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Intermediate Patient Case Results Edward Carter ShadowHealth

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Chief Complaint Finding: Established chief complaint Finding: Reports pain ( ) Pro Tip: Beginning your conversation with your patient by asking an open-ended question about their hospital visit is a best practice for gauging your patient's general condition. Example Question: What brings you to the hospital? Finding: Reports blood in urine ( ) Pro Tip: Beginning your conversation with your patient by asking an open-ended question about their symptoms is a best practice for gauging your patient's general condition. Example Question: What are your symptoms? Finding: Reports increased frequency of urination ( ) Pro Tip: A patient with flank pain and blood in urine may have kidney stones, a bladder infection, or another serious complaint that may affect urinary patterns. Example Question: Have you had urinary symptoms? Orientation Finding: Asked about orientation Finding: Oriented to own person (Available) Pro Tip: You should ask patients, especially geriatric ones or those on a potentially mind-altering medication, to state their name so you can determine their cognitive functioning. Example Question: Can you tell me who you are? Finding: Oriented to place (Available) Pro Tip: You should ask patients, especially geriatric ones or those on a potentially mind-altering medication, to identify where they are so you can determine their cognitive functioning. Example Question: Do you know where you are right now? Finding: Oriented to situation ( ) Pro Tip: You should ask patients, especially geriatric ones or those on a potentially mind-altering medication, to identify their reason for being here so you can determine their cognitive functioning. Example Question: Do you know why you are here today? Finding: Oriented to time (Available) Pro Tip: You should ask patients, especially geriatric ones or those on a potentially mind-altering medication, to identify the date and year so you can determine their cognitive functioning. Example Question: What is the date and year? History of Present Illness Finding: Asked about onset and duration of symptoms Finding: Reports pain began 3 days ago ( ) Pro Tip: Discovering how long ago the pain began is the first step in understanding whether the pain is chronic or acute. Example Question: When did your pain begin?

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