Shoshanna Tillman Musculoskeletal Shadow Health

Shoshanna Tillman Musculoskeletal Shadow Health

Subjective Data Collection: 57 of 57 (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.
Chief Complaint

Finding:

Asked about chief complaint

Finding:

Reports fatigue
(Found)
Pro Tip: Asking your patient in open terms about the reason for their visit allows them to explain their concerns in their own words, providing a foundation for your interview.
Example Question:
What brings you in today?

Finding:

Reports joint pain
(Found)
Pro Tip: Asking your patient in open terms about the reason for their visit allows them to explain their concerns in their own words, providing a foundation for your interview.

Example Question:
What brings you in today?

History of Present Illness

Finding:

Asked about onset of pain

Finding:

Reports having joint pain for 3 months
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.

Example Question:
When did your pain begin?

Finding:

Asked about location of pain

Finding:

Reports pain in hands and wrists
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.

Example Question:
Where do you feel the pain?

Finding:

Reports full body pain
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.

Example Question:
Where do you feel the pain?

Finding:

Asked about timing of pain

Finding:

Reports that the pain is worst in the morning when she wakes up
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.

Example Question:
When in the day do you have pain?

Finding:

Reports that the pain is constant
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.

Example Question:
When in the day do you have pain?

Finding:

Asked about characteristics of pain

Finding:

Reports pain in wrists and hands is dull, throbbing, and stiff
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.

Example Question:
What is the pain like in your hands and wrists?

Finding:

Reports full body pain is stiff and achy
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.

Example Question:
What is the full body pain like?

Finding:

Asked about aggravating factors of pain

Finding:

Reports that holding her coffee mug in the morning is difficult
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.

Example Question:
Does anything make your pain worse?

Finding:

Reports pain is worse after long periods of typing or holding art tools
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.

Example Question:
Does anything make your

pain worse?

Finding:

Reports pain is worse after long periods of sitting
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.

Example Question:
Does anything make your pain worse?

Finding:

Asked about relieving factors of pain

Finding:

Reports that hot showers make her feel better
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.

Example Question:
Does anything make your pain feel better?

Finding:

Asked about severity of pain

Finding:

Reports pain is currently at 2
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.

Example Question:
How would you rate your pain currently?

Finding:

Reports pain was 3-4 before diclofenac
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.

Example Question:
How would you rate your pain before taking diclofenac?

Finding:

Asked about onset of fatigue

Finding:

Reports 3 months of fatigue
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.

Example Question:
When did your fatigue begin?

Finding:

Asked about timing of fatigue

Finding:

Reports that the fatigue is constant
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.

Example Question:
Is the fatigue constant?

Finding:

Reports fatigue worsens as the day goes on
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.

Example Question:
Does your fatigue worsen throughout the day?

Finding:

Asked about aggravating factors for fatigue

Finding:

Denies aggravating factors for fatigue
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.

Example Question:
Does anything make your fatigue worse?

Finding:

Asked about relieving factors for fatigue

Finding:

Denies relieving factors for fatigue
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.

Example Question:
Does anything relieve your fatigue?

Finding:

Asked about impact on daily activities

Finding:

Reports daily activities are doable
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.

Example Question:
Can you complete your daily activities?

Finding:

Denies pain with daily activities
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.

Example Question:
Do your daily activities cause you pain?

Finding:

Reports daily activities take longer
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.

Example Question:
Do your daily activities take longer?

Finding:

Reports feeling drained after completing daily activities
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the

disorder, especially through questions about timing, severity, and types of symptoms.

Example Question:
Do you feel more tired after completing daily activities?

Finding:

Asked about perceived cause of fatigue

Finding:

Reports feeling that it might be stress or hormones
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.

Example Question:
Is there anything you believe could be causing your fatigue?

Past Medical History

Finding:

Asked about allergies

Finding:

Reports codeine allergy
(Found)
Pro Tip: A patient’s past medical history includes their health conditions, what preventative and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.

Example Question:
Do you have any allergies?

Finding:

Reports codeine reaction is rash and itching on body
(Available)
Pro Tip: A patient’s past medical history includes their health conditions, what preventative and maintenance treatments they have received, and any previous medical interventions they have received.

Example Question:
What reaction do you have when you take codeine?

Finding:

Denies latex allergy
(Available)
Pro Tip: A patient’s past medical history includes their health conditions, what preventative and maintenance treatments they have received, and any previous medical interventions they have received.

Example Question:
Do you have any latex allergies?

Finding:

Denies food allergies
(Found)
Pro Tip: A patient’s past medical history includes their health conditions, what preventative and maintenance treatments they have received, and any previous medical interventions they have received.

Example Question:
Do you have any food allergies?

Finding:

Denies environmental allergies
(Available)
Pro Tip: A patient’s past medical history includes their health conditions, what preventative and maintenance treatments they have received, and any previous medical interventions they have received.

Example Question:
Do you have any environmental allergies?

Finding:

Asked about existing health conditions

Finding:

Denies existing health conditions
(Found)
Pro Tip: A patient’s past medical history includes their health conditions, what preventative and maintenance treatments they have received, and any previous medical interventions they have received.

Example Question:
Do you have any existing health conditions?

Finding:

Asked about history of mental health

Finding:

Denies history of mental health conditions
(Found)
Pro Tip: A patient’s past medical history includes their health conditions, what preventative and maintenance treatments they have received, and any previous medical interventions they have received.

Example Question:
Do you have a history of mental health conditions?

Finding:

Asked about hospitalizations

Finding:

Reports childbirth 3 times
(Found)
Pro Tip: A patient’s past medical history includes their health conditions, what preventative and maintenance treatments they have received, and any previous medical interventions they have received.

Example Question:
Have you ever been hospitalized?

Finding:

Asked about surgeries

Finding:

Denies having had surgery
(Found)
Pro Tip: A patient’s past medical history includes their health conditions, what preventative and maintenance treatments they have received, and any previous medical interventions they have received.

Example Question:
Have you ever had surgery?

Home Medications

Finding:

Asked about home medications

Finding:

Reports previously taking ibuprofen
(Found)
Pro Tip: Asking about a patient’s home medications gives you information on the nature of their health conditions and how effectively they are being managed. This helps determine the need for you to adjust the patient’s treatments or medication regimen.

Example Question:
Do you take any medications?

Finding:

Reports taking diclofenac sodium
(Found)
Pro Tip: Asking about a patient’s home medications gives you information on the nature of their health conditions and how effectively they are being managed. This helps determine the need for you to adjust the patient’s treatments or medication regimen.

Example Question:
Do you take any medications?

Finding:

Reports having an IUD
(Found)
Pro Tip: Asking about a patient’s home medications gives you information on the nature of their health conditions and how effectively they are being managed. This helps determine the need for you to adjust the patient’s treatments or medication regimen.

Example Question:
Do you take any medications?

Finding:

Followed up on diclofenac sodium

Finding:

Reports taking diclofenac sodium ER 50 mg
(Found)
Pro Tip: Asking about a patient’s home medications gives you information on the nature of their health conditions and how effectively they are being managed. This helps determine the need for you to adjust the patient’s treatments or medication regimen.

Example Question:
What dose is your diclofenac sodium?

Finding:

Reports taking diclofenac sodium twice daily
(Available)
Pro Tip: Asking about

a patient’s home medications gives you information on the nature of their health conditions and how effectively they are being managed. This helps determine the need for you to adjust the patient’s treatments or medication regimen.

Example Question:
How often do you take diclofenac sodium?

Finding:

Reports taking loratadine
(Found)
Pro Tip: Asking about a patient’s home medications gives you information on the nature of their health conditions and how effectively they are being managed. This helps determine the need for you to adjust the patient’s treatments or medication regimen.

Example Question:
Do you take any other medications?

Finding:

Reports taking loratadine 10 mg once daily
(Available)
Pro Tip: Asking about a patient’s home medications gives you information on the nature of their health conditions and how effectively they are being managed. This helps determine the need for you to adjust the patient’s treatments or medication regimen.

Example Question:
How often do you take loratadine?

Finding:

Reports taking loratadine for allergies
(Available)
Pro Tip: Asking about a patient’s home medications gives you information on the nature of their health conditions and how effectively they are being managed. This helps determine the need for you to adjust the patient’s treatments or medication regimen.

Example Question:
What do you take loratadine for?

Social History

Finding:

Asked about tobacco use

Finding:

Denies tobacco use
(Found)
Pro Tip: A patient’s social history includes factors such as tobacco, alcohol, and drug use, sexual history, and occupational and environmental exposure history. It helps you understand the patient’s lifestyle and potential risk factors for health issues.

Maureen Hopkins Shadow health Treatment Plan

Example Question:
Do you use tobacco products?

Finding:

Asked about alcohol use

Finding:

Reports drinking alcohol socially
(Found)
Pro Tip: A patient’s social history includes factors such as tobacco, alcohol, and drug use, sexual history, and occupational and environmental exposure history. It helps you understand the patient’s lifestyle and potential risk factors for health issues.

Example Question:
Do you drink alcohol?

Finding:

Asked about drug use

Finding:

Denies illicit drug use
(Found)
Pro Tip: A patient’s social history includes factors such as tobacco, alcohol, and drug use, sexual history, and occupational and environmental exposure history. It helps you understand the patient’s lifestyle and potential risk factors for health issues.

Example Question:
Do you use any recreational drugs?

Finding:

Asked about sexual history

Finding:

Reports heterosexual orientation
(Found)
Pro Tip: A patient’s social history includes factors such as tobacco, alcohol, and drug use, sexual history, and occupational and environmental exposure history. It helps you understand the patient’s lifestyle and potential risk factors for health issues.

Example Question:
What is your sexual orientation?

Finding:

Asked about number of sexual partners

Finding:

Reports having one sexual partner
(Found)
Pro Tip: A patient’s social history includes factors such as tobacco, alcohol, and drug use, sexual history, and occupational and environmental exposure history. It helps you understand the patient’s lifestyle and potential risk factors for health issues.

Example Question:
How many sexual partners have you had in the past year?

Finding:

Asked about contraceptive use

Finding:

Reports using an IUD for contraception
(Found)
Pro Tip: A patient’s social history includes factors such as tobacco, alcohol, and drug use, sexual history, and occupational and environmental exposure history. It helps you understand the patient’s lifestyle and potential risk factors for health issues.

Example Question:
What method of contraception do you use?

Finding:

Asked about occupation

Finding:

Reports being an artist
(Found)
Pro Tip: A patient’s social history includes factors such as tobacco, alcohol, and drug use, sexual history, and occupational and environmental exposure history. It helps you understand the patient’s lifestyle and potential risk factors for health issues.

Example Question:
What is your occupation?

Finding:

Asked about home life and living situation

Finding:

Reports living alone in a studio apartment
(Found)
Pro Tip: A patient’s social history includes factors such as tobacco, alcohol, and drug use, sexual history, and occupational and environmental exposure history. It helps you understand the patient’s lifestyle and potential risk factors for health issues.

Example Question:
Tell me about your living situation.

Finding:

Asked about hobbies and interests

Finding:

Reports enjoying painting and sculpting in free time
(Available)
Pro Tip: A patient’s social history includes factors such as tobacco, alcohol, and drug use, sexual history, and occupational and environmental exposure history. It helps you understand the patient’s lifestyle and potential risk factors for health issues.

Example Question:
What are your hobbies and interests?

Family History

Finding:

Asked about family history of health conditions

Finding:

Reports maternal grandmother had osteoarthritis
(Found)
Pro Tip: A patient’s family history includes information about the health of their relatives, including any conditions or diseases that run in the family. This information can help you assess the patient’s risk factors and make informed decisions about their care.

Example Question:
Do you have a family history of any medical conditions?

Finding:

Reports father had hypertension
(Available)
Pro Tip: A patient’s family history includes information about the health of their relatives, including any conditions or diseases that run in the family. This information can help you assess the patient’s risk factors and make informed decisions about their care.

Example Question:
Do you have a family history of hypertension?

Finding:

Reports mother had osteoarthritis
(Available)
Pro Tip: A patient’s family history includes information about the health of their relatives, including any conditions or diseases that run in the family. This information can help you assess the patient’s risk factors and make informed decisions about their care.

Example Question:
Do you have a family history of osteoarthritis?

Finding:

Reports brother had a heart attack at age 45
(Available)
Pro Tip: A patient’s family history includes information about the health of their relatives, including any conditions or diseases that run in the family. This information can help you assess the patient’s risk factors and make informed decisions about their care.

Example Question:
Do you have a family history of heart disease?

Finding:

Reports sister had breast cancer at age 50
(Available)
Pro Tip: A patient’s family history includes information about the health of their relatives, including any conditions or diseases that run in the family. This information can help you assess the patient’s risk factors and make informed decisions about their care.

Example Question:
Do you have a family history of cancer?

Review of Systems: General

Finding:

Asked about fever

Finding:

Reports no fever
(Found)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Have you had a fever recently?

Finding:

Asked about chills

Finding:

Reports no chills
(Found)
Pro Tip: The review of systems is a comprehensive list of questions that help you

identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Have you had chills recently?

Finding:

Asked about weight loss

Finding:

Reports no significant weight loss
(Found)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Have you experienced any significant weight loss recently?

Finding:

Asked about weight gain

Finding:

Reports no significant weight gain
(Found)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Have you experienced any significant weight gain recently?

Finding:

Asked about appetite changes

Finding:

Reports no appetite changes
(Found)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Have you noticed any changes in your appetite?

Finding:

Asked about fatigue

Finding:

Reports fatigue for the past 3 months
(Found)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Have you been experiencing fatigue?

Finding:

Asked about weakness

Finding:

Reports no weakness
(Found)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Have you noticed any weakness in your body?

Finding:

Asked about sweats

Finding:

Reports no sweats
(Found)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Have you had any excessive sweating?

Finding:

Asked about trouble sleeping

Finding:

Reports occasional trouble sleeping due to pain
(Available)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Do you have any trouble sleeping?

Finding:

Asked about changes in sleep pattern

Finding:

Reports occasional changes in sleep pattern due to pain
(Available)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Have you noticed any changes in your sleep pattern?

Review of Systems: Skin

Finding:

Asked about rashes

Finding:

Reports rash and itching on body as a reaction to codeine
(Available)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Have you noticed any rashes on your skin?

Finding:

Asked about dryness or moisture of skin

Finding:

Reports normal skin dryness and moisture
(Available)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Have you noticed any changes in the dryness or moisture of your skin?

Finding:

Asked about changes in hair or nails

Finding:

Reports no changes in hair or nails
(Found)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Have you noticed any changes in your hair or nails?

Finding:

Asked about sores or ulcers

Finding:

Reports no sores or ulcers
(Found)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Have you noticed any sores or ulcers on your skin?

Finding:

Asked about itching

Finding:

Reports itching as a reaction to codeine
(Available)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Have you experienced any itching on your skin?

Finding:

Asked about changes in moles

Finding:

Reports no changes in moles
(Found)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Have you noticed any changes in your moles?

Review of Systems: Head

Finding:

Asked about headaches

Finding:

Reports occasional tension headaches
(Available)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Have you had any headaches?

Finding:

Asked about head injury

Finding:

Denies recent head injury or trauma
(Found)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Have you had any recent head injuries or trauma?

Finding:

Asked about dizziness

Finding:

Reports occasional dizziness when getting up quickly
(Available)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Do you experience any dizziness?

Finding:

Asked about changes in vision

Finding:

Reports no changes in vision
(Found)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall

health.

Example Question:
Have you noticed any changes in your vision?

Review of Systems: Ears

Finding:

Asked about ear pain

Finding:

Denies ear pain or discomfort
(Found)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Do you have any ear pain or discomfort?

Finding:

Asked about changes in hearing

Finding:

Reports occasional difficulty hearing in noisy environments
(Available)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Have you noticed any changes in your hearing?

Finding:

Asked about ear drainage

Finding:

Denies ear drainage or discharge
(Found)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Do you have any ear drainage or discharge?

Review of Systems: Eyes

Finding:

Asked about changes in vision

Finding:

Reports no changes in vision
(Found)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Have you noticed any changes in your vision?

Finding:

Asked about eye pain

Finding:

Denies eye pain or discomfort
(Found)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Do you have any eye pain or discomfort?

Finding:

Asked about eye discharge

Finding:

Reports occasional eye discharge in the mornings
(Available)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Do you experience any eye discharge, especially in the mornings?

Finding:

Asked about dryness or itching of the eyes

Finding:

Reports occasional dryness and itching of the eyes due to allergies
(Available)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Do you have any dryness or itching in your eyes?

Review of Systems: Nose and Sinuses

Finding:

Asked about nasal congestion

Finding:

Reports occasional nasal congestion due to allergies
(Available)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Do you experience nasal congestion?

Finding:

Asked about runny nose

Finding:

Reports occasional runny nose due to allergies
(Available)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Do you have a runny nose?

Finding:

Asked about changes in smell

Finding:

Reports no changes in sense of smell
(Found)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Have you noticed any changes in your sense of smell?

Review of Systems: Mouth and Throat

Finding:

Asked about sore throat

Finding:

Denies sore throat or throat pain
(Found)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Do you have a sore throat or throat pain?

Finding:

Asked about mouth sores

Finding:

Denies mouth sores or ulcers
(Found)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Have you noticed any mouth sores or ulcers?

Finding:

Asked about changes in taste

Finding:

Reports no changes in sense of taste
(Found)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Have you noticed any changes in your sense of taste?

Review of Systems: Neck

Finding:

Asked about neck pain

Finding:

Denies neck pain or discomfort
(Found)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Do you have any neck pain or discomfort?

Finding:

Asked about lumps or swelling in the neck

Finding:

Reports no lumps or swelling in the neck
(Found)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Have you noticed any lumps or swelling in your neck?

Review of Systems: Respiratory

Finding:

Asked about shortness of breath

Finding:

Reports occasional shortness of breath with strenuous activity
(Available)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Do you experience shortness of breath?

Finding:

Asked about cough

Finding:

Reports occasional cough due to allergies
(Available)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Do you have a cough?

Finding:

Asked about phlegm or mucus production

Finding:

Reports occasional phlegm or mucus production with cough due to allergies
(Available)

Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Do you notice any phlegm or mucus production when you cough?

Review of Systems: Cardiovascular

Finding:

Asked about chest pain

Finding:

Denies chest pain or discomfort
(Found)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Do you have any chest pain or discomfort?

Finding:

Asked about palpitations

Finding:

Reports occasional palpitations during times of stress or anxiety
(Available)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Do you experience palpitations, especially during times of stress or anxiety?

Finding:

Asked about swelling in the ankles or legs

Finding:

Denies swelling in the ankles or legs
(Found)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Do you have any swelling in your ankles or legs?

Review of Systems: Gastrointestinal

Finding:

Asked about abdominal pain

Finding:

Denies abdominal pain or discomfort
(Found)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Do you have any abdominal pain or discomfort?

Finding:

Asked about nausea

Finding:

Reports occasional nausea after eating spicy foods
(Available)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Do you experience nausea, especially after eating spicy foods?

Finding:

Asked about vomiting

Finding:

Denies vomiting or vomiting blood
(Found)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Do you vomit or have you vomited blood?

Review of Systems: Genitourinary

Finding:

Asked about changes in urinary frequency

Finding:

Reports occasional increased urinary frequency during times of stress
(Available)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Have you noticed any changes in your urinary frequency, especially during times of stress?

Finding:

Asked about changes in urine color

Finding:

Reports no changes in urine color
(Found)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Have you noticed any changes in the color of your urine?

Finding:

Asked about pain or discomfort with urination

Finding:

Denies pain or discomfort with urination
(Found)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Do you experience any pain or discomfort when you urinate?

Review of Systems: Musculoskeletal

Finding:

Asked about joint pain

Finding:

Denies joint pain or discomfort
(Found)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Do you have any joint pain or discomfort?

Finding:

Asked about muscle pain

Finding:

Reports occasional muscle pain after strenuous exercise
(Available)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Do you experience muscle pain, especially after strenuous exercise?

Finding:

Asked about back pain

Finding:

Denies back pain or discomfort
(Found)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Do you have any back pain or discomfort?

Review of Systems: Neurologic

Finding:

Asked about changes in coordination

Finding:

Reports no changes in coordination
(Found)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Have you noticed any changes in your coordination?

Finding:

Asked about changes in sensation

Finding:

Reports occasional numbness and tingling in fingers and toes
(Available)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Have you noticed any changes in sensation, such as numbness or tingling in your fingers or toes?

Finding:

Asked about changes in memory or concentration

Finding:

Reports occasional difficulty with memory and concentration, especially when stressed
(Available)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Have you noticed any changes in your memory or concentration, especially when you’re stressed?

Review of Systems: Psychiatric

Finding:

Asked about changes in mood

Finding:

Reports occasional mood swings and periods of feeling down
(Available)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Have you noticed any changes in your mood, such as mood swings or periods of feeling down?

Finding:

Asked about changes in sleep pattern

Finding:

 

Reports occasional changes in sleep pattern due to stress
(Available)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Have you noticed any changes in your sleep pattern, especially due to stress?

Review of Systems: Endocrine

Finding:

Asked about heat or cold intolerance

Finding:

Reports no heat or cold intolerance
(Found)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Do you have any heat or cold intolerance?

Finding:

Asked about changes in weight

Finding:

Reports no significant weight changes
(Found)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Have you noticed any significant changes in your weight?

Review of Systems: Hematologic/Lymphatic

Finding:

Asked about easy bruising or bleeding

Finding:

Denies easy bruising or bleeding
(Found)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Do you experience easy bruising or bleeding?

Finding:

Asked about swollen lymph nodes

Finding:

Denies swollen lymph nodes
(Found)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Have you noticed any swollen lymph nodes in your body?

Review of Systems: Allergic/Immunologic

Finding:

Asked about allergies or allergic reactions

Finding:

Reports allergies to codeine, occasional allergic reactions
(Available)
Pro Tip: The review of systems is a comprehensive list of questions that help you identify any symptoms the patient may be experiencing but hasn’t mentioned yet. It’s a systematic way to gather information about the patient’s overall health.

Example Question:
Do you have any allergies or have you experienced any allergic reactions, especially to codeine?