Shadow Health Assignments
Arun Patel Hypertension and Type 2 Diabetes shadow health Subjective Data
Subjective Data Collection: 20 of 20 (100.0%)
Category
Scored Items
Experts selected these topics as essential components of a strong, thorough interview with this patient.
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Patient Data
Not Scored
A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.
Chief Complaint
Finding:
Established chief complaint
Finding:
Reports coming in for check-up
(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 is your primary reason for this visit?- Arun Patel Hypertension and Type 2 Diabetes Shadow Health Subjective Data
Subjective Data Collection: 20 of 20 (100.0%)
Category: Scored Items
Experts have chosen these topics as important parts of the patient interview.
Patient Data: Not Scored
A combination of questions will provide better patient information. The following are details about the patient’s case.
Chief Complaint
– Established the main reason for the visit.
– Reports coming in for a check-up.History of Present Illness
– Asked about relevant health conditions.
– Reports having hypertension (high blood pressure).
– Reports having type 2 diabetes.
– Reports having generalized anxiety disorder (GAD).Asked about when symptoms started:
– Reports hypertension diagnosis 1 year ago.
– Reports diabetes diagnosis 5 years ago.
– Reports GAD diagnosis 13 years ago.Asked about associated symptoms:
– Reports increased thirst.
– Reports increased urination.
– Reports weight gain of 15 pounds.
– Reports fatigue and discomfort.
– Reports increased worry.Asked about non-medicational diabetes management:
– Reports owning a glucometer.
– Reports sporadically checking blood sugar.
– Reports sporadic checking due to disliking the glucometer’s pinch.Past Medical History
– Asked about allergies.
– Denies known allergies.– Asked about previous hospitalizations.
– Denies previous hospitalizations.Home Medications
– Asked about home medications.
– Reports taking hydrochlorothiazide for hypertension.
– Reports taking metformin for type 2 diabetes.
– Reports taking escitalopram for anxiety.
– Denies taking vitamins and supplements.– Followed up on hydrochlorothiazide.
– Reports hydrochlorothiazide tablets are each 50 milligrams.
– Reports taking one hydrochlorothiazide tablet a day.
– Reports taking hydrochlorothiazide with breakfast.
– Reports starting hydrochlorothiazide 1 year ago.
– Reports taking the last dose of hydrochlorothiazide this morning.
– Denies hydrochlorothiazide adverse effects.– Followed up on metformin.
– Reports metformin tablets are each 850 milligrams.
– Reports taking one metformin tablet three times daily.
– Reports taking one metformin tablet each with breakfast, lunch, and dinner.
– Reports starting metformin 5 years ago.
– Reports taking the last dose of metformin this morning.
– Denies metformin adverse effects.– Followed up on escitalopram.
– Reports escitalopram tablets are each 20 milligrams.
– Reports taking one escitalopram tablet a day.
– Reports taking escitalopram with breakfast.
– Reports beginning escitalopram 13 years ago.
– Reports taking the last dose of escitalopram this morning.
– Denies escitalopram adverse effects.– Asked about medication regimen adherence.
– Denies missing doses.Social History
– Asked about activity.
– Reports a sedentary activity level.– Asked about diet.
– Reports eating take-out frequently.
– Reports enjoying comfort foods when stressed.
– Denies binge-eating but feels like eating more than usual.– Asked about substance use.
– Denies tobacco and nicotine use.
– Denies alcohol use.– Asked about income level.
– Reports moderate income from a graduate student stipend.Family Medical History
– Asked about relevant family history.
– Reports mother diagnosed with high cholesterol and diabetes.
– Reports father diagnosed with hypertension.Review of Systems
– Asked about review of systems for genitourinary.
– Denies difficulty urinating.
– Denies pain during urination.
– Denies changes in urine characteristics.– Asked about review of systems for cardiovascular.
– Denies palpitations.
– Denies chest pain.
– Denies history of blood clots.
– Denies claudication.
History of Present Illness
- Finding:Asked about relevant health conditions
- Finding:Reports hypertension
(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:
Do you have high blood pressure?
Finding:
Reports type 2 diabetes
(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:
Do you have diabetes?
Finding:
Reports generalized anxiety disorder
(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:
Do you have anxiety?
Finding:
Asked about onset and duration of disorders
Finding:
Reports hypertension diagnosis 1 year 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:
When did your high blood pressure start?
Finding:
Reports diabetes diagnosis 5 years 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:
When did your diabetes start?
Finding:
Reports GAD diagnosis 13 years 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 your anxiety start?
Finding:
Asked about associated symptoms
Finding:
Reports increased thirst
(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:
Have you been thirsty?
Finding:
Reports increased urination
(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:
Have you been urinating frequently?
Finding:
Reports weight gain of 15 pounds
(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:
Have you had any weight changes?
Finding:
Reports fatigue and discomfort
(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:
Have you been fatigued?
Finding:
Reports increased worry
(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:
Have you been excessively worrying?
Finding:
Asked about onset and duration of associated symptoms
Finding:
Reports increased thirst began 1 month 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:
When did your thirst increase?
Finding:
Reports increased urination began 1 month 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:
When did you start urinating more frequently?
Finding:
Reports weight gain over the last 3 months
(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 gain weight?
Finding:
Reports fatigue and discomfort over the last 3 months
(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 long have you felt fatigued?
Finding:
Asked about non-medicational diabetes management
Finding:
Reports owning glucometer
(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:
Do you have a blood sugar monitor?
Finding:
Reports checking blood sugar sporadically
(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 do you check your blood sugar?
Finding:
Reports sporadic checking is because of disliking the glucometer’s pinch
(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 do you check your blood sugar?
Past Medical History
- Finding:Asked about allergies
Finding:
Denies known 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 allergies?
Finding:
Asked about previous hospitalizations
Finding:
Denies previous 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 ever been hospitalized?
Home Medications
Finding:
Asked about home medications
Finding:
Reports taking hydrochlorothiazide for hypertension
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. 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 medication for your high blood pressure?
Finding:
Reports taking metformin for type 2 diabetes
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. 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 medication for your diabetes?
Finding:
Reports taking escitalopram for anxiety
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. 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 medication for your anxiety?
Finding:
Denies taking vitamins and supplements
(Available)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. 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 vitamins and supplements do you take?
Finding:
Followed up on hydrochlorothiazide
Finding:
Reports hydrochlorothiazide tablets are each 50 milligrams
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. 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 much hydrochlorothiazide do you take?
Finding:
Reports taking one hydrochlorothiazide tablet a day
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. 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 often do you take hydrochlorothiazide?
Finding:
Reports taking hydrochlorothiazide with breakfast
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. 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 often do you take hydrochlorothiazide?
Finding:
Reports starting hydrochlorothiazide 1 year ago
(Available)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. 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:
When did you start taking hydrochlorothiazide?
Finding:
Reports taking last dose of hydrochlorothiazide this morning
(Available)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. 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:
When was your last dose of hydrochlorothiazide?
Finding:
Denies hydrochlorothiazide adverse effects
(Available)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. 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 experience any adverse effects from hydrochlorothiazide?
Finding:
Followed up on metformin
Finding:
Reports metformin tablets are each 850 milligrams
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. 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 much metformin do you take?
Finding:
Reports taking metformin tablet three times daily
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. 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 often do you take metformin?
Finding:
Reports taking one metformin tablet each with breakfast, lunch, and dinner
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. 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 often do you take metformin?
Finding:
Reports starting metformin 5 years ago
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. 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:
When did you start taking metformin?
Finding:
Reports taking last dose of metformin this morning
(Available)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. 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:
When was your last dose of metformin?
Finding:
Denies metformin adverse effects
(Available)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. 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 experience any adverse effects from metformin?
Finding:
Followed up on escitalopram
Finding:
Reports escitalopram tablets are each 20 milligrams
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. 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 much escitalopram do you take?
Finding:
Reports taking one escitalopram tablet a day
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. 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 often do you take escitalopram?
Finding:
Reports taking escitalopram with breakfast
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. 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 often do you take escitalopram?
Finding:
Reports began taking escitalopram 13 years ago
(Available)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. 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:
When did you start taking escitalopram?
Finding:
Reports taking last dose of escitalopram this morning
(Available)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. 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:
When did you take your last dose of escitalopram?
Finding:
Denies escitalopram adverse effects
(Available)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. 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 experience any adverse effects from escitalopram?
Finding:
Asked about medication regimen adherence
Finding:
Denies missing doses
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. 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 missed any doses of your medication?
Social History
Finding:
Asked about activity
Finding:
Reports sedentary activity level
(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:
Do you get any regular physical activity?
Finding:
Asked about diet
Finding:
Reports eating take-out frequently
(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:
Do you eat take out?
Finding:
Reports enjoying comfort foods when stressed
(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:
Do you eat comfort foods?
Finding:
Denies binge-eating but feels like he eats more than he should
(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:
Do you overeat?
Finding:
Asked about substance use
Finding:
Denies tobacco and nicotine use
(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:
Do you smoke cigarettes?
Finding:
Denies alcohol use
(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:
Do you drink any alcohol?
- Finding:Asked about income level
- Finding:Reports moderate income from graduate student stipend
(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:
What level of income do you make?
Family Medical History
- Finding:Asked about relevant family history
- Finding:Reports mother diagnosed with high cholesterol and diabetes
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.Example Question:
Does your mother have health problems?
Finding:
Reports father diagnosed with hypertension
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.Example Question:
Does your father have health problems?
Review of Systems
Finding:
Asked about review of systems for genitourinary
Finding:
Denies difficulty urinating
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had any difficulty urinating?
Finding:
Denies pain during urination
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had any pain during urination?
Finding:
Denies changes in urine characteristics
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had any changes in your urine?
Finding:
Asked about review of systems for cardiovascular
Finding:
Denies palpitations
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had palpitations?
Finding:
Denies chest pain
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had chest pain?
Finding:
Denies history of blood clots
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(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.Example Question:
Have you had blood clots?
Finding:
Denies claudication