SHADOWHEALTH HEENT SUBJECTIVE

SHADOWHEALTH HEENT SUBJECTIVE Subjective Data Collection: 32 of 32 (100.0%) Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions. Found: Indicates an item that you found. Available: Indicates an item that is available to be found. Category Scored Items Experts selected these topics as essential components of a strong, thorough interview with this patient. Patient Data Not Scored A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case. Relevant Medical History Finding: Asked about history of headache Finding: Reports occasional headaches (Found)Pro Tip: Sinus problems can result in increased pressure buildup and headaches. Asking Tina if she gets headaches is soliciting information about possible symptoms that she experiences.Example Question:Do you get headaches? Finding: Asked about frequency and/or duration of headaches Finding: Headaches occur once a week (Found)Pro Tip: Establishing a timeline for how often Tina gets headaches will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers.Example Question:How frequently do your headaches occur? Finding: Headaches last "a few hours" (Found)Pro Tip: Establishing a timeline for how long Tina's headaches last will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers.Example Question:For how long do your headaches last? Finding: Asked about character and location of headaches Finding: Describes headaches as tight and throbbing (Found)Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.Example Question:What do your headaches feel like? Finding: Describes headache location as behind her eyes (Found)Pro Tip: Specifying the location of pain can narrow and define where Tina's pain is occurring. Soliciting this information allows you to more accurately treat her symptoms.Example Question:Where do you feel your headaches? Finding: Asked to rate headache pain on a scale Finding: Rates headaches as a 2 or 3 (Found)Pro Tip: Pain severity might change for a variety of reasons. Asking Tina to rate the severity of her pain on a scale of 1-10 will provide a quantified and relative measurement of her condition.Example Question:On a scale of 1 to 10, how bad are your headaches? Finding: Asked about headache treatment Finding: Reports treating headaches with Tylenol (Found)Pro Tip: Tina's response to a question about managing her headaches will reveal the severity of her symptoms, her health literacy, and the way she's complied with previous treatment plans.Example Question:Do you take anything to treat your headaches? Finding: Reports Tylenol and rest usually resolve symptoms (Found)Pro Tip: Tina's response to a question about managing her headaches will reveal the severity of her symptoms, her health literacy, and the way she's complied with previous treatment plans.Example Question:Does the Tylenol help with your headaches? Finding: Asked about headache triggers Finding: Reports headaches only happen when reading or studying (Found)Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.Example Question:When do you get headaches? Finding: Reports that blurry vision and headaches often coincide (Available)Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.Example Question:Do your headaches coincide with your blurry vision? Finding: Asked about vision problems Finding: Reports occasional blurry vision (Found)Pro Tip: Broad, open questions will allow Tina to describe, in her own words, the specific pain and discomfort that she is experiencing.Example Question:Have you been having problems with your vision? Finding: Asked about character of blurry vision Finding: Describes blurry vision as "fuzzy letters" (Found)Pro Tip: Broad, open questions will allow Tina to describe, in her own words, the specific pain and discomfort that she is experiencing.Example Question:What's your blurry vision like? Finding: Asked about onset and frequency of blurry vision Finding: Reports worsening vision began within the past year (Found)Pro Tip: Establishing a timeline of when Tina's blurry vision has been worsening will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers.Example Question:When did your vision begin worsening? Finding: Blurry vision only occurs when reading for long periods (Found)Pro Tip: Establishing a timeline of Tina's blurry vision will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers.Example Question:When does your blurry vision occur? Finding: Reports noticing it increasing in the past few months (Available)Pro Tip: Establishing a timeline of Tina's blurry vision will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers.Example Question:Have you been getting blurry vision more often? Finding: Asked about relieving factors for blurry vision Finding: Reports that resting eyes seems to help (Found)Pro Tip: Tina's response to a question about recent vision management will reveal the severity of her symptoms, her health literacy, and the way she's complied with previous treatment plans.Example Question:What makes your blurry vision go away? Finding: Asked about vision care Finding: Reports last vision exam was in childhood (Found)Pro Tip: Asking Tina when her last vision test was will indicate the degree to which she's seen her vision as something that has needed medical attention.Example Question:When was your last vision exam? Finding: Reports no corrective lens use (Found)Pro Tip: Corrective lenses ight indicate a recent change in vision. Asking Tina whether she has glasses or contacts solicits information about her vision history.Example Question:Do you use corrective lenses? Finding: Asked about current nasal problems Finding: Reports no current nasal problems (Found)Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.Example Question:Do you ever have a runny nose? Review of Systems Finding: Asked about eye problems Finding: Reports occasional itchy eyes (Found)Pro Tip: Environmental factors can often be primary allergy triggers. Asking whether Tina's cat allergy can make her eyes itch can reveal one such trigger.Example Question:Does your cat allergy make your eyes itch? Finding: Reports no general eye problems other than blurry vision (Found)Pro Tip: Sinusitis can create pressure behind the eyes, causing eye pain. Asking Tina whether she is experiencing eye pain solicits information about possible symptoms.Example Question:Do you have general problems with your eyes? Finding: Reports no eye pain (Found)Pro Tip: Sinusitis can create pressure behind the eyes, causing eye pain. Asking Tina whether she is experiencing eye pain solicits information about possible symptoms.Example Question:Do you have eye pain? Finding: Reports no eye dryness (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.Example Question:Do you have eye dryness? Finding: Reports no eye redness (Available)Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.Example Question:Do you have eye redness? Finding: Asked about triggers for itchy eyes Finding: Reports cat allergy is trigger for itchy eyes (Found)Pro Tip: Discerning what's making Tina's eyes itch can point to possible triggers like environmental factors, bodily positions, or movements that may have a bearing on Tina's breathing.Example Question:Does being around cats make your eyes itch? Finding: Asked about treatment of itchy eyes Finding: Reports not taking medication for itchy eyes (Found)Pro Tip: Tina's response to a question about managing her itchy eyes will reveal the severity of her symptoms, her health literacy, and the way she's complied with previous treatment plans.Example Question:Are you taking medication for your itchy eyes? Finding: Asked about head problems Finding: Reports no problems other than occasional headaches (Available)Pro Tip: Broad, open questions will allow Tina to describe, in her own words, the specific pain and discomfort that she is experiencing.Example Question:Other than headaches, are you experiencing head problems? Finding: Reports no current headache (Found)Pro Tip: Assessing how a patient feels in the current moment can allow you to juxtapose their chief complaint alongside symptoms they experience. Asking Tina if she currently has a headache solicits information about how she is feeling now.Example Question:Do you currently have a headache? Finding: Asked about ear problems Finding: Reports no general ear problems (Found)Pro Tip: Soliciting a shallow medical history relevant to Tina's chief complaint will allow you to assess her condition relative to past concerns.Example Question:Are you having general ear problems? Finding: Reports no ear pain (Found)Pro Tip: Ear pain can suggest an ear infection, during which the middle of the ear becomes clogged with fluid and mucous. Asking Tina if she has ear pain might indicate a possible ear infection.Example Question:Do you have ear pain? Finding: Reports no ear discharge (Found)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.Example Question:Do you have ear discharge? Finding: Asked about changes in hearing Finding: Reports no hearing changes (Found)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.Example Question:Have you had changes in your hearing? Finding: Reports no difficulty hearing (Found)Pro Tip: Soliciting a shallow medical history relevant to Tina's chief complaint will allow you to assess her condition relative to past concerns.Example Question:Do you have difficulty hearing? Finding: Asked about nasal and sinus problems Finding: Reports occasional runny nose (Found)Pro Tip: Infected sinuses can manifest as nose problems. Asking Tina about her nasal symptoms solicits information about her sinuses and possible sinus problems.Example Question:Do you have general nose problems? Finding: Reports no frequent sinus problems (Found)Pro Tip: Infected sinuses can manifest as nose problems. Asking Tina about her nasal symptoms solicits information about her sinuses and possible sinus problems.Example Question:Do you have frequent sinus congestion? Finding: Reports no nosebleeds (Found)Pro Tip: Nosebleeds are often caused by sinusitis. Asking Tina if she ever gets nosebleeds solicits information about her medical history.Example Question:Have you had nosebleeds? Finding: Asked about triggers of runny nose Finding: Reports cat allergy is trigger for runny nose (Found)Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.Example Question:Do your allergies trigger your runny nose? Finding: Asked about treatment of runny nose Finding: Reports not taking medication for runny nose (Found)Pro Tip: Tina's response to a question about managing her runny nose will reveal the severity of her symptoms, her health literacy, and the way she's complied with previous treatment plans.Example Question:Are you taking any medication for your runny nose? Finding: Reports only treatment is avoiding trigger and showering (Found)Pro Tip: Tina's response to a question about managing her runny nose will reveal the severity of her symptoms, her health literacy, and the way she's complied with previous treatment plans.Example Question:How have you been treating your runny nose? Finding: Asked about mouth problems Finding: Reports no general mouth problems (Found)Pro Tip: Broad, open questions will allow Tina to describe, in her own words, the specific pain and discomfort that she is experiencing.Example Question:Have you had general mouth problems? Finding: Reports no bleeding gums (Available)Pro Tip: If left untreated, gum problems, like abscesses, can result in sinusitis. Asking Tina if she has problems with her gums solicits information about possible causes of her symptoms.Example Question:Have you had bleeding gums? Finding: Reports no mouth pain (Found)Pro Tip: In some cases, infection can spread to a cheekbone through an infected tooth. Asking Tina if she's had mouth pain might indicate a problem area that has caused infection.Example Question:Have you had mouth pain? Finding: Reports no mouth sores (Available)Pro Tip: In some cases, infection can spread to a cheekbone through an infection in the mouth. Asking Tina if she has any mouth sores might indicate a problem area that has caused infection.Example Question:Have you had mouth sores? Finding: Reports no tongue problems (Found)Pro Tip: If left untreated, tongue problems, like abscesses, can result in sinusitis. Asking Tina if she has problems with her tongue solicits information about possible causes of her symptoms.Example Question:Have you had tongue problems? Finding: Reports no dry mouth (Found)Pro Tip: Sinusitis can result in dry mouth. Asking if Tina's had a dry mouth might indicate a sign of sinusitis.Example Question:Have you had a dry mouth? Finding: Asked about dentition Finding: Reports no current dental problems (Found)Pro Tip: In some cases, infection can spread to a cheekbone through an infected tooth. Asking Tina if she's had any dental problems might indicate a problem area that has caused infection.Example Question:Do you have current dental problems? Finding: Reports visit within the last 2 years (Found)Pro Tip: Seeing a dentist regularly can assure that among other things, tooth infections, which can cause sinusitis, do not go untreated. Asking Tina when she last saw a dentist will reveal her health literacy and indicate whether or not her mouth is a problem area.Example Question:When was your last dental visit? Finding: Reports regular visits in childhood (Found)Pro Tip: Seeing a dentist regularly as a child can lay the foundation for good dental hygiene and prevent infection. Asking Tina how often she saw the dentist as a child will suggest her health and dental history.Example Question:Did you visit the dentist regularly as a child? Finding: Reports a few cavities in childhood (Available)Pro Tip: In some cases, infection can spread to a cheekbone through an infected tooth. Asking Tina what dental problems she's had might indicate a problem area that has caused infection.Example Question:Did you have cavities as a child? Finding: Asked about throat problems Finding: Reports no general throat problems (Found)Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.Example Question:Have you been having general throat problems? Finding: Reports no sore throat (Found)Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.Example Question:Have you had a sore throat? Finding: Reports no voice changes (Found)Pro Tip: Sinusitis can often lead to tonsil problems and voice changes. Asking Tina if she has noticed any changes to her voice would indicate whether her symptoms might be caused by sinus problems.Example Question:Has your voice changed? Finding: Asked about lymph node problems Finding: Reports no general lymph node problems (Found)Pro Tip: Swollen lymph nodes may appear in the neck when an infection is present. Asking Tina whether she has had any problems with her lymph nodes will solicit a history of her condition.Example Question:Have you been having problems with your lymph nodes? Finding: Reports no painful lymph nodes (Found)Pro Tip: Swollen lymph nodes may appear in the neck when an infection is present. Asking Tina whether her lymph nodes have been painful will solicit a history of her condition.Example Question:Have your lymph nodes been painful? Finding: Reports no swollen lymph nodes (Found)Pro Tip: Swollen lymph nodes may appear in the neck when an infection is present. Asking Tina whether her lymph nodes have been swollen will solicit a history of her condition.Example Question:Have your lymph nodes been swollen? Finding: Asked about thyroid problems Finding: Reports no known thyroid problems (Found)Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.Example Question:Have you been diagnosed with thyroid problems? Relevant Family History Finding: Asked family history of head problems Finding: Reports no family history of head problems (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if she has a family history of head problems can reveal generational patterns.Example Question:Do head problems run in your family? Finding: Reports no family history of migraines (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if she has a family history of migraines can reveal generational patterns.Example Question:Do you have a family history of migraines? Finding: Asked family history of eye problems Finding: Reports no family history of eye problems (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if she has a family history of eye problems can reveal generational patterns.Example Question:Do you have a family history of eye problems? Finding: Reports no family history of glaucoma (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if she has a family history of glaucoma can reveal generational patterns.Example Question:Do you have a family history of glaucoma? Finding: Asked family history of ear problems Finding: Reports no family history of ear problems (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if she has a family history of ear problems can reveal generational patterns.Example Question:Do ear problems run in your family? Finding: Reports no family history of hearing loss (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if she has a family history of hearing loss can reveal generational patterns.Example Question:Do you have a family history of hearing loss? Finding: Asked family history of nasal problems Finding: Reports sister has regular hay fever (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if she has a family history of hay fever can reveal generational patterns.Example Question:Has anyone in your family had hay fever? Finding: Asked family history of mouth problems Finding: Reports no family history of mouth problems (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if she has a family history of mouth problems can reveal generational patterns.Example Question:Do mouth problems run in your family? Finding: Reports no family history of dental problems (Available)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if she has a family history of dental problems can reveal generational patterns.Example Question:Do you have a family history of dental problems? Finding: Reports no family history of mouth cancer (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if she has a family history of mouth cancer can reveal generational patterns.Example Question:Do you have a family history of mouth cancer? Finding: Asked family history of throat and gland problems Finding: Reports no family history of thyroid problems (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if she has a family history of thyroid problems can reveal generational patterns.Example Question:Do thyroid problems run in your family? Finding: Reports no family history of lymph node cancers (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if she has a family history of lymph node cancers can reveal generational patterns.Example Question:Do you have a family history of lymph node cancers? Finding: Reports no family history of throat cancer (Available)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if she has a family history of throat cancer can reveal generational patterns.Example Question:Do you have a family history of throat cancer? Comments