Arun Patel Hypertension and Type 2 Diabetes shadow health Subjective Data
Subjective Data Collection: 20 of 20 (100.0%)
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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.
Chief Complaint
Finding:
Established chief complaint
Finding:
Reports coming in for check-up
(Found)
Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.
Example Question:
What is your primary reason for this visit?
History of Present Illness
Finding:
Asked about relevant health conditions
Finding:
Reports hypertension
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Do you have high blood pressure?
Finding:
Reports type 2 diabetes
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Do you have diabetes?
Finding:
Reports generalized anxiety disorder
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Do you have anxiety?
Finding:
Asked about onset and duration of disorders
Finding:
Reports hypertension diagnosis 1 year ago
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
When did your high blood pressure start?
Finding:
Reports diabetes diagnosis 5 years ago
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
When did your diabetes start?
Finding:
Reports GAD diagnosis 13 years ago
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
When did your anxiety start?
Finding:
Asked about associated symptoms
Finding:
Reports increased thirst
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Have you been thirsty?
Finding:
Reports increased urination
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Have you been urinating frequently?
Finding:
Reports weight gain of 15 pounds
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Have you had any weight changes?
Finding:
Reports fatigue and discomfort
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Have you been fatigued?
Finding:
Reports increased worry
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Have you been excessively worrying?
Finding:
Asked about onset and duration of associated symptoms
Finding:
Reports increased thirst began 1 month ago
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
When did your thirst increase?
Finding:
Reports increased urination began 1 month ago
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
When did you start urinating more frequently?
Finding:
Reports weight gain over the last 3 months
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
When did you gain weight?
Finding:
Reports fatigue and discomfort over the last 3 months
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
How long have you felt fatigued?
Finding:
Asked about non-medicational diabetes management
Finding:
Reports owning glucometer
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Do you have a blood sugar monitor?
Finding:
Reports checking blood sugar sporadically
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
How often do you check your blood sugar?
Finding:
Reports sporadic checking is because of disliking the glucometer’s pinch
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
How often do you check your blood sugar?
Past Medical History
Finding:
Asked about allergies
Finding:
Denies known allergies
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Do you have any allergies?
Finding:
Asked about previous hospitalizations
Finding:
Denies previous hospitalizations
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Have you ever been hospitalized?
Home Medications
Finding:
Asked about home medications
Finding:
Reports taking hydrochlorothiazide for hypertension
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
Do you take any medication for your high blood pressure?
Finding:
Reports taking metformin for type 2 diabetes
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
Do you take any medication for your diabetes?
Finding:
Reports taking escitalopram for anxiety
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
Do you take any medication for your anxiety?
Finding:
Denies taking vitamins and supplements
(Available)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
What vitamins and supplements do you take?
Finding:
Followed up on hydrochlorothiazide
Finding:
Reports hydrochlorothiazide tablets are each 50 milligrams
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
How much hydrochlorothiazide do you take?
Finding:
Reports taking one hydrochlorothiazide tablet a day
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
How often do you take hydrochlorothiazide?
Finding:
Reports taking hydrochlorothiazide with breakfast
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
How often do you take hydrochlorothiazide?
Finding:
Reports starting hydrochlorothiazide 1 year ago
(Available)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
When did you start taking hydrochlorothiazide?
Finding:
Reports taking last dose of hydrochlorothiazide this morning
(Available)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
When was your last dose of hydrochlorothiazide?
Finding:
Denies hydrochlorothiazide adverse effects
(Available)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
Do you experience any adverse effects from hydrochlorothiazide?
Finding:
Followed up on metformin
Finding:
Reports metformin tablets are each 850 milligrams
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
How much metformin do you take?
Finding:
Reports taking metformin tablet three times daily
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
How often do you take metformin?
Finding:
Reports taking one metformin tablet each with breakfast, lunch, and dinner
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
How often do you take metformin?
Finding:
Reports starting metformin 5 years ago
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
When did you start taking metformin?
Finding:
Reports taking last dose of metformin this morning
(Available)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
When was your last dose of metformin?
Finding:
Denies metformin adverse effects
(Available)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
Do you experience any adverse effects from metformin?
Finding:
Followed up on escitalopram
Finding:
Reports escitalopram tablets are each 20 milligrams
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
How much escitalopram do you take?
Finding:
Reports taking one escitalopram tablet a day
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
How often do you take escitalopram?
Finding:
Reports taking escitalopram with breakfast
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
How often do you take escitalopram?
Finding:
Reports began taking escitalopram 13 years ago
(Available)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
When did you start taking escitalopram?
Finding:
Reports taking last dose of escitalopram this morning
(Available)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
When did you take your last dose of escitalopram?
Finding:
Denies escitalopram adverse effects
(Available)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
Do you experience any adverse effects from escitalopram?
Finding:
Asked about medication regimen adherence
Finding:
Denies missing doses
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
Have you missed any doses of your medication?
Social History
Finding:
Asked about activity
Finding:
Reports sedentary activity level
(Found)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.
Example Question:
Do you get any regular physical activity?
Finding:
Asked about diet
Finding:
Reports eating take-out frequently
(Found)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.
Example Question:
Do you eat take out?
Finding:
Reports enjoying comfort foods when stressed
(Found)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.
Example Question:
Do you eat comfort foods?
Finding:
Denies binge-eating but feels like he eats more than he should
(Found)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.
Example Question:
Do you overeat?
Finding:
Asked about substance use
Finding:
Denies tobacco and nicotine use
(Available)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.
Example Question:
Do you smoke cigarettes?
Finding:
Denies alcohol use
(Found)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.
Example Question:
Do you drink any alcohol?
Finding:
Asked about income level
Finding:
Reports moderate income from graduate student stipend
(Found)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.
Example Question:
What level of income do you make?
Family Medical History
Finding:
Asked about relevant family history
Finding:
Reports mother diagnosed with high cholesterol and diabetes
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.
Example Question:
Does your mother have health problems?
Finding:
Reports father diagnosed with hypertension
(Found)
Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.
Example Question:
Does your father have health problems?
Review of Systems
Finding:
Asked about review of systems for genitourinary
Finding:
Denies difficulty urinating
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you had any difficulty urinating?
Finding:
Denies pain during urination
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you had any pain during urination?
Finding:
Denies changes in urine characteristics
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you had any changes in your urine?
Finding:
Asked about review of systems for cardiovascular
Finding:
Denies palpitations
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you had palpitations?
Finding:
Denies chest pain
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you had chest pain?
Finding:
Denies history of blood clots
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you had blood clots?
Finding:
Denies claudication
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