COPD Debbie OConnor shadow health Subjective Data

COPD Debbie O’Connor shadow health Subjective Data

Subjective Data Collection: 32 of 32 (100.0%)

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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.

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

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Finding:

Established chief complaint and reason for admittance

&nbspSubjective Action&nbspPro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.&nbspExample Question: “when did your symptoms start?”” data-html=”true” data-title=”Reports a bronchospasm three days ago (Found)” data-original-title=””>

Finding:

Reports a bronchospasm three days ago

(Found)

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

Example Question:

When did your symptoms start?
&nbspSubjective Action&nbspPro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.&nbspExample Question: “what are your symptoms?”” data-html=”true” data-title=”Reports increased difficulty breathing (Found)” data-original-title=””>

Finding:

Reports increased difficulty breathing

(Found)

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

Example Question:

What are your symptoms?
&nbspSubjective Action&nbspPro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.&nbspExample Question: “what can i do for you?”” data-html=”true” data-title=”Reports desire for smoking cessation aids (Found)” data-original-title=””>

Finding:

Reports desire for smoking cessation aids

(Found)

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

Example Question:

What can I do for you?

History of Present Illness

Finding:

Asked about additional symptoms

&nbspSubjective Action&nbspPro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.&nbspExample Question: “do you feel fatigued?”” data-html=”true” data-title=”Reports fatigue and weakness (Found)” data-original-title=””>

Finding:

Reports fatigue and weakness

(Found)

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

Example Question:

Do you feel fatigued?
&nbspSubjective Action&nbspPro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.&nbspExample Question: “do you have purulent sputum?”” data-html=”true” data-title=”Reports purulent sputum (Found)” data-original-title=””>

Finding:

Reports purulent sputum

(Found)

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

Example Question:

Do you have purulent sputum?
&nbspSubjective Action&nbspPro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.&nbspExample Question: “do you have a cough?”” data-html=”true” data-title=”Reports cough (Found)” data-original-title=””>

Finding:

Reports cough

(Found)

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

Example Question:

Do you have a cough?
&nbspSubjective Action&nbspPro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.&nbspExample Question: “how do you feel about your symptoms?”” data-html=”true” data-title=”Reports feeling anxious about symptoms and worsening health issues (Found)” data-original-title=””>

Finding:

Reports feeling anxious about symptoms and worsening health issues

(Found)

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

Example Question:

How do you feel about your symptoms?

Finding:

Asked about onset and duration of symptoms

&nbspSubjective Action&nbspPro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.&nbspExample Question: “when did your fatigue begin?”” data-html=”true” data-title=”Reports most severe fatigue and difficulty breathing began three days ago (Available)” data-original-title=””>

Finding:

Reports most severe fatigue and difficulty breathing began three days ago

(Available)

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

Example Question:

When did your fatigue begin?
&nbspSubjective Action&nbspPro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.&nbspExample Question: “when did your productive cough begin?”” data-html=”true” data-title=”Reports purulent sputum production started two weeks ago (Found)” data-original-title=””>

Finding:

Reports purulent sputum production started two weeks ago

(Found)

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

Example Question:

When did your productive cough begin?
&nbspSubjective Action&nbspPro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.&nbspExample Question: “how long have you had your symptoms?”” data-html=”true” data-title=”Reports respiratory symptoms increased in the last four months (Available)” data-original-title=””>

Finding:

Reports respiratory symptoms increased in the last four months

(Available)

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

Example Question:

How long have you had your symptoms?

Finding:

Followed up on characteristics of respiratory distress

&nbspSubjective Action&nbspPro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.&nbspExample Question: “what does your sputum look like?”” data-html=”true” data-title=”Reports sputum is mostly clear with occasional yellow, gray, or dark color (Found)” data-original-title=””>

Finding:

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

(Found)

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

Example Question:

What does your sputum look like?
&nbspSubjective Action&nbspPro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.&nbspExample Question: “are you wheezing?”” data-html=”true” data-title=”Reports wheezing (Available)” data-original-title=””>

Finding:

Reports wheezing

(Available)

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

Example Question:

Are you wheezing?
&nbspSubjective Action&nbspPro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.&nbspExample Question: “what does your cough sound like?”” data-html=”true” data-title=”Reports cough sounds like crackling (Available)” data-original-title=””>

Finding:

Reports cough sounds like crackling

(Available)

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

Example Question:

What does your cough sound like?

Finding:

Asked about aggravating factors

&nbspSubjective Action&nbspPro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.&nbspExample Question: “does exertion make your symptoms worse?”” data-html=”true” data-title=”Reports exertion worsens symptoms (Available)” data-original-title=””>

Finding:

Reports exertion worsens symptoms

(Available)

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

Example Question:

Does exertion make your symptoms worse?
&nbspSubjective Action&nbspPro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.&nbspExample Question: “when do you have coughing fits?”” data-html=”true” data-title=”Reports coughing fits after smoking (Found)” data-original-title=””>

Finding:

Reports coughing fits after smoking

(Found)

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

Example Question:

When do you have coughing fits?

Finding:

Asked about treatment and relieving factors of respiratory symptoms

&nbspSubjective Action&nbspPro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.&nbspExample Question: “how long do you wait between cigarettes?”” data-html=”true” data-title=”Reports trying to hold off on smoking cigarettes as long as possible (Found)” data-original-title=””>

Finding:

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

(Found)

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

Example Question:

How long do you wait between cigarettes?

Finding:

Asked about severity of respiratory distress

&nbspSubjective Action&nbspPro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.&nbspExample Question: “can you rate your symptoms on a scale of 1 to 10?”” data-html=”true” data-title=”Reports breathing difficulty and associated discomfort is a 6/10 (Found)” data-original-title=””>

Finding:

Reports breathing difficulty and associated discomfort is a 6/10

(Found)

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

Example Question:

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

Finding:

Asked about effects of health on social activity

&nbspSubjective Action&nbspPro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.&nbspExample Question: “how do your symptoms prevent you from social activities?”” data-html=”true” data-title=”Reports low social activity – doesn’t feel up to getting out and about (Found)” data-original-title=””>

Finding:

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

(Found)

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

Example Question:

How do your symptoms prevent you from social activities?

Past Medical History

Finding:

Asked about existing health conditions

&nbspSubjective Action&nbspPro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.&nbspExample Question: “do you have chronic bronchitis?”” data-html=”true” data-title=”Reports chronic bronchitis related to COPD (Found)” data-original-title=””>

Finding:

Reports chronic bronchitis related to COPD

(Found)

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

Example Question:

Do you have chronic bronchitis?

Finding:

Followed up on chronic bronchitis COPD diagnosis

&nbspSubjective Action&nbspPro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.&nbspExample Question: “what of copd were you diagnosed with?”” data-html =true data-title=”Reports diagnosed with “Class B” COPD (Found)” data-original-title=”>

Finding:

Reports diagnosed with “Class B” COPD

(Found)

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

Example Question:

What class of COPD were you diagnosed with?
&nbspSubjective Action&nbspPro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.&nbspExample Question: “what was your respiratory episode?”” data-html=”true” data-title=”Reports diagnosed after respiratory distress episode (Found)” data-original-title=””>

Finding:

Reports diagnosed after respiratory distress episode

(Found)

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

Example Question:

What was your respiratory episode?

Finding:

Asked about ER visits or hospitalizations

&nbspSubjective Action&nbspPro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.&nbspExample Question: “when were you hospitalized?”” data-html=”true” data-title=”Reports hospitalization after miscarriage at age 24 (Available)” data-original-title=””>

Finding:

Reports hospitalization after miscarriage at age 24

(Available)

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

Example Question:

When were you hospitalized?
&nbspSubjective Action&nbspPro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.&nbspExample Question: “when was your most recent hospitalization?”” data-html=”true” data-title=”Reports most recent hospitalization was two years ago (Found)” data-original-title=””>

Finding:

Reports most recent hospitalization was two years ago

(Found)

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

Example Question:

When was your most recent hospitalization?
&nbspSubjective Action&nbspPro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.&nbspExample Question: “what was your recent hospitalization for?”” data-html=”true” data-title=”Reports most recent hospitalization was for respiratory distress episode (Found)” data-original-title=””>

Finding:

Reports most recent hospitalization was for respiratory distress episode

(Found)

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

Example Question:

What was your recent hospitalization for?

Home Medications

Finding:

Asked about home medications

&nbspSubjective Action&nbspPro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.&nbspExample Question: “do you take a laba?”” data-html=”true” data-title=”Reports taking a long-acting beta-agonist (LABA) (Found)” data-original-title=””>

Finding:

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

(Found)

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

Example Question:

Do you take a LABA?

Finding:

Followed up on LABA

&nbspSubjective Action&nbspPro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.&nbspExample Question: “do you use a laba inhaler?”” data-html=”true” data-title=”Reports the LABA is formoterol inhaler (Found)” data-original-title=””>

Finding:

Reports the LABA is formoterol inhaler

(Found)

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

Example Question:

Do you use a LABA inhaler?
&nbspSubjective Action&nbspPro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.&nbspExample Question: “what is the dosage of your inhaler?”” data-html=”true” data-title=”Reports formoterol dose of 12 micrograms (Found)” data-original-title=””>

Finding:

Reports formoterol dose of 12 micrograms

(Found)

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

Example Question:

What is the dosage of your inhaler?
&nbspSubjective Action&nbspPro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.&nbspExample Question: “how often do you take your inhaler?”” data-html=”true” data-title=”Reports only using once every 12 hours, once in the morning and once at night (Found)” data-original-title=””>

Finding:

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

(Found)

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

Example Question:

How often do you take your inhaler?
&nbspSubjective Action&nbspPro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.&nbspExample Question: “when is the last time you used your inhaler?”” data-html=”true” data-title=”Reports using LABA this morning (Available)” data-original-title=””>

Finding:

Reports using LABA this morning

(Available)

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

Example Question:

When is the last time you used your inhaler?
&nbspSubjective Action&nbspPro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.&nbspExample Question: “is the inhaler effective?”” data-html=”true” data-title=”Reports the LABA is not very effective (Available)” data-original-title=””>

Finding:

Reports the LABA is not very effective

(Available)

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

Example Question:

Is the inhaler effective?
&nbspSubjective Action&nbspPro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.&nbspExample Question: “do you have any side effects from your inhaler?”” data-html=”true” data-title=”Denies medication side effects (Available)” data-original-title=””>

Finding:

Denies medication side effects

(Available)

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

Example Question:

Do you have any side effects from your inhaler?

Finding:

Asked about supplements and vitamins

&nbspSubjective Action&nbspPro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.&nbspExample Question: “do you take vitamins?”” data-html=”true” data-title=”Denies use of supplements or vitamins (Found)” data-original-title=””>

Finding:

Denies use of supplements or vitamins

(Found)

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

Example Question:

Do you take vitamins?

Finding:

Asked about medication regimen adherence

&nbspSubjective Action&nbspPro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.&nbspExample Question: “do you miss doses of your medication?”” data-html=”true” data-title=”Denies missing doses (Found)” data-original-title=””>

Finding:

Denies missing doses

(Found)

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

Example Question:

Do you miss doses of your medication?

Finding:

Asked about spirometry

&nbspSubjective Action&nbspPro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.&nbspExample Question: “do you take spirometry readings at home?”” data-html=”true” data-title=”Reports sporadic spirometry readings at home (Found)” data-original-title=””>

Finding:

Reports sporadic spirometry readings at home

(Found)

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

Example Question:

Do you take spirometry readings at home?
&nbspSubjective Action&nbspPro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.&nbspExample Question: “what is your most recent spirometry reading?”” data-html=”true” data-title=”Reports most recent FEV1 reading was 1.37 L, 49% of her predicted FEV1 (Found)” data-original-title=””>

Finding:

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

(Found)

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

Example Question:

What is your most recent spirometry reading?

Finding:

Asked about oxygen use

&nbspSubjective Action&nbspPro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.&nbspExample Question: “do you use oxygen even though smoke?”” data-html =true data-title=”Denies oxygen therapy due to cigarette smoking (Found)” data-original-title=””>

Finding:

Denies oxygen therapy due to cigarette smoking

(Found)

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

Example Question:

Do you use oxygen even though you smoke?

Finding:

Asked about allergies

&nbspSubjective Action&nbspPro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.&nbspExample Question: “do you have any allergies?”” data-html=”true” data-title=”Denies allergies (Found)” data-original-title=””>

Finding:

Denies allergies

(Found)

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

Example Question:

Do you have any allergies?

Finding:

Asked about vaccines

&nbspSubjective Action&nbspPro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.&nbspExample Question: “have you had a flu shot?”” data-html=”true” data-title=”Denies recent influenza vaccine (Available)” data-original-title=””>

Finding:

Denies recent influenza vaccine

(Available)

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

Example Question:

Have you had a flu shot?
&nbspSubjective Action&nbspPro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.&nbspExample Question: “have you had a pneumonia vaccine?”” data-html=”true” data-title=”Denies recent pneumococcal vaccines (Available)” data-original-title=””>

Finding:

Denies recent pneumococcal vaccines

(Available)

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

Example Question:

Have you had a pneumonia vaccine?

Social History

Finding:

Asked about living environment

&nbspSubjective Action&nbspPro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.&nbspExample Question: “who do you live with?”” data-html=”true” data-title=”Reports she lives with her daughter (Found)” data-original-title=””>

Finding:

Reports she lives with her daughter

(Found)

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

Example Question:

Who do you live with?
&nbspSubjective Action&nbspPro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.&nbspExample Question: “when did you move in with your daughter?”” data-html=”true” data-title=”Reports recently moving in with her daughter because of her declining health (Found)” data-original-title=””>

Finding:

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

(Found)

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

Example Question:

When did you move in with your daughter?
&nbspSubjective Action&nbspPro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.&nbspExample Question: “is your home stressful?”” data-html=”true” data-title=”Reports stress from arguments with daughter over smoking (Available)” data-original-title=””>

Finding:

Reports stress from arguments with daughter over smoking

(Available)

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

Example Question:

Is your home stressful?

Finding:

Asked about substance use

&nbspSubjective Action&nbspPro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.&nbspExample Question: “do you smoke cigarettes?”” data-html=”true” data-title=”Reports cigarette smoking (Found)” data-original-title=””>

Finding:

Reports cigarette smoking

(Found)

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

Example Question:

Do you smoke cigarettes?
&nbspSubjective Action&nbspPro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.&nbspExample Question: “do you drink alcohol?”” data-html=”true” data-title=”Denies drinking alcohol (Found)” data-original-title=””>

Finding:

Denies drinking alcohol

(Found)

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

Example Question:

Do you drink alcohol?
&nbspSubjective Action&nbspPro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.&nbspExample Question: “do you use illegal drugs?”” data-html=”true” data-title=”Denies using illegal substances (Found)” data-original-title=””>

Finding:

Denies using illegal substances

(Found)

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

Example Question:

Do you use illegal drugs?

Finding:

Followed up on current cigarette smoking

&nbspSubjective Action&nbspPro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.&nbspExample Question: “how many cigarettes do you smoke a day?”” data-html=”true” data-title=”Reports three to five cigarettes a day for the past four months (Found)” data-original-title=””>

Finding:

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

(Found)

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

Example Question:

How many cigarettes do you smoke a day?
&nbspSubjective Action&nbspPro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.&nbspExample Question: “what triggers your smoking?”” data-html=”true” data-title=”Reports stressful situations trigger her smoking (Available)” data-original-title=””>

Finding:

Reports stressful situations trigger her smoking

(Available)

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

Example Question:

What triggers your smoking?
&nbspSubjective Action&nbspPro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.&nbspExample Question: “why do you want to quit smoking?”” data-html=”true” data-title=”Reports daughter convinced her to quit smoking because of declining health issues (Available)” data-original-title=””>

Finding:

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

(Available)

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

Example Question:

Why do you want to quit smoking?
&nbspSubjective Action&nbspPro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.&nbspExample Question: “what was your husband’s cause of death?”” data-html=”true” data-title=”Reports husband’s death of lung cancer makes her want to quit (Available)” data-original-title=””>

Finding:

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

(Available)

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

Example Question:

What was your husband’s cause of death?

Finding:

Followed up on history of cigarette smoking

&nbspSubjective Action&nbspPro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.&nbspExample Question: “when did you start smoking?”” data-html=”true” data-title=”Reports started smoking at age 15 (Found)” data-original-title=””>

Finding:

Reports started smoking at age 15

(Found)

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

Example Question:

When did you start smoking?
&nbspSubjective Action&nbspPro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.&nbspExample Question: “have you ever quit smoking?”” data-html=”true” data-title=”Reports quit smoking when her daughter was young but started smoking again in her 30s (Found)” data-original-title=””>

Finding:

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

(Found)

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

Example Question:

Have you ever quit smoking?
&nbspSubjective Action&nbspPro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.&nbspExample Question: “how many pack years do you have?”” data-html=”true” data-title=”Reports 37 pack years according to an online calculator her daughter used (Available)” data-original-title=””>

Finding:

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

(Available)

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

Example Question:

How many pack years do you have?

Finding:

Followed up on smoking cessation

&nbspSubjective Action&nbspPro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.&nbspExample Question: “have you ever quit smoking using nicotine replacement therapy?”” data-html=”true” data-title=”Reports trying to quit several times unsuccessfully with nicotine replacement therapy (Available)” data-original-title=””>

Finding:

Reports trying to quit several times unsuccessfully with nicotine replacement therapy

(Available)

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

Example Question:

Have you ever quit smoking using nicotine replacement therapy?
&nbspSubjective Action&nbspPro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.&nbspExample Question: “what kind of nicotine replacement therapy have you tried?”” data-html=”true” data-title=”Reports having tried nicotine gum, lozenges, and patches (Available)” data-original-title=””>

Finding:

Reports having tried nicotine gum, lozenges, and patches

(Available)

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

Example Question:

What kind of nicotine replacement therapy have you tried?
&nbspSubjective Action&nbspPro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.&nbspExample Question: “why didn’t nicotine replacement therapy work?”” data-html=”true” data-title=”Reports nicotine replacement therapy failed because she did not want to deal with the required compliance (Available)” data-original-title=””>

Finding:

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

(Available)

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

Example Question:

Why didn’t nicotine replacement therapy work?
&nbspSubjective Action&nbspPro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.&nbspExample Question: “what is the longest amount of time you quit smoking?”” data-html=”true” data-title=”Reports her longest period without smoking was 10 years (Found)” data-original-title=””>

Finding:

Reports her longest period without smoking was 10 years

(Found)

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

Example Question:

What is the longest amount of time you quit smoking?

Finding:

Asked about exercise

&nbspSubjective Action&nbspPro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.&nbspExample Question: “why don’t you exercise?”” data-html=”true” data-title=”Denies exercise due to fatigue, exhaustion, exacerbated symptoms upon exertion (Found)” data-original-title=””>

Finding:

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

(Found)

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

Example Question:

Why don’t you exercise?

Finding:

Asked about diet

&nbspSubjective Action&nbspPro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.&nbspExample Question: “what do you eat at home?”” data-html=”true” data-title=”Reports eating mostly frozen meals when daughter is at work (Found)” data-original-title=””>

Finding:

Reports eating mostly frozen meals when daughter is at work

(Found)

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

Example Question:

What do you eat at home?
&nbspSubjective Action&nbspPro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.&nbspExample Question: “do you cook?”” data-html=”true” data-title=”Reports her daughter cooks healthy meals for her (Found)” data-original-title=””>

Finding:

Reports her daughter cooks healthy meals for her

(Found)

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

Example Question:

Do you cook?

Family Medical History

Finding:

Asked about relevant family history

&nbspSubjective Action&nbspPro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.&nbspExample Question: “did your father smoke?”” data-html=”true” data-title=”Reports father, smoker, died of a heart attack (Found)” data-original-title=””>

Finding:

Reports father, smoker, died of a heart attack

(Found)

Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.

Example Question:

Did your father smoke?
&nbspSubjective Action&nbspPro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.&nbspExample Question: “did your mother smoke?”” data-html=”true” data-title=”Reports mother died of smoking-related pneumonia (Found)” data-original-title=””>

Finding:

Reports mother died of smoking-related pneumonia

(Found)

Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.

Example Question:

Did your mother smoke?
&nbspSubjective Action&nbspPro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.&nbspExample Question: “did your husband smoke?”” data-html=”true” data-title=”Reports husband smoked and died of lung cancer (Available)” data-original-title=””>

Finding:

Reports husband smoked and died of lung cancer

(Available)

Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.

Example Question:

Did your husband smoke?
&nbspSubjective Action&nbspPro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.&nbspExample Question: “does your daughter smoke?”” data-html=”true” data-title=’Reports daughter is a “health nut” non-smoker (Available)’ data-original-title=””>

Finding:

Reports daughter is a “health nut” non-smoker

(Available)

Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.

Example Question:

Does your daughter smoke?

Review of Systems

Finding:

Asked about weight changes

&nbspSubjective Action&nbspPro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.&nbspExample Question: “how much weight have you gained?”” data-html=”true” data-title=”Reports weight gain of 30 pounds in the last two years (Found)” data-original-title=””>

Finding:

Reports weight gain of 30 pounds in the last two years

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

How much weight have you gained?

Finding:

Asked about review of systems for HEENT

&nbspSubjective Action&nbspPro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.&nbspExample Question: “are you nearsighted?”” data-html=”true” data-title=”Reports vision is nearsighted (Found)” data-original-title=””>

Finding:

Reports vision is nearsighted

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Are you nearsighted?
&nbspSubjective Action&nbspPro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.&nbspExample Question: “do you wear glasses?”” data-html=”true” data-title=”Reports wearing glasses (Found)” data-original-title=””>

Finding:

Reports wearing glasses

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Do you wear glasses?

Finding:

Asked about review of systems for integumentary

&nbspSubjective Action&nbspPro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.&nbspExample Question: “have you noticed changes in your skin color?”” data-html=”true” data-title=”Reports yellowing of skin, nails, and teeth (Found)” data-original-title=””>

Finding:

Reports yellowing of skin, nails, and teeth

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Have you noticed changes in your skin color?
&nbspSubjective Action&nbspPro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.&nbspExample Question: “are your fingernails blue?”” data-html=”true” data-title=”Denies cyanosis (Found)” data-original-title=””>

Finding:

Denies cyanosis

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Are your fingernails blue?

Finding:

Asked about review of systems for genitourinary

&nbspSubjective Action&nbspPro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.&nbspExample Question: “are you postmenopausal?”” data-html=”true” data-title=”Reports being postmenopausal (Found)” data-original-title=””>

Finding:

Reports being postmenopausal

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Are you postmenopausal?
&nbspSubjective Action&nbspPro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.&nbspExample Question: “are you sexually active?”” data-html=”true” data-title=”Reports not sexually active (Available)” data-original-title=””>

Finding:

Reports not sexually active

(Available)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Are you sexually active?

Activities of Daily Living

Finding:

Asked about ADLs

&nbspSubjective Action&nbspPro Tip: Information about a patient’s activities of daily living will help you determine if their wellbeing is at risk. Questions about your patient’s ability to bathe themselves, feed themselves, or walk without assistance will help you determine whether the patient can care for themselves at home.&nbspExample Question: “do you have trouble moving around your home?”” data-html=”true” data-title=”Reports difficulty moving around home (Found)” data-original-title=””>

Finding:

Reports difficulty moving around home

(Found)

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

Example Question:

Do you have trouble moving around your home?
&nbspSubjective Action&nbspPro Tip: Information about a patient’s activities of daily living will help you determine if their wellbeing is at risk. Questions about your patient’s ability to bathe themselves, feed themselves, or walk without assistance will help you determine whether the patient can care for themselves at home.&nbspExample Question: “do you have difficulty getting dressed?”” data-html=”true” data-title=”Reports difficulty with activities like dressing or cooking due to exhaustion (Found)” data-original-title=””>

Finding:

Reports difficulty with activities like dressing or cooking due to exhaustion

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