Shadow Health -Nicole Diaz- PTSD

Shadow Health -Nicole Diaz- PTSDPSYCH C487 Shadow Health -Nicole Diaz- PTSD Nicole Diaz- PTSD Chief Complaint Finding: Established chief complaint Finding: Reports sleep problems (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? History of Present Illness Finding: Asked about onset and frequency of sleep problems Finding: Reports sleep problems for the past 10+ years (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 history of sleep problems? Finding: Reports having problems sleeping most nights of the week (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 have you been having sleep problems? Finding: Asked about sleep quality and characteristics Finding: Reports recent sleep problems include nightmares (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 wakes you up at night? Finding: Reports falling asleep often takes more than an hour (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: How long does it take for you to fall asleep? Finding: Reports waking up two or three times during the night for "at least ten minutes" (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: How often do you wake up during the night? Finding: Reports waking in the morning feeling "out of it" and not rested (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 when you wake up in the morning? Finding: Reports frequent snoring (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: Do you snore? Finding: Asked about sleep habits Finding: Reports going to bed "around midnight," but feeling "too nervous" to sleep (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 is your sleep like? Finding: Reports actually falling asleep at 2 or 3 AM (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 time do you fall asleep? Finding: Reports checking her windows and doors twice before going to bed (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 do you usually do before bed? Finding: Reports no screen use (television or computer) before bed (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: Do you use the computer or watch TV before you go to sleep? Finding: Reports average wake time of 7 AM (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 time do you wake up? Finding: Reports sleeping an average of 4 or 5 hours a night (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 much sleep do you get a night? Finding: Reports sleeping alone in a quiet room (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: Can you describe where you sleep? Finding: Asked about patterns for sleep problems Finding: Reports that stress and anxiety exacerbate sleep problems (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 makes it harder for you to sleep? Past Medical History Finding: Asked about existing health conditions Finding: Reports hypertension diagnosis (Found) Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Do you have high blood pressure? Finding: Followed up on hypertension diagnosis Finding: Diagnosed age 45 (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 high blood pressure first diagnosed? Finding: Asked about history of mental health Finding: Reports PTSD diagnosis (Found) Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Do you have PTSD? Finding: Followed up about symptoms of PTSD diagnosis Finding: Reports depression accompanies PTSD diagnosis (Found) Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: What makes you feel depressed? Finding: Reports anxiety as a symptom of PTSD (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 makes you anxious? Finding: Reports sleep problems are a symptom of PTSD diagnosis (Found) Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: What are the symptoms of your PTSD? Finding: Followed up on onset of PTSD Finding: Reports diagnosis age 35 (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 were you diagnosed with PTSD? Finding: Reports PTSD cause is military sexual assault (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 brought on the post traumatic stress disorder? Finding: Reports MST was at age 23 (Found) Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: How long have you had MST? Finding: Reports event involved commanding officer and ostracization from unit (Available) Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: What happened when you were sexually assaulted? Finding: Reports left military at 28, but did not seek immediate care (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 did you get help for your PTSD symptoms? Finding: Followed up on aggravating factors for PTSD Finding: Reports stress triggers PTSD symptoms (Found) Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: How do you experience stress? Finding: Reports avoiding crowds or most social situations (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: Does your anxiety prevent you from completing your usual activities? Finding: Reports fear of "losing control" of a situation (Available) Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Do you feel nervous in new situations? Finding: Reports discussing event is triggering (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: Are you ok with talking about what happened? Finding: Reports difficulties with relationships and emotional/physical intimacy (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: How does ptsd affect your relationships? Finding: Asked about non-medication coping strategies Finding: Reveals belief that she has a moderate level of self-care (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: How do you perceive your health? Finding: Reports therapy dog helps (Found) Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: How does your service dog help? Finding: Reports smoking helps (Found) Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: How do you cope with anxiety? Finding: Reports avoiding stimulating environments when anxious or stressed (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: How do you cope with anxiety? Finding: Asked about suicidal ideation and self-harm Finding: Reports occasional feelings that "sometimes I feel like life is not worth living" (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: Why do you feel like you can't cope with stress? Finding: Denies active suicidal ideation or self-harm (Found) Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Have you ever tried to hurt yourself? Finding: Followed up on suicide planning Finding: Denies suicide planning (Found) Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Have you ever tried to hurt yourself? Finding: Reports suicidal ideation is a symptom of depression (Available) Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: What is the impact of your suicidal ideation? Finding: Asked about past suicide attempts Finding: Denies past suicide attempts (Found) Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Have you ever attempted suicide? Finding: Asked about homicidal ideation Finding: Denies homicidal ideation (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 thoughts of hurting others? Finding: Asked about previous psychiatric hospitalizations Finding: Denies past psychiatric admissions (Found) Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Have you had to go to the hospital for a psychiatric disorder? Home Medications Finding: Asked about home medications Finding: Reports medication for hypertension (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: What medications do you take? Finding: Reports medication for depression (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: What medications do you take? Finding: Reports medication for anxiety (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: What medications do you take? Finding: Denies taking vitamins (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 take vitamins? Finding: Denies taking herbal supplements (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 supplements? Finding: Asked about medication regimen adherence Finding: Reports using a smartphone app to manage medications (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: How do you manage your medication? Finding: Denies missing doses of medication (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 remember to take your medication? Finding: Denies missing doses of medication because of 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 miss doses of your medication because of side effects? Finding: Denies difficulty obtaining medications because of finances (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 difficulty obtaining medication because of finances? Finding: Denies difficulty obtaining medications because of transportation (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 difficulty obtaining medication? Finding: Followed up on last dose of home medications Finding: Reports taking all medications as scheduled today (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: When was the last time you took any medications? Finding: Denies taking blood pressure medication today - not scheduled until evening (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: Have you already taken your home medications today? Finding: Reports taking medication for depression this morning as scheduled (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: Are you needing your home medications? Finding: Reports taking medication for anxiety this morning as scheduled (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: Are you needing your home medications? Finding: Followed up on medication for hypertension Finding: Reports taking losartan (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 do you take for your blood pressure? Finding: Reports losartan dosage: 100 mg (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: How much losartan do you take? Finding: Reports losartan frequency: 1x daily (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 hypertension medication? Finding: Denies losartan 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: What side effects are you experiencing from your medications? Finding: Followed up on medication for anxiety Finding: Reports taking buspirone HCL (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 anxiety medication do you take? Finding: Reports buspirone HCL dosage: 30 mg (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: What doses are your medications? Finding: Reports buspirone HCL frequency: 15mg pill twice daily (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 much buspirone do you take? Finding: Denies buspirone HCL 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: What side effects are you experiencing from your medications? Finding: Reports taking buspirone HCL for 1 year (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: How long have you taken buspirone? Finding: Reports buspirone HCL is effective in reducing anxiety (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: Has the anxiety medication been helpful? Finding: Followed up on medication for depression Finding: Reports taking bupropion HCL (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 depression medication did you take? Finding: Reports bupropion HCL dosage: 150 mg (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: How much bupropion are you taking? Finding: Reports bupropion HCL frequency: twice daily (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 frequent is your bupropion prescribed for? Finding: Denies bupropion HCL 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: What side effects are you experiencing from your medications? Finding: Reports taking bupropion HCL for 1 year (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: How long have you been taking bupropion? Finding: Reports taking various antidepressants in the past (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: How long have you taken antidepressants? Finding: Reports bupropion HCL is effective for treating depression (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: Has your antidepressant helped? Social History Finding: Asked about occupation and education Finding: Reports working as a grant writer (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 have a job? Finding: Reports undergraduate degree in English (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 degree do you have? Finding: Asked about illicit drug use Finding: Denies illicit drug use (Found) Pro Tip: A patient's social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient's social history can also unveil the influence of their present illnesses in their social lives. Example Question: Do you use drugs now? Finding: Asked about alcohol use Finding: Reports rare alcohol use (Found) Pro Tip: A patient's social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient's social history can also unveil the influence of their present illnesses in their social lives. Example Question: When did you last drink alcohol? Finding: Followed up on alcohol use Finding: Reports drinking less than once a month (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 often do you drink alcohol? Finding: Reports drinking 1 - 2 drinks in a sitting (Available) Pro Tip: A patient's social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient's social history can also unveil the influence of their present illnesses in their social lives. Example Question: How much alcohol do you drink? Finding: Asked about tobacco and nicotine use 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? Finding: Followed up on cigarette smoking Finding: Reports smoking 3 - 4 cigarettes a day (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 much do you smoke? Finding: Reports started smoking in her early twenties (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 become a smoker? Finding: Reports quitting on and off over the last 20 years (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 tried to quit smoking? Finding: Asked about living situation, safety, and support system Finding: Reports being single (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: Are you single? Finding: Reports living alone but has service dog (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 live alone? Finding: Reports feeling safe at home (Available) Pro Tip: A patient's social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient's social history can also unveil the influence of their present illnesses in their social lives. Example Question: Do you feel safe at home? Finding: Asked about activity level and exercise Finding: Reports moderate activity level (Found) Pro Tip: A patient's social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient's social history can also unveil the influence of their present illnesses in their social lives. Example Question: What is your activity level? Finding: Reports past bike riding, although she doesn't ride her bike anymore (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: Describe your exercise on a typical day? Finding: Reports walking service dog daily (Found) Pro Tip: A patient's social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient's social history can also unveil the influence of their present illnesses in their social lives. Example Question: Describe your exercise on a typical day? Finding: Reports decreasing activity level (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 been sedentary? Finding: Asked about diet Finding: Reports eating mostly carry-out food (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 are your eating habits? Finding: Reports breakfast is typically a yogurt (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 in an average day? Finding: Reports lunch is typically a sandwich or burger (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 in an average day? Finding: Reports dinner is typically fast food (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 in an average day? Finding: Reports enjoying comfort foods when stressed (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 experienced changes in your eating habits? Finding: Denies binge-eating but feels like she eats more than she should (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 over eat? Finding: Denies eating a low-salt diet (Available) Pro Tip: A patient's social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient's social history can also unveil the influence of their present illnesses in their social lives. Example Question: Do you watch your salt intake? Finding: Asked about appetite Finding: Reports loss of appetite (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 lost your appetite? Finding: Asked about last menstrual period Finding: Reports having menstrual periods (has not yet reached menopause) (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 long ago was your last period? Finding: Reports LMP was 2 weeks ago (Found) Pro Tip: A patient's social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient's social history can also unveil the influence of their present illnesses in their social lives. Example Question: How long ago was your last period? Finding: Reports periods are becoming irregular (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: Is your period regular? Finding: Asked about recent sexual activity Finding: Reports not currently sexually active (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: Are you sexually active? Finding: Reports last sexual activity was more than a year ago (Found) Pro Tip: A patient's social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient's social history can also unveil the influence of their present illnesses in their social lives. Example Question: When did you last have sex? Review of Systems Finding: Asked about general symptoms Finding: Reports weight gain (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 do you feel about your weight? Finding: Denies fever (Available) Pro Tip: Understanding a patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have a fever? Finding: Denies chills (Available) Pro Tip: Understanding a patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you get chills? Finding: Denies night sweats (Available) Pro Tip: Understanding a patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Have you been having night sweats? Finding: Followed up on weight gain Finding: Reports gaining 20 lbs (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: Has your weight changed recently? Finding: Reports weight gain occurred over last 2 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: When was your weight change? Finding: Reports weight gain was unintentional (Found) Pro Tip: Understanding a patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Have you had unexpected weight loss? Finding: Asked about review of systems for gastrointestinal Finding: Denies nausea (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 feeling nauseated? Finding: Denies abdominal pain (Available) Pro Tip: Understanding a patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you currently have abdominal pain? Finding: Denies difficulty swallowing (Available) Pro Tip: Understanding a patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Have you had trouble swallowing? Finding: Denies vomiting (Available) Pro Tip: Understanding a patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Have you been vomiting? Finding: Denies constipation (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 feeling constipated? Finding: Denies diarrhea (Available) Pro Tip: Understanding a patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have diarrhea? Finding: Denies changes in stool or bowel patterns (Available) Pro Tip: Understanding a patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Have you had regular bowel movements? Finding: Asked about review of systems for neurological Finding: Denies weakness (Available) Pro Tip: Understanding a patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you feel weak? Finding: Denies headaches (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 get headaches? Finding: Denies syncope, dizziness, fainting, or vertigo (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: Any dizziness or light headedness? Finding: Denies changes in coordination (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: How is your coordination? Finding: Denies changes in memory (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: How would you describe your memory? Finding: Denies recent falls