Example Question: Do you lose your balance often? for anxiety, last dose this morning Bupropion HCL (12H) 150 mg b.i.d. Example Question: Can you please describe the pain? Finding: Denies exposure to secondhand smoke (Found)Pro Tip: Exposure to secondhand smoke can be especially detrimental to an asthmatic patient's health. Example Question: How long have you noticed swelling around the wound? Example Question: Do you wear glasses or contacts? Example Question: Do you have any nose problems right now? The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint, such as oral infection or recent trauma. Depending on when the drug was most recently taken, it could interfere with medications. Finding: Reports currently working toward undergraduate degree (Found)Pro Tip: Finding out a patient's level of education can give you a baseline for her health literacy. Finding: Reports foot wound (Found)Pro Tip: If a patient mentions pain, it's important to determine what specifically is causing her pain, if she knows. Tina Jones: Mom has high cholesterol and blood pressure, I think. Student: Can you tell me about your father's health? Previous levels of lipids if ever checked or known. Tina Jones: Whatever pain medication the ER gave me is helping. Finding: Denies muscle weakness (Available)Pro Tip: Asking about muscle weakness is one possible component of a review of systems interview. Finding: Followed up on effectiveness of ointment. But he never hit us or anything. Established chief complaint Reports sporadic chest pain. Uncovering the age of death can help you assess the patient's current risks. Asks about symptoms, smoking, and personal and family history of respiratory disease. Finding: Denies seasonal allergies (Available)Pro Tip: Asking about seasonal allergies can help you understand a patient's complete set of allergies over the course of a year. MEDICAL HISTORY QUESTIONNAIRE TODAY'S DATE: _____ ***Since this is your medical history and it will be used in evaluating your health, it is extremely important that the questions be answered as accurately and completely as possible. Things were only hard like that for a few months. So, I guess at first I just focused on getting things done--groceries, laundry, insurance papers and stuff. Example Question: Do you have any reaction to dust? If the patient reports a history of constipation, it could be a symptom of dietary or gastrointestinal problems. Example Question: Does your foot pain affect your work? cancer, heart disease, hypertension, diabetes. I get headaches sometimes, but that's all. Existing conditions can also inform your treatment and understanding of the patient's current health issues. If the patient reports a history of gas, it could be a symptom of dietary or gastrointestinal problems. As a currently presenting symptom, it could impact the patient's care plan. Student: When did you realize you were allergic to cats? Planning Pro Tip: Assess how well the patient can bear weight and walk. Example Question: Do you have muscle pain? Finding: Asked about relevant medical history. Example Question: Can you rate the pain on a scale of 0 to 10? Finding: Reports taking ibuprofen (Advil) for 2 days (Found)Pro Tip: Discovering how long your patient has been taking pain medication is a crucial part of the history of her condition or injury. Example Question: When did you first notice the pus? Example Question: Do you ever have ringing in your ears? Exam includes checking weight and height, and listening to heart and lungs. Example Question: Does anyone live at home with you? Example Question: How often do you check your blood sugar? The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint. I definitely don't anymore, though. Finding: Asked review of systems for urinary. Tina Jones: I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint. Example Question: What happened to cause you to stop smoking pot? Contributing factors are a past history of hospitalization and asthma attacks, as well as sedentary lifestyle and obesity. The infection is the most immediate threat to the patient's health, and the wound is at risk for delayed healing because of the patient's uncontrolled blood glucose. You will also want to review Ms. Jones' systems, psychosocial history, and family medical history. They're crazy, but nobody's diagnosed with anything. Example Question: What is your reaction to cats? Tina Jones: For as long as I've been around. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint. Example Question: Did you receive the chicken pox vaccine? "I have a monitor at home, but to be honest I don't really use it that often." Example Question: Does your father have health conditions? Finding: Denies circulation problems (Available)Pro Tip: Poor circulation is the result of other diseases like obesity, diabetes, or cardiac conditions. Example Question: Have you had mouth pain? A history of irregular periods could indicate hormonal or endocrine problems. It is important to ask your patient about the flu vaccine. Even getting up and ready for church was too overwhelming. Finding: Asked about review of systems for head. Asking Tina if her maternal grandmother had high blood pressure can reveal generational patterns. Finding: Denies breast rashes (Available)Pro Tip: Asking about abnormal characteristics of a patient's breasts, such as a rash, is one way of assessing overall breast health. Finding: Reports seeing pus draining from wound (Found)Pro Tip: Asking about discharge helps you determine the characteristics of a wound. Asking Tina if her mother had high blood pressure can reveal generational patterns. Finding: Reports mother diagnosed with high blood pressure (Found)Pro Tip: Family histories might indicate a genetic predisposition. As a currently presenting symptom, it could impact the patient's care plan. If the patient reports a history of vomiting, it could be a symptom of a recurring gastrointestinal problem. You also want to identify any potential issues with substance abuse. Example Question: Do you have a history of suicidal thinking? Example Question: Have you experienced any type of abuse? Finding: Asked about prior hospitalizations. Example Question: When was your last hospitalization? I know I need sleep, too. It's killing me. Example Question: Did you receive the polio vaccine? Example Question: How many puffs do you typically take? Example Question: How many days have you needed pain medication? Finding: Denies swollen glands (Found)Pro Tip: Asking about a patient's glands in general could include lymph nodes or thyroid glands. Example Question: When was your last alcoholic drink? Finding: Denies flank pain (Available)Pro Tip: Flank pain can be a sign of kidney infection. Finding: Reports pain affects ability to stand at work for long periods of time (Available)Pro Tip: Understanding the impact of your patient's wound on daily activities helps inform your plan for care. Example Question: Have you had jaw problems? Student: Have you had any neurological problems? Pay close attention to this information as it will help guide your exam. Student: I understand your foot hurts, but I need to know this information to make sure I take care of the problem correctly. Tina Jones: I usually use two puffs from my inhaler, but sometimes I need three. Prevent worsening infection by educating the patient about wound care and self-monitoring. Finding: Reports occasionally taking acetaminophen (Tylenol) for headaches (Available)Pro Tip: Finding out about your patient's use of over-the-counter medications, vitamins, and supplements will help you get a complete health history and avoid unwanted drug interactions. Example Question: Have you had any family members with cancer? Example Question: How are your lymph nodes? Student: What made you stop taking medication for your diabetes? Example Question: Did you receive the HPV vaccine? Intervene - Pain: Administer prescribed analgesics to provide optimal pain relief. 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