Shadow Health - Tina Jones, Health History With Complete Solution 2026

Shadow Health - Tina Jones, Health History With Complete Solution 2026 Health History Tips & Tricks: - ANSWER TJ Health Interview Student: Hello! - ANSWER Diana Shadow: Hi. I'm Preceptor Diana. I will explain the details of this assignment and your objectives, just as a preceptor would in real life. Pay close attention to this information as it will help guide your exam. At the end of this prebrief, you will answer a short question about the upcoming assignment. During the simulation, you may return to these instructions at any time by scrolling to the top of your transcript. Student: What is the situation? - ANSWER Diana Shadow: Your patient is Tina Jones:, a 28-year-old African American woman who has just been admitted to Shadow General Hospital for a painful foot wound. Your role in this simulation is that of a healthcare provider who will take Ms. Jones' health history, a key component of her admission process. Student: What are my objectives in this assessment? - ANSWER Diana Shadow: A health history requires you to ask questions related to Ms. Jones' past and present health, from her current foot wound to her pre-existing conditions. You will also want to review Ms. Jones' systems, psychosocial history, and family medical history. These assessments together will give you a comprehensive picture of Ms. Jones' overall health. If you discover any disease states, ask about symptoms and the patient's experiences of them. Your questioning should cover a broad array of the symptoms' characteristics. Throughout the conversation, you should educate and empathize with Ms. Jones when appropriate to increase her health literacy and sense of well-being. Regardless of whether you have assessed Ms. Jones previously, ask all questions that are necessary for obtaining a complete health history. While you should communicate with patients using accessible, everyday language, it is standard practice to use professional medical terminology everywhere else, such as in documenting physical findings and nursing notes. You may complete the exam activities in any order and move between them as needed. After obtaining Ms. Jones' health history, you will complete an information processing activity. You will identify and prioritize diagnoses, then create a plan to address the identified diagnoses. Student: What else will this exam involve? - ANSWER Diana Shadow: You will complete nursing tasks to protect the patients safety, privacy, and health. You can document your findings, including vital signs, in the Electronic Health Record. This record provides necessary information for healthcare professionals who will continue patient care. Besides Subjective Data Collection, and Education and Empathy, there are activities within the simulation that provide valuable practice for their real-world counterparts, but they are not automatically graded by the simulation. Student: How will I be evaluated? - ANSWER Diana Shadow: In this assignment, you will be evaluated on your Subjective Data Collection, as well as your Education and Empathy. Your success in Education and Empathy is based on whether you promptly respond after identifying a moment worthy of therapeutic communication. The evaluation of your interview is dependent on how you word your questions therapeutically and precisely and explore all relevant topics with comprehensive breadth and depth. You will also be evaluated on your ability to collect data and form nursing diagnoses in the information processing activity. This assignment takes on average between 90 and 110 minutes. This exam may take longer than in real life, because in this safe simulation, students of all experience levels can take time to hone and review their skills. You can pause and resume the assignment at any time; your work is always saved automatically. Student: How does this assignment prepare me for the real world? - ANSWER Diana Shadow: In this assessment, you will become familiarized with the structure and content of a health history exam so that with real-life patients, you can: º ask effective and comprehensive questions º obtain a thorough health history º evaluate the patient's risk of disease, infection, injury, and complications º educate and empathize º reflect on your experience and identify areas to improve º identify and prioritize nursing diagnoses º and develop a plan to address nursing diagnoses. Diana Shadow: In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: Why is it important to obtain a patient's complete health history? - ANSWER Student: So that you understand if there are any problems related to their chief complaint. Also, to help treat their current condition. Diana Shadow: Time to begin. - ANSWER Patient Exam - Vital Signs: - ANSWER Height: 170 cm, Weight: 90 kg, BMI: 31, Random blood glucose: 238, Temperature: 102.4° F, Blood pressure: 138/90 mmHg, Heart rate: 90, Respiratory rate: 18, O2 sat: 98% Patient Exam - Interview: - ANSWER Student: Hello, my name is Catlain, I am your nurse today. - ANSWER Tina Jones: Hey. Student: Can you confirm your name? - ANSWER Tina Jones: Tina Jones:. Student: Why did you come in today? - ANSWER Tina Jones: I got this scrape on my foot a while ago, and it got really infected. It's killing me. Student: What additional symptoms have you experienced? - ANSWER Tina Jones: I mean, it's all red and swollen, and there's pus, it feels hot, it hurts like hell... It's got all that going on. Student: Can you rate your current pain level on a scale of 0 to 10? - ANSWER Tina Jones: ...Like a 7. It hurts a lot, but whatever pain med the ER gave me is helping a little bit. Student: Please describe the pain. - ANSWER Tina Jones: It's throbbing and like, sharp if I try to put weight on it. Student: How did you hurt your foot? - ANSWER Tina Jones: I was changing a light bulb, and I had to use our little stepstool to reach it. My foot slid off the bottom step and it got all scraped up. I didn't realize how sharp the edge was! Student: Has your foot been draining any liquids? - ANSWER Tina Jones: Yeah, there's definitely pus. Student: What color was the pus? - ANSWER Tina Jones: It's... white or maybe off-white. Student: How have you treated the wound? - ANSWER Tina Jones: I've been taking Advil for my foot for a few days. Student: What did you do to treat your foot after your accident? - ANSWER Tina Jones: I made sure to clean it and keep it bandaged. And I put Neosporin on it. Student: How effective was the Neosporin? - ANSWER Tina Jones: Well, I'm here, so I guess it didn't do its job. Student: Can you walk with your foot being injured? - ANSWER Tina Jones: No, I can't. I can't put any weight on it without like, shooting pain. Student: What preexisting medical conditions do you have? - ANSWER Tina Jones: I mean, I have asthma and diabetes, but right I now I just care about my foot! Student: I understand your foot hurts, but I need to know this information to make sure I take care of the problem correctly. - ANSWER Tina Jones: Thanks. Student: When were you diagnosed with diabetes? - ANSWER Tina Jones: I was diagnosed when I was 24. Student: What do you do to manage your asthma? - ANSWER 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. Student: What medications did you take for your diabetes? - ANSWER Tina Jones: It was metformin. Student: Do you currently take medicine for your diabetes? - ANSWER Tina Jones: No, I don't take anything for my diabetes anymore. Student: What made you stop taking medication for your diabetes? - ANSWER Tina Jones: I guess I just got sick of feeling sick and gassy all the time, and it was overwhelming, remembering to take pills and check my sugar. I feel a lot better now that I'm just eating healthier than I did when I was taking the pills. Student: Do you monitor your blood glucose? - ANSWER Tina Jones: I have a monitor at home, but to be honest I don't really use it that often. Student: How frequently do you urinate? - ANSWER Tina Jones: I don't know. Every hour or two when I'm awake? Student: What is your current diet? - ANSWER Tina Jones: It's pretty good, I think. I'm not a huge health nut or anything. Student: Have you had any change in appetite? - ANSWER Tina Jones: Yeah, lately I've definitely been much hungrier than usual. Student: Has your weight changed? - ANSWER Tina Jones: Yeah, I've lost some weight recently. Student: Do you know why you lost weight? - ANSWER Tina Jones: I don't know what caused it, I just lost weight. Student: How often do you have asthma exacerbations? - ANSWER Tina Jones: I haven't had a full attack in years. But my breathing definitely acts up. . .not always. Max twice a week. Student: What asthma symptoms have you experienced? - ANSWER Tina Jones: My chest and throat get tight, and I start to wheeze. It feels like I can't take in air, like I can't get enough air into my lungs. Student: How many puffs do you take when using your asthma inhaler? - ANSWER Tina Jones: I usually use two puffs from my inhaler, but sometimes I need three. [Nurse confirmed with Pharmacy: albuterol 90mcg/spray MDI] Student: What are some things that trigger your asthma? - ANSWER Tina Jones: Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. Student: What allergies do you have? - ANSWER Tina Jones: I'm allergic to cats. Student: When did you realize you were allergic to cats? - ANSWER Tina Jones: For as long as I've been around. Student: How effective was your pain medication at home? - ANSWER Tina Jones: Whatever pain medication the ER gave me is helping. Before I came in, I was just taking Advil. For the past few days, the Advil wasn't doing much for me -- it would only last a couple of hours. Student: What medication allergies do you have? - ANSWER Tina Jones: I'm allergic to penicillin. Student: What food allergies do you have? - ANSWER Tina Jones: I don't have any food allergies that I know of. Student: Are you allergic to dust, mold, or pollen? - ANSWER Tina Jones: Well. . . I don't know if it's allergies, but sometimes my asthma acts up around dust. Student: What immunizations have you received? - ANSWER Tina Jones: I got a tetanus booster for work about a year ago. For the other kinds, I got all the required ones when I was a kid, and for college...I'm sure I have a record somewhere at home. Student: Have you received a flu vaccine? - ANSWER Tina Jones: No. Student: Have you had any prior hospitalizations? - ANSWER Tina Jones: Well, before this I went a bunch of times when I was little, for asthma attacks. This is the first time I've been in the hospital since I was probably sixteen, though. Student: Have you had any gastrointestinal problems? - ANSWER Tina Jones: No. I've never really had stomach or bowel problems. Student: Do you have a family history of psychiatric illness? - ANSWER Tina Jones: No. They're crazy, but nobody's diagnosed with anything. Finding: Reports father was diagnosed with Type 2 diabetes (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her father had diabetes can reveal generational patterns. - ANSWER Example Question: Does your father have health conditions? Finding: Reports father was diagnosed with high blood pressure (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her father had high blood pressure can reveal generational patterns. - ANSWER Example Question: Does your father have health conditions? Finding: Reports father was diagnosed with high cholesterol (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her father had high cholesterol can reveal generational patterns. - ANSWER Example Question: Does your father have health conditions? Finding: Followed up on father's death - ANSWER Finding: Reports father died at age 58 (Found)Pro Tip: Following up on the death of an immediate family member is important for gathering details that could be relevant to the patient's case. Uncovering the age of death can help you assess the patient's current risks. - ANSWER Example Question: How old was your father when he died? Finding: Reports cause of death was a car accident (Found)Pro Tip: Following up on the death of an immediate family member is important for gathering details that could be relevant to the patient's case. Uncovering the cause of death can help you assess the patient's current risks. - ANSWER Example Question: What caused your father's death? Finding: Followed up on coping with father's death - ANSWER Finding: Reports past grief (Found)Pro Tip: Asking about Tina's reaction to her father's death is a vital part of patient-centered care. You may discover that a patient experiencing grief needs additional resources and support. - ANSWER Example Question: How are you coping with your father's death? Finding: Reports feeling at peace now (Found)Pro Tip: Asking about Tina's reaction to her father's death is a vital part of patient-centered care. You should assess her needs to determine if providing any addition resources or support is appropriate. - ANSWER Example Question: How are you coping now? Finding: Asked about paternal grandfather's health - ANSWER Finding: Reports paternal grandfather diagnosed with Type 2 diabetes (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her paternal grandfather had diabetes can reveal generational patterns. - ANSWER Example Question: Does your paternal grandfather have health conditions? Finding: Reports paternal grandfather diagnosed with high blood pressure (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her paternal grandfather had high blood pressure can reveal generational patterns. - ANSWER Example Question: Does your paternal grandfather have health conditions? Finding: Reports paternal grandfather diagnosed with high cholesterol (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her paternal grandfather had high cholesterol can reveal generational patterns. - ANSWER Example Question: Does your paternal grandfather have health conditions? Finding: Reports paternal grandfather died of colon cancer (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if any of her family members had cancer is essential for understanding her risks. - ANSWER Example Question: Have you had any family members with cancer? Finding: Asked about paternal grandmother's health - ANSWER Finding: Reports paternal grandmother diagnosed with high blood pressure (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her paternal grandmother had high blood pressure can reveal generational patterns. - ANSWER Example Question: Does your paternal grandmother have health conditions? Finding: Asked about maternal grandfather's health - ANSWER Finding: Reports maternal grandfather diagnosed with high blood pressure (Available)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her maternal grandfather had high blood pressure can reveal generational patterns. - ANSWER Example Question: Does your maternal grandfather have health conditions? Finding: Reports maternal grandfather diagnosed with high cholesterol (Available)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her maternal grandfather had high cholesterol can reveal generational patterns. - ANSWER Example Question: Does your maternal grandfather have health conditions? Finding: Asked about maternal grandmother's health - ANSWER Finding: Reports maternal grandmother diagnosed with high blood pressure (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her maternal grandmother had high blood pressure can reveal generational patterns. - ANSWER Example Question: Does your maternal grandmother have health conditions? Finding: Reports maternal grandmother diagnosed with high cholesterol (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her maternal grandmother had high cholesterol can reveal generational patterns. - ANSWER Example Question: Does your maternal grandmother have health conditions? Finding: Asked about brother's health - ANSWER Finding: Denies brother having diagnosed health problems (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her brother has any health problems can reveal potential risks. - ANSWER Example Question: Does your brother have health conditions? Finding: Asked about sister's health - ANSWER Finding: Reports sister diagnosed with asthma (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her asthma can help you develop a sense of health patterns within her family. - ANSWER Example Question: Does your sister have health conditions? Finding: Asked about family history of obesity - ANSWER Finding: Reports that family members are overweight (Found)Pro Tip: Asking about trends such as obesity can help you fill in holes in the history that your patient may have missed and can allow you insight into other inherited diseases that affect relatives outside of immediate family. - ANSWER Example Question: Does obesity run in your family? Finding: Asked about family history of thyroid issues - ANSWER Finding: Denies family history of thyroid issues (Found)Pro Tip: Asking about trends such as thyroid issues can help you fill in holes in the history that your patient may have missed, and can allow you insight into other inherited diseases that affect relatives outside of immediate family. - ANSWER Example Question: Do you have a family history of thyroid problems? Finding: Asked about family history of substance abuse - ANSWER Finding: Reports 1 uncle has alcoholism (Found)Pro Tip: Asking about trends in substance abuse can help you understand your patient's risk for inherited diseases linked to addiction. - ANSWER Example Question: Do you have relatives with addiction problems? Finding: Asked about family history of headaches - ANSWER Finding: Denies family history of headaches (Found)Pro Tip: Asking about trends such as headaches can help you fill in holes in the history that your patient may have missed and can allow you insight into other inherited diseases that affect relatives outside of immediate family. - ANSWER Example Question: Do you have a family history of headaches? Review of Systems - ANSWER Finding: Asked about constitutional health - ANSWER Finding: Reports occasional tiredness or fatigue (Available)Pro Tip: Asking about tiredness or fatigue is one possible component of a review of systems interview. The patient's response to questions about general, constitutional health may uncover additional problems not discovered during the discussion of the patient's chief complaint. - ANSWER Example Question: Are you fatigued? Finding: Reports typical sleep pattern (Available)Pro Tip: Asking about the patient's typical sleep pattern is one possible component of a review of systems interview. The patient's response to questions about general, constitutional health may uncover additional problems not discovered during the discussion of the patient's chief complaint. - ANSWER Example Question: Have you noticed changes in your sleep? Finding: Reports fever (Available)Pro Tip: Asking about additional symptoms, such as fever, is one possible component of a review of systems interview. The patient's response to questions about general, constitutional health may uncover additional problems not discovered during the discussion of the patient's chief complaint - ANSWER Example Question: Are you feeling feverish right now? Finding: Denies chills (Available)Pro Tip: Asking about additional symptoms, such as chills, is one possible component of a review of systems interview. The patient's response to questions about general, constitutional health may uncover additional problems not discovered during the discussion of the patient's chief complaint. - ANSWER Example Question: Have you had chills? Finding: Denies night sweats (Available)Pro Tip: Asking about additional symptoms, such as night sweats, is one possible component of a review of systems interview. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint. - ANSWER Example Question: Have you had night sweats? Finding: Asked about review of systems for mental health - ANSWER Finding: Denies depression (Available)Pro Tip: Asking about the patient's history with depression is one possible component of a review of systems interview and may provide insight into their ability to cope in the event of painful physical trauma. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint. - ANSWER Example Question: Do you have a history of depression? Finding: Denies suicidal ideation or attempts (Available)Pro Tip: Asking about the patient's suicidal ideation one possible component of a review of systems interview and may provide insight into their ability to cope in the event of painful physical trauma. Higher levels of pain have been associated with thoughts of self-harm. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint. - ANSWER Example Question: Do you have a history of suicidal thinking? Finding: Asked about review of systems for head - ANSWER Finding: Reports occasional headaches (Available)Pro Tip: Asking about headache frequency is one possible component of a review of systems interview. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint. - ANSWER Example Question: Do you ever get headaches? Finding: Denies current headache (Available)Pro Tip: Asking Tina is she currently has a headache is important because it might be contributing to her current discomfort and should be treated promptly. - ANSWER Example Question: Do you have a headache? Finding: Denies head injury (Available)Pro Tip: Asking about the patient's history of physical trauma, including head injury, is one possible component of a review of systems interview. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint. - ANSWER Example Question: Have you had any head injuries? Finding: Asked about review of systems for ears - ANSWER Finding: Denies change in hearing (Available)Pro Tip: Asking about changes in hearing is one possible component of a review of systems interview. The patient's response to questions about this topic may uncover additional problems, such as hearing loss, not discovered during the discussion of the patient's chief complaint. - ANSWER Example Question: Has your hearing changed? Finding: Denies ringing or tinnitus (Available)Pro Tip: Ringing in the ears can suggest an ear infection, during which the middle of the ear becomes clogged with fluid and mucous, which can affect hearing, or hearing loss. Asking Tina if she has ear pain might indicate a possible ear infection and a reason for changes in her hearing. - ANSWER Example Question: Do you ever have ringing in your ears? Finding: Denies ear pain (Available)Pro Tip: Ear pain can suggest an ear infection, during which the middle of the ear becomes clogged with fluid and mucous, which can affect hearing. Asking Tina if she has ear pain might indicate a possible ear infection and a reason for changes in her hearing. - ANSWER Example Question: Have you had ear pain? Finding: Denies ear discharge (Available)Pro Tip: Ear discharge is the leakage of blood, pus, or wax from the ear and can be the result of a ruptured eardrum, eczema, or swimmer's ear. Asking whether she's noticed ear discharge could indicate whether she has a ruptured eardrum. - ANSWER Example Question: Have you had ear discharge? Finding: Asked about review of systems for eyes and vision - ANSWER Finding: Reports periods of blurry vision (Found)Pro Tip: Asking about changes in vision is one possible component of a review of systems interview. 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 vision loss. - ANSWER Example Question: Have you noticed any changes in your vision? Finding: Denies corrective lenses (Available)Pro Tip: Asking about the patient's use of corrective lenses is one possible component of a review of systems interview. 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 vision loss. - ANSWER Example Question: Do you wear glasses or contacts? Finding: Reports infrequent itchy eyes (Available)Pro Tip: Asking about symptoms, such as itchy eyes, is one possible component of a review of systems interview. 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 allergic reactions or infection. - ANSWER Example Question: Have you had itchy eyes? Finding: Reports infrequent eye redness (Available)Pro Tip: Asking about symptoms, such as eye redness, is one possible component of a review of systems interview. 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 allergic reactions or infection. - ANSWER Example Question: Have you had red eyes? Finding: Reports infrequent discharge, crusting or wateriness (Available)Pro Tip: Asking about symptoms, such as eye discharge, is one possible component of a review of systems interview. 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 allergic reactions or infection. Example Question: Have you had watery eyes? - ANSWER Finding: Denies eye pain (Available)Pro Tip: Asking about symptoms, such as eye pain, is one possible component of a review of systems interview. 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 allergic reactions, infection, or physical trauma. - ANSWER Example Question: Have you had eye pain? Finding: Denies dry eyes (Available)Pro Tip: Dry eyes occur when the eyes do not produce enough tears to lubricate them. Asking Tina if she has dry eyes solicits information about one particular symptom. - ANSWER Example Question: Have you had dry eyes? Finding: Asked about review of systems for nose - ANSWER Finding: Denies current nose problems (Found)Pro Tip: Asking about symptoms, such as nose problems, is one possible component of a review of systems interview. 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 allergic reactions, infection, or physical trauma. - ANSWER Example Question: Do you have any nose problems right now? Finding: Reports infrequent runny nose (Found)Pro Tip: Asking about symptoms, such as runny nose, is one possible component of a review of systems interview. 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 unspecified allergies. - ANSWER Example Question: Have you had a runny nose? Finding: Reports infrequent sinus problems (Available)Pro Tip: Asking about symptoms, such as frequent sinus issues, is one possible component of a review of systems interview. 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 unspecified allergies. - ANSWER Example Question: Have you had problems with your sinuses? Finding: Denies nosebleeds (Available)Pro Tip: Asking about symptoms, such as frequent nosebleeds, is one possible component of a review of systems interview. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint. - ANSWER Example Question: Have you had nosebleeds? Finding: Denies change in sense of smell (Available)Pro Tip: Asking about symptoms, such as a change in smell, is one possible component of a review of systems interview. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint. - ANSWER Example Question: Has your sense of smell changed? Finding: Asked about review of systems for mouth and jaw - ANSWER Finding: Denies dental problems (Found)Pro Tip: Asking about symptoms, such as dental problems, is one possible component of a review of systems interview. 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. - ANSWER Example Question: Do you have any mouth problems? Finding: Reports last dental visit was several years ago (Available)Pro Tip: Asking about a patient's dental care is one possible component of a review of systems interview. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint. - ANSWER Example Question: When did you last see a dentist? Finding: Denies change in sense of taste (Available)Pro Tip: Asking about symptoms, such as a change in taste, is one possible component of a review of systems interview. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint. - ANSWER Example Question: Has your sense of taste changed? Finding: Denies dry mouth (Available)Pro Tip: Asking about symptoms, such as dry mouth, is one possible component of a review of systems interview. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint. - ANSWER Example Question: Have you had dry mouth? Finding: Denies mouth pain (Available)Pro Tip: Asking about symptoms, such as oral pain, is one possible component of a review of systems interview. 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. - ANSWER Example Question: Have you had mouth pain? Finding: Denies mouth sores (Available)Pro Tip: Asking about symptoms, such as mouth sores, is one possible component of a review of systems interview. 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. - ANSWER Example Question: Have you had mouth sores? Finding: Denies gum problems (Available)Pro Tip: Asking about symptoms, such as gum problems, is one possible component of a review of systems interview. 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. - ANSWER Example Question: Have you had gum problems? Finding: Denies tongue problems (Available)Pro Tip: Asking about symptoms, such as tongue pain, is one possible component of a review of systems interview. 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. - ANSWER Example Question: Have you had tongue problems? Finding: Denies jaw problems (Available)Pro Tip: Asking about symptoms, such as jaw problems, is one possible component of a review of systems interview. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint. - ANSWER Example Question: Have you had jaw problems? Finding: Asked about review of systems for neck, throat and glands - ANSWER Finding: Denies difficulty swallowing (Available)Pro Tip: Asking if a patient has difficulty swallowing is one possible component of a review of systems interview. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint. - ANSWER Example Question: Have you had difficulty swallowing? Finding: Denies sore throat (Available)Pro Tip: Asking if a patient has a sore throat is one possible component of a review of systems interview. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint. - ANSWER Example Question: Have you had a sore throat? Finding: Denies lymph node problems (Available)Pro Tip: Asking about a patient's lymph nodes is one possible component of a review of systems interview. Swollen lymph nodes may appear in the neck when an infection is present. - ANSWER Example Question: How are your lymph nodes? Finding: Denies frequent sore throat (Available)Pro Tip: Asking if a patient has recurring throat problems is one possible component of a review of systems interview. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint. - ANSWER Example Question: Do you have any throat problems? Finding: Denies swollen glands (Found)Pro Tip: Asking about a patient's glands in general could include lymph nodes or thyroid glands. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint. - ANSWER Example Question: Do you have any swollen glands? Finding: Denies voice changes (Available)Pro Tip: Asking about changes in a patient's voice is one possible component of a review of systems interview. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint. - ANSWER Example Question: Have you had voice changes? Finding: Asked about breast health - ANSWER Finding: Reports doing occasional breast exams (Available)Pro Tip: Asking if a patient perform breast self-examinations is important because it reveals a patient's level of health literacy. - ANSWER Example Question: Do you perform breast self-examinations? Finding: Denies swelling (Available)Pro Tip: Asking about abnormal characteristics of a patient's breasts, such as swelling, is one way of assessing overall breast health. - ANSWER Example Question: Do you have any breast swelling? 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. - ANSWER Example Question: Do you have a rash on your breasts? Finding: Denies lumps (Available)Pro Tip: Asking about abnormal characteristics of a patient's breasts, such as lumps, is one way of assessing overall breast health. Lumps have a range of severity, as they could be the result of breast injury or cancerous growths, but any abnormalities should be handled with the highest level of concern. - ANSWER Example Question: Do you have any lumps in your breasts? Finding: Denies nipple discharge (Available)Pro Tip: Asking about abnormal characteristics of a patient's breasts, such as nipple discharge, is one way of assessing overall breast health. - ANSWER Example Question: Have you experienced nipple discharge? Finding: Denies ever having a mammogram (Available)Pro Tip: Inquiring into what breast screenings Tina has had can lead to a discussion about any test results and their implications for her cardiovascular health. If she has not had any screenings, it provides an opportunity for patient education. - ANSWER Example Question: Have you had a mammogram? Finding: Denies history of breast cancer (Available)Pro Tip: If a patient has a history of breast cancer, it is important that you look for signs of recurrence and engage in preventative care, as well as patient education. You may also need to provide further support and resources to the patient. - ANSWER Example Question: Have you had breast cancer? Finding: Asked about review of systems for respiratory - ANSWER Finding: Denies current breathing problems (Available)Pro Tip: Asking about general breathing problems can provide a comparative baseline for assessing Tina's current condition and previous breathing concerns. - ANSWER Example Question: Have you had breathing problems? Finding: Denies current wheezing (Available)Pro Tip: Patients who experience chronic asthma may be accustomed to wheezing and, as a result, might not volunteer this information. Asking Tina if she's been wheezing illustrates how her asthma is presenting. - ANSWER Example Question: Have you been wheezing? Finding: Denies current chest tightness (Available)Pro Tip: Asking about chest tightness is one possible component of a review of systems interview. As a currently presenting symptom, it could indicate a change in patient status. If the patient reports a history of chest tightness, it could be a symptom of asthma or another respiratory problem. - ANSWER Example Question: Have you had chest tightness? Finding: Denies pain while breathing (Available)Pro Tip: Asking about pain during breathing is one possible component of a review of systems interview. As a currently presenting symptom, it could indicate a change in patient status. If the patient reports a history of pain during breathing, it could be a symptom of asthma or another respiratory problem. - ANSWER Example Question: Does it hurt when you breathe? Finding: Denies frequent coughing (Available)Pro Tip: Asking about coughing is one possible component of a review of systems interview. As a currently presenting symptom, it could indicate an asthma exacerbation or a new respiratory infection. - ANSWER Example Question: Have you been coughing? Finding: Asked about review of systems for cardiovascular - ANSWER Finding: Denies chest pain or discomfort (Available)Pro Tip: Asking about chest pain is one possible component of a review of systems interview. As a currently presenting symptom, it could indicate a change in patient status. If the patient reports a history of chest pain, it could be a symptom of a recurring cardiovascular problem. - ANSWER Example Question: Do you ever have chest pain? Finding: Denies palpitations (Available)Pro Tip: Asking about palpitations is one possible component of a review of systems interview. As a currently presenting symptom, it could indicate a change in patient status. If the patient reports a history of palpitations, it could be a symptom of a recurring cardiovascular problem. - ANSWER Example Question: Have you had palpitations? Finding: Denies irregular heartbeat (Available)Pro Tip: Asking about heartbeat patterns is one possible component of a review of systems interview. As a currently presenting symptom, it could indicate a change in patient status. If the patient reports a history of irregular heartbeat, it could be a symptom of a recurring cardiovascular problem. - ANSWER Example Question: Has your heartbeat been irregular? Finding: Denies easy bruising (Available)Pro Tip: Asking if a patient bruises easily is one possible component of a review of systems interview. Bruising easily can be indicative of anemia or a more serious blood disorder. - ANSWER Example Question: Have you noticed bruising more than usual? Finding: Denies edema (Available)Pro Tip: Asking about edema is one possible component of a review of systems interview. Edema is caused by the presence of excess fluid in the tissues, and it can indicate an infection, weak heart or veins, or other organ problems. - ANSWER Example Question: Have you noticed any swelling in your legs? Finding: Denies circulation problems (Available)Pro Tip: Poor circulation is the result of other diseases like obesity, diabetes, or cardiac conditions. Asking Tina whether she's experienced poor circulation indicates whether she might suffer from underlying cardiac concerns. - ANSWER Example Question: Do you have circulation problems? Finding: Asked review of systems for gastrointestinal - ANSWER Finding: Denies nausea (Available)Pro Tip: Currently presenting nausea can be caused by changes in blood sugar, a reaction to medication, stress, or even spreading infection. If the patient reports a history of nausea, it could be a symptom of a recurring gastrointestinal problem. - ANSWER Example Question: Have you had nausea? Finding: Denies vomiting (Available)Pro Tip: Vomiting can be caused by a pain response, a reaction to medication, stress, or even spreading infection. If the patient reports a history of vomiting, it could be a symptom of a recurring gastrointestinal problem. - ANSWER Example Question: Have you been vomiting? Finding: Denies stomach pain (Available)Pro Tip: Asking about stomach pain is one possible component of a review of systems interview. As a currently presenting symptom, it could indicate a change in patient status. If the patient reports recurring stomach pain, it could be a symptom of a gastrointestinal problem. - ANSWER Example Question: Do you have stomach pain? Finding: Denies change in bowel movements (Available)Pro Tip: Asking about changes in bowel movements can help you understand a patient's baseline patterns. Any recent or abrupt changes could impact the patient's care plan, such as administering treatment for constipation or diarrhea. - ANSWER Example Question: Have you had changes in your bowel movements? Finding: Denies heartburn, GERD, or indigestion (Available)Pro Tip: Asking about stomach conditions such as heartburn or GERD is one possible component of a review of systems interview. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint. - ANSWER Example Question: Do you ever get heartburn? Finding: Denies constipation (Available)Pro Tip: Asking about constipation is one possible component of a review of systems interview. As a currently presenting symptom, it could impact the patient's care plan. If the patient reports a history of constipation, it could be a symptom of dietary or gastrointestinal problems. - ANSWER Example Question: Do you have constipation? Finding: Denies diarrhea or loose stool (Available)Pro Tip: Asking about diarrhea is one possible component of a review of systems interview. As a currently presenting symptom, it could impact the patient's care plan. If the patient reports a history of diarrhea, it could be a symptom of dietary or gastrointestinal problems. - ANSWER Example Question: Do you have diarrhea? Finding: Denies excessive flatulence or bloating (Available)Pro Tip: Asking about gas or bloating is one possible component of a review of systems interview. As a currently presenting symptom, it could impact the patient's care plan. If the patient reports a history of gas, it could be a symptom of dietary or gastrointestinal problems. Example Question: Do you have flatulence? - ANSWER Finding: Asked review of systems for urinary - ANSWER Finding: Denies painful or difficult urination (Available)Pro Tip: Asking about pain during urination is one possible component of a review of systems interview. As a currently presenting symptom, it could result in a change to the patient's care plan. A history of pain during urination could be a symptom of genitourinary problems. - ANSWER Example Question: Does it hurt when you urinate? Finding: Reports waking up to urinate during the night (Available)Pro Tip: Frequent urination at night can be a sign of uncontrolled blood sugar or UTI. As a currently presenting symptom, nocturia could result in a change to the patient's care plan. A history of nocturia could be a symptom of genitourinary or endocrine problems such as diabetes. - ANSWER Example Question: Do you wake up at night to urinate? Finding: Reports large amount of urine (Found)Pro Tip: Polyuria is a common symptom of diabetes. Establishing that Tina is producing a large amount of urine is important for understanding the current state of her condition and treatment needs. - ANSWER Example Question: Do you urinate frequently? Finding: Denies blood in urine (Available)Pro Tip: As a currently presenting symptom, blood in the urine is a serious symptom that requires immediate intervention. A history of hematuria could be a symptom of genitourinary problems. - ANSWER Example Question: Do you ever notice blood in your urine? Finding: Denies flank pain (Available)Pro Tip: Flank pain can be a sign of kidney infection. As a currently presenting symptom, flank pain could result in a change to the patient's care plan. A history of flank pain could be a symptom of genitourinary problems. - ANSWER Example Question: Do you have flank pain? Finding: Denies incontinence (Available)Pro Tip: As a currently presenting symptom, incontinence could result in a change to the patient's care plan. A history of incontinence could be a symptom of genitourinary or pelvic problems. Example Question: Are you able to hold your urine? - ANSWER Finding: Denies history of urinary tract or bladder infection (Available)Pro Tip: Asking about a history of bladder or urinary tract infections is one possible component of a review of systems interview. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint. - ANSWER Example Question: Have you ever had a urinary infection? Finding: Asked review of systems for reproductive - ANSWER Finding: Reports last menstrual period was 3 weeks ago (Available)Pro Tip: Establishing the patient's last menstrual period will help you determine if the patient could be pregnant. A potential pregnancy impacts important parts of the patient's care plan, including which medications are administered. - ANSWER Example Question: When was your last period? Finding: Reports that periods are irregular (Available)Pro Tip: Asking about menstrual regularity is one possible component of a review of systems interview. A history of irregular periods could indicate hormonal or endocrine problems. - ANSWER Example Question: Are your periods regular? Finding: Denies past pregnancies (Available)Pro Tip: A patient's history of pregnancy can shed light on other health conditions, body systems, or risk factors. It's important to learn about any past pregnancies, live births, or miscarriages. - ANSWER Example Question: Have you ever been pregnant? Finding: Denies vaginal itching or discomfort (Available)Pro Tip: Asking about vaginal discomfort, such as itching or burning, is one possible component of a review of systems interview. Symptoms like these could indicate a yeast or sexually transmitted infection. - ANSWER Example Question: Do you experience vaginal burning? Finding: Reports normal vaginal discharge (Available)Pro Tip: Asking about vaginal discharge is one possible component of a review of systems interview. If a patient reports atypical discharge, it could indicate a yeast or sexually transmitted infection. - ANSWER Example Question: What is your vaginal discharge like? Finding: Denies history of STIs (Available)Pro Tip: Asking about a patient's history of STIs is one possible component of a review of systems interview. A history of STIs could cause complications with the genitourinary system. - ANSWER Example Question: Have you ever been diagnosed with a sexually transmitted infection? Finding: Reports past condom use (Available)Pro Tip: Asking about a patient's past condom use is one possible component of a review of systems interview. Sexual activity without condoms increases a patient's risk of STIs, and can be an indicator of a patient's health literacy. - ANSWER Example Question: Do you use condoms when you are sexually active? Finding: Denies other injuries besides foot wound (Available)Pro Tip: Discovering additional injuries can reveal more information about the circumstances that caused the presenting injury. - ANSWER Example Question: Did you injure anything besides your foot? Finding: Reports being barefoot at the time of injury (Available)Pro Tip: Asking about clothing, footwear, and other protective elements being worn at the time of injury helps you discover the totality of the circumstances. - ANSWER Example Question: Were you wearing shoes when you fell? Finding: Denies seeing a healthcare provider for the injury until now (Available)Pro Tip: It's crucial to ask whether your patient has seen another provider for the injury, because any previous medical intervention will help you understand the progression of the wound. - ANSWER Example Question: Have you seen a healthcare provider for this injury? Finding: Asked about drainage from the foot wound - ANSWER Finding: Reports that the wound bled a little after sustaining the injury (Available)Pro Tip: Asking about bleeding helps you determine the characteristics of a wound. - ANSWER Example Question: Did your foot bleed? Finding: Reports seeing pus draining from wound (Found)Pro Tip: Asking about discharge helps you determine the characteristics of a wound. - ANSWER Example Question: Did you notice any discharge from the wound? Finding: Reports noticing pus 2 days ago (Available)Pro Tip: Pinpointing exactly when the patient noticed the arrival of pus gives you an important data point for when an active infection began. - ANSWER Example Question: When did you first notice the pus? Finding: Followed up on drainage - ANSWER Finding: Reports pus as white or yellow (Found)Pro Tip: The color of discharge from a wound can provide insight into its severity and characteristics. - ANSWER Example Question: What color is the drainage from your wound? Finding: Denies odor from the wound (Available)Pro Tip: The odor of discharge from a wound can provide insight into its severity and characteristics. - ANSWER Example Question: Does the wound have an odor? Finding: Asked about home treatment of foot wound - ANSWER Finding: Reports wound care regimen of bandaging (Available)Pro Tip: Asking specifically how often a patient changed a bandage will let you know if an infection spread through improper hygiene, or for other reasons such as uncontrolled blood sugar. - ANSWER Example Question: How often do you change your bandage? Finding: Reports cleaning wound twice a day (Available)Pro Tip: Asking specifically how often a patient cleaned a wound will let you know if an infection spread through improper hygiene, or for other reasons such as uncontrolled blood sugar. - ANSWER Example Question: How often did you clean the wound? Finding: Reports applying bacitracin, neomycin and polymyxin B (Neosporin) (Found)Pro Tip: Determining what products a patient used to sterilize or treat a wound establishes home care routines and health literacy. - ANSWER Example Question: Did you use any ointment on the wound? Finding: Followed up on effectiveness of ointment - ANSWER Finding: Reports bacitracin, neomycin and polymyxin B (Neosporin) was ineffective (Found)Pro Tip: Understanding the effect of a home medication can help you determine the severity of the wound. Tina's diabetes diagnosis will have a large impact on her body's healing ability, which should be taken into consideration during your exam. - ANSWER Example Question: Did the ointment help? Finding: Asked about other foot wound symptoms - ANSWER Finding: Reports swelling around foot wound (Found)Pro Tip: Asking about the presence of swelling helps you gather information about your patient's complaint, as well as potential related illnesses. - ANSWER Example Question: Is there swelling around the wound? Finding: Reports swelling worsened in the past 2 days (Available)Pro Tip:Finding out how long swelling appeared will help you understand the timeline for the infection progression. - ANSWER Example Question: How long have you noticed swelling around the wound? Finding: Reports redness around the wound (Found)Pro Tip: Asking about redness will help you understand the timeline for the infection progression. - ANSWER Example Question: Did you notice any redness around the wound? Finding: Reports that the wound feels warm (Found)Pro Tip: Asking about warmth will help you understand the timeline for the infection progression. - ANSWER Example Question: Does the wound feel warm? Finding: Explored impact of patient's foot injury on activities of daily living - ANSWER Finding: Reports pain affects ability to walk (Available)Pro Tip: Understanding the impact of your patient's wound on daily activities helps inform your plan for care. With a foot wound, it is imperative to discern if a patient can walk or not, as a lack of mobility can compromise quality of life. - ANSWER Example Question: Does your injury impact your ability to walk? 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. With a foot wound, it is imperative to discern if a patient can stand or not, as this can compromise quality of life and impact job performance. - ANSWER Example Question: Does your foot pain affect your work? Finding: Reports pain prevented her from being able to walk to class (Available)Pro Tip: For patients who are also students, you can find out what schoolwork they are missing, and help them make accommodations so they don't fall behind. - ANSWER Example Question: Has your injury prevented you from going to class? Past Medical History - ANSWER Finding: Asked about preexisting medical conditions - ANSWER Finding: Reports diabetes (Found)Pro Tip: It is important to identify any existing medical conditions, as that information is an integral part of a complete health history. Existing conditions can also inform your treatment and understanding of the patient's current health issues. In Tina's case, it is important to identify her diabetes diagnosis because that condition has a direct relationship with her current foot infection. - ANSWER Example Question: Do you have any existing conditions? Finding: Reports asthma (Found)Pro Tip: It is important to identify any existing medical conditions, such as Tina's asthma, because that information is an integral part of her health history. Existing conditions can also inform your treatment and understanding of the patient's current health issues. - ANSWER Example Question: Do you have any other conditions? Finding: Followed up on diabetes diagnosis - ANSWER Finding: Reports specific age of diagnosis was 24 (Found)Pro Tip: Learning the diagnosis date of your patient's illness is an essential element of the illnesses history. - ANSWER Example Question: At what age were you diagnosed with diabetes? Finding: Reports that her diabetes is Type 2 (Available)Pro Tip: The type of diabetes your patient has will drastically affect how you care for her. - ANSWER Example Question: Do you know what type of diabetes you have? Finding: Asked about diabetes management through lifestyle changes - ANSWER Finding: Reports staying away from sweets (Available)Pro Tip: Asking your patient specifically about sugar intake can help you understand the history of her diabetes as well as her health literacy. - ANSWER Example Question: Tell me more about any sugars you consume. Finding: Reports drinking diet coke instead of regular (Available)Pro Tip: Particularly for diabetic patients, asking about intake of drinks that contain sugar can reveal additional sources of carbohydrates that the patient may not consider. - ANSWER Example Question: Do you drink sugary drinks? Finding: Asked about current diabetes medication use - ANSWER Finding: Reports that she does not currently take medication for diabetes (Found)Pro Tip: Asking about diabetes medication is important to understanding if your patient's disease is under control. - ANSWER Example Question: Do you take prescribed medication for your diabetes? Finding: Asked about past diabetes medication use - ANSWER Finding: Reports that she used to take diabetes medication (Found)Pro Tip: Asking about Tina's medication history for asthma will provide a timeline of treatment. You will be able to see what has been effective and ineffective in the past, which will allow you to make a more informed decision about current treatment. - ANSWER Example Question: Have you ever taken medication for your diabetes? Finding: Reports previous medication was prescription metformin (Found)Pro Tip: Asking about a patient's medication history for a particular condition, such as Tina's past prescription for metformin, will provide a timeline of her asthma treatment. You will be able to see what has been effective and ineffective in the past, which will allow you to make a more informed decision about current treatment. - ANSWER Example Question: Do you remember what you were prescribed for diabetes? Finding: Reports last use of medication was 3 years ago (Available)Pro Tip: It important to discover when Tina stopped taking any medications and what caused her to stop. Discovering her reason for noncompliance will allow you to make a more informed decision about current treatment. - ANSWER Example Question: When was the last time you took your diabetes medication on a regular basis? Finding: Followed up on stopping diabetes regimen - ANSWER Finding: Reports disliking diabetes medication side effects (Found)Pro Tip: Asking about side effects from medication can provide information about your patient's reaction to treatment. - ANSWER Example Question: Did the metformin cause any side effects? Finding: Reports that she didn't like checking sugar and taking daily pills (Found)Pro Tip: Asking reasons for noncompliance can reveal information about your patient's health literacy, side effects, financial situation, and more. - ANSWER Example Question: What's preventing you from taking your diabetes medication? Finding: Asked about blood glucose monitoring - ANSWER Finding: Reports infrequent blood glucose monitoring (Found)Pro Tip: Your patient's blood sugar monitoring habits are an important part of her health literacy and home treatment. - ANSWER Example Question: Tell me about your blood sugar monitoring. Finding: Reports she last checked blood sugar a month ago (Available)Pro Tip: Your patient's blood sugar monitoring habits are an important part of her health literacy and home treatment. - ANSWER Example Question: How often do you check your blood sugar? Finding: Reports confusion about what the numbers mean (Available)Pro Tip: Your patient's blood sugar monitoring habits are an important part of her health literacy and home treatment. If you find gaps in the patient's literacy, that is your opportunity to provide education. - ANSWER Example Question: What are your usual blood sugar levels? Finding: Asked about thirst - ANSWER Finding: Reports increased thirst (Found)Pro Tip: Your patient's thirst can offer insight into underlying medical conditions. Knowing that Tina is diabetic, you will want to explore this classic symptom of the condition. - ANSWER Example Question: Have you been more thirsty lately? Finding: Reports increased water intake (Available)Pro Tip: Your patient's fluid intake can offer insight into underlying medical conditions. Knowing that Tina is diabetic, you will want to explore this classic symptom of the condition. - ANSWER Example Question: Are you drinking more water than normal? Finding: Asked about frequency of urination - ANSWER Finding: Reports more frequent urination (Found)Pro Tip: Your patient's urination habits can offer insight into underlying medical conditions and general health. Knowing that Tina is diabetic, you will want to explore this classic symptom of the condition. - ANSWER Example Question: Have you been urinating more often than usual? Finding: Reports urinating every hour or two during the day (Found)Pro Tip: Your patient's urination habits can offer insight into underlying medical conditions and general health. Knowing that Tina is diabetic, you will want to explore this classic symptom of the condition. - ANSWER Example Question: How often do you urinate during the day? Finding: Reports urinating 2 to 3 times during the night (Available)Pro Tip: Discovering if Tina has nocturia can offer insight into underlying medical conditions and general health. - ANSWER Example Question: How often do you wake up at night to urinate? Finding: Asked about diet - ANSWER Finding: Reports eating a bowl of cereal for breakfast yesterday (Available)Pro Tip: In a health history, it is important to get an idea of a patient's typical dietary patterns. This can be achieved by asking for a 24-hour diet recall. - ANSWER Example Question: What did you eat for breakfast yesterday? Finding: Reports eating mac and cheese for lunch yesterday (Available)Pro Tip: In a health history, it is important to get an idea of a patient's typical dietary patterns. This can be achieved by asking for a 24-hour diet recall. - ANSWER Example Question: What did you eat for lunch yesterday? Finding: Reports eating chicken and roll for dinner yesterday (Available)Pro Tip:Finding out the foods a patient last ate can provide evidence for any current stomach upset and for their current level of hunger and blood sugar status and can affect medications given while in your care. - ANSWER Example Question: What did you eat for your last meal? Finding: Asked about change in appetite - ANSWER Finding: Reports increased appetite (Found)Pro Tip: Identifying if a patient has recently experienced a change in appetite is important, as it could indicate an underlying endocrine or psychiatric condition. - ANSWER Example Question: Have you noticed an increase in appetite? Finding: Reports change in appetite began a month ago (Available)Pro Tip: Determining the onset of appetite change can reveal important details about underlying health conditions. - ANSWER Example Question: When did you notice the increase in your appetite? Finding: Asked about weight change - ANSWER Finding: Reports recent loss of 10 lbs (Available)Pro Tip: Determining the exact amount of weight loss can indicate whether i