Case: 165484 Karen BarnesDate: 03/06/2021Instructions:Type patient encounter informationdirectlyinto each box of the template. Students should avoid the
... [Show More] use of the following terms:"WNL"/"Normal", etc and should document systems with specificity and accuracy. Students are also expected to incorporate any feedback faculty haveprovided on previous cases into each subsequent assignment.CC: 49-year-old femaleHPI:pertinent s/s; +/- ROS/prior episodes/recent travel/ill contactsMs. Barnes is a 49-year-old female with chest pain and dyspnea that started 2Chief complaint is a short 1-2 statement or word phraseweeks ago during a ski run activity in the cold. She reports that the chest painfrom patient and should be listed in "quotes"radiates to the left arm and has a squeezing quality to it.The pain is exacerbated"Exertional mid-chest pain that radiates to leftby fast walking in the cold and relieved by resting.arm with a squeezing quality"Onset:Chest pain 2 week ago during a cross-country ski runLocation:Mid chest that radiates to left armDuration:The chest pain comes and goes. Lasts several minutes and occurs1-2times a weekCharacter:Chest pain with a squeezy quality and radiates to the left arm. Painscale of 5 or 6 on scale of 1-10Aggravating/alleviating factors: Precipitated by exercise and improves withrestRelated symptoms:Dyspnea that occurs with chest pain with exertionTreatments:NothingSignificance:Chest pain in someone with her medical and family history canindicate a serious problemPMHxSurgHxtype/when/why/complicationschild/adultillness/hospitalizations/immunizationsNo surgical historyHistory of hypertension and high cholesterolMissed this year's flu vaccination
Case: 165484 Karen BarnesDate: 03/06/2021FamHxSHxGrandparents (if known)/Parents/siblings/childrenTobacco/vaping/ETOH/illicit drug use/occupational/environmental/relationshipsETOH: Drinks 1-2 glasses of wine each nightFather died at age 65 of strokeMother died at age 54 with heart diseaseTobacco: Previous smoker: Quit 15 years agoOlder sister age 58: recent open-heart surgeryDenies use of recreational drugsPatient reports a very stressful jobReproductive HxAllergies(Food, Drug, Environmental, etc.)Female: Age of menarche/menstruation cycleNo known allergiesduration/gravida para status/Childbirth hx/sexual hx andconcerns/LMP/menopauseList of Medications/supplements(prescription, OTC, complementaryBreast/cervical screening (if any)alternative therapies)Male: Sexual hx and concerns/issues with fertility (ifany)/Testicular or prostate screening (if applicable)Hydrochlorothiazide 12.5mg dailyScreening for STI's (if applicable)Up to date for cancer screening for gender.Annual gynecological exam normalNot currently sexually activeReview of Systems: (ROS) Use this column toFrom the ROS: list/highlight the current symptoms/complaints to generatedocument the ROS below.a list of pertinent "reported or denied" symptoms below:General:Chest pain with dyspnea, deniesPertinent Positive ROS:Chest pain middle chest that radiates to left arm, historyfatigue, weakness, sleep disturbanceof hypertension and high cholesterol,Dyspnea with exertionHEENT:No complaint of headache, visionproblem, ear pain or sinus problemsPertinent Negative ROS:Denies wheezing, or recent change in sleep pattern,Pulmonary:shortness of breath with exertion,denies change in diet, no complaint of nausea/vomiting/diarrhea or change in [Show Less]