Identifying Information. Subjective Medical/Social Database
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- Susan Shepherd
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1 Clinical Case Study 1 Identifying Information Patient s Name: John smith D.O.B.: Unit Number: Sex: Male Ethnic: Cuban Birth Place: U.S.A. Address: First street, Brooklyn, NY Telephone: Informant: Mother (English speaking) and seems reliable. No translator use. Subjective Medical/Social Database *Reason for Visit: He had a fever and is not acting like his usual self *History of Present Illness: Child was fine until this am when mom noted a fever of 103. The child has not been complaining of anything except the new onset of a sore throat. The child denies any vomiting, diarrhea, and has been urinating. The mother reports that the child is a well child. He was acting different this am and became agitated easily. She reports that he is usually a quiet and he has never been agitated before. The child acts scared of you and it takes frequent reassurance for you to get the vital signs done. According to the mother, this is markedly different behavior for him. The mother reports that he is a good child who has never given him any problem. She admits he was out last night at a dance at school but then did not come home until 3 pm. She reports that he had never done this before. *Past Medical History: - Perinatal history: Born to a 27 years old Hispanic mother, G2P2. (+) prenatal care. Mother is healthly Denies any medications or illicit drugs use before and during pregnancy. - Gestation: 39 wks - Birth History: NSVD, Vertex. w/o any problems during labor and delivery. No intrapartum meds used except epidural pain meds. - Neonatal period: Birth weight: 7 lbs 9 oz. Discharged home with the mother after 2 days.
2 Clinical Case Study 2 No problems while stays in nursery. - Early feeding history: No breast-fed. Enfamil 4 0z Q2-3 hrs. No feeding problems. - Common Childhood Illness, Serious Illness/Operation/Hospitalizations: None - Accidents: None - Current Medications/OTC/Alternative /home remedy: No. - Allergies: NKDA. Immunizations: Up to date. - Primary care Provider: Dr. Sawer Review of System General: Denies any problems Skin: Dry skin of the scalp and near the eyebrows, denies itching. Birthmark at the buttock. Head: Denies any head injury or fallen to ground. Eye: Denies any tearing, discharge, and redness. No vision test is done. Ears: Denies any ear-tugging/ pulling behavior. No Q-tip use. Denies any ear discharge and history of ear infection. Nose/Sinus: Occasional sneezing with clear mucous secretion. Denies any bleeding and history of cold. Mouth/Throat: Denies any lesion. Go for dental care regularly.. Denies any history of throat infection. Dentition: Reported not teething yet. Neck: Denies wryneck, difficulty turning head. Respiratory: Denies difficulty breathing Cardiovascular: Denies history of heart abnormality, heart murmur and anemia. Gastrointestinal:. Denies flatus, diarrhea, constipation, or blood in stools. Genitourinary (Male): Not sexually active Denies blood in urine, difficulty voiding, or balloon-like at tip of penis while urinate. Denies any discharge, redness or enlargement at external genitalia. Musculoskeletal: Denies any birth injury and congenital deformities. Denies notice any difficulty extremity movement/ stiffness. Neurological: Denies history of syncope. Denies any seizures or tremors. Hematological: Denies history of anemia or any hematological disease. Denies bruising easily and any past blood transfusion. Endocrine: Denies any history of endocrine disease.
3 Clinical Case Study 3 Family Profile A&W A&W A&W A&W yr 16 Key: male female A&W: alive and well Family History: Denies any family history of heart disease, hypertension, stroke, diabetes, blood disorder, sickle cell disease, thalassemia, anemia, arthritis, gout, allergies (eczema, sinusitis, seasonal, food or medication), asthma, obesity, mental illness, seizure disorder, kidney disorder, TB, hepatitis B, HIV, congenital abnormality, genetic order and other forms of cancer. Social Profile Both parents live together in 2 nd floor rented apartment in Brooklyn. The father works 5 days a week.. John, their 14-year-old is a 10th grader in gifted classes. The l6 year old is in college already. Both children are very bright. No religion or other organizational support. Mother is the main caretaker. Mother states relationship with husband is fine. Lack of family support and financial problems are their major stressors. Developmental Base-motor, Language, Cognitive, Social
4 Clinical Case Study 4 Milestones: Development was normal School Performance: Is in gifted classes. Plays the violin and is considered gifted. Activities of Daily Living Nutrition: Eats on the run. Occasionally has breakfast Sleep: Bedtime at 11 p.m. and wakes up at 6 a.m. Sleeps well. Elimination: BM: brownish and soft stool once/2 days. Behavior concerns: No Injury Risks: Smoke detector (+), Pet (-), Gun (-), and passive smoke (-). Family members : Alcohol (-),illicit drug use (-). Environment Risks: Describes it is a new apartment in a nice area. Objectives Vital Signs: Temp: l03 Apical Pulse: 140 bpm. R.R: 26 breaths/min. BP 160/88 Growth: Wt: 144 lbs. Ht: 5 feet 5 General Appearance : Alert, well-groomed adolescent who has no apparent respiratory distress and obvious dysmorphic features. He initially was very agitated during the visit and then has non biliuous emesis once and seems calmer. Skin: Warm, sweaty skin with good skin turgor, mildly flushed appearance. No dry, peeling skin of the trunk and extremities. No cyanosis, jaundice, petechiae, bruising, hemagioma and café-au-lait spots. HEENT: Head: Normocephalic w/o deformities or prominent bony ridge. Eyes: Symmetric eyebrows. No ptosis, erythema, tearing or masses Nystagmus noted. PERRL with (+) red reflex, central cornea light reflex. Iris: clear marking w/o brushfield s spots. Sclera: white w/o icteric or hemorrhage. Intact extraocular movement. No crossing eyes. Ears: Symmetrical, normal set ear w/o deformities. No periauricular skintag or dimple. T.M: intact, pearly gray with (+) LM/LR. Dry, flaky wax in the canal w/o redness, lesion or any discharge
5 Clinical Case Study 5 Nose: patent with pink, glistening nasal mucosa. Slightly Swollen turbinates with irritation of kisselbacks triangle, deviate /perforate septum or intranasal masses /polyps. Slight crusted mucoid secretion in both nares. Mouth/Throat: Symmetry of smile/cry. Lips pink and moist without cracking or scaliness. Palate intact. Buccal mucosa pink, moist w/o thrush, white patch, lesion, or ecchymosis. Slight redness at back of pharynx. Tonsil (+3) with white exudates. Teeth: normal Neck/LNs: Supple with good ROM. Clavicles intact No other palpable enlarged LNs. No thyroid enlargement. Chest/Lung: No deformities or asymmetry in shape of the chest. No chest wall retraction. Clear breathing sound bilaterally. C-V: Equal femoral and brachial pulses bilaterally. Normal S1, S2 sounds w/o murmur. PMI at the level of 5 th interspace andto the left of midclavicular line. Abdominal: Soft and protuberant. No palpable organomegaly or masses. Bowel sounds (+) at 4 quadrants. No umbilical hernia. Genitalia: Normal uncircumcised male genitalia with 2 descended testicles. No hydrocele. Urethra opening (+) w/o hypospadia. Tanner stages I. Anus: Patent w/o displacement or anal fissure. Good external spincter tone. Wink (+). Extremities: Normal extremities with 10 fingers/toes.normal muscle strength/bulk. Spine: Midline, normal curvature w/o dimple or hair tuft. Neurological: Reflex brisk and +4. Can a mild tremor noted of hands Gait slightly ataxic Differential Diagnosis Lab tests
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CHRISTIANA SPINE CENTER NEW PATIENT QUESTIONNAIRE NAME Today s Date CHIEF COMPLAINT _ (Please use your pen to mark painful areas) Front Back Date of Birth When did the pain begin: Allergies and reaction:
Water Supply: City Well
Endocrine Information Sheet Please complete this endocrine information sheet and bring to your child s appointment. Date: Child s Name: Date of Birth: Age: Race/Sex Address: City: State: Zip Code: Home
LAKES INTERNAL MEDICINE
LAKES INTERNAL MEDICINE HEALTH HISTORY QUESTIONNAIRE Please print this and complete and bring to your initial appointment. Today's Date Last Name First Name Middle Initial Date of Birth Male Female Education
New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )
New Patient Documentation Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( ) Age: Birthdate: E Email: Social: Sex: Male Female Height: Weight:
Patient History Form
Patient Personal Information Name: Date: Age: Occupation: Employer's name: Briefly describe your daily activities at work: Sex: male female Marital Status: single married divorced widowed Spouse's name:
Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?
PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician:
Modesto Gastroenterology Medical Corporation
Page 1 of 5 Modesto Gastroenterology Medical Corporation Magdy S. Elsakr, M.D. Board Certified Gastroenterologist 2336 Sylvan Avenue, Suite A, Modesto, CA 95355, Phone: 209-338-0292, Fax: 209-338-0298
New Patient Intake Form
New Patient Intake Form Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name _ Address City State Zip Code Leave Messages on: (Circle one) Home Cell Work Don t leave messages
REASON FOR REFERRAL Referred for blisters and rash of mucous membranes and skin.
Report 1 Listen to the audio to fill in the blanks. Name: DERMATOLOGY CONSULTATION REPORT REASON FOR REFERRAL Referred for blisters and rash of mucous membranes and skin. HISTORY OF PRESENT ILLNESS Rash
DATE OF BIRTH: MELANOMA INTAKE
MELANOMA INTAKE GENERAL INFORMATION How was your first diagnosed? (Check the diagnosis that describes your condition.) Melanoma Merkel Cell Carcinoma Squamous Cell Carcinoma Basal Cell Carcinoma Other
Morris Medical Center, P.A.
Today s date: Name : Age Date of Birth Height Weight Right hand dominant Left hand dominant Sex: Male Female Chief Complaints; Current Pain Level (0 ~ 10) 0 1 2 3 4 5 6 7 8 9 10 Average Pain Level (0 ~
Providence Medical Group
Providence Medical Group To our valued patients: In order to provide you with our full attention when you come for an appointment, we would like to ask you to be aware of the following guidelines. Insurance
Please complete this form before your Doctor visit. We will review this together and make any changes needed.
1 Medical History Please complete this form before your Doctor visit. We will review this together and make any changes needed. Name Date of Birth Date of visit What is your height? weight? Medical History,
Osher Center for Integrative Medicine Pediatric Intake Form Name: Date: Date of Birth: Age: Current Pediatrician:
Pediatric Intake Form Name: Date: Date of Birth: Age: Current Pediatrician: How did you hear about us? What are your goals for this visit? Where would you like to see improvement in your child s health?
Review of Systems NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient,
LOS ANGELES CANCER NETWORK NEW PATIENT HEALTH QUESTIONNAIRE NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient, In order to offer optimal care for you, we need to understand your complete health status
Allina Health United Lung and Sleep Clinic
Medical History Form Date Allina Health United Lung and Sleep Clinic Name Last First MI Date of birth What lung problem do you want us to help you with: Who is your primary care provider? Social History