Tanner Bailey Pain Management shadow health Subjective data

• 
  

  Finding:

  Established chief complaint and reason for admittance

• 
  

  Finding:

  Reports chronic lower back pain resulting from work injury

  (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 chief complaint?
• 
  

  Finding:

  Reports wanting a prescription for opioids

  (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 chief complaint?

Title: Understanding Tanner Bailey’s Pain Management in Shadow Health Interview

Subjective Data Collection: 25 of 25 (100.0%)

Chief Complaint

– Tanner Bailey has reported chronic lower back pain due to a work injury.
– He is seeking a prescription for opioids to manage his pain.

History of Present Illness

– The pain began thirteen weeks ago after lifting a heavy box.
– The pain is described as sharp and burning, with occasional tingling.
– Pain intensity varies throughout the day and can be aggravated by movement.
– Hospital exams didn’t diagnose the type of back injury, and ibuprofen was prescribed.
– Physical therapy was recommended but not followed consistently.
– The pain has not improved since its onset.

Home Medications

– Tanner started ibuprofen 13 weeks ago after hospitalization but stopped using it 11 weeks ago.
– He switched to alcohol as a stronger analgesic but stopped using it one week ago.
– He used opioids from his friend’s surgery for a week, taking 325 mg acetaminophen and 5 mg hydrocodone.
– The opioids were taken twice daily and were effective as pain relief.

Social History

– Tanner’s income is steady but low as a theater director.
– He identifies as transgender (female to male) and wears a chest binder.
– He drinks alcohol for pain relief, consuming more since the injury.
– He denies using illicit drugs or nicotine products.
– He reports no adverse effects or dependency on alcohol.

Overall, Tanner Bailey experiences chronic back pain and has tried various medications, including opioids, ibuprofen, and alcohol, for pain relief. His social history includes his gender identity, income level, and alcohol consumption.

• 
  

  Finding:

  Asked about onset of injury

• 
  

  Finding:

  Reports sustaining injury thirteen 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 the pain start?
• 
  

  Finding:

  Reports injury occurred after lifting a heavy box

  (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 the pain start?
• 
  

  Finding:

  Reports pain onset immediately after injury

  (Found)

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

  Example Question:

  When did the pain start?
• 
  

  Finding:

  Reports being driven to hospital immediately after injury

  (Found)

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

  Example Question:

  Did you go to the hospital?

• 
  

  Finding:

  Followed up on hospitalization

• 
  

  Finding:

  Reports hospital exams could not diagnose the type of back injury

  (Found)

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

  Example Question:

  What did the hospital diagnose you with?
• 
  

  Finding:

  Reports hospital prescribed ibuprofen

  (Found)

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

  Example Question:

  Did the hospital prescribe you anything?
• 
  

  Finding:

  Reports being told at the hospital to attend physical therapy

  (Found)

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

  Example Question:

  Did the hospital recommend anything?

• 
  

  Finding:

  Asked about frequency, duration, and timing of pain

• 
  

  Finding:

  Reports back injury and pain have not healed since onset

  (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 your pain levels changed since your injury?
• 
  

  Finding:

  Reports pain fluctuates in and out throughout the day at irregular intervals

  (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 does the pain occur?

• 
  

  Finding:

  Asked about additional symptoms of injury

• 
  

  Finding:

  Denies additional symptoms

  (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 other symptoms do you have?

• 
  

  Finding:

  Asked about aggravating factors of pain

• 
  

  Finding:

  Reports exertion such as walking, bending, or lifting aggravate pain

  (Found)

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

  Example Question:

  Does exertion make your pain worse?
• 
  

  Finding:

  Reports at-home physical therapy exercises aggravated pain, discouraging attendence of physical therapy

  (Found)

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

  Example Question:

  Does exercise make your pain worse?

• 
  

  Finding:

  Asked about nonmedicational treatment and relieving factors of pain

• 
  

  Finding:

  Reports drinking alcohol relieves pain

  (Found)

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

  Example Question:

  Does drinking alcohol relieve your pain?
• 
  

  Finding:

  Reports shifting positions when sitting or lying down can slightly relieve pain

  (Found)

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

  Example Question:

  Does shifting positions relieve your pain?
• 
  

  Finding:

  Reports resting slightly relieves pain

  (Found)

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

  Example Question:

  Does resting relieve your pain?
• 
  

  Finding:

  Denies trying heat or ice packs

  (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 tried heat packs?

• 
  

  Finding:

  Asked about characteristics of pain

• 
  

  Finding:

  Descibes pain as usually sharp and burning

  (Found)

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

  Example Question:

  What is the pain like?
• 
  

  Finding:

  Describes pain as occasionally tingling

  (Found)

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

  Example Question:

  What is the pain like?

• 
  

  Finding:

  Asked about severity of pain

• 
  

  Finding:

  Reports sometimes pain is not present or low, or 0-2

  (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 much pain are you in?
• 
  

  Finding:

  Reports sometimes pain is moderate to severe, or 4-7

  (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 much pain are you in?

• 
  

  Finding:

  Asked about other existing health conditions

• 
  

  Finding:

  Denies other health problems

  (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 other health problems do you have?

• 
  

  Finding:

  Asked about history of mental health

• 
  

  Finding:

  Denies mental health disorders

  (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 a history of psychiatric illness?

• 
  

  Finding:

  Asked about allergies

• 
  

  Finding:

  Denies 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 relevant family medical history

• 
  

  Finding:

  Reports mother has depression and is an alcoholic

  (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:

  Can you tell me about your family history?

• 
  

  Finding:

  Asked about gender-affirming medications

• 
  

  Finding:

  Reports currently taking testosterone enanthate for gender-affirmation therapy

  (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:

  Are you currently taking testosterone?

• 
  

  Finding:

  Asked about home medications for injury

• 
  

  Finding:

  Reports previously taking ibuprofen for back pain

  (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 ibuprofen?
• 
  

  Finding:

  Reports previously taking opioid analgesics for back pain

  (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 opioids?

• 
  

  Finding:

  Followed up on testosterone therapy

• 
  

  Finding:

  Reports testosterone is in injection form

  (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 form is your testosterone in?
• 
  

  Finding:

  Reports dosage is 100 milligrams per week

  (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 dosage is your testosterone?
• 
  

  Finding:

  Reports having taken testosterone for two years

  (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:

  How long have you taken testosterone?
• 
  

  Finding:

  Reports most recent dose of testosterone was yesterday

  (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 testosterone?

• 
  

  Finding:

  Followed up on ibuprofen

• 
  

  Finding:

  Reports buying over-the-counter ibuprofen to avoid the hassle of filling a prescription

  (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:

  Did you fill your prescription?
• 
  

  Finding:

  Reports having taken two 200 milligram ibuprofen pills at a time

  (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:

  How much ibuprofen did you take?
• 
  

  Finding:

  Reports having taken ibuprofen every four hours

  (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:

  How often did you take ibuprofen?
• 
  

  Finding:

  Reports ibuprofen was ineffective as an analgesic

  (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:

  Did ibuprofen help the pain?

• 
  

  Finding:

  Followed up on opioid analgesic

• 
  

  Finding:

  Reports having been given opioids leftover from his friend’s surgery

  (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:

  Where did you obtain opioids?
• 
  

  Finding:

  Reports the opioids were a combination of 325 milligrams acetaminophen and 5 milligrams hydrocodone

  (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 dose of opioids did you take?
• 
  

  Finding:

  Reports having taken the opioids twice daily, morning and night

  (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:

  How often did you take the opioids?
• 
  

  Finding:

  Reports the opioids were effective as an analgesic

  (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:

  Did opioids help the pain?
• 
  

  Finding:

  Denies being dependent on opioids

  (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:

  Are you dependent on opioids?

• 
  

  Finding:

  Asked about medication timeline

• 
  

  Finding:

  Reports having started ibuprofen 13 weeks ago just after hospitalization and stopping 11 weeks 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:

  What period of time did you take ibuprofen?
• 
  

  Finding:

  Reports stopping ibuprofen 11 weeks ago to more safely use alcohol as a stronger analgesic

  (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 stop taking ibuprofen?
• 
  

  Finding:

  Reports stopping alcohol use 1 week ago to more safely use opioids as a stronger analgesic

  (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:

  When did you stop drinking alcohol?
• 
  

  Finding:

  Reports having taken the opioids for a week until running out this morning

  (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 period of time did you take the opioids?

• 
  

  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 income level

• 
  

  Finding:

  Reports steady but low income as a theatre director

  (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?

• 
  

  Finding:

  Asked about gender identity

• 
  

  Finding:

  Reports transgender (female to male) identity

  (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 gender do you identify as?
• 
  

  Finding:

  Reports wearing a chest binder to masculinize appearance

  (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 do you do to masculizine your appearance?

• 
  

  Finding:

  Asked about substance use

• 
  

  Finding:

  Reports using 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 illicit drugs

  (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 used illicit substances?
• 
  

  Finding:

  Denies using nicotine or tobacco

  (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 used nicotine products?

• 
  

  Finding:

  Followed up on alcohol use

• Finding:Reports increasing alcohol use for its slight efficacy as an analgesic
  

  (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 often did you drink alcohol before your injury?
• 
  

  Finding:

  Reports drinking 1-2 servings of alcohol a month before injury

  (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 often did you drink alcohol before your injury?
• 
  

  Finding:

  Reports now drinking 3 servings of alcohol a day

  (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 servings of alcohol do you have a day?
• 
  

  Finding:

  Reports spreading alcohol servings throughout the day

  

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  (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:

  When in the day do you drink?
• Finding:Denies adverse effects of alcohol
  

  (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 have adverse effects from alcohol use?
• Finding:Denies dependency on alcohol
  

  (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:

  Are you dependent on alcohol?

• Finding:Asked about intoxication during risky activities

• Finding:Denies intoxication during risky activities