Week 4
Shadow Health Digital Clinical Experience Health History Documentation

SUBJECTIVE DATA:
Chief Complaint (CC): Painful scrape on right foot
History of Present Illness (HPI): Tina, a 28-year-old African American woman, presents with a scrape on her right foot that is infected and needs treatment. According to her, the pain has gotten much more severe over the course of the previous two days. She gives the level of pain a score of 7 out of 10. She reports that the pain does not spread to any other areas of their bodies. Following the injury, the foot developed a swollen and reddened appearance. The component that makes the situation worse is carrying weight.  Shadow Health Digital Clinical Experience Health History Documentation Essay
Medications: Tramadol for pain
Advil for cramps
Proventil inhaler for asthma
Tylenol for headaches
Allergies: Reports penicillin, cat, and dust allergies.
Past Medical History (PMH): Diagnosed with asthma at 21 years. Diagnosed with diabetes at age 24
Past Surgical History (PSH): Denies past surgeries
Sexual/Reproductive History: heterosexual, no pregnancy. Uses condoms as birth control.
Personal/Social History: Patient enjoys consuming alcohol on occasions and spending time with friends. Her highest level of education is a bachelor’s degree in accounting. She has a family and friends that are willing to provide support. Denies smoking cigarettes or marijuana. Goes to a Baptist church, where she is active in volunteering and bible study.
Immunization History: received all childhood vaccinations. Got HPV vaccine as a teenager. Flu vaccine not current. Tetanus booster received in the past year.
Health Maintenance: Immunizations are current. No recent pelvic exam. Last pap smear was three years ago. Denies monitoring of blood pressure and blood sugar. Patient reports conducting physical exam in the gym.
Significant Family History:
Mother, 50 years, has hypertension and high cholesterol.
Father died at 58 of car accident, history of hypertension and diabetes.
Brother is overweight
Sister has asthma.
Maternal grandfather died at 78 from stroke.
Maternal grandmother died at 73, from stroke.  Shadow Health Digital Clinical Experience Health History Documentation Essay

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Paternal grandfather died at 65 from colon cancer, history of diabetes, and high blood pressure.
Paternal grandmother still living, history of high cholesterol and hypertension.
No family history of thyroid issues or mental health issues.
Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History).Remember that the information you include in this section is based on what the patient tells you. To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.

General: Denies weight changes, weakness, fatigue, or fever.
HEENT: reports occasional headaches when reading. Reports blurry vision, does not wear contact lenses. Denies ear pain, loss of hearing or ear discharge. Denies nasal congestion, runny nose, or sinus pain. Denies sore throat or swallowing difficulty.
Neck: Denies neck pain or swelling
Breasts: Denies pain, or masses. Denies nipple discharge
Respiratory: Denies cough, shortness of breath, wheezing or labored breathing.
Cardiovascular/Peripheral Vascular: Denies palpitations, chest pain, chest tightness. Reports swelling in the wound area.
Gastrointestinal: Reports increased appetite. Denies nausea, vomiting, diarrhea, abdominal pain, constipation, or changes in bowel movements.
Genitourinary: Reports irregular menstrual cycle. Denies polyuria or pain or burning sensation on urination.
Musculoskeletal: Denies muscle pain, muscle injury, joint pain, or back pain.
Psychiatric: Denies history of anxiety, depression, or suicidal ideation.
Neurological: Denies dizziness, vertigo, sense of imbalance, loss of coordination, or numbness or tingling in the extremities.
Skin: Denies rash or lesions. Reports skin discoloration around the neck.
Hematologic: Denies bleeding or history of anemia.
Endocrine: Denies fever, chills, cold or heat intolerance.

SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

Chief Complaint (CC):

History of Present Illness (HPI):

Medications:

Allergies:

Past Medical History (PMH):

Past Surgical History (PSH):

Sexual/Reproductive History:

Personal/Social History:

Immunization History:

Health Maintenance:

Significant Family History (Include history of parents, maternal/paternal Grandparents, siblings, and children):

Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History). Remember that the information you include in this section is based on what the patient tells you. To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.   Shadow Health Digital Clinical Experience Health History Documentation Essay

General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.

                HEENT:

Neck:

                Breasts:

                Respiratory:

                Cardiovascular/Peripheral Vascular:

                Gastrointestinal:

                Genitourinary:

                Musculoskeletal:

                Psychiatric:

                Neurological:

                Skin:

                Hematologic:

                Endocrine:

Shadow Health Digital Clinical Experience Health History Documentation Essay