drugs. She drinks alcohol occasionally, last was 2weeks ago, and was 1 drink. She does not exercise. Review of Systems: General: Denies changes inweight and general fatigue. She denies fevers, chills,and night sweats. • Cardiac: Denies a diagnosis ofhypertension, but states that she has been told herblood pressure was high in the past. She deniesknown history of murmurs, dyspnea on exertion,OverviewTranscriptSubjective Data CollectionObjective Data CollectionEducation & EmpathyDocumentationLifespanReview QuestionsSelf-ReflectionDocumentation / Electronic Health Record
Student DocumentationStudent DocumentationModel DocumentationModel DocumentationSocial Hx: No tobacco use No exposure to second-hand smoke Occasional alcohol use Last smoked marijuana age 20-21 Lives at mom's house with sister 24 hour diet recall: Breakfast this morning: Toast with butter and honeyand orange juice. Lunch yesterday: pizza. Dinner:Baked potatoes with broccoli and cheese soup. Normal diet: Breakfast: cereal, toast or muffin. Lunch: sandwichand chips, sometimes french fries. Dinners: Chickenbreast or hamburgers with a vegetable and rolls andpotatoes. Snacks: Pretzels, chips, french fries orcrackers. Family Hx: Paternal grandfather died of colon cancer Denies family history of bowel or liver disease. ROS: General: Alert and oriented x 4. Appears appropriatesource of information. Denies any changes in weight,fever, chills, fatigue or night sweats. Skin: States dry skin on arms and legs. Skindiscoloration around neck. Cardiovascular: Denies hypertension diagnosis.Denies chest pain, palpitations, dyspnea on exertion,paroxysmal nocturnal dyspnea or edema. Respiratory: Denies any shortness of breath,wheezing, cough, sputum, hemoptysis, pneumonia,bronchitis, emphysema, tuberculosis. Space historyof asthma, last hospitalization was age 16. Gastrointestinal: Abdominal issues as describedabove. Normal BM every other day. Last BM lastnight. Describes stool as light or dark brown. Deniesacid reflux, diarrhea, constipation, blood or mucousin stools. Denies any gassiness or bloating. Deniesnausea or vomiting. Reports decrease in appetite inthe past 3 weeks. Denies any history of GERD. Genitourinary: States nocturia, waking 2-3 times anight to urinate. Polyuria every 1-2 hours whenawake. States urine light yellow/clear. Denies anyburning, foul odor or blood in urine. LMP: 1 monthago. Denies pregnancy due to not sexually active.
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- Fall '15
- Gastroesophageal reflux disease , Physical Assessment