Intermediate Patient Case Results
Edward Carter ShadowHealth
Chief Complaint
Finding:
Established chief complaint
Finding:
Reports pain
( )
Pro
... [Show More] Tip: Beginning your conversation with your patient by asking an open-ended question
about their hospital visit is a best practice for gauging your patient's general condition.
Example Question:
What brings you to the hospital?
Finding:
Reports blood in urine
( )
Pro Tip: Beginning your conversation with your patient by asking an open-ended question
about their symptoms is a best practice for gauging your patient's general condition.
Example Question:
What are your symptoms?
Finding:
Reports increased frequency of urination
( )
Pro Tip: A patient with flank pain and blood in urine may have kidney stones, a bladder
infection, or another serious complaint that may affect urinary patterns.
Example Question:
Have you had urinary symptoms?
Orientation
Unguided Intermediate Patient Case Results EDWARD CARTER SHADOWHEALTH
Finding:
Asked about orientation
Finding:
Oriented to own person
(Available)
Pro Tip: You should ask patients, especially geriatric ones or those on a potentially
mind-altering medication, to state their name so you can determine their cognitive
functioning.
Example Question:
Can you tell me who you are?
Finding:
Oriented to place
(Available)
Pro Tip: You should ask patients, especially geriatric ones or those on a potentially
mind-altering medication, to identify where they are so you can determine their cognitive
functioning.
Example Question:
Do you know where you are right now?
Finding:
Oriented to situation
( )
Pro Tip: You should ask patients, especially geriatric ones or those on a potentially
mind-altering medication, to identify their reason for being here so you can determine their
cognitive functioning.
Example Question:
Do you know why you are here today?
Finding:
Oriented to time
(Available)
Pro Tip: You should ask patients, especially geriatric ones or those on a potentially
mind-altering medication, to identify the date and year so you can determine their cognitive
functioning.
Example Question:
What is the date and year?
History of Present Illness
Finding:
Asked about onset and duration of symptoms
Finding:
Reports pain began 3 days ago
( )
Pro Tip: Discovering how long ago the pain began is the first step in understanding whether
the pain is chronic or acute.
Example Question:
When did your pain begin?
Finding:
Reports pain has gradually increased since onset
(Available)
Pro Tip: The way that pain changes over time can help you understand its causes and how
to treat it.
Example Question:
Has your pain changed since the onset?
Finding:
Reports increased urinary frequency began 3 days ago
(Available)
Pro Tip: Polyuria and increased urinary urgency can be symptoms of several diseases,
including kidney stones, bladder infections, or even uncontrolled diabetes.
Example Question:
How long have you had to urinate more?
Finding:
Reports pinkish urine starting early this morning
(Available)
Pro Tip: Asking about the onset of the blood in the patient's urine helps you understand its
development as an emerging health problem.
Example Question:
When did you start seeing blood in your urine?
Finding:
Reports pain has been constant
(Available)
Pro Tip: Determining patterns of pain helps you understand patient context; constant pain
can affect a patient's ability to answer questions or make decisions.
Example Question:
Is your pain constant?
Finding:
Followed up on urinary frequency
Finding:
Reports urinating about once an hour
( )
Pro Tip: Asking a patient with increased urinary frequency how often they use the bathroom
allow you to assess the condition's potential causes and its affect on the patient.
Example Question:
How often do you urinate?
Finding:
Reports waking up to use the bathroom
(Available)
Pro Tip: Asking a patient with increased urinary frequency if they use the bathroom at night
allow you to assess the condition's potential causes and its affect on the patient.
Example Question:
Do you have to wake up to urinate?
Finding:
Reports waking up four to five times a night to use the bathroom
(Available)
Pro Tip: Asking a patient with increased urinary frequency how often they use the bathroom
at night allow you to assess the condition's potential causes and its affect on the patient.
Example Question:
How many times a night do you have to wake up to urinate?
Finding:
Asked about location of pain
Finding:
Reports pain is in lower left side (flank pain)
( )
Pro Tip: Establishing the location of a patient's pain can provide insight into its cause, and
help you determine if the pain progresses or migrates.
Example Question:
Where is your pain?
Finding:
Denies radiating pain
(Available)
Pro Tip: Determining if a patient's pain radiates can indicate its cause or the course of an
infection.
Example Question:
Does the pain radiate?
Finding:
Asked about characteristics of pain
Finding:
Describes pain as sharp and shooting
( )
Pro Tip: Determining how your patient describes the characteristics of the pain can be
important data to support the cause of the pain.
Example Question:
How would you describe your pain?
Finding:
Asked about aggravating factors of pain
Finding:
Reports nothing makes the pain worse
( )
Pro Tip: Aggravating factors are conditions that worsen a patient's pain, such as activities of
living like eating or movement. Identifying these conditions helps you avoid them while the
patient is in your care.
Example Question:
Does anything make your pain wors [Show Less]