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[email protected] Tina Jones Subjective Data Collection: 50 of 50 (100.0%)
Subjective Data Collection: 50 of 50 (100.0%)
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Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
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Found:
This indicates an item that you found.
Available:
This 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.
Current Health Status
Finding:
Confirmed reason for visit
Finding:
Reports needing a pre-employment physical
Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.
Example Question:
Can I confirm that you are here for a physical?
Finding:
Reports no current acute health problems
Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.
Example Question:
Do you have any current health problems?
Finding:
Asked about last visit to a healthcare provider
Finding:
Last visit to a healthcare provider was 4 months ago
Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history.
Example Question:
When did you see a healthcare provider?
Finding:
Reason for last visit was annual gynecological exam
Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. Asking Tina why she saw a healthcare provider might indicate any recent health concerns or problems.
Example Question:
Why did you see a healthcare provider?
Finding:
Last general physical examination was 5 months ago when she was prescribed metformin and daily inhaler
Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history.
Example Question:
When was your last physical exam?
Finding:
Asked about current prescription medications
Finding:
Reports taking diabetes medication
Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Asking Tina if she has been taking medication for her diabetes will indicate her treatment plan and the degree to which she is following it.
Example Question:
Have you been taking medication for your diabetes?
Finding:
Reports using a daily inhaler
Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Asking Tina if she still has her inhaler will indicate her treatment plan and the degree to which she is following it.
Example Question:
Do you use a daily inhaler?
Finding:
Reports taking prescription birth control pills
Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans.
Example Question:
Are you taking any form of birth control?
Finding:
Followed up about diabetes medication
Finding:
Medication is metformin
Pro Tip: Follow up questions about Tina’s medication history will help you to understand her treatment plan and recent health history.
Example Question:
What is the name of your diabetes medication?
Finding:
Started taking metformin 5 months ago
Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history.
Example Question:
How long have you been taking metformin?
Finding:
Reports that eating probiotic yogurt helps with side effects and they have abated over time
Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history.
Example Question:
Have you noticed any side effects from the metformin?
Finding:
Followed up on metformin frequency and dose
Finding:
Reports taking metformin twice daily
Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history.
Example Question:
How many times a day do you take metformin?
Finding:
Metformin dose is 850 mg
Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history.
Example Question:
What is the dose of your metformin?
Finding:
Asked about asthma medication
Finding:
Reports using Flovent inhaler twice daily
Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina’s been using her inhaler more frequently since exacerbation can indicate how she’s been treating her symptoms since exacerbation.
Example Question:
How often do you use your daily inhaler?
Finding:
Has a Proventil rescue inhaler
Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina if she has a rescue inhaler for her asthma will indicate her treatment plan and the degree to which she complies with it.
Example Question:
Do you have a rescue inhaler?
Finding:
Last use of Proventil inhaler was three months ago
Pro Tip: Soliciting a shallow history of a patient’s medication history can reveal recent exacerbation. Asking Tina when she last used her inhaler will indicate when her symptoms most recently required medical treatment.
Example Question:
When did you last use your rescue inhaler?
Finding:
Has used Proventil inhaler twice in the last year
Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina’s been using her inhaler more frequently since exacerbation can indicate how she’s been treating her symptoms since exacerbation.
Example Question:
How often do you use your rescue inhaler?
Finding:
Followed up about birth control prescription
Finding:
Started taking birth control 4 months ago
Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan.
Example Question:
How long ago did you start taking birth control?
Finding:
Reason for birth control was to manage PCOS symptoms
Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words.
Example Question:
Why did you decide to start taking birth control?
Finding:
Birth control type is Yaz (drospirenone and ethinyl estradiol)
Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Confirming the name of Tina’s birth control pill will solicit information about her health history and current treatment plan.
Example Question:
What type of birth control do you use?
Finding:
Takes birth control pill daily
Pro Tip: Follow up questions about
birth control type and use will help you to understand Tina’s health history and compliance with her treatment plan.
Example Question:
How often do you take your birth control?
Finding:
Asked about inhaler
Finding:
Reports using Proventil inhaler twice in the last year
Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina’s been using her inhaler more frequently since exacerbation can indicate how she’s been treating her symptoms since exacerbation.
Example Question:
How often do you use your rescue inhaler?
Finding:
Reports using Proventil inhaler two to three in the last year
Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina’s been using her inhaler more frequently since exacerbation can indicate how she’s been treating her symptoms since exacerbation.
Example Question:
How often do you use your rescue inhaler?
Finding:
Reports a previous use of QVAR inhaler but discontinued use due to cost
Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina’s been using her inhaler more frequently since exacerbation can indicate how she’s been treating her symptoms since exacerbation.
Example Question:
Have you used any other inhalers in the past?
Finding:
Reports using Albuterol inhaler in the past
Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina’s been using her inhaler more frequently since exacerbation can indicate how she’s been treating her symptoms since exacerbation.
Example Question:
Have you used any other inhalers in the past?
Finding:
Asked about asthma exacerbation
Finding:
Reports exacerbation 5 months ago
Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Tina’s exacerbation history will reveal the frequency and severity of her symptoms.
Example Question:
When did your asthma symptoms most recently worsen?
Finding:
Reports no current asthma symptoms
Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina’s currently experiencing any asthma symptoms will help you to understand her current health status.
Example Question:
Are you currently experiencing any asthma symptoms?
Finding:
Asked about asthma symptoms
Finding:
Reports occasional wheezing
Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Tina’s description of her wheezing will indicate the severity and frequency of her symptoms.
Example Question:
How often do you experience wheezing?
Finding:
Wheezing is usually triggered by allergies
Pro Tip: Understanding the triggers for Tina’s wheezing can help you to develop a comprehensive treatment plan.
Example Question:
What seems to trigger your wheezing?
Finding:
Asked about allergies
Finding:
Reports occasional hay fever symptoms
Pro Tip: Allergies can exacerbate asthma symptoms. Asking Tina about her allergies will help you to understand potential triggers for her asthma exacerbations.
Example Question:
Do you have any allergies?
Finding:
Asked about tobacco use
Finding:
Reports no current tobacco use
Pro Tip: Tobacco use is a common trigger for asthma exacerbation. Confirming that Tina doesn’t use tobacco will help you to understand potential triggers for her asthma exacerbations.
Example Question:
Do you use tobacco?
Finding:
Reports no history of tobacco use
Pro Tip: Tobacco use is a common trigger for asthma exacerbation. Confirming that Tina has never used tobacco will help you to understand potential triggers for her asthma exacerbations.
Example Question:
Have you ever used tobacco products?
Finding:
Asked about alcohol use
Finding:
Reports no current alcohol use
Pro Tip: Alcohol use can exacerbate asthma symptoms. Confirming that Tina doesn’t use alcohol will help you to understand potential triggers for her asthma exacerbations.
Example Question:
Do you use alcohol?
Finding:
Reports no history of alcohol use
Pro Tip: Alcohol use can exacerbate asthma symptoms. Confirming that Tina has never used alcohol will help you to understand potential triggers for her asthma exacerbations.
Example Question:
Have you ever used alcohol?
Finding:
Asked about caffeine use
Finding:
Reports drinking 2-3 cups of coffee per day
Pro Tip: Caffeine can exacerbate asthma symptoms. Asking Tina about her caffeine consumption will help you to understand potential triggers for her asthma exacerbations.
Example Question:
How much caffeine do you consume on a daily basis?
Finding:
Asked about recreational drug use
Finding:
Reports no current recreational drug use
Pro Tip: Recreational drug use can exacerbate asthma symptoms. Confirming that Tina doesn’t use recreational drugs will help you to understand potential triggers for her asthma exacerbations.
Example Question:
Do you use recreational drugs?
Finding:
Reports no history of recreational drug use
Pro Tip: Recreational drug use can exacerbate asthma symptoms. Confirming that Tina has never used recreational drugs will help you to understand potential triggers for her asthma exacerbations.
Example Question:
Have you ever used recreational drugs?
Finding:
Asked about exercise routine
Finding:
Reports regular exercise routine of yoga and light jogging
Pro Tip: Understanding Tina’s exercise routine will help you to develop a comprehensive treatment plan.
Example Question:
Tell me about your exercise routine.
Finding:
Exercise routine includes yoga
Pro Tip: Understanding Tina’s exercise routine will help you to develop a comprehensive treatment plan.
Example Question:
What types of exercise do you do?
Finding:
Exercise routine includes light jogging
Pro Tip: Understanding Tina’s exercise routine will help you to develop a comprehensive treatment plan.
Example Question:
What types of exercise do you do?
Finding:
Asked about exercise frequency
Finding:
Exercises 3-4 hours on average per week
Pro Tip: Understanding Tina’s exercise frequency will help you to develop a comprehensive treatment plan.
Example Question:
How often do you exercise?
Finding:
Asked about exercise intensity
Finding:
Describes exercise intensity as light or moderate
Pro Tip: Understanding Tina’s exercise intensity will help you to develop a comprehensive treatment plan.
Example Question:
How would you describe the intensity of your exercise routine?
Finding:
Asked about exercise duration
Finding:
Each exercise session lasts approximately 45 minutes
Pro Tip: Understanding Tina’s exercise duration will help you to develop a comprehensive treatment plan.
Example Question:
How long do your exercise sessions typically last?
Finding:
Asked about exercise location
Finding:
Exercises at home
Pro Tip: Understanding Tina’s exercise location will help you to develop a comprehensive treatment plan.
Example Question:
Where do you usually exercise?
Finding:
Asked about exercise routine changes
Finding:
Hasn’t made any
changes to exercise routine
Pro Tip: Understanding any recent changes in Tina’s exercise routine will help you to develop a comprehensive treatment plan.
Example Question:
Have you made any changes to your exercise routine recently?
Finding:
Reports experiencing stress
Pro Tip: Stress can exacerbate asthma symptoms. Understanding Tina’s stress levels will help you to develop a comprehensive treatment plan.
Example Question:
Are you experiencing any stress in your life?
Finding:
Asked about stress triggers
Finding:
Reports stress related to work and college
Pro Tip: Identifying specific stress triggers will help you to develop a comprehensive treatment plan.
Example Question:
What aspects of work or college are causing you stress?
Finding:
Reports occasional trouble sleeping
Pro Tip: Poor sleep can exacerbate asthma symptoms. Understanding Tina’s sleep patterns will help you to develop a comprehensive treatment plan.
Example Question:
Are you experiencing any sleep problems?
Finding:
Asked about sleep duration
Finding:
Typically sleeps 6-7 hours per night
Pro Tip: Sleep duration can impact asthma symptoms. Understanding Tina’s sleep duration will help you to develop a comprehensive treatment plan.
Example Question:
How many hours of sleep do you get on average each night?
Finding:
Asked about sleep quality
Finding:
Describes sleep quality as fair, often waking up during the night
Pro Tip: Poor sleep quality can exacerbate asthma symptoms. Understanding Tina’s sleep quality will help you to develop a comprehensive treatment plan.
Example Question:
How would you rate the quality of your sleep?
Finding:
Reports a history of anxiety
Pro Tip: Anxiety can exacerbate asthma symptoms. Understanding Tina’s history of anxiety will help you to develop a comprehensive treatment plan.
Example Question:
Have you experienced anxiety in the past?
Finding:
Reports occasional use of rescue inhaler for anxiety
Pro Tip: Some individuals use inhalers as a coping mechanism for anxiety. Understanding Tina’s use of her inhaler for anxiety will help you to develop a comprehensive treatment plan.
Example Question:
Tell me about your history of anxiety and your use of the rescue inhaler for anxiety.
Finding:
Asked about mental health treatment
Finding:
Hasn’t received any formal mental health treatment
Pro Tip: Exploring Tina’s mental health treatment history will help you to understand her overall well-being.
Example Question:
Have you ever received treatment for your mental health?
Finding:
Reports occasional use of rescue inhaler for anxiety
Pro Tip: Some individuals use inhalers as a coping mechanism for anxiety. Understanding Tina’s use of her inhaler for anxiety will help you to develop a comprehensive treatment plan.
Example Question:
Tell me about your history of anxiety and your use of the rescue inhaler for anxiety.
Finding:
Asked about social support
Finding:
Reports a strong support system of family and friends
Pro Tip: Social support can positively impact asthma management. Understanding Tina’s support system will help you to develop a comprehensive treatment plan.
Example Question:
Do you have a strong support system of family and friends?
Finding:
Asked about medication adherence
Finding:
Reports good adherence to asthma medications
Pro Tip: Adherence to asthma medications is crucial for managing symptoms. Confirming Tina’s adherence will help you to understand her treatment plan compliance.
Example Question:
How often do you take your asthma medications?
Finding:
Asked about any medication side effects
Finding:
Reports no significant medication side effects
Pro Tip: Some asthma medications can have side effects. Understanding Tina’s experience with medication side effects will help you to develop a comprehensive treatment plan.
Example Question:
Have you experienced any side effects from your asthma medications?
Finding:
Asked about medication changes
Finding:
No recent changes in asthma medications
Pro Tip: Understanding any recent changes in Tina’s asthma medications will help you to develop a comprehensive treatment plan.
Example Question:
Have there been any changes to your asthma medications recently?
Finding:
Reports using albuterol inhaler twice in the last year
Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina’s been using her inhaler more frequently since exacerbation can indicate how she’s been treating her symptoms since exacerbation.
Example Question:
How often do you use your rescue inhaler?
Finding:
Reports using albuterol inhaler twice in the last year
Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina’s been using her inhaler more frequently since exacerbation can indicate how she’s been treating her symptoms since exacerbation.
Example Question:
How often do you use your rescue inhaler?
Finding:
Reports a previous use of QVAR inhaler but discontinued use due to cost
Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina’s been using her inhaler more frequently since exacerbation can indicate how she’s been treating her symptoms since exacerbation.
Example Question:
Have you used any other inhalers in the past?
Finding:
Reports using Albuterol inhaler in the past
Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina’s been using her inhaler more frequently since exacerbation can indicate how she’s been treating her symptoms since exacerbation.
Example Question:
Have you used any other inhalers in the past?
Finding:
Asked about asthma exacerbation
Finding:
Reports exacerbation 5 months ago
Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Tina’s exacerbation history will reveal the frequency and severity of her symptoms.
Example Question:
When did your asthma symptoms most recently worsen?
Finding:
Reports no current asthma symptoms
Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina’s currently experiencing any asthma symptoms will help you to understand her current health status.
Example Question:
Are you currently experiencing any asthma symptoms?
Finding:
Asked about asthma symptoms
Finding:
Reports occasional wheezing
Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Tina’s description of her wheezing will indicate the severity and frequency of her symptoms.
Example Question:
How often do you experience wheezing?
Finding:
Wheezing is usually triggered by allergies
Pro Tip: Understanding the triggers for Tina’s wheezing can help you to develop a comprehensive treatment plan.
Example Question:
What seems to trigger your wheezing?
Finding:
Asked about allergies
Finding:
Reports occasional hay fever symptoms
Pro Tip: Allergies can exacerbate asthma symptoms. Asking Tina about her allergies will help you to understand potential triggers for her asthma exacerbations.
Example Question:
Do you have any allergies?
Finding:
Asked about tobacco use
Finding:
Reports no current tobacco use
Pro Tip: Tobacco use is a common trigger for asthma exacerbation. Confirming that Tina doesn’t use tobacco will help you to understand potential triggers for her asthma exacerbations.
Example Question:
Do you use tobacco?
Finding:
Reports no history of tobacco use
Pro Tip: Tobacco use is a common trigger for asthma exacerbation. Confirming that Tina has never used tobacco will help you to understand potential triggers for her asthma exacerbations.
Example Question:
Have you ever used tobacco products?
Finding:
Asked about alcohol use
Finding:
Reports no current alcohol use
Pro Tip: Alcohol use can exacerbate asthma symptoms. Confirming that Tina doesn’t use alcohol will help you to understand potential triggers for her asthma exacerbations.
Example Question:
Do you use alcohol?
Finding:
Reports no history of alcohol use
Pro Tip: Alcohol use can exacerbate asthma symptoms. Confirming that Tina has never used alcohol will help you to understand potential triggers for her asthma exacerbations.
Example Question:
Have you ever used alcohol?
Finding:
Asked about caffeine use
Finding:
Reports drinking 2-3 cups of coffee per day
Pro Tip: Caffeine can exacerbate asthma symptoms. Asking Tina about her caffeine consumption will help you to understand potential triggers for her asthma exacerbations.
Example Question:
How much caffeine do you consume on a daily basis?
Finding:
Asked about recreational drug use
Finding:
Reports no current recreational drug use
Pro Tip: Recreational drug use can exacerbate asthma symptoms. Confirming that Tina doesn’t use recreational drugs will help you to understand potential triggers for her asthma exacerbations.
Example Question:
Do you use recreational drugs?
Finding:
Reports no history of recreational drug use
Pro Tip: Recreational drug use can exacerbate asthma symptoms. Confirming that Tina has never used recreational drugs will help you to understand potential triggers for her asthma exacerbations.
Example Question:
Have you ever used recreational drugs?
Finding:
Asked about exercise routine
Finding:
Reports regular exercise routine of yoga and light jogging
Pro Tip: Understanding Tina’s exercise routine will help you to develop a comprehensive treatment plan.
Example Question:
Tell me about your exercise routine.
Finding:
Exercise routine includes yoga
Pro Tip: Understanding Tina’s exercise routine will help you to develop a comprehensive treatment plan.
Example Question:
What types of exercise do you do?
Finding:
Exercise routine includes light jogging
Pro Tip: Understanding Tina’s exercise routine will help you to develop a comprehensive treatment plan.
Example Question:
What types of exercise do you do?
Finding:
Asked about exercise frequency
Finding:
Exercises 3-4 hours on average per week
Pro Tip: Understanding Tina’s exercise frequency will help you to develop a comprehensive treatment plan.
Example Question:
How often do you exercise?
Finding:
Asked about exercise intensity
Finding:
Describes exercise intensity as light or moderate
Pro Tip: Understanding Tina’s exercise intensity will help you to develop a comprehensive treatment plan.
Example Question:
How would you describe the intensity of your exercise routine?
Finding:
Asked about exercise duration
Finding:
Each exercise session lasts approximately 45 minutes
Pro Tip: Understanding Tina’s exercise duration will help you to develop a comprehensive treatment plan.
Example Question:
How long do your exercise sessions typically last?
Finding:
Asked about exercise location
Finding:
Exercises at home
Pro Tip: Understanding Tina’s exercise location will help you to develop a comprehensive treatment plan.
Example Question:
Where do you usually exercise?
Finding:
Asked about exercise routine changes
Finding:
Hasn’t made any changes to exercise routine
Pro Tip: Understanding any recent changes in Tina’s exercise routine will help you to develop a comprehensive treatment plan.
Example Question:
Have you made any changes to your exercise routine recently?
Finding:
Reports experiencing stress
Pro Tip: Stress can exacerbate asthma symptoms. Understanding Tina’s stress levels will help you to develop a comprehensive treatment plan.
Example Question:
Are you experiencing any stress in your life?
Finding:
Asked about stress triggers
Finding:
Reports stress related to work and college
Pro Tip: Identifying specific stress triggers will help you to develop a comprehensive treatment plan.
Example Question:
What aspects of work or college are causing you stress?
Finding:
Reports occasional trouble sleeping
Pro Tip: Poor sleep can exacerbate asthma symptoms. Understanding Tina’s sleep patterns will help you to develop a comprehensive treatment plan.
Example Question:
Are you experiencing any sleep problems?
Finding:
Asked about sleep duration
Finding:
Typically sleeps 6-7 hours per night
Pro Tip: Sleep duration can impact asthma symptoms. Understanding Tina’s sleep duration will help you to develop a comprehensive treatment plan.
Example Question:
How many hours of sleep do you get on average each night?
Finding:
Asked about sleep quality
Finding:
Describes sleep quality as fair, often waking up during the night
Pro Tip: Poor sleep quality can exacerbate asthma symptoms. Understanding Tina’s sleep quality will help you to develop a comprehensive treatment plan.
Example Question:
How would you rate the quality of your sleep?
Finding:
Reports a history of anxiety
Pro Tip: Anxiety can exacerbate asthma symptoms. Understanding Tina’s history of anxiety will help you to develop a comprehensive treatment plan.
Example Question:
Have you experienced anxiety in the past?
Finding:
Reports occasional use of rescue inhaler for anxiety
Pro Tip: Some individuals use inhalers as a coping mechanism for anxiety. Understanding Tina’s use of her inhaler for anxiety will help you to develop a comprehensive treatment plan.
Example Question:
Tell me about your history of anxiety and your use of the rescue inhaler for anxiety.
Finding:
Asked about mental health treatment
Finding:
Hasn’t received any formal mental health treatment
Pro Tip: Exploring Tina’s mental health treatment history will help you to understand her overall well-being.
Example Question:
Have you ever received treatment for your mental health?
Finding:
Reports occasional use of rescue inhaler for anxiety
Pro Tip: Some individuals use inhalers as a coping mechanism for anxiety. Understanding Tina’s use of her inhaler for anxiety will help you to develop a comprehensive treatment plan.
Example Question:
Tell me about your history of anxiety and your use of the rescue inhaler for anxiety.
Finding:
Asked about social support
Finding:
Reports a strong support system of family and friends
Pro Tip: Social support can positively impact asthma management. Understanding Tina’s support system will help you to develop a comprehensive treatment plan.
Example Question:
Do you have a strong support system of family and friends?
Finding:
Asked about medication adherence
Finding:
Reports good adherence to asthma medications
Pro Tip: Adherence to asthma medications is crucial for managing symptoms. Confirming Tina’s adherence will help you to understand her treatment plan compliance.
Example Question:
How often do you take your asthma medications?
Finding:
Asked about any medication side effects
HEENT Objective Data Collection for Tina Jones
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.
Current Health Status
-
Finding:
Confirmed reason for visit
-
Finding:
Reports needing a pre-employment physical
-
Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation(Found)
Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.Example Question:
Can I confirm that you are here for a physical? -
Finding:
Reports no current acute health problems
(Found)
Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.Example Question:
Do you have any current health problems?
-
Finding:
Asked about last visit to a healthcare provider
-
Finding:
Last visit to a healthcare provider was 4 months ago
(Found)
Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history.Example Question:
When did you see a healthcare provider? -
Finding:
Reason for last visit was annual gynecological exam
(Found)
Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. Asking Tina why she saw a healthcare provider might indicate any recent health concerns or problems.Example Question:
Why did you see a healthcare provider? -
Finding:
Last general physical examination was 5 months ago when she was prescribed metformin and daily inhaler
(Found)
Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history.Example Question:
When was your last physical exam? Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation
-
Finding:
Asked about current prescription medications
-
Finding:
Reports taking diabetes medication
(Found)
Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Asking Tina if she has been taking medication for her diabetes will indicate her treatment plan and the degree to which she is following it.Example Question:
Have you been taking medication for your diabetes? -
Finding:
Reports using a daily inhaler
(Found)
Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Asking Tina if she still has her inhaler will indicate her treatment plan and the degree to which she is following it.Example Question:
Do you use a daily inhaler? -
Finding:
Reports taking prescription birth control pills
(Found)
Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans.Example Question:
Are you taking any form of birth control?
-
Finding:
Followed up about diabetes medication
-
Finding:
Medication is metformin
(Found)
Pro Tip: Follow up questions about Tina’s medication history will help you to understand her treatment plan and recent health history.Example Question:
What is the name of your diabetes medication? -
Finding:
Started taking metformin 5 months ago
(Found)
Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history.Example Question:
How long have you been taking metformin? -
Finding:
Reports that eating probiotic yogurt helps with side effects and they have abated over time
(Found)
Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history.Example Question:
Have you noticed any side effects from the metformin?
-
Finding:
Followed up on metformin frequency and dose
-
Finding:
Reports taking metformin twice daily
(Found)
Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history.Example Question:
How many times a day do you take metformin? -
Finding:
Metformin dose is 850 mg
(Found)
Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history.Example Question:
What is the dose of your metformin?
-
Finding:
Asked about asthma medication
-
Finding:
Reports using Flovent inhaler twice daily
(Found)
Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina’s been using her inhaler more frequently since exacerbation can indicate how she’s been treating her symptoms since exacerbation. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & DocumentationExample Question:
How often do you use your daily inhaler? -
Finding:
Has a Proventil rescue inhaler
(Found)
Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina if she has a rescue inhaler for her asthma will indicate her treatment plan and the degree to which she complies with it.Example Question:
Do you have a rescue inhaler? -
Finding:
Last use of Proventil inhaler was three months ago
(Found)
Pro Tip: Soliciting a shallow history of a patient’s medication history can reveal recent exacerbation. Asking Tina when she last used her inhaler will indicate when her symptoms most recently required medical treatment.Example Question:
When did you last use your rescue inhaler? -
Finding:
Has used Proventil inhaler twice in the last year
(Available)
Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina’s been using her inhaler more frequently since exacerbation can indicate how she’s been treating her symptoms since exacerbation.Example Question:
How often do you use your rescue inhaler?
-
Finding:
Followed up about birth control prescription
-
Finding:
Started taking birth control 4 months ago
(Found)
Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan.Example Question:
How long ago did you start taking birth control? -
Finding:
Reason for birth control was to manage PCOS symptoms
(Found)
Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words.Example Question:
Why did you decide to start taking birth control? -
Finding:
Birth control type is Yaz (drospirenone and ethinyl estradiol)
(Found)
Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Confirming the name of Tina’s birth control pill will solicit information about her health history and current treatment plan. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & DocumentationExample Question:
What type of birth control do you use? -
Finding:
Takes birth control pill daily
(Found)
Pro Tip: Follow up questions about Tina’s birth control prescription can help you to understand how effectively she complies with her treatment plan.Example Question:
How often do you take your birth control pill? -
Finding:
Takes birth control pill at the same time every day
(Found)
Pro Tip: Follow up questions about Tina’s birth control prescription can help you to understand how effectively she complies with her treatment plan.Example Question:
Do you take your pill at the same time every day? -
Finding:
Reports no skipped days
(Available)
Pro Tip: Follow up questions about Tina’s birth control prescription can help you to understand how effectively she complies with her treatment plan.Example Question:
Have you missed any days of your birth control pill?
-
Finding:
Asked about current non-prescription medications
-
Finding:
Reports rare Advil use for cramps
(Found)
Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes non prescription drugs will indicate her current treatment plan.Example Question:
Do you take Advil? -
Finding:
Reports no OTC herbal products
(Found)
Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes herbal products will indicate her current treatment plan.Example Question:
Do you use any herbal products? -
Finding:
Reports no OTC vitamins
(Found)
Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes vitamins will indicate her current treatment plan.Example Question:
Do you take any vitamins? -
Finding:
Reports no OTC supplements
(Found)
Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes supplements will indicate her current treatment plan.Example Question:
Do you take any supplements?
-
Finding:
Asked about allergies
-
Finding:
Confirms allergies
(Found)
Pro Tip: Discerning what’s making Tina’s asthma worse can point to possible triggers like environmental factors, bodily positions, allergies, or movement that may have a bearing on Tina’s breathing. Asking Tina what triggers her allergies will indicate, in part, Tina’s health literacy.Example Question:
Can you confirm your allergies? -
Finding:
Reports no new allergies
(Found)
Pro Tip: Discerning whether anything is making Tina’s asthma worse can point to possible new triggers like environmental factors, bodily positions, or movements that may have a bearing on Tina’s breathing.Example Question:
Have you noticed any new allergies?
-
Finding:
Followed up on seasonal allergies
-
Finding:
Reports no recent seasonal allergy symptoms
(Found)
Pro Tip: Discerning whether anything is making Tina’s asthma worse can point to possible triggers like environmental factors, bodily positions, or movements that may have a bearing on Tina’s breathing.Example Question:
Have you been having seasonal allergies? -
Finding:
Reports no current medication for allergies
(Found)
Pro Tip: Tina’s response to a question about managing her allergies will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.Example Question:
Are you taking any medication for your allergies?
-
Finding:
Asked about diabetes
-
Finding:
Reports managing diabetes with diet and exercise in addition to medication
(Found)
Pro Tip: Tina’s response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & DocumentationExample Question:
How are you managing your diabetes?
-
Finding:
Asked about blood glucose monitoring
-
Finding:
Reports checking blood sugar once a day
(Found)
Pro Tip: Tina’s response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.Example Question:
How often do you monitor your blood glucose? -
Finding:
Checks sugar in the morning
(Found)
Pro Tip: Tina’s response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.Example Question:
When do you check your blood glucose? -
Finding:
Blood sugar number is usually around 90
(Found)
Pro Tip: Tina’s response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.Example Question:
What is your average blood sugar number? -
Finding:
Reports having adequate supplies
Objective Data Collection: 70 of 73 (95.9%)
Hover To Reveal…
Hover over the Patient Data items below to reveal important information, including Pro Tips.
-
Found:
Indicates an item that you found.
-
Available:
Indicates an item that is available to be found.
Category
Scored Items
Experts selected these examinations as essential components of objective data collection for this patient.
Patient Data
Not Scored
Thorough examinations will yield better patient data. The following actions reveal the objective data of the patient’s case. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation
HEENT
Finding:
Inspected head and neck
Finding:
Scattered pustules on face and facial hair on upper lip
(Found)
Pro Tip: Inspecting the facial skin for the presence of discoloration, lesions, or abnormal hair growth assesses for underlying medical problems.Example Question:
Finding:
Head is normocephalic, atraumatic
(Found)
Pro Tip: Because your patient may have unknowingly hit her head during her fall, giving special attention to your observation of the size and the shape of your patient’s head can identify any indications of trauma.Example Question:
Finding:
Normal scalp hair distribution
(Found)
Pro Tip: It’s important to inspect your patient’s hair for distribution, color, and texture because abnormal hair growth or characteristics can indicate underlying health problems.Example Question:
Finding:
Acanthosis nigricans noted on neck
(Available)
Pro Tip: Skin changes are common in patients with uncontrolled diabetes. A thorough inspection should be conducted of your patient’s skin, especially in folds around the neck, axilla, and groin.Example Question:
Finding:
Inspected eyebrows and orbital area
Finding:
Right eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema
(Found)
Pro Tip: Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions.Example Question:
Finding:
Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema
(Found)
Pro Tip: Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions.Example Question:
Finding:
Palpated scalp
Finding:
No masses
(Found)
Pro Tip: Female hair loss can indicate an underlying health problem or skin infection. Inspecting the scalp and hair for texture, distribution, and quantity helps to identify lesions or masses.Example Question:
Finding:
Palpated sinuses
Finding:
No frontal sinus tenderness
(Found)
Pro Tip: Palpating the frontal sinuses checks for sinusitis.Example Question:
Finding:
No maxillary sinus tenderness
(Found)
Pro Tip: Palpating the maxillary sinuses checks for sinusitis.Example Question:
Finding:
Palpated jaw
Finding:
No clicks, full ROM
(Found)
Pro Tip: Palpating the jaw checks for crepitus can identify TMJ or injury.Example Question:
Finding:
Palpated lymph nodes
Finding:
No axillary lymphadenopathy
(Found)
Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy.Example Question:
Finding:
No supraclavicular lymphadenopathy
(Found)
Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & DocumentationExample Question:
Finding:
Palpated thyroid
Finding:
Thyroid smooth without nodules, no goiter
(Found)
Pro Tip: Palpating the thyroid gland for size, shape, and consistency, and noting any nodules or tenderness, helps to identify signs of a thyroid disorder.Example Question:
Finding:
Inspected eyelids and conjunctiva
Finding:
Upper eyelids: conjunctiva pink, no lesions, white sclera
(Found)
Pro Tip: Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition.Example Question:
Finding:
Lower eyelids: conjunctiva pink, no lesions, white sclera
(Found)
Pro Tip: Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition.Example Question:
Finding:
Tested PERRL with penlight
Finding:
Right pupil: equal, round, reactive to light
(Found)
Pro Tip: When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems.Example Question:
Finding:
Left pupil: equal, round, reactive to light
(Found)
Pro Tip: When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems.Example Question:
Finding:
Tested eye movements
Finding:
Normal convergence
(Found)
Pro Tip: This test accommodation assesses the eye’s ability to focus on close objects.Example Question:
Finding:
EOMs intact bilaterally, no nystagmus
(Found)
Pro Tip: For this examination, the patient should look in the six cardinal fields without moving her head. Lag, nystagmus, and deviations may indicate neurologic conditions.Example Question:
Finding:
Tested peripheral vision
Finding:
Peripheral vision intact in both eyes, all fields
(Found)
Pro Tip:Example Question:
Finding:
Inspected interior eyes with ophthalmoscope
Finding:
Mild retinopathic changes on right
(Found)
Pro Tip: Patients with diabetes are at risk for diabetic retinopathy. By visualizing the fundus, you can look for any retinopathic changes.Example Question:
Finding:
Left fundus with sharp disc margins, no hemorrhages
Finding:
Palpated abdomen – deep
Finding:
Right upper quadrant: no masses, guarding or rebound
(Found)
Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses.Example Question:
Finding:
Right lower quadrant: no masses, guarding or rebound
(Found)
Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & DocumentationExample Question:
Finding:
Left upper quadrant: no masses, guarding or rebound
(Found)
Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses.Example Question:
Finding:
Left lower quadrant: no masses, guarding or rebound
(Found)
Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses.Example Question:
Finding:
Palpated organs
Finding:
Liver: palpable 1 cm below right costal margin
(Found)
Pro Tip: Palpating the liver identifies enlargement, displacement, tenderness, and consistency, which can indicate important health problems.Example Question:
Finding:
Spleen: not palpable
(Found)
Pro Tip: Palpating the spleen identifies enlargement or displacement, which can indicate a number of serious health conditions.Example Question:
Finding:
Right kidney: not palpable, no masses
(Found)
Pro Tip: Healthy kidneys are not usually palpable. Attempting to palpate the kidney helps determine enlargement or tenderness.Example Question:
Finding:
Left kidney: not palpable, no masses
(Found)
Pro Tip: Healthy kidneys are not usually palpable. Attempting to palpate the kidney helps determine enlargement or tenderness.Example Question:
Musculoskeletal
Finding:
Inspected neck
Finding:
Neck without swelling, masses, or deformity
(Available)
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.Example Question:
Finding:
Inspected upper extremities
Finding:
Right shoulder without swelling, masses, or deformity
(Found)
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.Example Question:
Finding:
Right arm without swelling, masses, or deformity
(Found)
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.Example Question:
Finding:
Right elbow without swelling, masses, or deformity
(Found)
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.Example Question:
Finding:
Right wrist and hand without swelling, masses, or deformity
(Found)
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.Example Question:
Finding:
Left shoulder without swelling, masses, or deformity
(Found)
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.Example Question:
Finding:
Left arm without swelling, masses, or deformity
(Found)
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.Example Question:
Finding:
Left elbow without swelling, masses, or deformity
(Found)
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.Example Question:
Finding:
Left wrist and hand without swelling, masses, or deformity
(Found)
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.Example Question:
Finding:
Fingernails: no ridges or abnormalities in nails, pink nailbeds
(Found)
Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & DocumentationExample Question:
Finding:
Inspected hips
Finding:
Hips without swelling, masses, or deformity
(Found)
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.Example Question:
Finding:
Inspected lower extremities
Finding:
Right leg without swelling, masses, or deformity
(Found)
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.Example Question:
Finding:
Right knee without swelling, masses, or deformity
(Found)
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.Example Question:
Finding:
Right ankle without swelling, masses, deformity, or discoloration
(Found)
Pro Tip: A thorough inspection of your patient’s affected ankle aids in the estimation of the extent of tissue injury and disability.Example Question:
Finding:
Right foot without swelling, masses, or deformity
(Found)
Pro Tip: Wound appearance relates information about the extent of injury or infection, as well as healing status.Example Question:
Finding:
Left leg without swelling, masses, or deformity
(Found)
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.Example Question:
Finding:
Left knee without swelling, masses, or deformity
(Found)
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.Example Question:
Finding:
Left ankle without swelling, masses, or deformity
(Found)
Pro Tip: The inspection of your patient’s unaffected ankle provides a comparison to the affected side and aids in the assessment for possible unknown injury inflicted during the fall.Example Question:
Finding:
Left foot without swelling, masses, or deformity
(Found)
Pro Tip: Your patient has diabetes and may unknowingly have wounds on her unindicated foot due to possible neuropathy.Example Question:
Finding:
Toenails: no ridges or abnormalities in nails, pink nailbeds
(Found)
Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease.Example Question:
Finding:
Tested ROM for upper extremities
Finding:
Right and left shoulders: full ROM
(Found)
Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. The assessment should also include the comparison of bilateral sides.Example Question:
Finding:
Right and left elbows: full ROM
(Found)
Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. The assessment should also include the comparison of bilateral sides.Example Question:
Finding:
Right and left wrists: full ROM
(Found)
Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. The assessment should also include the comparison of bilateral sides.Example Question:
-
Finding:
Tested ROM for spine
-
Finding:
Rotate left: full ROM
(Found)
Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. The assessment should also include the comparison of bilateral sides.Example Question:
-
Finding:
Rotate right: full ROM
(Found)
Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. The assessment should also include the comparison of bilateral sides.Example Question:
-
Finding:
Extension: full ROM
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(Found)
Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & DocumentationExample Question:
-
Finding:
Flexion: full ROM