Alcohol Use Disorder Rachel Adler shadow health Subjective Data Collection
Alcohol Use Disorder Rachel Adler shadow health Subjective Data Collection
Subjective Data Collection: 51 of 51 (100.0%)
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Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
Found:
Indicates an item that you found.
Available:
Indicates an item that is available to be found.
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 and reason for admittance
Alcohol Use Disorder Rachel Adler shadow health Subjective Data Collection
Finding:
Reports car accident
(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:
Why were you admitted?
Finding:
Reports 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 caused your injury?
Finding:
Reports passive suicidal ideation
(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 brings you in today?
History of Present Illness
Finding:
Followed up on details of car accident
Finding:
Reports loss of consciousness
(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 lose consciousness during the car accident?
Finding:
Reports being unsure of how the accident happened
(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:
Do you know what caused the car accident?
Finding:
Reports wearing seatbelt
(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:
Were you wearing a seatbelt?
Finding:
Reports being the driver – no other passengers in car
(Available)
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:
Who was driving before the car accident?
Finding:
Reports was told she would get a ticket for DUI
(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 caused the car accident?
Finding:
Followed up on alcohol use just prior to car accident
Finding:
Reports drinking before accident
(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:
Were you drinking before the accident?
Finding:
Reports being unsure of how many drinks – “at least 5”
(Available)
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:
How much did you drink before the accident?
Finding:
Reports was drinking with friends at a party
(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:
Who were you drinking with?
Finding:
Reports left party to drive home because she was mad at her girlfriend and could not take any more
(Available)
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:
Why did you leave the party?
Finding:
Asked about driving impaired
Finding:
Reports knew she was driving under the influence but did not care
(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 know you were too drunk to drive?
Finding:
Reports have driven in past after drinking, but this time she did not care if she injured herself
(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 care that you were driving under the influence?
Finding:
Followed up on impaired driving – risk for self harm
Finding:
Reports has had enough of life and did not care if she got hurt/died
(Available)
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 drive under the influence in order to hurt yourself?
Finding:
Reports had not thought about self harm before accident
(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 you ever wanted to hurt yourself before the accident?
Finding:
Reports since accident, not sure what to think about what she did
(Available)
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:
How do you feel since the accident?
Finding:
Asked about onset and duration of pain
Finding:
Reports pain started immediately after accident
(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 you last experience the pain?
Finding:
Reports accident was last night
(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 car accident happen?
Finding:
Reports accident was at 10 pm
(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 car accident happen?
Finding:
Asked about location of pain
Finding:
Reports pain is in right wrist
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Alcohol Use Disorder Rachel Adler shadow health Subjective Data Collection 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 your wrist hurt?
Finding:
Asked about aggravating factors of pain
Finding:
Reports increased pain when bending or twisting (R) wrist
(Available)
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:
Is your pain worse with movement?
Finding:
Reports increased pain when trying to lift items, even small ones such as a hairbrush Alcohol Use Disorder Rachel Adler shadow health Subjective Data Collection
(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:
Is your pain worse with movement?
Finding:
Asked about treatment and relieving factors of pain
Finding:
Reports rest improves 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 lying down help your pain?
Finding:
Reports ibuprofen has significantly reduced 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:
Has ibuprofen helped your pain?
Finding:
Reports wearing sling helps
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Alcohol Use Disorder Rachel Adler shadow health Subjective Data Collection 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:
Has wearing the sling helped your pain?
Finding:
Asked about characteristics of pain
Finding:
Reports pain is aching
(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:
Is the pain aching?
Finding:
Denies sharp or shooting 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 Alcohol Use Disorder Rachel Adler shadow health Subjective Data Collection. 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:
Do you have shooting pain?
Finding:
Asked about severity of pain
Finding:
Reports current pain level is 2/10
(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:
How would you rate your pain?
Finding:
Reports pain without medication was 8/10
(Available)
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:
How would you rate your pain without medication?
Past Medical History
Finding:
Asked about existing health conditions
Finding:
Reports no known health problems
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
What health problems do you have?
Finding:
Asked about history of mental health
Finding:
Denies previous history of mental illness diagnoses
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Do you have a history of psychiatric illness?
Finding:
Denies past depression
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Have you experienced any depression or sadness?
Finding:
Reports feeling anxious over the past six months – has not sought treatment/counseling
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Have you felt anxious?
Finding:
Reports can not deal with stress of school and life in general
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Is your life stressful?
Finding:
Reports that she does not care what happens to her anymore (passive suicidal ideation)
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
How do you cope with stress?
Finding:
Followed up on stress issues
Finding:
Reports stress over parental relationships
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
How do you get along with your parents?
Finding:
Reports stress over school
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Can you tell me about school?
Finding:
Reports stress over grades
