Felipe Barbosa Sick Visit Shadow Health Subjective Data Collection
Felipe’s Details
These are the important facts about Felipe’s case. They help you understand what’s happening with him.
Table of Contents
What’s Bothering Felipe the Most
When you ask Felipe why he’s here, he tells you he has a rash and he’s feeling pain.
Pro Tip: It’s helpful to ask open questions so Felipe can tell you what’s wrong in his own words. For example, you can ask, “What made you decide to come in today?”
History of Felipe’s Sickness
You ask Felipe when his symptoms started. He tells you his rash started four days ago and he felt tingling in that area. Then, two days ago, the rash got worse and he started feeling pain.
Pro Tip: When someone tells you about their symptoms, it’s important to ask more questions about when they started and how bad they are. You can ask, “When did you first feel tingling?”
Where Felipe’s Feeling It
Felipe tells you the rash is on his lower back, specifically on the right side. He also says the pain is in the same spot.
Pro Tip: Asking where exactly someone feels pain or discomfort helps you understand their condition better. You might ask, “Can you point to where it hurts?”
How It Feels
Felipe says the rash is red and has small blisters. The pain feels like burning to him.
Pro Tip: Learning more about the symptoms, like how they look and feel, helps you understand the problem. You can ask, “Can you describe how the rash looks?”
What Makes It Worse or Better
Felipe tells you his pain gets worse when he sweats or feels hot. Using an ice pack didn’t help much.
Pro Tip: Knowing what makes the symptoms better or worse can guide treatment. You could ask, “Does anything make the pain go away?”
How Bad It Is
Felipe rates his pain as a 7 out of 10. He says it’s constant.
Pro Tip: Understanding how bad the symptoms are helps determine the best treatment. You might ask, “On a scale of 0 to 10, how bad is the pain?”
Felipe’s Medical History
You ask Felipe if he has any existing medical conditions. He says no. He also mentions having chickenpox when he was younger but denies any surgeries or hospitalizations.
Pro Tip: Knowing Felipe’s medical history helps you understand his overall health. You might ask, “Have you ever had any operations?”
Allergies
Felipe says he doesn’t have any food or medication allergies, nor does he have a latex allergy. He also denies having any allergies to things in the environment.
Focused Exam: Depression Abigail Harris Shadow health Objective data
Felipe Barbosa Sick Visit Shadow Health Subjective Data Collection
Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
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Found:
Indicates an item that you found.
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Available:
Indicates an item that is available to be found.
- Felipe Barbosa Sick Visit Shadow Health Subjective Data Collection
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.
Chief Complaint
- Finding:Asked about chief complaint
- Finding:Reports rash
(Found)
Pro Tip: Asking your patient in open terms about the reason for their visit allows them to explain their concerns in their own words, providing a foundation for your interview.Example Question:
What brings you in today?
Finding:
Reports pain
(Found)
Pro Tip: Asking your patient in open terms about the reason for their visit allows them to explain their concerns in their own words, providing a foundation for your interview.Example Question:
What brings you in today?
History of Present Illness
- Finding:Asked about onset of symptoms
- Finding:
Reports tingling in area of rash four days ago
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.Example Question:
Have you felt tingling anywhere?
Finding:
Reports rash broke out two days ago
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.Example Question:
How long have you had this rash?
Finding:
Reports pain began two days ago
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.Example Question:
When did the pain start?
Finding:
Asked about location of symptoms
Finding:
Reports rash is on right lower back
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.Example Question:
What part of your back is the rash on?
Finding:
Reports pain is on right lower back
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.Example Question:
Where is the pain on your back?
Finding:
Denies pain radiating
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.Example Question:
Does the pain from your rash travel?
Finding:
Asked about characteristics of symptoms
Finding:
Reports rash is red
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.Example Question:
Is your rash red?
Finding:
Reports rash is made up of small blisters
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.Example Question:
Is the rash made up of blisters?
Finding:
Reports pain is burning
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.Example Question:
Is anywhere burning? Felipe Barbosa Sick Visit Shadow Health Subjective Data Collection
- Finding:Asked about aggravating factors
- Finding:Reports pain is worse when he is sweating or hot
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms. Felipe Barbosa Sick Visit Shadow Health Subjective Data CollectionExample Question:
Does sweating cause rash pain?
- Finding:Asked about relieving factors
- Finding:Reports ice pack was not very effective
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.Example Question:
Did the ice pack help your pain?
- Finding:Asked about timing of pain
- Finding:Reports pain is constant
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.Example Question:
Is the pain in your back constant?
- Finding:Asked about severity of pain
- Finding:Reports pain is a 7 out of 10
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to ask a wide variety of follow-up questions about the history of the present illness. This can help providers better understand the nature of the disorder, especially through questions about timing, severity, and types of symptoms.Example Question:
Can you rate your rash pain on a scale?
Past Medical History
- Finding:Asked about existing medical conditions
- Finding:Denies existing medical conditions
(Found)
Pro Tip: A patient’s past medical history includes their health conditions, what preventative and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.Example Question:
Do you have a history of medical issues?
- Finding:Asked about childhood illness
- Finding:Reports having chickenpox as a child
(Found)
Pro Tip: A patient’s past medical history includes their health conditions, what preventative and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.Example Question:
Have you had chicken pox?
- Finding:Asked about surgeries
- Finding:Denies previous surgeries
(Found)
Pro Tip: A patient’s past medical history includes their health conditions, what preventative and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.Example Question:
What surgeries have you had?
- Finding:Asked about hospitalizations
- Finding:Denies previous hospitalizations
(Found)
Pro Tip: A patient’s past medical history includes their health conditions, what preventative and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.Example Question:
Have you been hospitalized recently?
- Finding:Asked about allergies
- Finding:Denies food allergies
(Found)
Pro Tip: A patient’s past medical history includes their health conditions, what preventative and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.Example Question:
What food allergies do you have?
Finding:
Denies medication allergies
(Available)
Pro Tip: A patient’s past medical history includes their health conditions, what preventative and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.Example Question:
What medication allergies do you have?
Finding:
Denies latex allergy
(Available)
Pro Tip: A patient’s past medical history includes their health conditions, what preventative and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.Example Question:
Do you have a latex allergy?
Finding:
Denies environment allergies
