October 15, 2022

Tanner Bailey Pain Management shadow health Subjective data

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Subjective Data Collection: 25 of 25 (100.0%)

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Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.

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Available:

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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 and reason for admittance

Finding:

Reports chronic lower back pain resulting from work injury

(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 chief complaint?
Finding:

Reports wanting a prescription for opioids

(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 chief complaint?

History of Present Illness

Finding:

Asked about onset of injury

Finding:

Reports sustaining injury thirteen weeks 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 the pain start?
Finding:

Reports injury occurred after lifting a heavy box

(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 the pain start?
Finding:

Reports pain onset immediately after injury

(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 the pain start?
Finding:

Reports being driven to hospital immediately after injury

(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:

Did you go to the hospital?

Finding:

Followed up on hospitalization

Finding:

Reports hospital exams could not diagnose the type of back injury

(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:

What did the hospital diagnose you with?
Finding:

Reports hospital prescribed ibuprofen

(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:

Did the hospital prescribe you anything?
Finding:

Reports being told at the hospital to attend physical therapy

(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:

Did the hospital recommend anything?

Finding:

Asked about frequency, duration, and timing of pain

Finding:

Reports back injury and pain have not healed since onset

(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 your pain levels changed since your injury?
Finding:

Reports pain fluctuates in and out throughout the day at irregular intervals

(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 does the pain occur?

Finding:

Asked about additional symptoms of injury

Finding:

Denies additional symptoms

(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:

What other symptoms do you have?

Finding:

Asked about aggravating factors of pain

Finding:

Reports exertion such as walking, bending, or lifting aggravate pain

(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:

Does exertion make your pain worse?
Finding:

Reports at-home physical therapy exercises aggravated pain, discouraging attendence of physical therapy

(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:

Does exercise make your pain worse?

Finding:

Asked about nonmedicational treatment and relieving factors of pain

Finding:

Reports drinking alcohol relieves pain

(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:

Does drinking alcohol relieve your pain?
Finding:

Reports shifting positions when sitting or lying down can slightly relieve pain

(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:

Does shifting positions relieve your pain?

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Tanner Bailey Pain Management shadow health Subjective data