Rachel Adler conversation concept lab shadow health

Rachel Adler conversation concept lab shadow health

Rachel Adler conversation concept lab shadow health

Experience Overview

Interview Categories and Findings

Patient Data A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.

Introduction and Medical History

Established Reason for Visit

Finding: Reports needing an annual physical.

Pro Tip: Asking the patient’s reason for their visit is a practical way to establish a chief complaint.

Example Question: What brings you in today?

Past Medical History

Finding: Denies medical conditions.

Pro Tip: A broad question about the patient’s past medical history may prompt a more comprehensive answer.

Example Question: What medical conditions do you have?

Medications

General Medication Use

Finding: Reports taking occasional ibuprofen.

Pro Tip: Asking a patient what medications they take may prompt a broader response.

Example Question: What medications do you take?

Prescription Medication

Finding: Denies taking prescription medication.

Pro Tip: Asking the patient what medications are prescribed may prompt a response about daily or as-needed medication.

Example Question: Do you take any prescription medications?

OTC Medication

Finding: Only OTC medication is ibuprofen (no others reported).

Pro Tip: Asking specifically about a patient’s use of over-the-counter medications may prompt a more definitive response.

Example Question: Do you take any other over-the-counter medications?

Ibuprofen Usage

Finding: Takes ibuprofen to relieve menstrual cramps.

Pro Tip: It’s important to gather information about the reasons for medication use.

Example Question: For what reason do you take ibuprofen?

Finding: Takes ibuprofen monthly.

Pro Tip: Gather information about the frequency of medication use.

Example Question: How often do you take ibuprofen?

Finding: Takes 2 at a time.

Pro Tip: Collect information about the quantity of medication use.

Example Question: How many ibuprofen do you take at a time?

Finding: Typically takes 2 doses on the first day of the period.

Pro Tip: Gather information about the frequency of medication use.

Example Question: How many days do you take ibuprofen?

Finding: Unsure of the dosage but reports they are “regular strength”.

Pro Tip: Gather information about the quantity of medication use.

Example Question: What dosage of ibuprofen do you take?

Finding: Last dose was 2 weeks ago.

Pro Tip: Gather information about the frequency of medication use.

Example Question: When did you last take Advil?

Supplements

Finding: Denies vitamins.

Pro Tip: Asking a specific question about the use of vitamins will prompt a definitive answer.

Example Question: Do you take any vitamins?

Finding: Denies herbal supplements.

Pro Tip: Asking a specific question about the use of herbal supplements will prompt a definitive answer.

Example Question: Do you take any herbal supplements?

Allergies

General Allergies

Finding: Reports allergy to peanuts.

Pro Tip: Beginning with a broad question is a good entry into the topic.

Example Question: What allergies do you have?

Peanut Allergy

Finding: Discovered at age 4.

Pro Tip: Establishing the onset of an allergy is important.

Example Question: How old were you when you had your first reaction to peanuts?

Finding: Symptoms are itchy mouth and throat.

Pro Tip: Determine the type and extent of the allergic reaction.

Example Question: What are the symptoms of your peanut allergy?

Finding: Describes allergy as not severe.

Pro Tip: Ascertain the severity of the allergic reaction.

Example Question: How severe do you think your peanut allergy is?

Finding: Denies breathing problems after exposure.

Pro Tip: Ask about specific life-threatening reactions.

Example Question: Do you experience breathing problems when you eat peanuts?

Finding: Denies hospitalization for reaction to peanuts.

Pro Tip: Ask about past allergy-related hospitalizations.

Example Question: Have you ever been hospitalized for a reaction to peanuts?

Treatment and Avoidance

Finding: Treated with Benadryl.

Pro Tip: Ask about the patient’s ability and willingness to treat allergic reactions.

Example Question: How do you treat your peanut allergy?

Finding: Reports avoiding peanuts and peanut oil.

Pro Tip: Ask about the patient’s ability and willingness to avoid the allergen.

Example Question: How do you avoid eating peanuts?

Finding: Denies use of an EpiPen.

Pro Tip: Ask about access to specific resources for allergic reactions.

Example Question: Do you have an EpiPen?

Medication Allergies

Finding: Denies known medication allergies.

Pro Tip: Ask specifically about medication allergies.

Example Question: Are you allergic to any medications?

Other Allergies

Finding: Denies latex allergy.

Pro Tip: Ask specifically about latex allergy.

Example Question: Are you allergic to latex?

Finding: Denies food allergies or sensitivities (other than peanuts).

Pro Tip: Ask specifically about food allergies.

Example Question: Do you have any food allergies?

Finding: Denies known environmental allergies.

Pro Tip: Ask specifically about environmental allergies.

Example Question: Do you have any environmental allergies?

Substance Use

Tobacco and Nicotine Use

Finding: Reports “some” tobacco use.

Pro Tip: Ask about tobacco use during a health history interview.

Example Question: What tobacco products have you used?

Finding: Reports smoking cigarettes.

Pro Tip: Assess smoking patterns during a health history interview.

Example Question: What do you smoke?

Finding: Denies other forms of smoking tobacco such as cigars and pipes.

Pro Tip: Ask about other types of smoking tobacco to form a full picture of smoking patterns.

Example Question: Do you smoke cigars?

Finding: Denies using chew or smokeless forms of tobacco.

Pro Tip: Ask specifically about these products.

Example Question: Have you ever tried chewing tobacco?

Finding: Denies vaping or e-cigarettes.

Pro Tip: Ask about these products to form a more complete picture of tobacco use patterns.

Example Question: Have you ever tried an electronic cigarette?

Patterns of Tobacco Use

Finding: Reports smoking “really not very many” cigarettes.

Pro Tip: Determine the quantity of tobacco use to assess risk level.

Example Question: How much do you smoke?

Finding: Has smoked 3 times (one cigarette each time).

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