Pneumonia

Paper Instructions

Chief Complaint

 

Finding

Established chief complaint and reason for admittance

Finding

Reports fever

(Found)

Pro Tip A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.

Example Question Do you have a fever?

 

Finding

Reports chest pain

(Found)

Pro Tip A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.

Example Question Do you have chest pain?

 

Finding

Reports cough

(Found)

Pro Tip A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.

Example Question Do you have a cough?

 

History of Present Illness

Finding

Asked about additional symptoms

Finding

Reports fatigue

(Found)

Pro Tip Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question Are you fatigued?

 

Finding

Reports coughing up sputum

(Found)

Pro Tip Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question Do you cough anything up?

 

Finding

Reports sinus congestion

(Found)

Pro Tip Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question Are you feeling congested?

 

Finding

Reports muscle soreness

(Found)

Pro Tip Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question Are your muscles sore?

 

Finding

Asked about onset and duration of symptoms

Finding

Reports fatigue began 3 days ago

(Found)

Pro Tip Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question When did your fatigue start?

 

Finding

Reports chest pain began 3 days ago

(Found)

Pro Tip Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question When did your chest pain start?

 

Finding

Reports productive cough began 3 days ago

(Found)

Pro Tip Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question When did your cough start?

 

Finding

Reports sinus congestion began 3 days ago

(Found)

Pro Tip Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question When did your congestion start?

 

Finding

Reports fever began 1 day ago

(Found)

Pro Tip Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question When did your fever start?

 

Finding

Asked about frequency of symptoms

Finding

Reports fatigue is constant

(Found)

Pro Tip Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question How often are you fatigued?

 

Finding

Reports fever is constant

(Found)

Pro Tip Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question Is the fever constant?

 

Finding

Reports congestion is constant

(Available)

Pro Tip Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question How often are you congested?

 

Finding

Reports less severe chest pain is constant

(Found)

Pro Tip Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question How often do you have less severe chest pain?

 

Finding

Reports more severe chest pain occurs with coughing

(Found)

Pro Tip Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question How often do you have more severe chest pain?

 

Finding

Reports coughing every few minutes

(Found)

Pro Tip Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question How often do you cough?

 

Finding

Followed up on location of pain

Finding

Reports pain in lower right side of chest

(Found)

Pro Tip Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question Where is your pain located?

 

Finding

Followed up on characteristics of pain

Finding

Reports chest pain is dull

(Found)

Pro Tip Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question What is the pain like?

 

Finding

Followed up on characteristics of discharge

Finding

Reports coughing up rust-colored sputum

(Found)

Pro Tip Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question Can you describe your mucus?

 

Finding

Reports nasal mucus varies from yellow to green in color

(Available)

Pro Tip Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question Can you describe your mucus?

 

Finding

Asked about aggravating factors

Finding

Reports deep breathing aggravates chest pain

(Found)

Pro Tip Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question Does deep breathing hurt your chest?

 

Finding

Reports speaking aggravates chest pain

(Found)

Pro Tip Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question Does speaking hurt your chest?

 

Finding

Reports physical exertion aggravates chest pain and fatigue

(Found)

Pro Tip Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question Does exertion make your symptoms worse?

 

Finding

Asked about non-medicational relieving factors

Finding

Reports resting provides relief

(Found)

Pro Tip Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question Does resting help your symptoms?

 

Finding

Reports tea provides relief

(Found)

Pro Tip Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question Do you drink tea?

 

Finding

Reports humidifier steam provides slight relief

(Found)

Pro Tip Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question Do you use a humidifier?

 

Finding

Asked about severity of pain

Finding

Reports chest pain when not coughing is 2 out of 10

(Found)

Pro Tip Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question How severe is your chest pain when you’re not coughing?

 

Finding

Reports chest pain during normal coughing is 5 out of 10

(Found)

Pro Tip Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question How severe is your chest pain when coughing?

 

Past Medical History

Finding

Asked about pre-existing health conditions

Finding

Reports chronic kidney disease stage 2

(Found)

Pro Tip Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

Example Question Do you have any existing health conditions?

 

Finding

Reports hypertension

(Found)

Pro Tip Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

Example Question Do you have any existing health conditions?

Finding

Asked about onset and duration of pre-existing health conditions

Finding

Reports chronic kidney disease was diagnosed 9 years ago

(Found)

Pro Tip Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

Example Question When were you diagnosed with chronic kidney disease?

 

Finding

Reports hypertension was diagnosed 14 years ago

(Found)

Pro Tip Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

Example Question When were you diagnosed with hypertension?

 

Finding

Asked about hospitalizations

Finding

Denies recent hospitalizations

(Found)

Pro Tip Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

Example Question Have you been hospitalized recently?

 

Finding

Asked about allergies

Finding

Denies allergies

(Found)

Pro Tip Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

Example Question Do you have any allergies?

 

Finding

Asked about vaccines

Finding

Reports receiving pneumococcal vaccine 12 years ago

(Found)

Pro Tip Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

Example Question Have you had the pneumococcal vaccine?

 

Finding

Reports receiving flu vaccine 3 months ago

(Found)

Pro Tip Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

Example Question Have you had the flu shot this year?

 

Home Medications

Finding

Asked about home medications

Finding

Reports taking trandolapril/verapamil combination drug

(Found)

Pro Tip A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question Are you currently taking medications?

 

Finding

Reports taking chlorothiazide

(Found)

Pro Tip A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question Are you currently taking medications?

 

Finding

Reports taking aspirin

(Found)

Pro Tip A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question Are you currently taking medications?

 

Finding

Followed up on trandolapril/verapamil

Finding

Reports taking trandolapril/verapamil for hypertension and chronic kidney disease

(Found)

Pro Tip A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question Why do you take trandolapril/verapamil?

 

Finding

Reports pill contains 2 milligrams of trandolapril and 180 milligrams of verapamil

(Available)

Pro Tip A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question What dosage is the trandolapril/verapamil?

 

Finding

Reports taking trandolapril/verapamil pill once a day

(Found)

Pro Tip A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question How often do you take trandolapril/verapamil?

 

Finding

Reports having taken trandolapril/verapamil for 9 years

(Available)

Pro Tip A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question How long have you taken trandolapril/verapamil?

 

Finding

Reports last dose of trandolapril/verapamil was this morning

(Available)

Pro Tip A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question When was your last dose of trandolapril/verapamil?

 

Finding

Denies adverse effects from trandolapril/verapamil

(Available)

Pro Tip A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question Do you have adverse effects from trandolapril/verapamil?

 

Finding

Followed up on chlorothiazide

Finding

Reports taking chlorothiazide for hypertension

(Found)

Pro Tip A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question Why do you take chlorothiazide?

 

Finding

Reports chlorothiazide pill is 500 milligrams

(Available)

Pro Tip A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question What dosage is the chlorothiazide?

 

Finding

Reports taking chlorothiazide pill twice a day

(Found)

Pro Tip A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question How often do you take chlorothiazide?

 

Finding

Reports having taken chlorothiazide for 14 years

(Available)

Pro Tip A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question How long have you taken chlorothiazide?

 

Finding

Reports last dose of chlorothiazide was this morning

(Available)

Pro Tip A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question When was your last dose of chlorothiazide?

 

Finding

Reports chlorothiazide increases frequency of urination

(Available)

Pro Tip A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question Do you have adverse effects from chlorothiazide?

 

Finding

Followed up on aspirin

Finding

Reports taking aspirin for pain and fever

(Found)

Pro Tip A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question Why do you take aspirin?

 

Finding

Reports aspirin pill is 325 milligrams

(Available)

Pro Tip A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question What dosage is the aspirin?

 

Finding

Reports taking 2 aspirin pills every 6 hours, 3 times a day

(Found)

Pro Tip A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question How often do you take aspirin?

 

Finding

Reports having taken aspirin pills for 3 days

(Available)

Pro Tip A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question How long have you taken aspirin?

 

Finding

Reports last dose of aspirin was this morning

(Available)

Pro Tip A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question When was your last dose of aspirin?

 

Finding

Denies adverse effects from aspirin

(Available)

Pro Tip A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question Do you have adverse effects from aspirin?

 

Finding

Asked about vitamins and supplements

Finding

Reports taking calcium supplement

(Found)

Pro Tip A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question Do you take vitamins or supplements?

 

Finding

Reports taking vitamin D supplement

(Found)

Pro Tip A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question Do you take vitamins or supplements?

 

Finding

Followed up on calcium supplement

Finding

Reports taking calcium supplement for chronic kidney disease

(Available)

Pro Tip A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question Why do you take calcium supplements?

 

Finding

Reports calcium supplement is 1200 milligrams

(Available)

Pro Tip A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question What dosage are your calcium supplements?

 

Finding

Reports taking calcium supplement once a day

(Found)

Pro Tip A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question How often do you take calcium supplements?

 

Finding

Reports having taken calcium supplement for 9 years

(Available)

Pro Tip A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question How long have you been taking calcium supplements?

 

Finding

Reports last dose of calcium supplement was this morning

(Available)

Pro Tip A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question When did you last take a calcium supplement?

 

Finding

Denies adverse effects from calcium supplement

(Available)

Pro Tip A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question Do you have adverse effects from calcium supplements?

 

Finding

Followed up on vitamin D supplement

Finding

Reports taking vitamin D supplement for chronic kidney disease

(Available)

Pro Tip A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question Why do you take vitamin D supplements?

 

Finding

Reports vitamin D supplement is 15 micrograms

(Available)

Pro Tip A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question What dosage are your vitamin D supplements?

 

Finding

Reports taking vitamin D supplement once a day

(Found)

Pro Tip A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question How often do you take vitamin D supplements?

 

Finding

Reports having taken vitamin D supplement for 9 years

(Available)

Pro Tip A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question How long have you been taking vitamin D supplements?

 

Finding

Reports last dose of vitamin D was this morning

(Available)

Pro Tip A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question When did you last take a vitamin D supplement?

 

Finding

Denies adverse effects from vitamin D

(Available)

Pro Tip A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question Do you have adverse effects from vitamin D supplements?

 

Finding

Asked about medication regimen adherence

Finding

Denies missing medication doses

(Found)

Pro Tip A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question Do you miss doses of your medication?

 

Finding

Reports being able to afford medication

(Available)

Pro Tip A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question Are you able to afford your medication?

 

Finding

Reports using pillbox

(Found)

Pro Tip A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question Do you use a pillbox for your medication?

 

Finding

Asked about history of antibiotic use

Finding

Denies recent antibiotic regimen

(Found)

Pro Tip A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question Have you taken antibiotics recently?

 

Social History

Finding

Asked about substance use

Finding

Reports drinking 1-2 glasses of wine per week

(Found)

Pro Tip A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question Do you drink alcohol?

 

Finding

Denies tobacco use

(Found)

Pro Tip A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question Do you use tobacco products?

 

Finding

Denies illicit drug use

(Found)

Pro Tip A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question Do you use illicit drugs?

 

Finding

Asked about exercise

Finding

Reports taking 10 minute walks 2-3 times per week

(Found)

Pro Tip A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question What type of exercise do you do?

 

Finding

Asked about diet

Finding

Reports being a lacto-ovo-vegetarian

(Found)

Pro Tip A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question Do you have any dietary restrictions?

 

Finding

Reports usually eating pasta or salad

(Found)

Pro Tip A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question What do you eat on a typical day?

 

Finding

Asked about activities of daily living

Finding

Reports no difficulties with activities of daily living

(Found)

Pro Tip A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question Are you able to complete activities of daily living?

 

Family Medical History

Finding

Asked about relevant family medical history

Finding

Reports father had hypertension

 

Subjective

Dr. Douglas is a 72 yo African American female who lives at home with her husband. She presents to clinic today with complaints of cough, chest pain, SOBm and fatigue ongoing for 3 days and new onset of fever tMax 100.1 that began yesterday. She has tried aspirin without relief. She denies being around anyone sick recently or traveling outside the country. CC “I am having fever, chest pain, and cough” HPI Anita Douglas is a 72-year-old African-American female presenting with chest pain, nasal congestion, a productive cough, fatigue, and fever. Her symptoms began three days ago. She attempted to relieve her symptoms at home by taking aspirin and resting. She states fever began one day ago. She is having constant fatigue, congestion and fever. Her chest pain is characterized as dull and only occurs with coughing. Deep breathing and speaking aggravates her chest pain. Chest pain with coughing is 5 out of 10. She is taking her medications as prescribed.

Allergies

• No allergies to medications, latex, food or environment

PMH

• Chronic kidney disease type II, hypertension

PFH

• Reports paternal hypertension

Social History

• Retired veterinarian

• Lives with husband

• Eats ovo-lacto vegetarian diet, and usually eats pasta or salad

• Reports 1-2 glasses of wine per week

• Denies tobacco or illicit drug use

Health Promotion/Vaccines

• Reports pneumococcal vaccine 12 years ago and influenza vaccine 3 months ago

Review of Systems

• Constitutional Reports fever, fatigue, muscle soreness

• HEENT Reports sinus congestion

• Cardiovascular Reports chest pain

• Respiratory Reports productive cough

Objective

Dr. Douglas is a 72 yo African American female with past medical history of Chronic Kidney disease stage 2 diagnosed 9years ago and hypertension diagnosed 14 years ago. She is currently on Transolapril, verampamil, and chlorothiazide. She also takes calcium and vitamin d supplements. She is alert and oriented x4, well informed about her health and medications. She does not smoke and drinks wine occassionally. She lives with her husband in their home and has a fairly active lifestyle. SHe is a lacto-ovo- vegetarian. She has a family history of hypertension on her father’s side. Both pareents are deceased. Her father passed in his 70’s from a heart