Shadow Health Digital Clinical Experience Health History Documentation
Shadow Health Digital Clinical Experience Health History Documentation
Subjective data:
Chief Complaint (CC): Painful scrape on right foot.
Current Medical History (HPI): The patient, identified as Miss Jones, is a 28-year-old African American female presenting with complaints of painful wound on her right foot after she fell a week ago. Cleansing, administering Neosporin, and bandaging the wound are the steps she’s taken thus far. She visited the emergency room, where a wound dressing was applied, an x-ray was obtained, and tramadol was prescribed for the pain relief. She rates the pain at 7/10. Shadow Health Digital Clinical Experience Health History Documentation
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Medications:
Proventil inhaler 90 mcg, 2-3 puffs
Tramadol 50mg TID
Neosporin ointment
Metformin
Tylenol 500 mg
Allergies:
Penicillin- rash
Cats- itching
Past Health History (PMH):
Asthma – diagnosed at the age of 2.5 years
Diabetes- diagnosed at age 24
Past Surgical History (PSH): No surgical history
Sex / Reproductive History: Denies sexual activity. No children, never been pregnant.
Personal / Social History: Drinks 1 to 2 times a week on weekends. She denies smoking cigarettes. Friends smoke but do not like being around people who smoke, being exposed as second-hand. Did pot 6 or 7 years ago. She lives in a common house with his mother and sister. The neighborhood is safe. She has worked as a superintendent of police in Central America and a ship from high school. works 32 hours a week sometimes less. Have occupational health insurance. to do a bachelor’s in accounting right now. denies the use of birth control. They do not have sex for a while. The opposite sex. she has never been pregnant. Volunteers and the Habitat for Humanity church team for drawing, catering, and other needed activities. It has a good support system. pt is a Baptist and finds comfort in God and considers church members as a family. She likes to spend her free time going out to the bar, dancing, watching TV, reading. Shadow Health Digital Clinical Experience Health History Documentation
Vaccination History: She took the flu vaccine for 5 to 6 years. tetanus booster 1 year ago. get all the kid’s vaccines.
Health Maintenance: A patient had seen her primary care physician 2 years ago. Dental examination a few years ago. She had the last vision as a child. She had a pap smear 4 years ago. She does not exercise but says she is always on her feet at work and considers that exercise. The meal consists of muffin or pumpkin bread for breakfast, a sandwich for lunch, and some other vegetarian meat for dinner. She likes pizza, mac and cheese. drinks eating coke. does not add salt to food. She took the flu vaccine for 5 to 6 years. tetanus booster 1 year ago. get all the kid’s vaccines. It reports sleep deprivation for the last two nights due to foot pain
Important Family History:
- Mother has cholesterol and hypertensin
- Father had high blood pressure and He died in a car accident.
- Sister has asthma
- Brother is obese
- Paternal grandfather had colon cancer, diabetes, and high blood
- Paternal grandmother is still alive but has htn, and cholesterol.
- Maternal grandfather died of a heart attack at the age of 80.
- Maternal grandmother died of a stroke five years Shadow Health Digital Clinical Experience Health History Documentation
Review of Systems:
General: No fatigue, fever, or weight loss
HEENT: c / o a headache when reading or reading as a strong, striking feeling behind the eyes. denies dizziness or head injuries. Eyes: c / o blurred vision becomes blurred when reading. denies eye pain.
Ear: Denies changes in hearing, ear infections, ear pain. Nose: Denies any changes in the nose. he denies losing the sense of smell. denies polyps. he denies nasal pain. denies nosebleeds, or sinus infections. The mouth / throat: No chewing or swallowing problems, denies changes in taste.
Neck: Denies reports of any neck injuries but reports click on his neck when reading but nothing serious. There are no swollen glands.
Breasts: she denies pain or tenderness only in her period. She denies any discharge from the breasts. she denies lumps on her breasts.
Respiratory: Breathing has been good for the past few days but become short of breath if have asthma attack. he denies coughing. The last full attack was in high school. Got an asthma attack three days ago. Asthma started with cats and dust presence. During Asthma attack experience tightness of the chest and throat as well as shortness of breath.
Cardiovascular / Peripheral Vascular: Denies reports of chest pain. denies heartbeat or complaints. There is no swelling of the leg, only under the right foot. Shadow Health Digital Clinical Experience Health History Documentation
Gastrointestinal: denies nausea, vomiting or abdominal pain.
Genitourinary: has periods of urination frequency. denies hematuria..
Musculoskeletal: Denies muscle weakness. no history of arthritis or gout..
Psychiatric: denies hx anxiety. She experienced episodes of depression when father died
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Neurological: Denies dizziness, vertigo or loss of balance.
Skin: Reports skin discoloration on neck. Hair on the chin, shin and abdomen
Hematologic: Denies blood clots or anemia.
Endocrine: has type 2 diabetes diagnosed 2 years ago.
Shadow Health Digital Clinical Experience Health History Documentation