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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