Conditions of the Musculoskeletal and Neurovascular Systems Shadow Health
Subjective Data Collection: 22 of 22 (100.0%)
Hover To Reveal…
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.
Confirmed Guardian’s Relationship
Finding:
Establish Relationship
Finding:
Ned reports he is Chelsea’s guardian
(Available)
Pro Tip: Determining the guardian’s relationship to a pediatric patient confirms the appropriate family members are present. Knowing who is with the pediatric patient will help you to develop the best approach to gathering information on the patient’s condition.
Example Question:
Is this your daughter?
Finding:
Chelsea reports Ned is her guardian
(Found)
Pro Tip: Determining the guardian’s relationship to a pediatric patient confirms the appropriate family members are present. Knowing who is with the pediatric patient will help you to develop the best approach to gathering information on the patient’s condition.
Example Question:
Can you confirm your name?
Chief Complaint
Finding:
Established Chief Complaint
Finding:
Patient reports left knee pain after a fall
(Found)
Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Allowing the patient’s guardian to voice concerns about the patient, or information on the patient’s symptoms, will yield important information on the chief complaint, as well as keep the guardian involved in the patient’s treatment.
Example Question:
Why did you come in?
Finding:
Guardian reports patient has been complaining of knee pain for “a few weeks”
(Found)
Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Allowing the patient’s guardian to voice concerns about the patient, or information on the patient’s symptoms, will yield important information on the chief complaint, as well as keep the guardian involved in the patient’s treatment.
Example Question:
Why did you come in?
History of Present Illness
Finding:
Asked about previous injuries
Finding:
Patient denies previous injury
(Found)
Pro Tip: Understanding a pediatric 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 been hurt at home?
Finding:
Guardian denies previous injury
(Found)
Pro Tip: Understanding a pediatric 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 been hurt at home?
Finding:
Asked about mechanism of injury
Finding:
Patient denies landing on head
(Found)
Pro Tip: Asking a patient about the duration and onset 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 remember the fall?
Finding:
Patient denies losing consciousness
(Found)
Pro Tip: Asking a patient about the duration and onset 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 remember the fall?
Finding:
Patient reports falling two or three feet
(Found)
Pro Tip: Asking a patient about the duration and onset 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 did you fall?
Finding:
Patient reports horse was standing still
(Found)
Pro Tip: Asking a patient about the duration and onset 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 did you fall?
Finding:
Patient reports blood glucose level was normal after fall
(Found)
Pro Tip: Asking a patient about the duration and onset 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:
What did you do after you fell?
Finding:
Asked about onset
Finding:
Patient reports mild pain on activity started two weeks ago
(Found)
Pro Tip: Asking a patient about the duration and onset 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 the discomfort begin?
Finding:
Patient reports severe pain started two days ago after a fall
(Found)
Pro Tip: Asking a patient about the duration and onset 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 the discomfort begin?
Finding:
Guardian reports noticing patient’s increase in pain after the fall two days ago
(Found)
Pro Tip: Asking a patient about the duration and onset 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 the discomfort begin?
Finding:
Asked about location
Finding:
Patient reports pain located at anterior proximal tibia
(Found)
Pro Tip: Asking a patient about the location of their symptoms or pain can solicit important information relevant to the history of their present illness. Details on the location of their discomfort will help you follow-up on any other conditions or symptoms.
Example Question:
Where does your knee hurt?
Finding:
Asked about duration
Finding:
Patient reports mild pain ending shortly after activity stops
(Found)
Pro Tip: Asking a patient about the duration and onset 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:
Does the pain last all day?
Finding:
Patient reports severe pain after fall improved the day after
(Found)
Pro Tip: Asking a patient about the duration and onset 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:
Is your pain getting better or worse?
Finding:
Asked about characteristics
Finding:
Patient reports mild pain on activity is dull
(Found)
Pro Tip: Asking a patient about the characteristics of their current health issues solicits information relevant to the history of their present illness. Details on the characteristics of their health issue will help you follow-up on any present conditions or symptoms.
Example Question:
Is the pain aching?
Finding:
Patient reports severe pain after the fall was throbbing
(Found)
Pro Tip: Asking a patient about the characteristics of their current health issues solicits information relevant to the history of their present illness. Details on the characteristics of their health issue will help you follow-up on any present conditions or symptoms.
Example Question:
Is the pain aching?
Finding:
Asked about aggravating factors
Finding:
Patient reports walking up steps aggravates pain
(Found)
Pro Tip: Asking a patient about relieving and aggravating factors of the current health issues solicits information relevant to the treatment and comfort of the patient. Details of relieving and aggravating factors will help you follow-up on any present conditions or symptoms.
Example Question:
What makes your pain worse?
Finding:
Patient reports kneeling aggravates pain
(Found)
Pro Tip: Asking a patient about relieving and aggravating factors of the current health issues solicits information relevant to the treatment and comfort of the patient. Details of relieving and aggravating factors will help you follow-up on any present conditions or symptoms.
Example Question:
What makes your pain worse?
Finding:
Patient reports mounting and dismounting a horse aggravates pain
(Found)
Pro Tip: Asking a patient about relieving and aggravating factors of the current health issues solicits information relevant to the treatment and comfort of the patient. Details of relieving and aggravating factors will help you follow-up on any present conditions or symptoms.
Example Question:
What makes your pain worse?
Finding:
Guardian confirms noticing the patient’s pain after physical activity
(Found)
Pro Tip: Asking a patient about relieving and aggravating factors of the patient current health issues solicits information relevant to the treatment and comfort of the patient. Details of relieving and aggravating factors will help you follow-up on any present conditions or symptoms.
Example Question:
What makes your pain worse?
Finding:
Asked about relieving factors
Finding:
Patient reports rest relieves pain
(Found)
Pro Tip: Asking a patient about relieving and aggravating factors of the current health issues solicits information relevant to the treatment and comfort of the patient. Details of relieving and aggravating factors will help you follow-up on any present conditions or symptoms.
Example Question:
Does anything help the pain?
Finding:
Patient denies using ice pack
(Found)
Pro Tip: Asking a patient about relieving and aggravating factors of the current health issues solicits information relevant to the treatment and comfort of the patient. Details of relieving and aggravating factors will help you follow-up on any present conditions or symptoms.
Example Question:
Does anything help the pain?
Finding:
Guardian reports patient refusing to use ice pack
(Found)
Pro Tip: Asking a patient about relieving and aggravating factors of the current health issues solicits information relevant to the treatment and comfort of the patient. Details of relieving and aggravating factors will help you follow-up on any present conditions or symptoms.
Example Question:
Does anything help the pain?
Finding:
Guardian reports acetaminophen was not effective
(Found)
Pro Tip: Asking a patient about relieving and aggravating factors of the current health issues solicits information relevant to the treatment and comfort of the patient. Details of relieving and aggravating factors will help you follow-up on any present conditions or symptoms.
Example Question:
Does anything help the pain?
Finding:
Asked about timing
Finding:
Patient denies the pain being worse or better at certain times of the day
(Found)
Pro Tip: Asking a patient about factors that may affect their current symptoms or present illness solicits information relevant to the treatment and comfort of the patient. Details on the timing of symptoms will help you follow-up on any present conditions or concerns.
Example Question:
Are the symptoms the same throughout the day?
Finding:
Guardian confirms the pain doesn’t seem worse or better at certain times of the day
(Found)
Pro Tip: Asking a patient about factors that may affect their current symptoms or present illness solicits information relevant to the treatment and comfort of the patient. Details on the timing of symptoms will help you follow-up on any present conditions or concerns.
Example Question:
Are the symptoms the same throughout the day?
Finding:
Asked about severity
Finding:
Patient reports mild pain on activity is “uncomfortable”
(Found)
Pro Tip: Asking a patient about the severity of their current symptoms or present illness solicits information relevant to the treatment and comfort of the patient. Details on the severity of symptoms will help you follow-up on any present conditions or concerns.
Example Question:
How severe are your symptoms?
Finding:
Patient reports severe pain after the fall was “really really bad”
(Found)
Pro Tip: Asking a patient about the severity of their current symptoms or present illness solicits information relevant to the treatment and comfort of the patient. Details on the severity of symptoms will help you follow-up on any present conditions or concerns.
Example Question:
How severe are your symptoms?
Finding:
Asked about activities of daily living
Finding:
Patient reports discomfort putting on pants and boots
(Found)
Pro Tip: Information about a patient’s activities of daily living will help you determine how the presenting illness impacts the patient’s life and wellbeing. Questions about your patient’s ability to bathe and dress themselves, transfer, or walk without assistance will help you determine necessary care.
Example Question:
Has your injury interfered with daily activities?
Finding:
Guardian reports patient’s discomfort while putting on boots
(Available)
Pro Tip: Information about a patient’s activities of daily living will help you determine how the presenting illness impacts the patient’s life and wellbeing. Questions about your patient’s ability to bathe and dress themselves, transfer, or walk without assistance will help you determine necessary care.
Example Question:
Do you need help with your daily activities?
Social History
Finding:
Asked about social history
Finding:
Patient reports all her friends are girls
(Available)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, activity level, and typical routine. As you are working with a patient and their guardian, it is important to ask about the patient’s social history to help you gain an understanding of the patient’s background. These factors can influence their current health and wellness.
Example Question:
Do you spend lots of time with family and friends?
Finding:
Patient reports having a close group of friends
(Found)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, activity level, and typical routine. As you are working with a patient and their guardian, it is important to ask about the patient’s social history to help you gain an understanding of the patient’s background. These factors can influence their current health and wellness.
Example Question:
How often do you see your friends?
Finding:
Patient reports being afraid of having her horse taken away
(Available)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, activity level, and typical routine. As you are working with a patient and their guardian, it is important to ask about the patient’s social history to help you gain an understanding of the patient’s background. These factors can influence their current health and wellness.
Example Question:
Do health problems prevent you from being social?
Finding:
Guardian reports that patient is well socialized
(Found)
Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, activity level, and typical routine. As you are working with a patient and their guardian, it is important to ask about the patient’s social history to help you gain an understanding of the patient’s background. These factors can influence their current health and wellness.
Example Question:
Does your daughter have hobbies?
Finding:
Asked about sports safety
Finding:
Denies wearing a helmet because of peer pressure
(Found)
Pro Tip: It is important to ask about the patient’s understanding of sports safety to help you gain insight into the patient’s background, habits, and sports knowledge. These factors can influence their current health and wellness.
Example Question:
When do you wear your helmet?
Review of Systems
Finding:
Asked about musculoskeletal
Finding:
Reports pain with ambulation in the day after the fall
(Available)
Pro Tip: Understanding a patient’s health and presenting illness involves a comprehensive overview of their systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Does pain limit your ability to walk?
Finding:
Denies pain with ambulation prior to the fall
(Available)
Pro Tip: Understanding a patient’s health and presenting illness involves a comprehensive overview of their systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Does pain limit your ability to walk?
Finding:
Reports full range of motion
(Found)
Pro Tip: Understanding a patient’s health and presenting illness involves a comprehensive overview of their systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
How is your range of motion?
Finding:
Reports pain within certain range of movements
(Found)
Pro Tip: Understanding a patient’s health and presenting illness involves a comprehensive overview of their systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
How is your range of motion?
Finding:
Reports being able to bear full weight on leg
(Found)
Pro Tip: Understanding a patient’s health and presenting illness involves a comprehensive overview of their systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Does bearing weight make the pain worse?
Finding:
Asked about neurological
Finding:
Patient denies abnormal gait
(Available)
Pro Tip: Understanding a patient’s health and presenting illness involves a comprehensive overview of their systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Did walking help your pain?
Finding:
Guardian denies noticing abnormal gait
(Available)
Pro Tip: Understanding a patient’s health and presenting illness involves a comprehensive overview of their systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Did walking help your pain?
Finding:
Patient denies numbness and tingling
(Found)
Pro Tip: Understanding a patient’s health and presenting illness involves a comprehensive overview of their systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you have any tingling since you fell?
Finding:
Patient denies weakness
(Found)
Pro Tip: Understanding a patient’s health and presenting illness involves a comprehensive overview of their systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you felt weak?
Finding:
Guardian denies noticing weakness
(Found)
Pro Tip: Understanding a patient’s health and presenting illness involves a comprehensive overview of their systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you felt weak?
Finding:
Asked about cardiovascular
Finding:
Patient denies swelling in lower extremities
(Found)
Pro Tip: Understanding a patient’s health and presenting illness involves a comprehensive overview of their systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Are your legs swollen?
Finding:
Patient denies ecchymosis in lower extremities
(Found)
Pro Tip: Understanding a patient’s health and presenting illness involves a comprehensive overview of their systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Are your legs swollen?
Finding:
Patient denies palpitations
(Available)
Pro Tip: Understanding a patient’s health and presenting illness involves a comprehensive overview of their systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
How is your heart rate?
Finding:
Asked about hematologic
Finding:
Patient denies recurrent or easy bruising
(Found)
Pro Tip: Understanding a patient’s health and presenting illness involves a comprehensive overview of their systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you bruise easily?
Finding:
Guardian denies noticing recurrent or easy bruising
(Found)
Pro Tip: Understanding a patient’s health and presenting illness involves a comprehensive overview of their systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you bruise easily?
Finding:
Asked about integumentary
Finding:
Patient denies itching, rash, or lesions
(Found)
Pro Tip: Understanding a patient’s health and presenting illness involves a comprehensive overview of their systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you have skin problems?
Finding:
Guardian denies noticing itching, rash, or lesions
(Found)
Pro Tip: Understanding a patient’s health and presenting illness involves a comprehensive overview of their systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you have skin problems?
Family History
Finding:
Asked about family history
Finding:
Guardian denies family history of musculoskeletal disease
(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:
Do health problems run in your family?
Finding:
Guardian denies family history of neurological disease
(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:
Do health problems run in your family?
Past Medical History
Finding:
Asked about type 1 diabetes
Finding:
Patient reports full treatment adherence
(Found)
Pro Tip: Asking about the patient’s relevant medical history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and treatments can indicate where you should follow-up for further care.
Example Question:
How is your diabetes?
Finding:
Patient denies diabetes symptoms
(Found)
Pro Tip: Asking about the patient’s relevant medical history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and treatments can indicate where you should follow-up for further care.
Example Question:
How is your diabetes?
Finding:
Guardian confirms patient is adherent
(Found)
Pro Tip: Asking about the patient’s relevant medical history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and treatments can indicate where you should follow-up for further care.
Example Question:
How is your diabetes?
Finding:
Guardian denies noticing diabetes symptoms
