? SOCIAL HISTORY: Nonsmoker, nondrinker. Social history: Tobacco Use: Currently smokes 1 1/2 PPD, has smoked for 15 to 20 years. MEDICATIONS: None. MCQ FOR OBSTETRIC-GYNECOLOGY Part A-Selected 155 MCQs/ 37pp Contents Votes: +1. She has a 25-pack-year history of smoking, but denies EtOH (ethanol) or illicit drug use. A typical example is TERENCE CARDINAL COOKE HEALTH CARE CENTER, NOTICE OF PRIVACY PRACTICES 8 (2003) ("Law Enforcement. Include dates of pertinent items. PAST MEDICAL HISTORY: The patient states that he is otherwise healthy with no other medical problems. That's medical terminology for "history" (hx) of "alcohol" (ETOH) abuse. She denies fever,nausea, vomiting, and myalgias. Mr. W presents for opioid and alcohol detoxification and rehabilitation. The Medical History – Written Example Please refer to this written example when you write-up all of your future medical histories in PCM-1. He denies use of any illegal substances and only occasionally consumes alcohol. She has a four-day history of nasal congestion, headache, sore throat, sneezing, and productive cough. Her parents are both healthy. She denies any accompanying fever, chills, or sweats. Additional anesthesia history comments: 10. throat, sneezing, and productive cough. ANESTHESIA MEDICAL HISTORY QUESTIONNAIRE ANESTHESIA HISTORY/AIRWAY YES NO COMMENTS 1. She has had no surgeries. Example of a Complete History and Physical Write-up Patient Name: Unit No: Location: Informant: patient, who is reliable, and old CPMC chart. If no, skip to question #6. In Basic Psychopathology: A Programmed Text. She denies the use of any medications and has no significant past medical history. He has typically been 400mg of ibuprofen 3-4 times a day for the past month. She has a four-day history of nasal congestion, headache, sore. Gastrointestinal. His medical history is unremarkable other than hypertension. The death of the 91-year-old in … PAST MEDICAL HISTORY: Positive for Hepatitis-B. intermittent pain in the left shoulder. She denies any past medical history and takes no medications. in addition to giving him high-flow oxygen, the most important treatment for this patient is: No history of eye surgeries, appendectomy, cholecystectomy, or hernia surgeries. No known drug allergies. Your medical history includes all the traits your family shares that you can’t see. He has just joined the middle school soccer team and noticed that he gets hives about 10 minutes into practice. Her mother has diabetes and high blood pressure. She denies smoking, recreational drug use or alcohol use. throat, sneezing, and productive cough. Past Medical History. Examinee instructions Opening scenario. Past Surgical History: Denies. She denies any recent illness or injuries. He denies any tobacco or illegal drugs and drinks alcohol occasionally. Swiss medical authorities dismissed rumors of BioNTtech-Pfizer coronavirus vaccine causing the death of an elderly patient. Her temperature is 98.7°F, pulse is 75/min, respirations are 20/min, and blood pressure is … Some neurological problems can present years after a causative event . He doesn't smoke but drinks several beers on the weekend. Denies the use of tobacco or alcohol. He … The past medical history defines a data base for future reference. He has tried marijuana several times but denies any other illegal drugs. His parents are both in good health. Past medical history: GERD diagnosed with visual examination of the esophagus, stomach and duodenum with a fiberoptic instrument. Initial evaluation of the patient with chronic cough (i.e., of more than eight weeks’ duration) should include a focused history and physical examination, and in most patients, chest radiography. Medications: No medications S/he denies performing any other work activities or vigorous recreational pursuits. He denies chest pain, chest tightness, or syncope. Diabetes as noted above. Kim Potter, 48, is charged with manslaughter in Wright's death during a traffic stop April 11 in Brooklyn Center. Her past medical history includes type 2 diabetes for 5 years and high cholesterol. The only unusual thing he remembers eating is two bags of popcorn at the movies with his grandson, 3 days before his symptoms began. Read this chapter of The Patient History: An Evidence-Based Approach to Differential Diagnosis, 2e online now, exclusively on AccessMedicine. Jackie is a 45-year-old white female with past medical historyof controlled hypertension, controlled asthma, and eczema. Past Medical History: 1. Does a physician have to document the reason why the history of present illness (HPI), review of systems (ROS), and past/family/social history (PFSH) were unobtainable or can it be inferred by other documentation within the HPI (eg, patient intubated, had severe dementia, etc)? His surgical history includes an orthoscopic repair to the left shoulder for a torn rotator cuff last year. Diovan 80 mg with hydrochlorothiazide 12.5 mg daily. He has had no surgeries in the past. Past medical history is irrelevant. Skin: clammy, moist skin. A) remove to a lower altitude. 7. You find the patient seated in bed. She denies any flashes, floaters, pain, redness or double vision. He denies recent fever, chills, or night sweats. The patient is a 32-year-old woman with a nine-month history of constitutional symptoms of ‘just not feeling good.’ She describes symptoms of abdominal malaise, epigastric discomfort that abruptly began without any triggers. Today’s date When was your child’s last physical exam? Do you have any health problems or medical conditions not related to pregnancy? loss over the past month. She denies any nausea, vomiting, diarrhea, or constipation. Hydrocodone as needed for pain. Reviewing medical history, test results, or other sources on another date will not count towards total time on the date of the encounter; Share or split visit when a physician and other qualified healthcare professional jointly provide face-to-face and non-face-to-face work related to the visit His temperature is 39.4°C (103.0°F), the pulse is 110/min, and the respirations are 26/min. It is caused by destruction of islet cells (the cells in the pancreas that make insulin) as well as a decrease in sensitivity of the liver and muscles to the actions of insulin. He has no past medical history or any hospitalizations for medical conditions. Mother denies any accidents and injuries. Suicide. He denies any thoughts of self harm, or harm to others. Smokes one pack of cigarettes per day over the last 10 years. Do you have any special positioning precautions on the OR table that would improve your comfort? Past Medical History: No past medical history to date. Dexter presented, 18 months ago, with a 3-month history of secondary encopresis. If no, skip to question #6. Upon request, the carrier can provide detailed information on why an applicant is declined, whether it was due to medical history, current exam results, driving record or something else. the cardiac catheterization history mentioned previously) do not have to be re-stated. This renders a level 4 or 5 new patient office visit or consult, or level 2 or 3 initial hospital service unobtainable based on the required components. Jackie is a 45-year-old white female with past medical history of controlled hypertension, controlled asthma, and eczema. Chief Concern: Chest pain for 1 month HPI: Mr. PH is a 52 y/o accountant with hypercholesterolemia and polycythemia vera who has Pt works as cashier, shifts no more than 6h. Endocrine: No history of thyroid disease. PAST MEDICAL HISTORY: hypertension -being managed by her primary care physician. Each clinical case scenario allows you to work through history taking, investigations, diagnosis and management. he is in the clinic today complaining of a swallowing difficulty that has progressively worsened over the past several months. A review of past medical problems and treatments not directly pertinent to the HPI completes the past medical history. There is no history of bowel or bladder problems. The doctor is saying that his/her diagnosis is that your son has a history of alcohol abuse, which he/she believes is contributing to your son's current condidition. ANESTHESIA MEDICAL HISTORY QUESTIONNAIRE ANESTHESIA HISTORY/AIRWAY YES NO COMMENTS 1. A 43 year old female with no past medical history presents to the Emergency Department (ED) with lower abdominal pain for the last three hours. Patient has no significant past medical history. Jackie is a 45-year-old white female with past medical history of controlled hypertension, controlled asthma, and eczema. Past, Family and/or Social History: The last section of the history component includes the PFSH. Allergies: The patient denies any chest pain or pressure, shortness of breath, dyspnea on exertion or change in the condition of two-pillow orthopnea. Your assessment reveals crackles to the bases of both lungs. PAST MEDICAL HISTORY: 1. She denies any pain with swallowing or speaking. Patient History HPI: 31 year-old female social worker who presents with 2 month history of fluctuating vision in both eyes. The past history focuses on the patient’s prior medical treatments and can include: • Prior major illnesses and injuries • Prior operations • Prior hospitalizations • Current medications • Allergies • Age appropriate immunization status • Age appropriate feeding/dietary status The family history … "Patient denies any pertinent family history associated with the current complaint". He has no other past medical history, takes no medications or herbal supplements, is not sexually active, and denies alcohol or illicit drug use. She hasa four-day history of nasal congestion, headache, sore. The patient notes that his symptoms have worsened in the past 2 days and denies any signs of bleeding, chest pain, or other complaints. Denies use of alcohol. Current Medications: Patient denies taking any prescribed or alternative medications. Stating that patient denies Crohns, etc.. does not constitute an ROS. No gait disturbances, weakness, numbness, hyperacusis, tingling and taste disturbances noted. Dexter is a 12-year-old boy who presents with his maternal grandmother for follow-up to primary care for secondary encopresis. Jackie is a 45-year-old white female with past medical history of controlled hypertension, controlled asthma, and eczema. The examinee lives in >, with >. For the past 24 hours, she feels like she has increased swelling and she presents now because of it. A) remove to a lower altitude. considered to be individual elements of Past Medical History Family History (FH): A review of medical events in the patient’s family which may include information about: The health status or cause of death of parents, siblings and children ; Specific diseases related to … He denies any fever, cough or sputum production but complains of profuse sweating off and on. Documentation of past, family, and social histories (PFSH) involves data obtained about the patient’s previous illness or medical conditions/therapies, family occurrences with illness, and relevant patient activities. He has no significant medical history. At that time, a comprehensive assessment revealed functional constipation resulting in encop … His past medical history includes hypertension and high cholesterol. Patient reports the symptoms are located and describes the quality as .Per patient, he/she has had associated but denies any .Symptoms are improved with and exacerbated by .Patient history of similar symptoms. Chief Complaint: This is the 3rd CPMC admission for this 83 year old woman with a long history of hypertension who presented with the chief complaint of substernal “toothache like” chest pain of 12 hours Past medical history. Do you have any special positioning precautions on the OR table that would improve your comfort? Denies ETOH. Sander is 67 years old with a long history of knee osteoarthritis for which he self medicates regularly with over-the-counter (otc naproxen. Without a complete past medical, family and social history (PFSH), it is impossible to document a comprehensive history. On examination, he is found to have a blood pressure of 90/50 mm Hg and a temperature of 101.7°F and is tender to palpation in the right upper quadrant of his abdomen. Comprehensive Adult History and Physical (Sample Summative H&P by M2 Student) Chief Complaint: “I got lightheadedness and felt too weak to walk” Source and Setting: Patient reported in an in-patient setting on Day 2 of his hospitalization. He denies any shortness of breath, but has some discomfort in the left lower chest when taking a deep breath. Her past medical history includes high blood pressure and abdominal surgery for colon cancer. Sexual/Reproductive History: Patient is not sexually active at this time. Medical: > Surgery: > Medications: > Allergies: > Personal/Social History: Patient denies smoking, alcohol use, and illicit drug use. He has no significant past medical history and no history of allergies. She has had two past sexual partners. ALLERGIES: HE DOES GET A RASH WHEN HE TAKES PENICILLIN. History of the case. An auditor credits the physician for a single comment correlated to each history for the PFSH. Vision is worse when lying down; at times her vision goes completely in both eyes. If the response to a question is “no,” record this as “patient denies…" (restate the question). Smokes one pack of cigarettes on a daily basis. States history of high blood pressure for past 10 years. Past Psych Hx: See HPI above He ***reports/denies any*** previous inpatient admissions, suicide attempts, or self-mutilating behaviors in the past. Applied for He doesn't smoke but drinks several beers on the weekend. She states that she is allergic to shellfish and reports that she uses alcohol on the weekends and smokes four to five cigarettes per day. Denies burning, pain, pruritus or swelling/redness to the vulva. Past Medical History (PMH): ... last TB test was this past August 2015 and results were negative, denies exposure ... denies history of stones, sexually active in a monogamous relationship, denies any discharge from genitals, denies any history of STI’s or kidney stones. He denies a known history of any medical or psychiatric disorders. Board denies Veteran’s claims for IHD and TDIU . The patient denies any history of tick bites. Musculoskeletal: Unremarkable. He is an honors student and is on the basketball team. The pt. (If yes) Tell me more. Able to perform own ADLs. Psychiatric: denies memory loss or depression, mood pleasant. Denies polyuria and polydipsia. (i.e., severe arthritis, artificial joints). He eats a healthy diet and works out at the gym five times a week. Her Clonidine has just been increased by her PCP in the past week from 0.1 mg to 0.2mg. She denies fever, nausea, vomiting, and myalgias. He is an honors student and is on the basketball team. Her past medical history consists of an appendectomy when she was a teenager; otherwise she has been healthy. throat, sneezing, and productive cough. The patient is very active with sports playing soccer, basketball, baseball, and track. In medicine, a social history (abbreviated "SocHx") is a portion of the medical history (and thus the admission note) addressing familial, occupational, and recreational aspects of the patient's personal life that have the potential to be clinically significant.. What to Do if Health Net Denies Chemotherapy Claim. On physical exam the patient is a well-developed, well-nourished male in moderate distress. Have you had anesthesia in the past? Hyperlipidemia 4. Chelsey Youman A Fresh Look at Christian History… No prior eye surgeries, hx of eye trauma, amblyopia or strabismus. ALLERGIES: There are no known drug allergies. He has been married for over 50 years. (i.e., severe arthritis, artificial joints). No IV drug abuse. This is Brandon Frechette from the mean streets of Chelmsford. This includes adults aged 55 to 80 years who have a 30 pack-year smoking history (1 pack a day for 30 years, 2 packs a day for 15 years) and currently smoke or have quit within the past 15 years. Currently he is fairly comfortable, with morphine helping with the pain. The patient has no significant medical history and has not had any surgeries in the past. he denies any past medical history and takes no medications. She denies excessive eye tearing, fever, cough, vomiting, diarrhea, cold or recent travel. Past Surgical History (PSH): None. Past Surgical History: Patient denies any previous surgical history. History of present illness. Cancer treatments have advanced radically in the past few decades. DATA BASE: SAMPLE HISTORY IDENTIFYING DATA (Use patient’s initials, not full name) CM is a 45-year-old, widowed, white saleswoman, born in the U.S. CHIEF COMPLAINT “Bad headaches” HISTORY OF PRESENT ILLNESS (HPI, Problem by problem) For about 3 months Mrs. M. has been increasingly troubled by headaches that are right- You don't have to have positive findings. The patient notes that his symptoms have worsened in the past 2 days and denies any signs of bleeding, chest pain, or other complaints. Hypertension. 6 You May Not Be Washing Your Hands Enough This is … The Medication History may be reconciled with the prescriber’s patient record for improved medication management and to assist in clinical decision support. Historians explain how the past informs the present Scott C. Martin, PhD, is Professor of History and American Culture Studies at Bowling Green State University. She smokes a half pack of cigarettes a day and drinks four to five beers per weekend night. Past medical history, family history, and social history.
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