible component of a review of systems interview. As a currently presenting symptom, it could indicate a change in patient status. If the patient reports a history of chest tightness, it could be a symptom of asthma or another respiratory problem. Example Question: Have you had chest tightness? Finding: Denies pain while breathing (Available)Pro Tip: Asking about pain during breathing is one possible component of a review of systems interview. As a currently presenting symptom, it could indicate a change in patient status. If the patient reports a history of pain during breathing, it could be a symptom of asthma or another respiratory problem. Example Question: Does it hurt when you breathe? Finding: Denies frequent coughing (Available)Pro Tip: Asking about coughing is one possible component of a review of systems interview. As a currently presenting symptom, it could indicate an asthma exacerbation or a new respiratory infection. Example Question: Have you been coughing? Finding: Asked about review of systems for cardiovascular ... Finding: Denies chest pain or discomfort (Available)Pro Tip: Asking about chest pain is one possible component of a review of systems interview. As a currently presenting symptom, it could indicate a change in patient status. If the patient reports a history of chest pain, it could be a symptom of a recurring cardiovascular problem. Example Question: Do you ever have chest pain? Finding: Denies palpitations (Available)Pro Tip: Asking about palpitations is one possible component of a review of systems interview. As a currently presenting symptom, it could indicate a change in patient status. If the patient reports a history of palpitations, it could be a symptom of a recurring cardiovascular problem. Example Question: Have you had palpitations? Finding: Denies irregular heartbeat (Available)Pro Tip: Asking about heartbeat patterns is one possible component of a review of systems interview. As a currently presenting symptom, it could indicate a change in patient status. If the patient reports a history of irregular heartbeat, it could be a symptom of a recurring cardiovascular problem. Example Question: Has your heartbeat been irregular? Finding: Denies easy bruising (Available)Pro Tip: Asking if a patient bruises easily is one possible component of a review of systems interview. Bruising easily can be indicative of anemia or a more serious blood disorder. Example Question: Have you noticed bruising more than usual? Finding: Denies edema (Available)Pro Tip: Asking about edema is one possible component of a review of systems interview. Edema is caused by the presence of excess fluid in the tissues, and it can indicate an infection, weak heart or veins, or other organ problems. Example Question: Have you noticed any swelling in your legs? Finding: Denies circulation problems (Available)Pro Tip: Poor circulation is the result of other diseases like obesity, diabetes, or cardiac conditions. Asking Tina whether she's experienced poor circulation indicates whether she might suffer from underlying cardiac concerns. Example Question: Do you have circulation problems? Finding: Asked review of systems for gastrointestinal ... Finding: Denies nausea (Available)Pro Tip: Currently presenting nausea can be caused by changes in blood sugar, a reaction to medication, stress, or even spreading infection. If the patient reports a history of nausea, it could be a symptom of a recurring gastrointestinal problem. Example Question: Have you had nausea? Finding: Denies vomiting (Available)Pro Tip: Vomiting can be caused by a pain response, a reaction to medication, stress, or even spreading infection. If the patient reports a history of vomiting, it could be a symptom of a recurring gastrointestinal problem. Example Question: Have you been vomiting? Finding: Denies stomach pain (Available)Pro Tip: Asking about stomach pain is one possible component of a review of systems interview. As a currently presenting symptom, it could indicate a change in patient status. If the patient reports recurring stomach pain, it could be a symptom of a gastrointestinal problem. Example Question: Do you have stomach pain? Finding: Denies change in bowel movements (Available)Pro Tip: Asking about changes in bowel movements can help you understand a patient's baseline patterns. Any recent or abrupt changes could impact the patient's care plan, such as administering treatment for constipation or diarrhea. Example Question: Have you had changes in your bowel movements? Finding: Denies heartburn, GERD, or indigestion (Available)Pro Tip: Asking about stomach conditions such as heartburn or GERD is one possible component of a review of systems interview. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint. Example Question: Do you ever get heartburn? Finding: Denies constipation (Available)Pro Tip: Asking about constipation is one possible component of a review of systems interview. As a currently presenting symptom, it could impact the patient's care plan. If the patient reports a history of constipation, it could be a symptom of dietary or gastrointestinal problems. Example Question: Do you have constipation? Finding: Denies diarrhea or loose stool (Available)Pro Tip: Asking about diarrhea is one possible component of a review of systems interview. As a currently presenting symptom, it could impact the patient's care plan. If the patient reports a history of diarrhea, it could be a symptom of dietary or gastrointestinal problems. Example Question: Do you have diarrhea? Finding: Denies excessive flatulence or bloating (Available)Pro Tip: Asking about gas or bloating is one possible component of a review of systems interview. As a currently presenting symptom, it could impact the patient's care plan. If the patient reports a history of gas, it could be a symptom of dietary or gastrointestinal problems. Example Question: Do you have flatulence? ... Finding: Asked review of systems for urinary ... Finding: Denies painful or difficult urination (Available)Pro Tip: Asking about pain during urination is one possible component of a review of systems interview. As a currently presenting symptom, it could result in a change to the patient's care plan. A history of pain during urination could be a symptom of genitourinary problems. Example Question: Does it hurt when you urinate? Finding: Reports waking up to urinate during the night (Available)Pro Tip: Frequent urination at night can be a sign of uncontrolled blood sugar or UTI. As a currently presenting symptom, nocturia could result in a change to the patient's care plan. A history of nocturia could be a symptom of genitourinary or endocrine problems such as diabetes. Example Question: Do you wake up at night to urinate? Finding: Reports large amount of urine (Found)Pro Tip: Polyuria is a common symptom of diabetes. Establishing that Tina is producing a large amount of urine is important for understanding the current state of her condition and treatment needs. Example Question: Do you urinate frequently? Finding: Denies blood in urine (Available)Pro Tip: As a currently presenting symptom, blood in the urine is a serious symptom that requires immediate intervention. A history of hematuria could be a symptom of genitourinary problems. Example Question: Do you ever notice blood in your urine? Finding: Denies flank pain (Available)Pro Tip: Flank pain can be a sign of kidney infection. As a currently presenting symptom, flank pain could result in a change to the patient's care plan. A history of flank pain could be a symptom of genitourinary problems. Example Question: Do you have flank pain? Finding: Denies incontinence (Available)Pro Tip: As a currently presenting symptom, incontinence could result in a change to the patient's care plan. A history of incontinence could be a symptom of genitourinary or pelvic problems. Example Question: Are you able to hold your urine?
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Finding: Denies history of urinary tract or bladder infection (Available)Pro Tip: Asking about a history of bladder or urinary tract infections is one possible component of a review of systems interview. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint. Example Question: Have you ever had a urinary infection? Finding: Asked review of systems for reproductive ... Finding: Reports last menstrual period was 3 weeks ago (Available)Pro Tip: Establishing the patient's last menstrual period will help you determine if the patient could be pregnant. A potential pregnancy impacts important parts of the patient's care plan, including which medications are administered. Example Question: When was your last period? Finding: Reports that periods are irregular (Available)Pro Tip: Asking about menstrual regularity is one possible component of a review of systems interview. A history of irregular periods could indicate hormonal or endocrine problems. Example Question: Are your periods regular? Finding: Denies past pregnancies (Available)Pro Tip: A patient's history of pregnancy can shed light on other health conditions, body systems, or risk factors. It's important to learn about any past pregnancies, live births, or miscarriages. Example Question: Have you ever been pregnant? Finding: Denies vaginal itching or discomfort (Available)Pro Tip: Asking about vaginal discomfort, such as itching or burning, is one possible component of a review of systems interview. Symptoms like these could indicate a yeast or sexually transmitted infection. Example Question: Do you experience vaginal burning? Finding: Reports normal vaginal discharge (Available)Pro Tip: Asking about vaginal discharge is one possible component of a review of systems interview. If a patient reports atypical discharge, it could indicate a yeast or sexually transmitted infection. Example Question: What is your vaginal discharge like? Finding: Denies history of STIs (Available)Pro Tip: Asking about a patient's history of STIs is one possible component of a review of systems interview. A history of STIs could cause complications with the genitourinary system. Example Question: Have you ever been diagnosed with a sexually transmitted infection? Finding: Reports past condom use (Available)Pro Tip: Asking about a patient's past condo
Shadow Health Tina Jones Respiratory Documentation
Course: Advanced Pathopharmacology & Physical Assessment For The Nurse Educator B (NRSG631B)
University: Colorado Technical University
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