Experts chose these topics as important parts of a thorough interview with this patient.
Table of Contents
Patient Data
Not Scored
Using both open and closed questions will provide better patient information. The following details are facts about the patient’s situation.
Main Concern
Finding:
Identified main concern
Finding:
Reports recent minor car accident
(Found)
Expert Tip: Patients decide to seek treatment for various reasons. Asking why Tina decided to seek treatment today might show her primary worries, the seriousness of her symptoms, or her inability to manage symptoms on her own.
Example Question:
What made you seek treatment today?
Finding:
Reports experiencing headaches
(Found)
Expert Tip: Symptoms often differ from one patient to another. Asking Tina if she’s had headaches specifies how her individual symptoms and pain show up.
Example Question:
Have you experienced any headaches?
Finding:
Reports neck discomfort
(Found)
Expert Tip: Symptoms often differ from one patient to another. Asking Tina if she’s felt neck stiffness specifies how her individual symptoms and pain show up.
Example Question:
Have you felt any neck stiffness?
History of Present Illness
Finding:
Inquired about symptom start
Finding:
Reports accident occurred a week ago
(Available)
Expert Tip: Gathering relevant information about Tina’s car accident will help you understand the circumstances of her injury and the injuries she sustained.
Example Question:
When did the accident happen?
Finding:
Reports symptoms started two days after accident
(Found)
Expert Tip: Symptoms often differ from one patient to another. Asking Tina when the headaches began specifies how her individual symptoms and pain show up.
Example Question:
When did the headaches start?
Finding:
Followed up on accident details
Finding:
Denies losing consciousness
(Found)
Expert Tip: Gathering relevant information about Tina’s car accident will help you understand the circumstances of her injury and the injuries she sustained.
Example Question:
Did you lose consciousness during the car accident?
Finding:
Reports low car speed
(Available)
Expert Tip: Gathering relevant information about Tina’s car accident will help you understand the circumstances of her injury and the injuries she sustained.
Example Question:
How fast was the car moving?
Finding:
Reports using seatbelt
(Found)
Expert Tip: Gathering relevant information about Tina’s car accident will help you understand the circumstances of her injury and the injuries she sustained.
Example Question:
Did you have your seatbelt on?
Finding:
Reports sitting in front passenger seat
(Found)
Expert Tip: Gathering relevant information about Tina’s car accident will help you understand the circumstances of her injury and the injuries she sustained.
Example Question:
Where were you seated in the car?
Finding:
Denies alcohol or drug use during accident
(Found)
Expert Tip: Gathering relevant information about Tina’s car accident will help you understand the circumstances of her injury and the injuries she sustained.
Example Question:
Was anyone in the car under the influence of alcohol?
Finding:
Asked about symptom frequency and duration
Finding:
Reports having daily headaches since they began
(Found)
Expert Tip: Symptoms often differ from one patient to another. Asking Tina how often she gets headaches specifies how her individual symptoms and pain show up.
Example Question:
How many days have you had a headache since they started?
Finding:
Reports headaches lasting 1-2 hours
(Found)
Expert Tip: Symptoms often differ from one patient to another. Asking Tina how long the headaches last specifies how her individual symptoms and pain show up.
Example Question:
How long do the headaches last?
Finding:
Reports last headache occurred yesterday afternoon
(Found)
Expert Tip: Symptoms often differ from one patient to another. Asking Tina when she got her last headaches specifies how her individual symptoms and pain show up.
Example Question:
When was your last headache?
Finding:
Inquired about pain location
Finding:
Reports headache pain in crown and back of head
(Found)
Expert Tip: Because symptoms often differ from one patient to another, asking Tina where her headaches occur will help treat her specific symptoms most effectively.
Example Question:
Where do you feel the headaches?
Finding:
Denies pain spreading to shoulders, back, or arms
(Found)
Expert Tip: Symptoms often differ from one patient to another. Asking Tina to describe how her injury feels will help understand her symptoms and pain.
Example Question:
Does the pain spread?
Finding:
Reports slight pain in back of neck muscles
(Found)
Expert Tip: Because symptoms often differ from one patient to another, asking Tina how her neck feels will help see how her pain manifests.
Example Question:
How does your neck feel?
Finding:
Denies tender scalp or injury
(Found)
Expert Tip: Symptoms often differ from one patient to another. Asking Tina if her scalp is tender specifies how her individual symptoms and pain show up.
Example Question:
Is your scalp sore?
Finding:
Denies jaw discomfort
(Found)
Expert Tip: Symptoms often differ from one patient to another. Asking Tina if her jaw hurts specifies how her individual symptoms and pain show up.
Example Question:
Do you have any jaw pain?
Finding:
Denies facial discomfort
(Found)
Expert Tip: Symptoms often differ from one patient to another. Asking Tina if she has facial pain specifies how her individual symptoms and pain show up.
Example Question:
Do you feel any facial pain?
Finding:
Asked about pain severity
Finding:
Rates current head and neck pain severity at 3 out of 10
(Found)
Expert Tip: Pain severity might change over time for various reasons. Asking Tina to rate her current pain on a scale from 0 to 10 provides a quantified measurement of her condition.
Example Question:
How bad is your current pain on a scale from 0 to 10?
Finding:
Rates worst pain severity at 4 out of 10
(Found)
Expert Tip: Pain severity might change over time for various reasons. Asking Tina to rate her pain when it started on a scale from 0 to 10 provides a quantified measurement of her condition.
Example Question:
How bad was your pain at its worst on a scale from 0 to 10?
Finding:
Inquired about headache characteristics
Finding:
Describes headache pain as dull ache
(Found)
Expert Tip: Symptoms often differ from one patient to another. Asking Tina to describe her headaches specifies how her individual symptoms and pain show up.
Example Question:
What do your headaches feel like?
Finding:
Denies sharp pain
(Found)
Expert Tip: Because symptoms often differ from one patient to another, asking Tina if her headaches feel sharp will help treat her specific symptoms most effectively.
Example Question:
Is the headache pain sharp?
Finding:
Reports non-cyclical headaches
(Found)
Expert Tip: By understanding Tina’s pain nature, you can treat her most effectively. Asking Tina if her headaches are cyclical will give insight into the extent of her pain.
Example Question:
Do your headaches come and go in cycles?
Finding:
Reports no clustered headaches
(Available)
Expert Tip: By understanding Tina’s pain nature, you can treat her most effectively. Asking Tina if her headaches come in clusters will give insight into the extent of her pain.
Example Question:
Do your headaches come in groups?
Finding:
Reports headaches with no sudden increase in pain
(Available)
Expert Tip: By understanding Tina’s pain nature, you can treat her most effectively. Asking Tina if her headaches suddenly increase will give insight into the extent of her pain.
Example Question:
Do your headaches suddenly get worse?
Finding:
Inquired about aggravating factors
Finding:
Considers car accident the main cause
(Found)
Expert Tip: Asking the patient about the primary cause of an injury is important.
Example Question:
What caused your pain?
Finding:
Reports pain when moving head or neck
(Found)
Expert Tip: Symptoms often differ from one patient to another. Asking Tina if moving her head hurts specifies how her individual symptoms and pain show up.
Example Question:
Does moving your head hurt?
Finding:
Reports headaches without a clear trigger
(Found)
Expert Tip: Pain severity might change for various reasons. Asking Tina what worsens her headaches might reveal activities, movements, or times that trigger her pain.
Example Question:
What makes your headaches worse?
Finding:
Inquired about pain relief methods for neck and headaches
Finding:
Does not use home remedies like heat or cold
(Available)
Expert Tip: Learning about the non-medication methods a patient uses for pain treatment helps understand the pain severity.
Example Question:
Have you tried home remedies?
Finding:
Feels better with rest
(Found)
Expert Tip: Understanding all relieving factors, including how symptoms change at rest, can help understand all contributing pain factors.
Example Question:
Does resting help with the headache?
Medical History
Finding:
Confirmed medication usage
Finding:
Confirms taking medications (no new ones mentioned)
(Found)
Expert Tip: Knowing what medications a patient takes is crucial for understanding their health history and avoiding unwanted drug interactions.
Example Question:
Are you using any new medications?
Finding:
Uses Tylenol more often
(Found)
Expert Tip: Knowing how much pain medication a patient uses is important to understand their pain level. If a patient takes pain medication but still feels pain, it could indicate higher pain severity than reported.
Example Question:
Do you use Tylenol?
Finding:
Unsure about Tylenol dosage
(Found)
Expert Tip: Knowing how much medication a patient takes reveals their current treatment plan. Asking Tina how much Tylenol she takes will show how effective over-the-counter medication is for her injury.
Example Question:
How much Tylenol do you take?
Finding:
Takes two Tylenol at a time
(Available)
Expert Tip: Asking how many pills a patient takes at once helps ensure they don’t take an unsafe dose.
Example Question:
How many Tylenol do you take at once?
Finding:
Takes Tylenol once daily
(Available)
Expert Tip: Knowing how often a patient takes medication reveals their current treatment plan. Asking Tina how often she takes Tylenol will show how effective over-the-counter medication is for her injury.
Example Question:
How often do you take Tylenol?
Finding:
Feels slightly better after taking Tylenol
(Found)
Expert Tip: Asking Tina if Tylenol helps assesses the headache severity and whether the current treatment plan is effective.
Example Question:
Does Tylenol help with the pain?
Finding:
Confirmed allergies
Finding:
Confirms no new allergies (Found)
Expert Tip: Asking Tina if she has new allergies shows how her health, beyond the main complaint, has been.
Example Question:
Do you have any new allergies?
Finding:
Asked about relevant neurological history
Finding:
Experienced frequent headaches in the past
(Found)
Expert Tip: Assessing which pain, if any, is “normal” versus caused by the accident helps understand the extent of her injuries.
Example Question:
Do you usually have headaches?
Finding:
Never had migraines before
(Found)
Expert Tip: Assessing which pain, if any, is “normal” versus caused by the accident helps understand the extent of her injuries.
Example Question:
Have you ever had migraines?
Finding:
Never had head trauma
(Found)
Expert Tip: After Tina’s car accident, it’s important to know if any head trauma predates the accident or if it’s a result of the crash.
Example Question:
Have you ever had any head trauma?
Finding:
No history of seizures
(Found)
Expert Tip: A car accident can cause a traumatic brain injury (TBI). Asking Tina if she’s had seizures might indicate if she’s experiencing TBI symptoms.
Example Question:
Have you had any seizures?
Social History
Finding:
Asked about sleep patterns
Finding:
No changes in sleep reported
(Found)
Expert Tip: A car accident can cause a traumatic brain injury (TBI). Asking Tina if her sleep patterns changed recently might indicate if she’s experiencing TBI symptoms.
Example Question:
Have your sleep patterns changed?
Finding:
No increased sleepiness or yawning reported
(Available)
Expert Tip: A car accident can cause a traumatic brain injury (TBI). Asking Tina if she feels sleepier than usual lately might indicate if she’s experiencing TBI symptoms.
Example Question:
Have you been feeling sleepier than usual lately?
Social Determinants of Health
Finding:
Asked about financial impact of the accident
Finding:
Has car insurance
(Available)
Expert Tip: Asking patients about Social Determinants of Health (SDOH) can uncover underlying social, political, or economic barriers to their health. Understanding a patient’s SDOH can lead to more informed and empathetic care, as it reveals the challenges they face.
Example Question:
Do you have car insurance?
Finding:
Doesn’t feel extra financial burden from accident
(Found)
Expert Tip: Asking patients about Social Determinants of Health (SDOH) can uncover underlying social, political, or economic barriers to their health. Understanding a patient’s SDOH can lead to more informed and empathetic care, as it reveals the challenges they face.
Example Question:
Will the car accident cause financial problems?
Review of Systems
Finding:
Asked about general symptoms
Finding:
No fever reported
(Found)
Expert Tip: After a head injury, asking Tina if she had a fever might indicate any additional complications from her neck trauma.
Example Question:
Have you had a fever?
Finding:
No chills reported
(Found)
Expert Tip: Chills after a car accident might indicate shock. Asking Tina if she had chills will reveal if she had shock after the accident.
Example Question:
Have you had any chills?
Finding:
No fatigue or energy changes reported
(Found)
Expert Tip: A car accident can cause a traumatic brain injury (TBI). Asking Tina if she feels more tired than usual lately might indicate if she’s experiencing TBI symptoms.
Example Question:
Have you felt more tired lately?
Finding:
No nausea or vomiting reported
(Found)
Expert Tip: Nausea is a symptom of concussion. Asking Tina if she felt nauseous might indicate if she had a concussion from the car accident.
Example Question:
Have you felt nauseous?
Finding:
No night sweats reported
(Found)
Expert Tip: Night sweats are a symptom of concussion. Asking Tina if she had night sweats might indicate if she had a concussion from the car accident.
Example Question:
Have you had night sweats?
Finding:
Asked about neurological symptoms
Finding:
No weakness on one side reported
(Found)
Expert Tip: A car accident can cause muscle or nerve damage leading to weakness on one side of the body. Asking Tina if one side feels weaker can indicate if she’s suffering from muscle damage.
Example Question:
Do you feel weaker on one side?
Finding:
No gait changes reported
(Found)
Expert Tip: A car accident can cause muscle or nerve damage. Asking Tina if her walking changed might indicate a muscle or tissue injury affecting her walk.
Example Question:
Have you noticed any changes in your walking
Shadow Health neurological assessment Subjective Data
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:
Established chief complaint
Finding:
Reports recent “fender bender”
(Found)
Pro Tip: Patients choose to seek treatment for a variety of reasons. Asking why Tina chose to seek treatment today might indicate primary concerns, the severity of her symptoms, or failure to manage symptoms herself.Example Question:
Why are you seeking treatment today?
Finding:
Reports headaches
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina if she’s had headaches specifies the way her individual symptoms and pain manifest.Example Question:
Have you had any headaches?
Finding:
Reports neck symptoms
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina if she’s had neck stiffness specifies the way her individual symptoms and pain manifest.Example Question:
Have you had any neck stiffness?
History of Present Illness
Finding:
Asked about onset of symptoms
Finding:
Reports accident occurred 1 week ago
(Available)
Pro Tip: Soliciting a relevant history of Tina’s car accident will allow you to understand the context in which she was injured and the injuries she sustained.Example Question:
When did the accident happen?
Finding:
Reports symptoms began 2 days after accident
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina when the headaches begin specifies the way her individual symptoms and pain manifest.Example Question:
When did the headaches begin?
Finding:
Followed up on details of car accident
Finding:
Denies loss of consciousness
(Found)
Pro Tip: Soliciting a relevant history of Tina’s car accident will allow you to understand the context in which she was injured and the injuries she sustained.Example Question:
Did you lose consciousness during the car accident?
Finding:
Reports low vehicle speed
(Available)
Pro Tip: Soliciting a relevant history of Tina’s car accident will allow you to understand the context in which she was injured and the injuries she sustained.Example Question:
How fast was the car going?
Finding:
Reports wearing seatbelt
(Found)
Pro Tip: Soliciting a relevant history of Tina’s car accident will allow you to understand the context in which she was injured and the injuries she sustained.Example Question:
Were you wearing your seatbelt?
Finding:
Reports sitting in front passenger seat
(Found)
Pro Tip: Soliciting a relevant history of Tina’s car accident will allow you to understand the context in which she was injured and the injuries she sustained.Example Question:
Where in the car were you sitting?
Finding:
Reports no alcohol or drug use during accident
(Found)
Pro Tip: Soliciting a relevant history of Tina’s car accident will allow you to understand the context in which she was injured and the injuries she sustained.Example Question:
Was anyone in the car under the influence of alcohol?
Finding:
Asked about frequency and duration of symptoms
Finding:
Reports headaches are daily since they began
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina how often she gets headaches specifies the way her individual symptoms and pain manifest.Example Question:
How many days have you had a headache since they started?
Finding:
Reports headaches last 1-2 hours
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina how long the headaches last specifies the way her individual symptoms and pain manifest.Example Question:
How long do the headaches last?
Finding:
Reports last headache was yesterday afternoon
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina when she got her last headaches specifies the way her individual symptoms and pain manifest.Example Question:
When was your last headache?
Finding:
Asked location of pain
Finding:
Reports headache pain in crown and back of head
(Found)
Pro Tip: Because symptoms often vary from patient to patient, asking Tina where her headaches are occurring will allow you to most effectively treat her specific symptoms.Example Question:
Where are the headaches located?
Finding:
Reports pain does not radiate into shoulders, back, or arms
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina to describe what her injury feels like specifies the way her symptoms and pain manifest.Example Question:
Does the pain radiate?
Finding:
Reports slight pain in back of neck muscles
(Found)
Pro Tip: Because symptoms often vary from patient to patient, asking Tina how her neck feels will allow you to see the ways in which her individual pain manifests.Example Question:
How does your neck feel?
Finding:
Denies scalp tenderness or injury
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina if her scalp is tender specifies the way her individual symptoms and pain manifest.Example Question:
Is your scalp tender?
Finding:
Denies jaw symptoms
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina if her jaw is tender specifies the way her individual symptoms and pain manifest.Example Question:
Do you have jaw pain?
Finding:
Denies facial pain
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina if she is experiencing facial pain specifies the way her individual symptoms and pain manifest.Example Question:
Do you have any facial pain?
Finding:
Asked about severity of pain
Finding:
Rates current head and neck pain severity at 3 out of 10
(Found)
Pro Tip: Pain severity might change over time for a variety of reasons. Asking Tina to rate the severity of her current pain on a scale of 1-10 will provide a quantified and relative measurement of her condition.Example Question:
How would you rate your current pain on a scale from 0 to 10?
Finding:
Rates pain severity at its worst is 4 out of 10
(Found)
Pro Tip: Pain severity might change over time for a variety of reasons. Asking Tina to rate the severity of her pain when it started on a scale of 1-10 will provide a quantified and relative measurement of her condition.Example Question:
How would you rate your pain at its worst on a scale from 0 to 10?
Finding:
Followed up on headache characteristics
Finding:
Reports headache pain as a dull ache
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina to describe what her headaches feel like specifies the way her individual symptoms and pain manifest.Example Question:
What do your headaches feel like?
Finding:
Denies sharp pain
(Found)
Pro Tip: Because symptoms often vary from patient to patient, asking Tina whether her headaches feel sharp will allow you to most effectively treat her specific symptoms.Example Question:
Is the headache pain sharp?
Finding:
Reports headaches not cyclic
(Found)
Pro Tip: By understanding the nature of Tina’s pain, you can most effectively treat her. Asking Tina whether her headaches are cyclic will give you a sense for the extent of her pain.Example Question:
Are your headaches cyclic?
Finding:
Reports headaches do not occur in clusters
(Available)
Pro Tip: By understanding the nature of Tina’s pain, you can most effectively treat her. Asking Tina whether her headaches come in clusters will give you a sense for the extent of her pain.Example Question:
Do your headaches come in clusters?
Finding:
Reports headaches not rapid in crescendo
(Available)
Pro Tip: By understanding the nature of Tina’s pain, you can most effectively treat her. Asking Tina whether her headaches crescendo will give you a sense for the extent of her pain.Example Question:
Do your headaches crescendo?
Finding:
Asked about aggravating factors
Finding:
Reports that car accident seems to be primary cause
(Found)
Pro Tip: It’s important to ask the patient if they know the primary cause of an injury.Example Question:
What caused your pain?
Finding:
Reports pain upon head or neck movement
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina if it hurts to move her head specifies the way her individual symptoms and pain manifest.Example Question:
Does it hurt to move your head?
Finding:
Reports headaches don’t have a discernible trigger
(Found)
Pro Tip: Pain severity might change for a variety of reasons. Asking Tina what makes her headaches worse might help you to understand sounds, movements, or times that trigger her pain.Example Question:
What makes your headaches worse?
Finding:
Asked about relieving factors for neck pain and headaches
Finding:
Denies home remedies such as heat or cold
(Available)
Pro Tip: Finding out the non-medication modalities that a patient is treating her pain with will help you understand the severity of the pain.Example Question:
Have you tried home remedies?
Finding:
Symptoms improve with rest
(Found)
Pro Tip: Understanding all of the relieving factors, including how a symptom changes at motion or at rest, can help you understand all of the contributing pain factors.Example Question:
Does the headache get better with rest?
Medical History
Finding:
Confirmed use of medications
Finding:
Confirms medications (no new medications reported)
(Found)
Pro Tip: Determining what, if any, medications a patient is taking is a crucial element of a thorough health history and will help you avoid unwanted drug interactions.Example Question:
Are you taking any new medications?
Finding:
Reports increased Tylenol use
(Found)
Pro Tip: The amount of pain medication a patient is taking is an important consideration in understanding their level of pain. For a patient who takes pain medication but still experiences pain, it can indicate higher pain severity than she is reporting.Example Question:
Have you been taking Tylenol?
Finding:
Followed up on Tylenol use
Finding:
Unsure of dosage
(Found)
Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina how much tylenol she takes will illustrate how effectively OTC medication works for her injury.Example Question:
What dose of tylenol do you take?
Finding:
Takes 2 Tylenol at a time
(Available)
Pro Tip: Asking how many pills a patient takes at once time can help you make sure a patient is not taking an unsafe dose.Example Question:
How many Tylenol do you take at a time?
Finding:
Takes Tylenol once a day
(Available)
Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina how often she takes tylenol will illustrate how effectively OTC medication works for her injury.Example Question:
How often do you take tylenol?
Finding:
Reports minor relief from Tylenol
(Found)
Pro Tip: Asking Tina if the Tylenol helps will allow you to assess the severity of her headaches and whether her current treatment plan is effective.Example Question:
Does the Tylenol help?
Finding:
Confirmed allergies
Finding:
Confirms allergies (no new allergies reported)
(Found)
Pro Tip: Asking Tina if she has any new allergies will allow you to understand how, beyond the chief complaint, Tina’s health has been.Example Question:
Do you have any new allergies?
Finding:
Asked about relevant neurological history
Finding:
Reports past frequent headaches
(Found)
Pro Tip: Assessing which of Tina’s pain (if any) is “normal” versus caused by the accident will allow you to understand the scope of her injuries.Example Question:
Do you usually get headaches?
Finding:
Denies history of migraine
(Found)
Pro Tip: Assessing which of Tina’s pain (if any) is “normal” versus caused by the accident will allow you to understand the scope of her injuries.Example Question:
Do you ever get migraines?
Finding:
Denies head trauma
(Found)
Pro Tip: After Tina’s car accident, it is important to establish whether head trauma she might be experiencing predates the accident or, rather, is a result of the crash.Example Question:
Have you ever had any head trauma?
Finding:
Denies history of seizures
(Found)
Pro Tip: A car accident can result in a traumatic brain injury (TBI). Asking Tina if she’s had seizures might indicate whether or not she is experiencing symptoms of a traumatic brain injury.Example Question:
Have you had any seizures?
Social History
Finding:
Asked about sleep
Finding:
Denies changes in sleep
(Found)
Pro Tip: A car accident can result in a traumatic brain injury (TBI). Asking Tina if her sleep habits have changed lately might indicate whether she is experiencing symptoms of a traumatic brain injury.Example Question:
Have your sleep habits changed?
Finding:
Denies increased sleepiness or yawning
(Available)
Pro Tip: A car accident can result in a traumatic brain injury (TBI). Asking Tina if she’s felt more sleepy lately might indicate whether she is experiencing symptoms of a traumatic brain injury.Example Question:
Have you felt more sleepy lately?
Social Determinants of Health
Finding:
Asked about impact of accident on finances
Finding:
Reports having car insurance
(Available)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.Example Question:
Do you have car insurance?
Finding:
Denies accident places extra burden on her financially
(Found)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.Example Question:
Is the car accident going to be a financial burden?
Review of Systems
Finding:
Asked about general symptoms
Finding:
Denies fever
(Found)
Pro Tip: Following a head injury, asking Tina whether she’s had a fever might indicate if she’s suffered any additional complications to her neck trauma.Example Question:
Have you had a fever?
Finding:
Denies chills
(Found)
Pro Tip: Chills after a car accident might indicate shock. Asking Tina if she’s had any chills will reveal whether or not she’s had shock following her accident.Example Question:
Have you had any chills?
Finding:
Denies fatigue or changes in energy level
(Found)
Pro Tip: A car accident can result in a traumatic brain injury (TBI). Asking Tina if she’s felt more fatigued lately might indicate whether she is experiencing symptoms of a traumatic brain injury.Example Question:
Have you felt fatigued?
Finding:
Denies nausea or vomiting
(Found)
Pro Tip: One symptom of a concussion is nausea. Asking Tina whether she’s felt nausea might reveal that she sustained a concussion in her car accident.Example Question:
Have you had nausea?
Finding:
Denies night sweats
(Found)
Pro Tip: One symptom of a concussion is nausea. Asking Tina whether she’s been vomiting might reveal that she sustained a concussion in her car accident.Example Question:
Have you had night sweats?
Finding:
Asked about review of systems for neurological
Finding:
Denies hemiparesis
(Found)
Pro Tip: A car accident can result in muscle damage and feeling weak on one side of the body. Asking Tina whether she feels weak on one side of her body can indicate whether she is suffering from muscle damage.Example Question:
Has one side of your body felt weaker than the other?
Finding:
Denies gait disturbance
(Found)
Pro Tip: A car accident can result in muscle damage or nerve damage. Asking Tina whether her gait has changed might indicate a muscle or tissue injury that is impacting the way she walks.Example Question:
Have you had any changes in your gait?
Finding:
Denies body weakness
(Available)
Pro Tip: A car accident can result in muscle damage and feeling weakness. Asking Tina whether she feels weak can indicate whether or not she is suffering from muscle damage.Example Question:
Have you felt weak?
Finding:
Denies seeing auras or halos
(Available)
Pro Tip: After Tina’s car accident, it is important to establish whether neurological problems she might be experiencing predate the accident or, rather, are a result of the crash. Asking Tina if she’s been seeing auras will indicate whether she’s experiencing a neurological disturbance.Example Question:
Have you experienced any auras?
Finding:
Denies dizziness, light-headedness, syncope, or disequilibrium
(Found)
Pro Tip: A car accident can result in a traumatic brain injury (TBI). Asking Tina if she’s felt dizzy might indicate whether she is experiencing symptoms of a traumatic brain injury.Example Question:
Have you felt dizzy?
Finding:
Denies loss of coordination
(Available)
Pro Tip: People with traumatic brain injuries commonly report loss of coordination. Asking Tina whether she’s lost coordination can indicate that she suffered a traumatic brain injury during her accident.Example Question:
Have you had any loss of coordination?
Finding:
Denies scotoma
(Available)
Pro Tip: People with traumatic brain injuries commonly report scotoma. Asking Tina whether she’s noticed any scotoma can indicate that she suffered a traumatic brain injury during her accident.Example Question:
Have you noticed any scotoma?
Finding:
Denies numbness or tingling
(Available)
Pro Tip: Tingling sensations after a car accident can suggest a herniated disc. Asking Tina whether she’s experiencing tingling sensations might indicate additional musculoskeletal damage caused by the accident.Example Question:
Have you had any tingling sensations?
Finding:
Denies facial flushing
(Available)
Pro Tip: A prolonged flush face can indicate cerebral compression. Asking Tina whether her face has been flushed will indicate if she is suffering from head trauma.Example Question:
Has your face been flushed?
Finding:
Asked about review of systems for psych and behavioral history
Finding:
Denies depression
(Available)
Pro Tip: After an accident, it is not uncommon to feel anxious or depressed. Asking Tina whether she’s felt depressed can indicate long-term concerns following her accident.Example Question:
Have you felt depressed?
Finding:
Denies increased irritability
(Available)
Pro Tip: One symptom of a concussion is irritability. Asking Tina whether she’s been irritable might reveal that she sustained a concussion in her car accident.Example Question:
Have you felt more irritable?
Finding:
Denies problems with concentration or memory
(Found)
Pro Tip: One symptom of a concussion is problems concentrating. Asking Tina whether she’s been experiencing problems concentrating might reveal that she sustained a concussion in her car accident.Example Question:
Have you had any problems concentrating?
Finding:
Denies confusion
(Available)
Pro Tip: One symptom of a concussion is confusion. Asking Tina whether she’s felt confusion might reveal that she sustained a concussion in her car accident.Example Question:
Have you felt confused?
Finding:
Asked about review of systems for eyes and vision
Finding:
Denies changes in vision since accident
(Found)
Pro Tip: Eye and vision problems are fairly common after a brain injury. Asking Tina whether her vision changed since her accident might indicate that she sustained a head injury.Example Question:
Has your vision changed since the accident?
Finding:
Reports occasional blurry vision (pre-dating accident)
(Found)
Pro Tip:Example Question:
Have you ever had blurry vision?
Finding:
Denies unilateral vision disturbance
(Available)
Pro Tip: Eye and vision problems are fairly common after a brain injury. Asking Tina whether she’s had vision problems in just one eye since her accident might indicate that she sustained a head injury.Example Question:
Have you had any vision problems in just one eye?
Finding:
Denies sensitivity to light
(Available)
Pro Tip: Eye and vision problems are fairly common after a brain injury. Asking Tina whether she is sensitive to light since her accident might indicate that she sustained a head injury.Example Question:
Are you sensitive to light since the accident?
Finding:
Asked about review of systems for ears, nose, and throat
Finding:
Denies nasal congestion or rhinorrhea
(Available)
Pro Tip: Whiplash from Tina’s car accident might result in congestion and sinus problems. Asking Tina if she’s been congested can indicate that she suffered from whiplash during the accident.Example Question:
Have you had any congestion?
Finding:
Denies tinnitus
(Available)
Pro Tip: Tinnitus, or hearing ringing, can result from the loudness of a car accident. Asking Tina whether she’s hearing ringing can indicate whether she is suffering from Tinnitus.Example Question:
Have you had ringing in your ears?
Finding:
Denies changes in hearing
(Available)
Pro Tip: Sudden Sensorineural Hearing Losses can be associated with head trauma caused by car accidents. Asking Tina if she’s experiencing hearing loss can indicate possible head trauma.Example Question:
Have you had any hearing loss?
Finding:
Denies difficulty swallowing
(Found)
Pro Tip: Whiplash from Tina’s car accident might result in damage to the soft tissue of her neck. Asking Tina if she is having trouble swallowing might suggest an injury that she sustained in the crash.Example Question:
Have you had any difficulty swallowing?
Family History
Finding:
Asked about relevant family history
Finding:
Denies family history of migraine
(Found)
Pro Tip: Some causes of migraines can be inherited, and so it’s important to understand your patient’s risk level.Example Question:
Is there a history of migraines in your family?
Finding:
Denies family history of epilepsy or seizures
(Available)
Pro Tip: Epilepsy or other forms of seizures can be inherited, and so it’s important to understand your patient’s risk level.Example Question:
Do you have a family history of epilepsy?
Finding:
Denies family history of Alzheimer’s disease
(Available)
Pro Tip: Conditions like Alzheimer’s disease can be inherited, and so it’s important to understand your patient’s risk level.Example Question:
Do you have a family history of Alzheimer’s disease?
Finding:
Denies family history of Parkinson’s disease
