Debbie O’Connor COPD shadow health Subjective Data

• 
  

  Finding:

  Established chief complaint and reason for admittance

• 
  

  Finding:

  Reports a bronchospasm three days ago

  (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:

  When did your symptoms start?
• 
  

  Finding:

  Reports increased difficulty breathing

  (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 are your symptoms?
• 
  

  Finding:

  Reports desire for smoking cessation aids

  (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 can I do for you?

• 
  

  Finding:

  Asked about additional symptoms

• 
  

  Finding:

  Reports fatigue and weakness

  (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 feel fatigued?
• 
  

  Finding:

  Reports purulent sputum

  (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 purulent sputum?
• 
  

  Finding:

  Reports cough

  (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 a cough?
• 
  

  Finding:

  Reports feeling anxious about symptoms and worsening health issues

  (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 do you feel about your symptoms?

• 
  

  Finding:

  Asked about onset and duration of symptoms

• 
  

  Finding:

  Reports most severe fatigue and difficulty breathing began three days ago

  (Available)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  When did your fatigue begin?
• 
  

  Finding:

  Reports purulent sputum production started two weeks 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 productive cough begin?
• 
  

  Finding:

  Reports respiratory symptoms increased in the last four months

  (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:

  How long have you had your symptoms?

• 
  

  Finding:

  Followed up on characteristics of respiratory distress

• 
  

  Finding:

  Reports sputum is mostly clear with occasional yellow, gray, or dark color

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  What does your sputum look like?
• 
  

  Finding:

  Reports wheezing

  (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:

  Are you wheezing?
• 
  

  Finding:

  Reports cough sounds like crackling

  (Available)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  What does your cough sound like?

• 
  

  Finding:

  Asked about aggravating factors

• 
  

  Finding:

  Reports exertion worsens symptoms

  (Available)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  Does exertion make your symptoms worse?
• 
  

  Finding:

  Reports coughing fits after smoking

  (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 do you have coughing fits?

• 
  

  Finding:

  Asked about treatment and relieving factors of respiratory symptoms

• 
  

  Finding:

  Reports trying to hold off on smoking cigarettes as long as possible

  (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 do you wait between cigarettes?

• 
  

  Finding:

  Asked about severity of respiratory distress

• 
  

  Finding:

  Reports breathing difficulty and associated discomfort is a 6/10

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  Can you rate your symptoms on a scale of 1 to 10?

• 
  

  Finding:

  Asked about effects of health on social activity

• 
  

  Finding:

  Reports low social activity – doesn’t feel up to getting out and about

  (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 do your symptoms prevent you from social activities?

Debbie O’Connor COPD Shadow Health Subjective Data

Subjective Data Collection: 32 of 32 (100.0%)

Category: Scored Items

Experts have chosen these topics as important parts of the patient interview.

Patient Data: Not Scored

A mix of questions will provide better patient information. The following are facts about the patient’s situation.

Chief Complaint

– Established reason for coming in.
– Reports having bronchospasm three days ago.
– Reports increased difficulty breathing.
– Reports wanting smoking cessation aids.

History of Present Illness

– Asked about other symptoms.
– Reports fatigue and weakness.
– Reports purulent sputum (thick mucus).
– Reports having a cough.
– Reports feeling anxious about symptoms.

Asked about when symptoms started:

– Reports most severe fatigue and breathing difficulty starting three days ago.
– Reports purulent sputum production beginning two weeks ago.
– Reports respiratory symptoms worsening in the last four months.

Followed up on respiratory distress characteristics:

– Reports sputum is mostly clear but sometimes yellow, gray, or dark.
– Reports wheezing.
– Reports cough sounding like crackling.

Asked about what makes symptoms worse:

– Reports exertion worsens symptoms.
– Reports coughing fits after smoking.

Asked about treatment and relief for respiratory symptoms:

– Reports trying to avoid smoking cigarettes as long as possible.
– Reports breathing difficulty and discomfort at 6 out of 10.

Asked about effects on social activity:

– Reports low social activity due to symptoms.

Past Medical History

– Asked about existing health conditions.
– Reports having chronic bronchitis related to COPD.
– Reports being diagnosed with “Class B” COPD.
– Reports being diagnosed after a respiratory distress episode.
– Asked about ER visits or hospitalizations.
– Reports hospitalization after miscarriage at age 24.
– Reports most recent hospitalization being two years ago.
– Reports most recent hospitalization being for a respiratory distress episode.

Home Medications

– Asked about home medications.
– Reports taking a long-acting beta-agonist (LABA).
– Followed up on LABA.
– Reports using a formoterol inhaler.
– Reports a formoterol dose of 12 micrograms.
– Reports using the LABA once every 12 hours.
– Reports using LABA this morning.
– Reports the LABA not being very effective.
– Denies medication side effects.

Asked about supplements and vitamins:

– Denies using supplements or vitamins.

Asked about medication regimen adherence:

– Denies missing doses.

Asked about spirometry:

– Reports sporadic spirometry readings at home.
– Reports most recent FEV1 reading was 1.37 L, 49% of predicted FEV1.

Asked about oxygen use:

– Denies oxygen therapy due to cigarette smoking.

Asked about allergies:

– Denies allergies.

Asked about vaccines:

– Denies recent influenza vaccine.
– Denies recent pneumococcal vaccines.

• Finding:Asked about existing health conditions

• Finding:Reports chronic bronchitis related to COPD
  

  (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 chronic bronchitis?

• 
  

  Finding:

  Followed up on chronic bronchitis COPD diagnosis

• 
  

  Finding:

  Reports diagnosed with “Class B” COPD

  (Found)

  Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

  Example Question:

  What class of COPD were you diagnosed with?
• 
  

  Finding:

  Reports diagnosed after respiratory distress episode

  (Found)

  Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

  Example Question:

  What was your respiratory episode?

• 
  

  Finding:

  Asked about ER visits or hospitalizations

• 
  

  Finding:

  Reports hospitalization after miscarriage at age 24

  (Available)

  Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

  Example Question:

  When were you hospitalized?
• 
  

  Finding:

  Reports most recent hospitalization was two years ago

  (Found)

  Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

  Example Question:

  When was your most recent hospitalization?
• 
  

  Finding:

  Reports most recent hospitalization was for respiratory distress episode

  (Found)

  Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

  Example Question:

  What was your recent hospitalization for?

• 
  

  Finding:

  Asked about home medications

• 
  

  Finding:

  Reports taking a long-acting beta-agonist (LABA)

  (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 a LABA?

• 
  

  Finding:

  Followed up on LABA

• 
  

  Finding:

  Reports the LABA is formoterol inhaler

  (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 use a LABA inhaler?
• 
  

  Finding:

  Reports formoterol dose of 12 micrograms

  (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:

  What is the dosage of your inhaler?
• 
  

  Finding:

  Reports only using once every 12 hours, once in the morning and once at night

  (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 your inhaler?
• 
  

  Finding:

  Reports using LABA 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 is the last time you used your inhaler?
• 
  

  Finding:

  Reports the LABA is not very effective

  (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:

  Is the inhaler effective?
• 
  

  Finding:

  Denies medication side 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 have any side effects from your inhaler?

• 
  

  Finding:

  Asked about supplements and vitamins

• 
  

  Finding:

  Denies use of supplements or vitamins

  (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 vitamins?

• 
  

  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:

  Do you miss doses of your medication?

• 
  

  Finding:

  Asked about spirometry

• 
  

  Finding:

  Reports sporadic spirometry readings at home

  (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 spirometry readings at home?
• 
  

  Finding:

  Reports most recent FEV1 reading was 1.37 L, 49% of her predicted FEV1

  (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:

  What is your most recent spirometry reading?

• 
  

  Finding:

  Asked about oxygen use

• 
  

  Finding:

  Denies oxygen therapy due to cigarette smoking

  (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 use oxygen even though you smoke?

• 
  

  Finding:

  Asked about allergies

• 
  

  Finding:

  Denies allergies

  (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 have any allergies?

• 
  

  Finding:

  Asked about vaccines

• 
  

  Finding:

  Denies recent influenza vaccine

  (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:

  Have you had a flu shot?
• 
  

  Finding:

  Denies recent pneumococcal vaccines

  (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:

  Have you had a pneumonia vaccine?

• 
  

  Finding:

  Asked about living environment

• 
  

  Finding:

  Reports she lives with her daughter

  (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:

  Who do you live with?
• 
  

  Finding:

  Reports recently moving in with her daughter because of her declining health

  (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:

  When did you move in with your daughter?
• 
  

  Finding:

  Reports stress from arguments with daughter over smoking

  (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:

  Is your home stressful?

• 
  

  Finding:

  Asked about substance use

• 
  

  Finding:

  Reports cigarette smoking

  (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 smoke cigarettes?
• 
  

  Finding:

  Denies drinking alcohol

  (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 alcohol?
• 
  

  Finding:

  Denies using illegal substances

  (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 use illegal drugs?

• 
  

  Finding:

  Followed up on current cigarette smoking

• 
  

  Finding:

  Reports three to five cigarettes a day for the past four months

  (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:

  How many cigarettes do you smoke a day?
• 
  

  Finding:

  Reports stressful situations trigger her smoking

  (Available)

  Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

  Example Question:

  What triggers your smoking?
• 
  

  Finding:

  Reports daughter convinced her to quit smoking because of declining health issues

  (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:

  Why do you want to quit smoking?
• 
  

  Finding:

  Reports husband’s death of lung cancer makes her want to quit

  (Available)

  Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

  Example Question:

  What was your husband’s cause of death?

• 
  

  Finding:

  Followed up on history of cigarette smoking

• 
  

  Finding:

  Reports started smoking at age 15

  (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:

  When did you start smoking?
• 
  

  Finding:

  Reports quit smoking when her daughter was young but started smoking again in her 30s

  (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:

  Have you ever quit smoking?
• 
  

  Finding:

  Reports 37 pack years according to an online calculator her daughter used

  (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:

  How many pack years do you have?

• 
  

  Finding:

  Followed up on smoking cessation

• 
  

  Finding:

  Reports trying to quit several times unsuccessfully with nicotine replacement therapy

  (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:

  Have you ever quit smoking using nicotine replacement therapy?
• 
  

  Finding:

  Reports having tried nicotine gum, lozenges, and patches

  (Available)

  Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

  Example Question:

  What kind of nicotine replacement therapy have you tried?
• 
  

  Finding:

  Reports nicotine replacement therapy failed because she did not want to deal with the required compliance

  (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:

  Why didn’t nicotine replacement therapy work?
• 
  

  Finding:

  Reports her longest period without smoking was 10 years

  (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 is the longest amount of time you quit smoking?

• 
  

  Finding:

  Asked about exercise

• 
  

  Finding:

  Denies exercise due to fatigue, exhaustion, exacerbated symptoms upon exertion

  (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:

  Why don’t you exercise?

• 
  

  Finding:

  Asked about diet

• 
  

  Finding:

  Reports eating mostly frozen meals when daughter is at work

  (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 do you eat at home?
• 
  

  Finding:

  Reports her daughter cooks healthy meals for her

  (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 cook?

• 
  

  Finding:

  Asked about relevant family history

• 
  

  Finding:

  Reports father, smoker, died of a heart attack

  (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:

  Did your father smoke?
• 
  

  Finding:

  Reports mother died of smoking-related pneumonia

  (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:

  Did your mother smoke?
• 
  

  Finding:

  Reports husband smoked and died of lung cancer

  (Available)

  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:

  Did your husband smoke?
• 
  

  Finding:

  Reports daughter is a “health nut” non-smoker

  (Available)

  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 daughter smoke?

• 
  

  Finding:

  Asked about weight changes

• 
  

  Finding:

  Reports weight gain of 30 pounds in the last two years

  (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:

  How much weight have you gained?

• 
  

  Finding:

  Asked about review of systems for HEENT

• 
  

  Finding:

  Reports vision is nearsighted

  (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:

  Are you nearsighted?
• 
  

  Finding:

  Reports wearing glasses

  (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:

  Do you wear glasses?

• 
  

  Finding:

  Asked about review of systems for integumentary

• 
  

  Finding:

  Reports yellowing of skin, nails, and teeth

  (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 noticed changes in your skin color?
• 
  

  Finding:

  Denies cyanosis

  (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:

  Are your fingernails blue?

• 
  

  Finding:

  Asked about review of systems for genitourinary

• 
  

  Finding:

  Reports being postmenopausal

  (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:

  Are you postmenopausal?
• 
  

  Finding:

  Reports not sexually active

  

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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:

  Are you sexually active?

• Finding:Asked about ADLs

• Finding:Reports difficulty moving around home
  

  (Found)

  Pro Tip: Information about a patient’s activities of daily living will help you determine if their wellbeing is at risk. Questions about your patient’s ability to bathe themselves, feed themselves, or walk without assistance will help you determine whether the patient can care for themselves at home.

  Example Question:

  Do you have trouble moving around your home?
• 
  

  Finding:

  Reports difficulty with activities like dressing or cooking due to exhaustion