Focused Exam: Chest Pain, Brian Foster Shadow health Subjective Data Collection: 30 of 30 (100.0%)

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Focused Exam: Chest Pain, Brian Foster Shadow health Subjective Data Collection: 30 of 30 (100.0%)

 

Subjective Data Collection: 30 of 30 (100.0%)

Hover To Reveal…

Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.

  • Found:

     Indicates an item that you found.

  • Available:

     Indicates an item that is available to be found.

Category

Scored Items

Experts selected these topics as essential components of a strong, thorough interview with this patient.

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. Focused Exam: Chest Pain, Brian Foster Shadow health Subjective Data Collection: 30 of 30 (100.0%)

Chief Complaint


  • Finding:

    Established chief complaint


  • Finding:

    Reports chest pain

    (Found)

    Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.

    Example Question:

    Do you have chest pain?

History of Present Illness


  • Finding:

    Asked about onset of pain


  • Finding:

    Reports chest pain started appearing in the past month

    (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. Focused Exam: Chest Pain, Brian Foster Shadow health Subjective Data Collection: 30 of 30 (100.0%)

    Example Question:

    When did your chest pain start?

  • Finding:

    Asked about location of pain


  • Finding:

    Reports pain is in center of the chest

    (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. Focused Exam: Chest Pain, Brian Foster Shadow health Subjective Data Collection: 30 of 30 (100.0%)

    Example Question:

    Where is the pain?

  • Finding:

    Reports pain does not radiate

    (Found)

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

    Example Question:

    Does the pain radiate?

  • Finding:

    Denies arm pain

    (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 experiencing arm pain?

  • Finding:

    Denies shoulder pain

    (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 experiencing shoulder pain?

  • Finding:

    Denies back 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:

    Are you experiencing back pain?

  • Finding:

    Denies neck pain

    (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. Focused Exam: Chest Pain, Brian Foster Shadow health Subjective Data Collection: 30 of 30 (100.0%)

    Example Question:

    Are you experiencing neck pain?

  • Finding:

    Asked about duration of pain episodes


  • Finding:

    Reports each pain episode lasted “several” minutes

    (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 does your chest pain last?

  • Finding:

    Asked about frequency of pain


  • Finding:

    Reports 3 pain episodes in past month

    (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 many times in the last month have you had chest pain?

  • Finding:

    Reports that pain episodes did not seem related

    (Available)

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

    Example Question:

    Did the episodes seem associated?

  • Finding:

    Asked about severity of pain


  • Finding:

    Reports current pain is 0 out of 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:

    How would you rate your pain on a scale of zero to ten?

  • Finding:

    Reports pain severity at its worst is 5 out of 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:

    How would you rate your pain on a scale of zero to ten?

  • Finding:

    Asked about characteristics of pain


  • Finding:

    Describes pain as tight and uncomfortable

    (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 describe your pain?

  • Finding:

    Denies crushing pain

    (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:

    Is the pain crushing?

  • Finding:

    Denies gnawing pain

    (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:

    Is the pain gnawing?

  • Finding:

    Denies burning pain

    (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:

    Is the pain burning?

  • Finding:

    Asked about aggravating factors


  • Finding:

    Reports pain is aggravated by activity

    (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 makes the pain worse?

  • Finding:

    Reports pain occurred with yard work and taking stairs

    (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 activity triggered the pain?

  • Finding:

    Reports pain does not worsen with eating

    (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:

    Is the pain worse when you eat?

  • Finding:

    Reports pain does not worsen after spicy foods

    (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:

    Is the pain worse after you eat spicy food?

  • Finding:

    Reports pain does not worsen after high-fat foods

    (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:

    Is the pain worse after you eat high-fat foods?

  • Finding:

    Asked about relieving factors


  • Finding:

    Reports pain relief with brief period of rest

    (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 relieves your pain?

  • Finding:

    Denies taking medication to treat chest 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:

    Did you take anything for the chest pain?

Past Medical History


  • Finding:

    Confirmed allergies


  • Finding:

    Confirms 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 new allergies?

  • Finding:

    Asked about related medical conditions


  • Finding:

    Denies angina diagnosis

    (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 angina?

  • Finding:

    Reports high blood pressure

    (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 high blood pressure?

  • Finding:

    Reports high cholesterol

    (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 high cholesterol?

  • Finding:

    Denies coronary artery disease

    (Available)

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

    Example Question:

    Do you have coronary artery disease?

  • Finding:

    Denies diabetes

    (Available)

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

    Example Question:

    Do you have diabetes?

  • Finding:

    Denies previous treatment for chest pain

    (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 had previous treatment for chest pain?

  • Finding:

    Asked about blood pressure monitoring


  • Finding:

    Does not frequently monitor BP at home

    (Found)

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

    Example Question:

    How often do you measure your blood pressure?

  • Finding:

    Reports infrequent BP checks

    (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 do you measure your blood pressure?

  • Finding:

    Denies knowledge of typical BP reading

    (Available)

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

    Example Question:

    What is your typical blood pressure reading?

  • Finding:

    Asked about past cardiac tests


  • Finding:

    Reports recent EKG test

    (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 recently had an EKG?

  • Finding:

    Reports annual stress test

    (Available)

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

    Example Question:

    Have you recently had a stress test?

  • Finding:

    Followed up on results of cardiac tests


  • Finding:

    Reports belief that EKG was normal

    (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 were the results of your last EKG?

  • Finding:

    Reports belief that stress test was normal

    (Available)

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

    Example Question:

    What were the results of your last stress test?

Home Medications


  • Finding:

    Asked about home medications


  • Finding:

    Reports taking high blood pressure medication

    (Found)

    Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

    Example Question:

    Do you take medication for high blood pressure?

  • Finding:

    Reports taking high cholesterol medication

    (Found)

    Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

    Example Question:

    Do you take medication for high cholesterol?

  • Finding:

    Reports occasional ibuprofen use

    (Available)

    Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

    Example Question:

    Do you take over the counter medications?

  • Finding:

    Reports taking fish oil

    (Found)

    Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

    Example Question:

    Do you take any supplements?

  • Finding:

    Denies aspirin regimen

    (Available)

    Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

    Example Question:

    Do you take aspirin?

  • Finding:

    Followed up on high blood pressure medication


  • Finding:

    Reports taking lisinopril

    (Found)

    Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

    Example Question:

    What medication do you take for high blood pressure?

  • Finding:

    Reports lisinopril dose is 20 mg

    (Available)

    Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

    Example Question:

    What dose of medication do you take for high blood pressure?

  • Finding:

    Reports taking lisinopril once daily

    (Available)

    Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

    Example Question:

    How frequently do you take medication for high blood pressure?

  • Finding:

    Followed up on high cholesterol medication


  • Finding:

    Reports taking atorvastatin

    (Found)

    Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

    Example Question:

    What medication do you take for high cholesterol?

  • Finding:

    Reports atorvastatin dose is 20 mg

    (Available)

    Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

    Example Question:

    What dose of medication do you take for high cholesterol?

  • Finding:

    Reports taking atorvastatin once daily

    (Available)

    Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

    Example Question:

    How frequently do you take medication for high cholesterol?

  • Finding:

    Reports taking atorvastatin at bedtime

    (Available)

    Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

    Example Question:

    What time of day do you take your high cholesterol medication?

  • Finding:

    Reports having taken atorvastatin for one year

    (Available)

    Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

    Example Question:

    How long have you taken cholesterol medication?

Social Determinants of Health


  • Finding:

    Asked about access to healthcare


  • Finding:

    Reports a primary care provider

    (Found)

    Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.

    Example Question:

    Do you have a primary care provider?

  • Finding:

    Reports last visit 3 months ago

    (Found)

    Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.

    Example Question:

    When was your last visit to a healthcare provider?

  • Finding:

    Reports usually sees healthcare provider every 6 months

    (Available)

    Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.

    Example Question:

    How often do you see a healthcare provider?

  • Finding:

    Denies transportation is a barrier to healthcare

    (Available)

    Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.

    Example Question:

    Do you have difficulty accessing healthcare because of transportation?

  • Finding:

    Denies finances are a barrier to healthcare

    (Available)

    Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.

    Example Question:

    Do you have trouble affording healthcare?

Social History


  • Finding:

    Asked about stress


  • Finding:

    Reports generally low stress lifestyle

    (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 your stress level?

  • Finding:

    Asked about exercise


  • Finding:

    Denies regular exercise routine

    (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 kind of exercise do you get?

  • Finding:

    Reports last regular exercising was 2 years ago

    (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 last exercise regularly?

  • Finding:

    Asked about typical diet


  • Finding:

    Reports typical breakfast is granola bar and instant breakfast shake

    (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 is a typical breakfast for you?

  • Finding:

    Reports typical lunch is turkey sub

    (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 is a typical lunch for you?

  • Finding:

    Reports typical dinner is grilled meat and vegetables

    (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 is a typical dinner for you?

  • Finding:

    Denies moderation of salt intake

    (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 moderate your salt intake?

  • Finding:

    Asked about fluid intake


  • Finding:

    Reports drinking 4 glasses of water daily

    (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 water every day?

  • Finding:

    Reports drinking 2 cups of coffee daily

    (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 much coffee do you drink per day?

  • Finding:

    Denies soda drinking

    (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 much soda do you drink per day?

  • Finding:

    Asked about substance use


  • Finding:

    Denies current illicit drug 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 use illicit drugs?

  • Finding:

    Denies tobacco 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 use tobacco?

  • Finding:

    Reports moderate alcohol consumption

    (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 consume alcohol?

  • Finding:

    Followed up on alcohol consumption


  • Finding:

    Reports drinking 2-3 alcoholic drinks per week

    (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:

    Reports 2-3 drinks in one sitting

    (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 alcoholic drinks do you have in one sitting?

  • Finding:

    Reports drinking only on weekends

    (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 do you drink alcohol?

Review of Systems


  • Finding:

    Asked about constitutional health


  • Finding:

    Denies fever

    (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 have a fever?

  • Finding:

    Denies chills

    (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:

    Do you have chills?

  • Finding:

    Denies fatigue

    (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 feel tired?

  • Finding:

    Denies night sweats

    (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:

    Do you have night sweats?

  • Finding:

    Denies weight loss

    (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 experienced recent weight loss?

  • Finding:

    Denies dizziness or lightheadedness

    (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 have dizziness?

  • Finding:

    Denies palpitations

    (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 have palpitations?

  • Finding:

    Asked review of systems for cardiovascular


  • Finding:

    Denies history of angina

    (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 have a history of angina?

  • Finding:

    Denies edema

    (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 have any swelling?

  • Finding:

    Denies circulation problems

    (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:

    Do you have any problems with circulation?

  • Finding:

    Denies blood clots

    (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 ever had a blood clot?

  • Finding:

    Denies history of rheumatic fever

    (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:

    Do you have a history of rheumatic fever?

  • Finding:

    Denies history of heart murmur

    (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:

    Do you have a history of heart murmur?

  • Finding:

    Denies easy bleeding

    (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 noticed any unusual bleeding?

  • Finding:

    Denies easy bruising

    (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 noticed any unusual bruising?

  • Finding:

    Denies blue skin

    (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:

    Has your skin ever turned blue?

  • Finding:

    Asked about review of systems for respiratory


  • Finding:

    Denies cough

    (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 have a cough?

  • Finding:

    Denies difficulty breathing

    (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 difficulty breathing?

  • Finding:

    Denies shortness of breath at rest

    (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:

    Do you have difficulty breathing when lying down?

  • Finding:

    Asked about review of systems for HEENT


  • Finding:

    Denies change in sense of taste

    (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 experienced a change in taste?

  • Finding:

    Denies sore throat

    (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 have a sore throat?

  • Finding:

    Denies difficulty swallowing

    (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:

    Do you have dysphagia?

  • Finding:

    Asked about review of systems for gastrointestinal


  • Finding:

    Denies nausea

    (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:

    Do you have nausea?

  • Finding:

    Denies vomiting

    (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 vomited recently?

  • Finding:

    Denies diarrhea

    (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 have diarrhea?

  • Finding:

    Denies constipation

    (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 have constipation?

  • Finding:

    Denies gassiness

    (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 been gassy?

  • Finding:

    Denies bloating

    (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:

    Do you have bloating?

  • Finding:

    Denies heartburn or GERD

    (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 have heartburn or GERD?

Family Medical History


  • Finding:

    Asked about relevant family history


  • Finding:

    Reports family history of heart attack

    (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:

    Has anyone in your family had a heart attack?

  • Finding:

    Denies family history of stroke

    (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:

    Do you have a family history of stroke?

  • Finding:

    Denies family history of pulmonary embolism