S: Subjective
Information the patient or patient representative told you
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Pa
...
S: Subjective
Information the patient or patient representative told you
This study source was downloaded by 100000860583932 from CourseHero.com on 01-27-2023 03:19:08 GMT -06:00
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Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses,
hospitalizations, and surgeries. Depending on the CC, more info may be needed.
Diagnosed with Type 2 diabetes at the age of 24, non-compliant with diet and medications.
Immunizations up to date with the exception of the flu shot.
Diagnosed with asthma at the age of 2.5 and was last hospitalized at the age of 16.
Heavy menstrual bleeding with irregular cycles, menarche at age 11.
Denis surgical history, broken bones, or recent hospitalizations.
Was hospitalized for asthma when she was a little girl and has never been intubated for asthma exacerbation.
Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent
data. Include health promotion such as use seat belts all the time or working smoke detectors in the house.
Single, unmarried, no children
Works 32 hours a week at Mid-American Copy & Ship as a supervisor
Going to school to obtain a bachelors degree in accounting, two months away from graduating
Enjoys reading books on her e-book reader, going to church activities and watching TV
Denies tabacco use, friends smoke when they go out a couple times a month
Used to use illicit drugs-marijuana, denies currently. Used marijuana “a lot” and “every weekend” for 5-6 years, from ages 15-21 and stopped
because it “wasn’t fun” Last usage was age 20-21
Social alcohol use (2 times per month)
Uses seatbelts consistently/Has working smoke detectors in her home
Lives with her mom and sister
Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for
death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if
pertinent.
Mother-HTN, HLD/Father-Type 2 diabetes, HLD, HTN-Died 1 year ago at age 58 in a car accident
Brother-Obese, no other known health problems/Sister-Asthma-well controlled and is overall healthy
Maternal grandmother-Died at age 73 from a stroke 5 y ago-Hx: HTN, HLD/ Maternal grandfather-Died at age 80 from heart attack-Hx: HTN, HLD
Paternal grandmother-Possible HTN and HLD, PT unsure/ Paternal grandfather-Died from colon cancer, unknown medical hx, died years ago
Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive
symptom and provide additional details.
This study source was downloaded by 100000860583932 from CourseHero.com on 01-27-2023 03:19:08 GMT -06:00
Constitutional Skin HEENT
☒Fatigue Denies
☒Weakness Denies
☒Fever/Chills Denies
☐Weight Gain Click or tap
here to enter text.
☐Weight Loss Click or tap
here to enter text.
☒Trouble Sleeping Denies
☒Night Sweats Denies
☐Other:
Click or tap here to enter
text.
☐Itching Click or tap
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☐Rashes Click or tap
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☐Nail Changes Click
or tap here to enter
text.
☐Skin Color Changes
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enter text.
☐Other:
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enter text.
☒Diplopia Denies
☐Eye Pain Click or tap
here to enter text.
☐Eye redness Click or
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☒Vision changes Reports
occasional blurry vision
(pre-dating accident)
☒Photophobia Denies
☐Eye discharge Click or
tap here to enter text.
☐Earache Click or tap here
to enter text.
☒Tinnitus Denies
☐Epistaxis Click or tap
here to enter text.
☒Vertigo Denies
☒Hearing Changes Denies
☐Hoarseness Click or tap here
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☐Oral Ulcers Click or tap here
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☐Sore Throat Click or tap here
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☐Congestion Click or tap here
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☐Rhinorrhea Click or tap here
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☒Other:
Denies unilateral vision
disturbance, denies difficulty
swallowing
Respiratory Neuro Cardiovascular
☐Cough Click or tap here to enter
text.
☐Hemoptysis Click or tap here to
enter text.
☐Dyspnea Click or tap here to enter
text.
☐Wheezing Click or tap here to enter
text.
☐Pain on Inspiration Click or tap here
to enter text.
☐Sputum Production
☐Other: Click or tap here to enter
text.
☒Syncope or
Lightheadedness Denies
☒Headache Started 5 days
ago after low speed car
accident in parking lot, occurs
daily for 1-2 hours at a time
and located at crown and
back of head, dull ache
☒Numbness Denies
☒Tingling Denies
☒Sensation Changes
☒Speech Deficits Denies. PT
speaking clear and concise
☒Other: Denies hemiparesis,
denies gait disturbance,
denies loss of coordination,
denies scotoma, denies facial
flushing
☐Chest pain Click or tap here to enter
text.
☐SOB Click or tap here to enter text.
☐Exercise Intolerance Click or tap here
to enter text.
☐Orthopnea Click or tap here to enter
text.
☐Edema Click or tap here to enter text.
☐Murmurs Click or tap here to enter
text.
☐Palpitations Click or tap
here to enter text.
☒Faintness Denies
☐OC Changes Click or tap
here to enter text.
☐Claudications Click or tap
here to enter text.
☐PND Click or tap here to
enter text.
☐Other: Click or tap here to
enter text.
This study source was downloaded by 100000860583932 from CourseHero.com on 01-27-2023 03:19:08 GMT -06:00
MSK GI GU PSYCH
☒Pain Neck pain with movement of
head and neck
☒Stiffness Neck stiffness
☐Crepitus Click or tap here to enter
text.
☒Swelling Neck swelling, noticed it
was hard to button the collar of her
shirt
☐Limited ROM
☐Redness Click or tap here to
enter text.
☐Misalignment Click or tap here to
enter text.
☐Other: Click or tap here to enter
text.
☒Nausea/Vomiting Denies
☐Dysphasia Click or tap here to enter
text.
☐Diarrhea Click or tap here to enter
text.
☐Appetite Change Click or tap here to
enter text.
☐Heartburn Click or tap here to enter
text.
☐Blood in Stool Click or tap here to
enter text.
☐Abdominal Pain Click or tap here to
enter text.
☐Excessive Flatus Click or tap here to
enter text.
☐Food Intolerance Click or tap here to
enter text.
☐Rectal Bleeding Click or tap here to
enter text.
☐Other:
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☐Urgency Click or tap here to
enter text.
☐Dysuria Click or tap here to
enter text.
☐Burning Click or tap here to
enter text.
☐Hematuria Click or tap here
to enter text.
☐Polyuria Click or tap here to
enter text.
☐Nocturia Click or tap here to
enter text.
☐Incontinence Click or tap
here to enter text.
☐Other: Click or tap here to
enter text.
☒Stress Reports increased
stress due to school
☒Anxiety Denies
☒Depression Denies
☐Suicidal/Homicidal Ideation
Click or tap here to enter text.
☒Memory Deficits Denies
☒Mood Changes Denies
☒Trouble Concentrating
Denies
☒Other: Denies increased
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