Tina Jones Health History Simulation Part 3
This flashcard set is designed to guide healthcare professionals through effective clinical interviews with patients experiencing asthma and unexplained weight loss. Each card highlights a key finding, offers a pro tip for clinical reasoning, and provides an example question to facilitate patient dialogue. Use this set to improve your diagnostic accuracy by uncovering timelines, symptom patterns, and potential underlying health concerns.
Example Question: When did you notice the increase in your appetite?
Finding: Reports change in appetite began a month ago (Available)Pro Tip: Determining the onset of appetite change can reveal important details about underlying health conditions.
Key Terms
Example Question: When did you notice the increase in your appetite?
Finding: Reports change in appetite began a month ago (Available)Pro Tip: Determining the onset of appetite change can reveal important details abo...
Example Question: How much weight have you lost?
Finding: Asked about weight change
Finding: Reports recent loss of 10 lbs (Available)Pro Tip: Determining the exact amount of weight loss can in...
Example Question: How long did it take you to lose 10 pounds?
Finding: Reports weight loss occurred over the past month (Available)Pro Tip: Finding out the timeline for weight loss can indicate if it's sudden ...
Example Question: Was your weight loss intentional?
Finding: Followed up on reason for weight change
Finding: Reports weight loss was unintentional (Found)Pro Tip: Unintentional weight loss can be...
Example Question: When was your last asthma attack?
Finding: Asked about history of asthma exacerbations
Finding: Reports last asthma attack was in high school (Available)Pro Tip: Discovering the ...
Example Question: When did you last have issues with asthma?
Finding: Reports last exacerbation was three days ago (Available)Pro Tip: Discovering the patient's most recent exacerbation can provide a timeline...
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| Term | Definition |
|---|---|
Example Question: When did you notice the increase in your appetite? | Finding: Reports change in appetite began a month ago (Available)Pro Tip: Determining the onset of appetite change can reveal important details about underlying health conditions. |
Example Question: How much weight have you lost? | Finding: Asked about weight change |
Example Question: How long did it take you to lose 10 pounds? | Finding: Reports weight loss occurred over the past month (Available)Pro Tip: Finding out the timeline for weight loss can indicate if it's sudden or gradual. |
Example Question: Was your weight loss intentional? | Finding: Followed up on reason for weight change |
Example Question: When was your last asthma attack? | Finding: Asked about history of asthma exacerbations |
Example Question: When did you last have issues with asthma? | Finding: Reports last exacerbation was three days ago (Available)Pro Tip: Discovering the patient's most recent exacerbation can provide a timeline of asthma symptoms and help you better understand the patient's condition and effectiveness of any treatments. |
Example Question: What do your asthma symptoms feel like? | Finding: Asked about asthma symptoms |
Example Question: Do you have trouble breathing? | Finding: Reports difficulty breathing during exacerbation (Found)Pro Tip: Asthma can have a profound impact on health, and it is important to discovered the severity of her condition by asking about symptoms during an exacerbation, such as difficulty breathing. |
Example Question: Do you ever wheeze? | Finding: Reports wheezing during exacerbation (Found)Pro Tip: Asthma can have a profound impact on health, and it is important to discovered the severity of her condition by asking about symptoms during an exacerbation, such as wheezing. |
Example Question: Have you been hospitalized in the past? | Finding: Asked about prior hospitalizations |
Example Question: Why were you hospitalized last time? | Finding: Reports last hospitalization was for asthma (Available)Pro Tip: Finding out if Tina has any past hospitalizations is the first step in understanding any past serious medical issues. In Tina's case, it will help you better understand her asthma and create a timeline. |
Example Question: When was your last hospitalization? | Finding: Reports last hospitalization was age 16 (Available)Pro Tip: Finding out the date of Tina's last hospitalization is important for understanding the timeline of her medical issues, asthma in particular. |
Example Question: How many times have you been hospitalized? | Finding: Reports about 5 total hospitalizations for asthma as a child and teen (Available)Pro Tip: Finding out the number of Tina's previous hospitalizations is important for understanding the history of her asthma. |
Example Question: Have you ever used a nebulizer? | Finding: Reports past nebulizer use (Available)Pro Tip: Finding out what treatments Tina received during her hospitalizations will give you a fuller picture of the history of her condition. |
Example Question: At what age were you diagnosed with asthma? | Finding: Reports specific age of diagnosis is 2.5 years old (Available)Pro Tip: Asthma can have a profound impact on health, and it is important to learn about the patient's history of the condition, including the age of diagnosis. |
Example Question: How do you manage your asthma? | Finding: Reports using an inhaler (Found)Pro Tip: Asking how your patient treats her asthma can provide important information about her medical history and health literacy. |
Example Question: What is the name of the inhaler prescription? | Finding: Reports inhaler is albuterol (Proventil) (Found)Pro Tip: Finding out the specific medication type or brand is essential in understanding whether it's a maintenance or rescue medication. |
Example Question: When did you last use your inhaler? | Finding: Reports last use of inhaler was 3 days ago (Available)Pro Tip: Determining the patient's last use of an inhaler clues you in to any recent breathing problems. |
Example Question: How often do you use your inhaler? | Finding: Reports using inhaler no more than 2 times per week (Available)Pro Tip: Discovering the frequency with which your patient uses her inhaler is an important aspect of determining the severity of her condition. |
Example Question: How many puffs do you typically take? | Finding: Reports typically taking 2 puffs (Found)Pro Tip: Discovering how much your patient uses her inhaler at any given time is a good indicator of the efficacy of her medication. |
Example Question: What's the most puffs you ever take? | Finding: Reports sometimes needing 3 puffs to control symptoms (Found)Pro Tip: Discovering how much your patient uses her inhaler at any given time is a good indicator of the efficacy of her medication. |
Example Question: What triggers your asthma problems? | Finding: Asked about asthma triggers |
Example Question: Does dust trigger your asthma? | Finding: Reports asthma triggered by dust (Found)Pro Tip: Dust is a common allergen, and discovering its effect on asthmatic patients is particularly important. |
Example Question: Do you have seasonal asthma triggers? | Finding: Denies seasonal triggers (Available)Pro Tip: Asking about seasonal triggers can help you understand a patient's complete set of asthma triggers over the course of a year. |
Example Question: What allergies do you have? | Finding: Asked about general allergies |
Example Question: What is your reaction to cats? | Finding: Followed up on cat allergy symptoms |
Example Question: Are you allergic to latex? | Finding: Asked about latex allergy |
Example Question: What medication allergies do you have? | Finding: Asked about medication allergies |
Example Question: What is your reaction to penicillin? | Finding: Asked about penicillin reaction |
Example Question: When was your last penicillin reaction? | Finding: Reports last penicillin reaction was in childhood (Available)Pro Tip: Determining a patient's last reaction to penicillin is part of gathering thorough information about her allergy. |
Example Question: Do you have any food allergies? | Finding: Asked about food allergies |
Example Question: Do you have any reaction to dust? | Finding: Asked if the patient has allergies to dust, mold, or pollen |
Example Question: Do you have any environmental allergies? | Finding: Reports dust causes sneezing, itchy eyes, and wheezing (Available)Pro Tip: Dust is a common allergen and discovering its effect on asthmatic patients is particularly important. |
Example Question: Do you have any seasonal allergies? | Finding: Denies seasonal allergies (Available)Pro Tip: Asking about seasonal allergies can help you understand a patient's complete set of allergies over the course of a year. |
Example Question: Are your immunizations current? | Finding: Asked about general immunizations received |
Example Question: Did you receive the measles vaccine? | Finding: Asked about childhood immunizations |
Example Question: Did you receive the polio vaccine? | Finding: Reports receiving polio shot (Available)Pro Tip: Discovering if a patient received a childhood polio vaccination reveals information about both her medical history and her susceptibility to infectious disease. |
Example Question: Did you receive the chicken pox vaccine? | Finding: Reports receiving varicella shot (Available)Pro Tip: Discovering if a patient has received a childhood varicella shot reveals information about both her medical history and her susceptibility to infectious disease. |
Example Question: Did you receive the Hepatitis vaccine? | Finding: Reports receiving Hepatitis A and B shot (Available)Pro Tip: Discovering if a patient has received a childhood Hepatitis A and B vaccination reveals information about both her medical history and her susceptibility to infectious disease. |
Example Question: Did you receive the meningitis vaccine? | Finding: Reports receiving meningococcal shot (Available)Pro Tip: Discovering if a patient has received a childhood meningococcal vaccination reveals information about both her medical history and her susceptibility to infectious disease. |
Example Question: Did you receive the HPV vaccine? | Finding: Reports receiving HPV vaccine series (Available)Pro Tip: Discovering if a patient has received the HPV vaccination reveals information about both her medical history and her susceptibility to infectious disease. |
Example Question: Did you get a flu shot this year? | Finding: Asked if the patient has received a flu vaccine |
Example Question: When was your last tetanus booster? | Finding: Asked if the patient received a tetanus immunization |
Example Question: What pain medication have you been taking? | Finding: Asked about use of pain medication |
Example Question: Have you taken any prescription pain medications? | Finding: Reports ER administered pain medication (Found)Pro Tip: The differences between prescription and over-the-counter pain medications can be vast and asking about the type of pain medication your patient has been using will help you fully understand her home treatment habits. |
Example Question: How many days have you needed pain medication? | Finding: Followed up on home pain medication |
Example Question: How many times a day do you take pain medication? | Finding: Reports taking doses at morning, noon and night (Available)Pro Tip: The frequency with which your patient takes pain medication can indicate the severity of her condition or injury. |
Example Question: How many pain pills do you take at a time? | Finding: Reports taking 2 pills each time (Available)Pro Tip: Determining the exact dose of pain medication your patient takes helps determine the severity of her condition or injury and will factor in to your care plan. |
Example Question: What is the dose of the pain medication? | Finding: Reports ibuprofen is regular strength (Available)Pro Tip: Determining the exact dose of pain medication your patient takes helps determine the severity of her condition or injury and will factor in to your care plan. |
Example Question: How effective is the pain medication? | Finding: Asked about the effectiveness of pain medication at home |
Example Question: How long does the pain medication last? | Finding: Reports pain returned in full every few hours (Found)Pro Tip: The efficacy of pain medication varies from patient to patient. Discovering a patient's individual response to pain medication is an important factor in your overall treatment plan. |
Example Question: What prescription medications do you take? | Finding: Asked about prescription medications |
Example Question: Do you take any over the counter medications? | Finding: Asked about use of OTC medication |
Example Question: Do you take any over the counter medications? | Finding: Reports occasionally taking acetaminophen (Tylenol) for headaches (Available)Pro Tip: Finding out about your patient's use of over-the-counter medications, vitamins, and supplements will help you get a complete health history and avoid unwanted drug interactions. |
Example Question: Do you take any supplements? | Finding: Denies taking supplements (Available)Pro Tip: Finding out about your patient's use of supplements will help you get a complete health history and avoid unwanted drug interactions. |
Example Question: Do you take any herbal supplements? | Finding: Denies taking herbals (Available)Pro Tip: Finding out about your patient's use of herbals will help you get a complete health history and avoid unwanted drug interactions. |
Example Question: What is your highest level of education? | Social History Finding: Asked about patient's level of education |
Example Question: What do you study? | Finding: Reports her major is accounting (Available)Pro Tip: Asking about a patient's course of study is a good practice to establish rapport with your patient. |
Finding: Asked about stressors | Finding: Reports she is currently under high stress (Found)Pro Tip: Stress can cause both physical and mental health problems and complications. Determining your patient's stress level is part of an overall picture of her health. |
Example Question: Does anyone live at home with you? | Finding: Asked about patient's living situation Finding: Reports living with mother and sister (Available)Pro Tip: Learning about your patient's living situation helps develop rapport and gives you a broad picture of her lifestyle. |
Example Question: Do you live in a house? | Finding: Reports living in a house (Available)Pro Tip: Learning about your patient's living situation helps develop rapport and gives you a broad picture of her lifestyle. |
Example Question: How many stories is your house? | Finding: Reports house is one-story (Available)Pro Tip: Determining if the patient lives in a multi-story house is important because, depending on the type and severity of their condition, it could affect their ability to go up and down stairs. |
Example Question: Tell me more about living at home. | Finding: Reports family members will be able to help with activities (Available)Pro Tip: Learning about your patient's living situation helps develop rapport and gives you a broad picture of her lifestyle. |
Example Question: What is your religious affiliation? | Finding: Asked about patient belief system Finding: Reports her religious affiliation is Baptist (Found)Pro Tip: An important part of a health history is developing rapport with the patient and fostering an atmosphere of respect. Learning about the patient's religious beliefs will allow you to provide the appropriate support and resources. |
Example Question: Have you experienced any type of abuse? | Finding: Asked if patient has experienced abuse Finding: Denies experiencing abuse (Found)Pro Tip: Determining if a patient has experienced abuse, whether it be emotional, physical, or financial, is important for understanding the patient's needs. It is necessary to approach this subject with the utmost respect and sensitivity. |
Example Question: Have you ever smoked marijuana? | Finding: Asked about illicit drug use Finding: Reports history of recreational marijuana smoking (Found)Pro Tip: Determining any recent or past history of drug use is essential to revealing any substance abuse issues, and if the patient is likely to seek drugs while admitted. |
Example Question: When did you last smoke marijuana? | Finding: Followed up on drug use Finding: Reports last use was at age 20 or 21 (Found)Pro Tip: When a patient reports drug use, it's important to determine the reason for drug use, as well as the timeline. Depending on when the drug was most recently taken, it could interfere with medications. You also want to identify any potential issues with substance abuse. |
Example Question: What happened to cause you to stop smoking pot? | Finding: Reports she stopped because of health reasons and waning interest (Available)Pro Tip: Communicating about why a patient stopped or started drug use gives insight into their attitudes and dependencies on a substance. |
Example Question: When was your last alcoholic drink? | Finding: Asked about alcoholic intake Finding: Reports last alcoholic drink was 3 weeks ago (Available)Pro Tip: Confirming when a patient had her last alcohol intake is important, because she will receive medications while admitted, and alcohol is often contraindicated. |
Example Question: How many alcoholic drinks do you have in one sitting? | Finding: Reports no more than 2 or 3 alcoholic drinks in one sitting (Available)Pro Tip: Finding out how many alcoholic drinks a patient has in a single day or sitting is essential to uncover any binge-drinking habits that can be unhealthy for your patient. |
Example Question: How many nights a week do you drink alcohol? | Finding: Reports no more than 1 or 2 nights a week drinking alcohol (Available)Pro Tip: Finding out how many nights a week your patient has alcohol gives insight into potential habits or abuse. |
Example Question: Have you ever smoked cigarettes? | Finding: Asked about tobacco use Finding: Denies smoking tobacco (Found)Pro Tip: Finding out if a patient uses tobacco products is important to understanding her overall health, and is a potential factor in delayed wound healing. |
Example Question: Do you vape? | Finding: Denies Vaping (Available)Pro Tip: Finding out if a patient uses tobacco products is important to understanding her overall health and is a potential factor in delayed wound healing. |
Example Question: Are you ever exposed to secondhand smoke? | Finding: Asked about secondhand smoke Finding: Denies exposure to secondhand smoke (Found)Pro Tip: Exposure to secondhand smoke can be especially detrimental to an asthmatic patient's health. |
Example Question: Does your mother have health conditions? | Family Medical History Finding: Asked about mother's health Finding: Reports mother diagnosed with high blood pressure (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her mother had high blood pressure can reveal generational patterns. |
Example Question: Does your mother have health conditions? | Finding: Reports mother diagnosed with high cholesterol (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her mother had high cholesterol can reveal generational patterns. |
Example Question: Does your father have health conditions? | Finding: Asked about father's health Finding: Reports father was diagnosed with Type 2 diabetes (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her father had diabetes can reveal generational patterns. |
Example Question: Does your father have health conditions? | Finding: Reports father was diagnosed with high blood pressure (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her father had high blood pressure can reveal generational patterns. |
Example Question: Does your father have health conditions? | Finding: Reports father was diagnosed with high cholesterol (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her father had high cholesterol can reveal generational patterns. |