Samantha Monroe Shadow Health Subjective Data

Samantha Monroe Shadow Health Subjective Data

Subjective Data Collection: 26 Of 27 (96.3%)

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Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.

  • Found:

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  • 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.

Confirmed Guardian’s Relationship

Finding:

Asked about relationship with patient

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Finding:

Reports being Samantha’s mother

(Found)

Pro Tip: Confirming the patient’s relationship with their guardian ensures that you are observing legal and ethical protections for patient privacy, and that you are speaking with someone who has access to the patient’s information.

Example Question:

What is your relationship to the patient?

Chief Complaint

Finding:

Asked about reason for visit

Finding:

Reports needing sports physical for soccer

(Found)

Pro Tip: Confirming the purpose of a patient’s visit is important for determining the scope of the exam. Knowing that a patient is seeking a pre-participation evaluation will guide your conversation and inform the physical exam actions that you take, all with the goal of determining if a patient is healthy enough to participate in sports. It is also important to know which sport(s) the patient plays. Some sports have a higher risk of concussions, while other may require participants to maintain a certain weight. Individual considerations must be made for each type of activity.

Example Question:

What brings you into the clinic?

Past Medical History

Finding:

Asked about medical conditions

Finding:

Denies having any medical conditions

(Found)

Pro Tip: Discussing the patient’s past medical history will alert you to any past or present medical conditions that may restrict a patient from participating in sports. Keep in mind the particular sport the patient wishes to participate in, as a contact sport like football has different risks than a sport like golf.

Example Question:

Do you have any medical conditions?

Finding:

Asked about history of surgery

Finding:

Reports only having a tonsillectomy

(Found)

Pro Tip: Discussing the patient’s past medical history will alert you to any past or present medical conditions that may restrict a patient from participating in sports. Keep in mind the particular sport the patient wishes to participate in, as a contact sport like football has different risks than a sport like golf.

Example Question:

Have you ever had surgery?

Finding:

Asked about missing organs

Finding:

Denies missing organs

(Found)

Pro Tip: Discussing the patient’s past medical history will alert you to any past or present medical conditions that may restrict a patient from participating in sports. Keep in mind the particular sport the patient wishes to participate in, as a contact sport like football has different risks than a sport like golf.

Example Question:

Are you missing any organs?

Finding:

Asked about allergies

Finding:

Denies being allergic to insects

(Available)

Pro Tip: Discussing the patient’s past medical history will alert you to any past or present medical conditions that may restrict a patient from participating in sports. Keep in mind the particular sport the patient wishes to participate in, as a contact sport like football has different risks than a sport like golf.

Example Question:

Are you allergic to insects?

Finding:

Denies environmental allergies

(Available)

Pro Tip: Discussing the patient’s past medical history will alert you to any past or present medical conditions that may restrict a patient from participating in sports. Keep in mind the particular sport the patient wishes to participate in, as a contact sport like football has different risks than a sport like golf.

Example Question:

Are you allergic to pollen?

Finding:

Denies food allergies

(Available)

Pro Tip: Discussing the patient’s past medical history will alert you to any past or present medical conditions that may restrict a patient from participating in sports. Keep in mind the particular sport the patient wishes to participate in, as a contact sport like football has different risks than a sport like golf.

Example Question:

Do you have food allergies?

Finding:

Denies medication allergies

(Available)

Pro Tip: Discussing the patient’s past medical history will alert you to any past or present medical conditions that may restrict a patient from participating in sports. Keep in mind the particular sport the patient wishes to participate in, as a contact sport like football has different risks than a sport like golf.

Example Question:

Do you have medication allergies?

Finding:

Asked about immunizations

Finding:

Reports being up to date on all immunizations

(Found)

Pro Tip: Discussing the patient’s past medical history will alert you to any past or present medical conditions that may restrict a patient from participating in sports. Keep in mind the particular sport the patient wishes to participate in, as a contact sport like football has different risks than a sport like golf.

Example Question:

Are your vaccinations up to date?

Home Medications

Finding:

Asked about medications

Finding:

Denies taking medications

(Found)

Pro Tip: Learning what medication the patient takes is important for understanding any conditions they may be suffering from, how those conditions are managed, and if those medications pose any risks for sports participation. Pay careful attention to any vitamins or supplements, as this is an important aspect of health for many athletes, and although they are meant to maintain and improve health, improper use of vitamins and supplements can be dangerous.

Example Question:

Do you take any medications?

Finding:

Asked about vitamins and supplements

Finding:

Reports taking a multivitamin

(Found)

Pro Tip: Learning what medication the patient takes is important for understanding any conditions they may be suffering from, how those conditions are managed, and if those medications pose any risks for sports participation. Pay careful attention to any vitamins or supplements, as this is an important aspect of health for many athletes, and although they are meant to maintain and improve health, improper use of vitamins and supplements can be dangerous.

Example Question:

Do you take vitamins?

Finding:

Reports drinking apple cider vinegar

(Found)

Pro Tip: Learning what medication the patient takes is important for understanding any conditions they may be suffering from, how those conditions are managed, and if those medications pose any risks for sports participation. Pay careful attention to any vitamins or supplements, as this is an important aspect of health for many athletes, and although they are meant to maintain and improve health, improper use of vitamins and supplements can be dangerous.

Example Question:

Do you take supplements?

Finding:

Reports belief that apple cider vinegar gives her energy

(Available)

Pro Tip: Learning what medication the patient takes is important for understanding any conditions they may be suffering from, how those conditions are managed, and if those medications pose any risks for sports participation. Pay careful attention to any vitamins or supplements, as this is an important aspect of health for many athletes, and although they are meant to maintain and improve health, improper use of vitamins and supplements can be dangerous.

Example Question:

How do supplements help you?

Review Of Systems

Finding:

Asked about passing out during or after exercise

Finding:

Denies passing out during exercise

(Found)

Pro Tip: For a pre-participation evaluation, it is important to tailor your questions to the individual patient and to their identified sport(s). For many sports, it is important to hit on several key systems: respiratory, musculoskeletal, and neurological. Uncovering any issues in these areas will help you determine if a patient is healthy enough to participate in sports or if their participation should be restricted due to health risks.

Example Question:

Have you passed out during soccer?

Finding:

Denies passing out after exercise

(Found)

Pro Tip: For a pre-participation evaluation, it is important to tailor your questions to the individual patient and to their identified sport(s). For many sports, it is important to hit on several key systems: respiratory, musculoskeletal, and neurological. Uncovering any issues in these areas will help you determine if a patient is healthy enough to participate in sports or if their participation should be restricted due to health risks.

Example Question:

Have you passed out after soccer?

Finding:

Reports that she has felt dizzy during gym class

(Found)

Pro Tip: For a pre-participation evaluation, it is important to tailor your questions to the individual patient and to their identified sport(s). For many sports, it is important to hit on several key systems: respiratory, musculoskeletal, and neurological. Uncovering any issues in these areas will help you determine if a patient is healthy enough to participate in sports or if their participation should be restricted due to health risks.

Example Question:

Have you passed out during or after exercise?

Finding:

Asked about dizziness

Finding:

Reports dizziness was due to skipping lunch

(Found)

Pro Tip: For a pre-participation evaluation, it is important to tailor your questions to the individual patient and to their identified sport(s). For many sports, it is important to hit on several key systems: respiratory, musculoskeletal, and neurological. Uncovering any issues in these areas will help you determine if a patient is healthy enough to participate in sports or if their participation should be restricted due to health risks.

Example Question:

Can you tell me more about feeling dizzy?

Finding:

Reports she only felt dizzy once or twice

(Found)

Pro Tip: For a pre-participation evaluation, it is important to tailor your questions to the individual patient and to their identified sport(s). For many sports, it is important to hit on several key systems: respiratory, musculoskeletal, and neurological. Uncovering any issues in these areas will help you determine if a patient is healthy enough to participate in sports or if their participation should be restricted due to health risks.

Example Question:

How often are you dizzy?

Finding:

Reports the last time she felt dizzy was last week

(Available)

Pro Tip: For a pre-participation evaluation, it is important to tailor your questions to the individual patient and to their identified sport(s). For many sports, it is important to hit on several key systems: respiratory, musculoskeletal, and neurological. Uncovering any issues in these areas will help you determine if a patient is healthy enough to participate in sports or if their participation should be restricted due to health risks.

Example Question:

When did you last feel dizzy?

Finding:

Asked about heart problems during and after exercise

Finding:

Denies heart problems during exercise

(Found)

Pro Tip: For a pre-participation evaluation, it is important to tailor your questions to the individual patient and to their identified sport(s). For many sports, it is important to hit on several key systems: respiratory, musculoskeletal, and neurological. Uncovering any issues in these areas will help you determine if a patient is healthy enough to participate in sports or if their participation should be restricted due to health risks.

Example Question:

Have you had heart problems during exercise?

Finding:

Denies heart problems after exercise

(Found)

Pro Tip: For a pre-participation evaluation, it is important to tailor your questions to the individual patient and to their identified sport(s). For many sports, it is important to hit on several key systems: respiratory, musculoskeletal, and neurological. Uncovering any issues in these areas will help you determine if a patient is healthy enough to participate in sports or if their participation should be restricted due to health risks.

Example Question:

Have you had heart problems after exercise?

Finding:

Asked about diagnosed heart problems

Finding:

Denies ever being told she has a heart problem

(Found)

Pro Tip: For a pre-participation evaluation, it is important to tailor your questions to the individual patient and to their identified sport(s). For many sports, it is important to hit on several key systems: respiratory, musculoskeletal, and neurological. Uncovering any issues in these areas will help you determine if a patient is healthy enough to participate in sports or if their participation should be restricted due to health risks.

Example Question:

Do you have known heart problems?

Finding:

Asked about heart tests

Finding:

Denies having any heart tests

(Available)

Pro Tip: For a pre-participation evaluation, it is important to tailor your questions to the individual patient and to their identified sport(s). For many sports, it is important to hit on several key systems: respiratory, musculoskeletal, and neurological. Uncovering any issues in these areas will help you determine if a patient is healthy enough to participate in sports or if their participation should be restricted due to health risks.

Example Question:

Have you ever had any heart tests?

Finding:

Asked about breathing during and after exercise

Finding:

Denies breathing problems during exercise

(Found)

Pro Tip: For a pre-participation evaluation, it is important to tailor your questions to the individual patient and to their identified sport(s). For many sports, it is important to hit on several key systems: respiratory, musculoskeletal, and neurological. Uncovering any issues in these areas will help you determine if a patient is healthy enough to participate in sports or if their participation should be restricted due to health risks.

Example Question:

How is your breathing during exercise?

Finding:

Denies breathing problems after exercise

(Found)

Pro Tip: For a pre-participation evaluation, it is important to tailor your questions to the individual patient and to their identified sport(s). For many sports, it is important to hit on several key systems: respiratory, musculoskeletal, and neurological. Uncovering any issues in these areas will help you determine if a patient is healthy enough to participate in sports or if their participation should be restricted due to health risks.

Example Question:

How is your breathing after exercise?

Finding:

Asked about history of seizures

Finding:

Denies ever having a seizure

(Found)

Pro Tip: For a pre-participation evaluation, it is important to tailor your questions to the individual patient and to their identified sport(s). For many sports, it is important to hit on several key systems: respiratory, musculoskeletal, and neurological. Uncovering any issues in these areas will help you determine if a patient is healthy enough to participate in sports or if their participation should be restricted due to health risks.

Example Question:

Have you ever had a seizure?

Finding:

Asked about musculoskeletal injuries

Finding:

Reports spraining her ankle when she was ten

(Found)

Pro Tip: For a pre-participation evaluation, it is important to tailor your questions to the individual patient and to their identified sport(s). For many sports, it is important to hit on several key systems: respiratory, musculoskeletal, and neurological. Uncovering any issues in these areas will help you determine if a patient is healthy enough to participate in sports or if their participation should be restricted due to health risks.

Example Question:

Have you had a stress fracture?

Finding:

Denies current musculoskeletal injuries

(Found)

Pro Tip: For a pre-participation evaluation, it is important to tailor your questions to the individual patient and to their identified sport(s). For many sports, it is important to hit on several key systems: respiratory, musculoskeletal, and neurological. Uncovering any issues in these areas will help you determine if a patient is healthy enough to participate in sports or if their participation should be restricted due to health risks.

Example Question:

Do you have any current musculoskeletal problems?

Finding:

Asked about rashes

Finding:

Denies rashes

(Found)

Pro Tip: For a pre-participation evaluation, it is important to tailor your questions to the individual patient and to their identified sport(s). For many sports, it is important to hit on several key systems: respiratory, musculoskeletal, and neurological. Uncovering any issues in these areas will help you determine if a patient is healthy enough to participate in sports or if their participation should be restricted due to health risks.

Example Question:

Do you have any rashes?

Finding:

Asked about history of head injuries

Finding:

Denies ever having a head injury

(Found)

Pro Tip: For a pre-participation evaluation, it is important to tailor your questions to the individual patient and to their identified sport(s). For many sports, it is important to hit on several key systems: respiratory, musculoskeletal, and neurological. Uncovering any issues in these areas will help you determine if a patient is healthy enough to participate in sports or if their participation should be restricted due to health risks.

Example Question:

Have you had a head injury?

Finding:

Denies concussions

(Found)

Pro Tip: For a pre-participation evaluation, it is important to tailor your questions to the individual patient and to their identified sport(s). For many sports, it is important to hit on several key systems: respiratory, musculoskeletal, and neurological. Uncovering any issues in these areas will help you determine if a patient is healthy enough to participate in sports or if their participation should be restricted due to health risks.

Example Question:

Have you had a concussion?

Finding:

Asked about numbness, tingling, and weakness in limbs

Finding:

Denies numbness in limbs

(Found)

Pro Tip: For a pre-participation evaluation, it is important to tailor your questions to the individual patient and to their identified sport(s). For many sports, it is important to hit on several key systems: respiratory, musculoskeletal, and neurological. Uncovering any issues in these areas will help you determine if a patient is healthy enough to participate in sports or if their participation should be restricted due to health risks.

Example Question:

Do you ever have numbness in your limbs?

Finding:

Denies tingling in limbs

(Found)

Pro Tip: For a pre-participation evaluation, it is important to tailor your questions to the individual patient and to their identified sport(s). For many sports, it is important to hit on several key systems: respiratory, musculoskeletal, and neurological. Uncovering any issues in these areas will help you determine if a patient is healthy enough to participate in sports or if their participation should be restricted due to health risks.

Example Question:

Do you feel tingling in your limbs?

Finding:

Denies weakness in limbs

(Found)

Pro Tip: For a pre-participation evaluation, it is important to tailor your questions to the individual patient and to their identified sport(s). For many sports, it is important to hit on several key systems: respiratory, musculoskeletal, and neurological. Uncovering any issues in these areas will help you determine if a patient is healthy enough to participate in sports or if their participation should be restricted due to health risks.

Example Question:

Do you have weakness in your limbs?

Finding:

Asked about exercising in the heat

Finding:

Reports becoming ill in the heat once in the 5th grade

(Available)

Pro Tip: For a pre-participation evaluation, it is important to tailor your questions to the individual patient and to their identified sport(s). For many sports, it is important to hit on several key systems: respiratory, musculoskeletal, and neurological. Uncovering any issues in these areas will help you determine if a patient is healthy enough to participate in sports or if their participation should be restricted due to health risks.

Example Question:

Have you ever become sick exercising in the heat?

Finding:

Asked about HEENT

Finding:

Denies eye problems

(Found)

Pro Tip: For a pre-participation evaluation, it is important to tailor your questions to the individual patient and to their identified sport(s). For many sports, it is important to hit on several key systems: respiratory, musculoskeletal, and neurological. Uncovering any issues in these areas will help you determine if a patient is healthy enough to participate in sports or if their participation should be restricted due to health risks.

Example Question:

Do you have any eye problems?

Finding:

Denies vision problems

(Available)

Pro Tip: For a pre-participation evaluation, it is important to tailor your questions to the individual patient and to their identified sport(s). For many sports, it is important to hit on several key systems: respiratory, musculoskeletal, and neurological. Uncovering any issues in these areas will help you determine if a patient is healthy enough to participate in sports or if their participation should be restricted due to health risks.

Example Question:

How is your vision?

Finding:

Denies hearing problems

(Available)

Pro Tip: For a pre-participation evaluation, it is important to tailor your questions to the individual patient and to their identified sport(s). For many sports, it is important to hit on several key systems: respiratory, musculoskeletal, and neurological. Uncovering any issues in these areas will help you determine if a patient is healthy enough to participate in sports or if their participation should be restricted due to health risks.

Example Question:

How is your hearing?

Finding:

Asked about menstrual period

Finding:

Reports she hasn’t started her menstrual period

(Found)

Pro Tip: For a pre-participation evaluation, it is important to tailor your questions to the individual patient and to their identified sport(s). For many sports, it is important to hit on several key systems: respiratory, musculoskeletal, and neurological. Uncovering any issues in these areas will help you determine if a patient is healthy enough to participate in sports or if their participation should be restricted due to health risks.

Example Question:

Have you started menstruating?

Family Medical History

Finding:

Asked about relevant family medical history

Finding:

Denies any family members having a genetic heart condition

(Found)

Pro Tip: Discussing family medical history can allow you to uncover any genetic risks to the patient. For pre-participation evaluations, it is important to focus on a family history of cardiac issues, as this could yield important information relating to the patient’s cardiac health.

Example Question:

Does anyone in your family have a genetic heart condition?

Finding:

Denies family members dying of cardiac problems

(Available)

Pro Tip: Discussing family medical history can allow you to uncover any genetic risks to the patient. For pre-participation evaluations, it is important to focus on a family history of cardiac issues, as this could yield important information relating to the patient’s cardiac health.

Example Question:

Has anyone in your family died of heart problems?

Finding:

Denies any unexpected deaths before the age of 35

(Available)

Pro Tip: Discussing family medical history can allow you to uncover any genetic risks to the patient. For pre-participation evaluations, it is important to focus on a family history of cardiac issues, as this could yield important information relating to the patient’s cardiac health.

Example Question:

Has anyone in your family died unexpectedly at a young age?

Finding:

Denies any family members having a pacemaker before age 35

(Found)

Pro Tip: Discussing family medical history can allow you to uncover any genetic risks to the patient. For pre-participation evaluations, it is important to focus on a family history of cardiac issues, as this could yield important information relating to the patient’s cardiac health.

Example Question:

Does anyone in your family have a pacemaker?

Social History

Finding:

Asked about perception of weight

Finding:

Reports feeling like she needs to lose baby fat

(Found)

Pro Tip: Discussing a patient’s social history is important for building rapport, understanding relevant aspects of daily living, and discovering risk factors that may have an impact on their ability to participate in sports. With athletes, it is important to focus on areas such as diet, while other areas such as substance use, alcohol use, and sexual activity may be discussed after asking a guardian to briefly step outside the room.

Example Question:

How do you feel about your overall health?

Finding:

Reports comparing herself to friends

(Found)

Pro Tip: Discussing a patient’s social history is important for building rapport, understanding relevant aspects of daily living, and discovering risk factors that may have an impact on their ability to participate in sports. With athletes, it is important to focus on areas such as diet, while other areas such as substance use, alcohol use, and sexual activity may be discussed after asking a guardian to briefly step outside the room.

Example Question:

How do you feel about your weight?

Finding:

Followed up on perception of weight

Finding:

Reports wanting to look athletic

(Found)

Pro Tip: Discussing a patient’s social history is important for building rapport, understanding relevant aspects of daily living, and discovering risk factors that may have an impact on their ability to participate in sports. With athletes, it is important to focus on areas such as diet, while other areas such as substance use, alcohol use, and sexual activity may be discussed after asking a guardian to briefly step outside the room.

Example Question:

What makes you want to lose weight?

Finding:

Reports feeling like she doesn’t fit in

(Found)

Pro Tip: Discussing a patient’s social history is important for building rapport, understanding relevant aspects of daily living, and discovering risk factors that may have an impact on their ability to participate in sports. With athletes, it is important to focus on areas such as diet, while other areas such as substance use, alcohol use, and sexual activity may be discussed after asking a guardian to briefly step outside the room.

Example Question:

Can you tell me more about feeling different than your friends?

Finding:

Asked about diet

Finding:

Reports being on the Mediterranean diet

(Found)

Pro Tip: Discussing a patient’s social history is important for building rapport, understanding relevant aspects of daily living, and discovering risk factors that may have an impact on their ability to participate in sports. With athletes, it is important to focus on areas such as diet, while other areas such as substance use, alcohol use, and sexual activity may be discussed after asking a guardian to briefly step outside the room.

Example Question:

What is your diet like?

Finding:

Reports avoiding sweets, “white carbs,” and processed foods

(Found)

Pro Tip: Discussing a patient’s social history is important for building rapport, understanding relevant aspects of daily living, and discovering risk factors that may have an impact on their ability to participate in sports. With athletes, it is important to focus on areas such as diet, while other areas such as substance use, alcohol use, and sexual activity may be discussed after asking a guardian to briefly step outside the room.

Example Question:

Do you avoid any foods?

Finding:

Reports skipping lunch once or twice each week

(Found)

Pro Tip: Discussing a patient’s social history is important for building rapport, understanding relevant aspects of daily living, and discovering risk factors that may have an impact on their ability to participate in sports. With athletes, it is important to focus on areas such as diet, while other areas such as substance use, alcohol use, and sexual activity may be discussed after asking a guardian to briefly step outside the room.

Example Question:

What are your eating habits?

Finding:

Reports skipping meals for the past month

(Found)

Pro Tip: Discussing a patient’s social history is important for building rapport, understanding relevant aspects of daily living, and discovering risk factors that may have an impact on their ability to participate in sports. With athletes, it is important to focus on areas such as diet, while other areas such as substance use, alcohol use, and sexual activity may be discussed after asking a guardian to briefly step outside the room.

Example Question:

How long have you been skipping meals?

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