Overview transcript subjective data collection

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OverviewTranscriptSubjective Data CollectionObjective Data CollectionEducation & EmpathyDocumentationSelf-ReflectionDocumentation / Electronic Health Record
12/10/2018Abdominal Pain Physical Assessment Assignment | Completed | Shadow Health2/5Student DocumentationStudent DocumentationModel DocumentationModel Documentationurination has had a small decrease, as well as adarker yellow color. There is no blood in her urine. Current Meds: Patient takes Accupril 10mg daily forhypertension. She does not take any over thecounter medication. Allergies: Patient has a latex allergy. No food,medication, or environmental allergies noted. Past Medical: Patient does have hypertension.Patient has no history of gastro issues, heartburns,or ulcers. She has not had appendicitis. She didhave Cholecystectomy at 42 and a caesareansection at 40. No other major medical issues orhospitilizations. Patient is up to date on vaccinesexcept for her seasonal flu shot. Social History: Patient eats a failry healthy diet andno fiber supplements. She drinks around 6 glassesof water a day and has no changes in thirst level.She does not drink caffeinated beverages. Patientdenies any smoking or illicet drug use. She usuallyhas around 4 drinks per month, usually white wine.She seems her doctor regularly and states that sheis in good health for her age. Last colonoscopy was10 years ago. She is generally physically active, butnot recently due to the abdominal pain. She attendsfitness class, gardens, and considers herselfindependent. She has had three pregnancies. Shehas a strong support system as she lives with herdaughter. She is a widow. Her husband of 50 yearspassed away 6 years ago. She currently dates aman named Max who she is sexually active with. Novaginal intercourse, though, just oral sex. Family History: Mother: passed away at age 88 from strok. Hadhypertension and Type II diabetes. Father: Passed away at age 82 and she hadhypertension and high cholesterol. Maternal grandparents: history of coronary arterydisease and Type II diabetes. Paternal grandparents: History of obesity,hypertension, and CVAs. Siblings: 80 year old brother with hypertension, highcholesterol, and prostate cancer. 81 year old brotherwith hypertension. Son: 48 and healthy. Daughter: 46 and healthy. ROS: General: Patient denies any fever or chills. Shenotes feeling exhausted lately. Gastro: Patient notes some bloating, increased gas,loss of appetite. She denies any nausea or vomiting.She denies any changes in weight. Genitourinary: Patient denies any pain whileurinating, no incontinence, no history of UTIs, nohistory of gyno issues, no vaginal bleeding orabnormal discharge. Started menopause at 45. Nobladder or kidney issues.
12/10/2018Abdominal Pain Physical Assessment Assignment | Completed | Shadow Health3/5Student DocumentationStudent DocumentationModel DocumentationModel DocumentationRespiratory: Patient denies any coughing or sorethroat. Denies any difficulty breathing or chest pain.

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