Shoshanna Tillman Musculoskeletal Shadow Health
Subjective Data Collection: 57 of 57 (100.0%)
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Patient Data
items below to reveal important information, including
Pro Tips
and
Example Questions
.
Found:
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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.
Chief Complaint
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Finding:
Asked about chief complaint
Finding:
Reports fatigue
(Found)
Pro Tip: Asking your patient in open terms about the reason for their visit allows them to explain their concerns in their own words, providing a foundation for your interview.
Example Question:
What brings you in today?
Finding:
Reports joint pain
(Found)
Pro Tip: Asking your patient in open terms about the reason for their visit allows them to explain their concerns in their own words, providing a foundation for your interview Shoshanna Tillman Musculoskeletal Shadow Health.
Example Question:
What brings you in today?
History of Present Illness
Finding:
Asked about onset of pain
Finding:
Reports having joint pain for 3 months
(Found)
Pro Tip: If a
patient reveals a medical condition
or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.
Example Question:
When did your pain begin?
Finding:
Asked about location of pain
Finding:
Reports pain in hands and wrists
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.
Example Question:
Where do you feel the pain?
Finding:
Reports full body pain
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.
Example Question:
Where do you feel the pain?
Finding:
Asked about timing of pain
Finding:
Reports that the pain is worst in the morning when she wakes up
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.
Example Question:
When in the day do you have pain?
Finding:
Reports that the pain is constant
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness Shoshanna Tillman Musculoskeletal Shadow Health. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.
Example Question:
When in the day do you have pain?
Finding:
Asked about characteristics of pain
Finding:
Reports pain in wrists and hands is dull, throbbing, and stiff
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.
Example Question:
What is the pain like in your hands and wrists?
Finding:
Reports full body pain is stiff and achy
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.
Example Question:
What is the full body pain like?
Finding:
Asked about aggravating factors of pain
Finding:
Reports that holding her coffee mug in the morning is difficult
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.
Example Question:
Does anything make your pain worse?
Finding:
Reports pain is worse after long periods of typing or holding art tools
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.
Example Question:
Does anything make your pain worse?
Finding:
Reports pain is worse after long periods of sitting
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.
Example Question:
Does anything make your pain worse?
Finding:
Asked about relieving factors of pain
Finding:
Reports that hot showers make her feel better
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.
Example Question:
Does anything make your pain feel better?
Finding:
Asked about severity of pain
Finding:
Reports pain is currently at 2
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.
Example Question:
How would you rate your pain currently?
Finding:
Reports pain was 3-4 before diclofenac
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.
Example Question:
How would you rate your pain before taking diclofenac?
Finding:
Asked about onset of fatigue
Finding:
Reports 3 months of fatigue
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.
Example Question:
When did your fatigue begin?
Finding:
Asked about timing of fatigue
Finding:
Reports that the fatigue is constant
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.
Example Question:
Is the fatigue constant?
Finding:
Reports fatigue worsens as the day goes on
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.
Example Question:
Does your fatigue worsen throughout the day?
Finding:
Asked about aggravating factors for fatigue
Finding:
Denies aggravating factors for fatigue
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.
Example Question:
Does anything make your fatigue worse?
Finding:
Asked about relieving factors for fatigue
Finding:
Denies relieving factors for fatigue
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.
Example Question:
Does anything relieve your fatigue?
Finding:
Asked about impact on daily activities
Finding:
Reports daily activities are doable
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.
Example Question:
Can you complete your daily activities?
Finding:
Denies pain with daily activities
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the
history of the present illness
. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.
Example Question:
Do your daily activities cause you pain?
Finding:
Reports daily activities take longer
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.
Example Question:
Do your daily activities take longer?
Finding:
Reports feeling drained after completing daily activities
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.
Example Question:
Do you feel more tired after completing daily activities?
Finding:
Asked about perceived cause of fatigue
Finding:
Reports feeling that it might be stress or hormones
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.
Example Question:
Is there anything you believe could be causing your fatigue?
Past Medical History
Finding:
Asked about allergies
Finding:
Reports codeine allergy
(Found)
Pro Tip: A patient’s past medical history includes their health conditions, what preventative and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.
Example Question:
Do you have any allergies?
Finding:
Reports codeine reaction is rash and itching on body
(Available)
Pro Tip: A patient’s past medical history includes their health conditions, what preventative and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.
Example Question:
What reaction do you have when you take codeine?
Finding:
Denies latex allergy
(Available)
Pro Tip: A patient’s past medical history includes their health conditions, what preventative and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.
Example Question:
Do you have any latex allergies?
Finding:
Denies food allergies
(Found)
Pro Tip: A patient’s past medical history includes their health conditions, what preventative and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.
Example Question:
Do you have any food allergies?
Finding:
Denies environmental allergies
(Available)
Pro Tip: A patient’s past medical history includes their health conditions, what preventative and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.
Example Question:
Do you have any environmental allergies?
Finding:
Asked about existing health conditions
Finding:
Denies existing health conditions
(Found)
Pro Tip: A patient’s past medical history includes their health conditions, what preventative and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.
Example Question:
Do you have any existing health conditions?
Finding:
Asked about history of mental health
Finding:
Denies history of mental health conditions
(Found)
Pro Tip: A patient’s past medical history includes their health conditions, what preventative and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.
Example Question:
Do you have a history of mental health conditions?
Finding:
Asked about hospitalizations
Finding:
Reports childbirth 3 times
(Found)
Pro Tip: A patient’s past medical history includes their health conditions, what preventative and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.
Example Question:
Have you ever been hospitalized?
Finding:
Asked about surgeries
Finding:
Denies having had surgery
(Found)
Pro Tip: A patient’s past medical history includes their health conditions, what preventative and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.
Example Question:
Have you ever had surgery?
Home Medications
Finding:
Asked about home medications
Finding:
Reports previously taking ibuprofen
(Found)
Pro Tip: Asking about a patient’s home medications gives you information on the nature of their health conditions and how effectively they are being managed. This helps determine the need for you to adjust the patient’s treatments or medication regimen.
Example Question:
Do you take any medications?
Finding:
Reports taking diclofenac sodium
(Found)
Pro Tip: Asking about a patient’s home medications gives you information on the nature of their
health conditions
and how effectively they are being managed. This helps determine the need for you to adjust the patient’s treatments or medication regimen.
Example Question:
Do you take any medications?
Finding:
Reports having an IUD
(Found)
Pro Tip: Asking about a patient’s home medications gives you information on the nature of their health conditions and how effectively they are being managed. Shoshanna Tillman Musculoskeletal Shadow Health This helps determine the need for you to adjust the patient’s treatments or medication regimen.
Example Question:
Do you take any medications?
Finding:
Followed up on diclofenac sodium
Finding:
Reports taking diclofenac sodium ER 50 mg
(Found)
Pro Tip: Asking about a patient’s home medications gives you information on the nature of their health conditions and how effectively they are being managed. This helps determine the need for you to adjust the patient’s treatments or medication regimen.
Example Question:
What dose is your diclofenac sodium?
Finding:
Reports taking diclofenac sodium twice daily
(Available)
Pro Tip: Asking about a patient’s home medications gives you information on the nature of their health conditions and how effectively they are being managed. This helps determine the need for you to adjust the patient’s treatments or medication regimen.
Example Question:
How often do you take diclofenac sodium?
Finding:
Reports taking diclofenac sodium for joint pain
(Found)
Pro Tip: Asking about a patient’s home medications gives you information on the nature of their health conditions and how effectively they are being managed. This helps determine the need for you to adjust the patient’s treatments or medication regimen.
Example Question:
What are you taking diclofenac sodium for?
Finding:
Reports diclofenac sodium has helped relieve the pain
(Found)
Pro Tip: Asking about a patient’s home medications gives you information on the nature of their health conditions and how effectively they are being managed. This helps determine the need for you to adjust the patient’s treatments or medication regimen.
Example Question:
Has diclofenac sodium helped your pain?
Finding:
Followed up on ibuprofen
Finding:
Reports having used to take ibuprofen 2-3 times a day as needed
(Found)
Pro Tip: Asking about a patient’s home medications gives you information on the nature of their health conditions and how effectively they are being managed. This helps determine the need for you to adjust the patient’s treatments or medication regimen.
Example Question:
How often did you take ibuprofen?
Finding:
Reports having used to take 400 mg of ibuprofen
(Found)
Pro Tip: Asking about a patient’s home medications gives you information on the nature of their health conditions and how effectively they are being managed. This helps determine the need for you to adjust the patient’s treatments or medication regimen.
Example Question:
What dose of ibuprofen did you take?
Finding:
Reports only taking ibuprofen before starting diclofenac
(Available)
Pro Tip: Asking about a patient’s home medications gives you information on the nature of their health conditions and how effectively they are being managed. This helps determine the need for you to adjust the patient’s treatments or medication regimen.
Example Question:
When were you taking ibuprofen?
Finding:
Reports having taken ibuprofen for joint pain
(Available)
Pro Tip: Asking about a patient’s home medications gives you information on the nature of their health conditions and how effectively they are being managed. This helps determine the need for you to adjust the patient’s treatments or medication regimen.
Example Question:
What were you taking ibuprofen for?
Finding:
Reports the ibuprofen helped the pain some
(Available)
Pro Tip: Asking about a patient’s home medications gives you information on the nature of their health conditions and how effectively they are being managed. This helps determine the need for you to adjust the patient’s treatments or medication regimen.
Example Question:
Did the ibuprofen help your pain?
Finding:
Followed up on IUD
Finding:
Reports IUD is levonorgestrel
(Found)
Pro Tip: Asking about a patient’s home medications gives you information on the nature of their health conditions and how effectively they are being managed. This helps determine the need for you to adjust the patient’s treatments or medication regimen.
Example Question:
What type of IUD do you have?
Finding:
Reports having current IUD for 2 years
(Available)
Pro Tip: Asking about a patient’s home medications gives you information on the nature of their health conditions and how effectively they are being managed. This helps determine the need for you to adjust the patient’s treatments or medication regimen.
Example Question:
How long have you had your IUD?
Finding:
Reports starting IUD after birth of youngest child
(Available)
Pro Tip: Asking about a patient’s home medications gives you information on the nature of their health conditions and how effectively they are being managed. This helps determine the need for you to adjust the patient’s treatments or medication regimen.
Example Question:
When did you first begin your IUD?
Finding:
Asked about medication regimen adherence
Finding:
Reports taking diclofenac as prescribed