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 Patient
Finding:
Established chief compla
...
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 Patient
Finding:
Established chief complaint
Finding:
Reports hitting head
(Found)
Pro Tip: A pediatric 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:
Do you remember details of the accident?
Finding:
Reports falling off skateboard
(Found)
Pro Tip: A pediatric 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 made you come here today?
Finding:
Reports scalp hematoma
(Found)
Pro Tip: A pediatric 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:
Where did you hurt when you fell?
Finding:
Reports headache
(Found)
Pro Tip: A pediatric 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 are your symptoms?
Finding:
Reports confusion
(Found)
Pro Tip: A pediatric 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:
Were you confused when you woke up?
Finding:
Reports dizziness
(Found)
Pro Tip: A pediatric 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:
Have you felt lightheaded or dizzy?
Finding:
Reports light sensitivity
(Found)
Pro Tip: A pediatric 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:
Have you been sensitive to light?
History of Present Illness Patient
Finding:
Asked patient about additional symptoms
Finding:
Reports also vomiting
(Found)
Pro Tip: Asking a pediatric patient about the duration and onset 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 noticed other symptoms?
Finding:
Reports also losing consciousness
(Found)
Pro Tip: Asking a pediatric patient about the duration and onset 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 have other health concerns?
Finding:
Denies noticing other injuries
(Available)
Pro Tip: Asking a pediatric patient about the duration and onset 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:
Where does it hurt besides your head?
Finding:
Asked patient onset and duration
Finding:
Reports headache started when he fell
(Found)
Pro Tip: Asking a pediatric patient about the duration and onset 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 long has your head been hurting?
Finding:
Reports confusion started when he fell
(Available)
Pro Tip: Asking a pediatric patient about the duration and onset 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 confusion begin?
Finding:
Reports dizziness started when he fell
(Found)
Pro Tip: Asking a pediatric patient about the duration and onset 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:
Can you describe your dizziness for me?
Finding:
Reports light sensitivity since he fell
(Available)
Pro Tip: Asking a pediatric patient about the duration and onset 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:
Are your eyes sensitive to light?
Finding:
Reports vomiting once after getting home
(Available)
Pro Tip: Asking a pediatric patient about the duration and onset 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 vomit after falling?
Finding:
Denies knowing duration of loss of consciousness
(Available)
Pro Tip: Asking a pediatric patient about the duration and onset 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 can you remember about losing consciousness?
Finding:
Asked patient about mechanism of injury
Finding:
Denies wearing helmet
(Found)
Pro Tip: Asking a pediatric patient about the duration and onset 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:
Can you tell me if you have a helmet?
Finding:
Denies knowing how he fell
(Found)
Pro Tip: Asking a pediatric patient about the duration and onset 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 remember details of the accident?
Finding:
Denies knowing how far he fell
(Found)
Pro Tip: Asking a pediatric patient about the duration and onset 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 far did you fall?
Finding:
Asked patient about history of present illness
Finding:
Reports going to skate park after school
(Found)
Pro Tip: Asking a pediatric patient about the duration and onset 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:
Was anyone with you when you fell?
Finding:
Reports being with his friend when he fell
(Available)
Pro Tip: Asking a pediatric patient about the duration and onset 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:
Was anyone with you when you fell?
Finding:
Reports walking home with his friend after he fell
(Available)
Pro Tip: Asking a pediatric patient about the duration and onset 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 do you remember about getting home?
Finding:
Reports being driven to emergency room by his stepfather
(Available)
Pro Tip: Asking a pediatric patient about the duration and onset 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 did you get to the ER?
Finding:
Asked patient about characteristics of pain
Finding:
Reports dull pain from headache
(Found)
Pro Tip: Asking a pediatric patient about the duration and onset 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.
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