In this course project assignment, you are presented with a medical history for two different patients. A medical history can be fairly brief or extremely lengthy, depending on the patient’s health history. Basic components of a medical history generally include the following pieces of information:
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- Patient demographics: Includes name, date of birth, gender, race etc.
- Chief complaint: Specifies the primary reason for the patient seeking care
- History of present illness: Includes details of chief complaint in chronological order
- Past medical history: Includes a list of current and past medical conditions
- Family history: Includes pertinent diagnoses of close family members
- Social history: Includes information about patient’s lifestyle and characteristics
- Medication history: Includes list of current and prior medication use
- Review of systems: Includes subjective findings from a head-to-toe examination
- Physical examination: Includes objective findings from a head-to-toe examination
You will be exploring the medical terminology used in these medical histories and will be asked to interpret the meanings of various words and abbreviations.
To complete this assignment, do the following:
- Download the clinical notes for the two patients:
Eric Rodriguez Medical History
Jaclyn DeMonte Medical History
- Download, complete, and submit the document below. This document contains questions you will answer regarding the medical histories for each patient.
Module 03 Course Project Assignment Template (The 4 captures are the questions, please answer on microsoft word)
Chief complaint
Lethargy and weight gain
PATIENT
Jaclyn M DeMonte
DOB 10/21/1985
AGE
31 yrs
SEX Female
PRN JE742116
FACILITY
Northstar Physicians Center
T (999) 999-9999
1234 Sunshine Way
100
Minneapolis, MN 99999
ENCOUNTER
NOTE TYPE SOAP Note
SEEN BY Nazir Ashaad
DATE 02/05/2017
AGE AT
DOS
31 yrs
Not signed
Patient identifying details and demographics
FIRST NAME Jaclyn
MIDDLE NAME M
LAST NAME DeMonte
SSN
–
SEX Female
DATE OF BIRTH 10/21/1985
DATE OF DEATH –
PRN JE742116
ETHNICITY Not Hispanic or
Latino
PREF.
LANGUAGE
English
RACE White,Asian
STATUS Active patient
CONTACT INFORMATION
ADDRESS LINE 1 323 Elast Drive
ADDRESS LINE 2 –
CITY Brownsville
STATE PA
ZIP CODE 49300
CONTACT BY Home Phone
EMAIL Jaclyn.demonte@
testpatient.com
HOME PHONE (555) 555-5555
MOBILE PHONE (555) 555-5555
OFFICE PHONE –
OFFICE
EXTENSION
–
FAMILY INFORMATION
NEXT OF KIN Marie Demonte
RELATION TO PATIENT Mother
PHONE 5555555555
ADDRESS –
PATIENT’S MOTHER’S
MAIDEN NAME
–
Encounter – Office Visit Date of service: 02/05/17 Patient: Jacl… https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
1 of 5 4/6/17, 3:40 PM
Active Medications
MEDICATION SIG START/STOP ASSOCIATED DX
Levothyroxine Sodium (Levoxyl) 100
MCG Oral Tablet
04/06/17 – Hypothyroidism
Historical Medications
MEDICATION SIG START/STOP ASSOCIATED DX
Ampicillin 250 mg oral capsule 04/10/14 –
05/10/14
–
Penicillin V Potassium 250 MG Oral
Tablet
05/01/14 –
10/06/16
Chronic sinusitis
Smoking History
STATUS EFFECTIVE DATE
Former smoker 04/06/2008
Encounter – Office Visit Date of service: 02/05/17 Patient: Jacl… https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
2 of 5 4/6/17, 3:40 PM
No Family health history recorded
Past medical history
MAJOR EVENTS
Fx radius- 1998
Septoplasty- December 2002
Acute pancreatitis- July 2006
Pregnancy and vaginal birth- November 2013
Hospitalized with abdominal px due to IBS- 2014
ONGOING MEDICAL PROBLEMS
Irritable Bowel Syndrome- In remission currently
Seasonal allergies
FAMILY HEALTH HISTORY
Mother- Irritable Bowel Syndrome, pancreatitis,
Addison disease
Father- CVD, Type II diabetes
Maternal GM- Stroke, Thyroid disease
Maternal GF- Died of myocardial infarction
Paternal GM- Cushing syndrome, Died of complications of thyroid cancer
Paternal GF- Unknown
Two maternal aunts diagnosed with breast cancer
PREVENTIVE CARE
Avoids allergens, controls IBS with strict diet
SOCIAL HISTORY
Nonsmoker. Quit in 2008.
NUTRITION HISTORY
Restricts seafood due to allergy.
High fiber diet helps to regulate IBS symptoms.
Small, frequent meals.
Describes her diet as “mostly vegan”.
Family health history
DIAGNOSIS ONSET DATE
Subjective
HPI
Jacyln presents today complaining of lethargy and weight gain. She has not changed her diet, nor exercise routine. She
denies night sweats, or chills, She denies visual changes, headache, neck pain, or nuchal rigidity. She had a septoplasty a
half-decade ago for a deviated septum and reports that it was successful and had increased her ease of breathing. She
reports seasonal allergies. She works as a dental hygienist are denies any recent trauma or lifestyle changes.
Review of Systems
Constitutional: per HPI
Encounter – Office Visit Date of service: 02/05/17 Patient: Jacl… https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
3 of 5 4/6/17, 3:40 PM
HEENT: Prior septoplasty for chronic sinusitis resistant to 4 weeks of ampicillin treatment. Patient reports head cold 7
weeks ago. Her PCP ruled out mononucleosis and treated with 1 g of ampicillin daily for 4 weeks. Today, she still reports
nasal congestion, drainage, low grade subjective fevers, and facial pain.
Respiratory: Congestion due to sinusitis
Cardiovascular: negative
Gastrointestinal: occasional epigastric abdominal pain associated with IBS
Genitourinary: negative
Musculoskeletal: negative
Endocrine: Lethargy, weight gain
Objective
PHYSICAL EXAM:
General: Sitting up, concerned. Swollen appearance. Pale face. Weight gain of 12 pounds since last visit 4 months ago.
Head & Neck: No anterior or posterior cervical or auricular lymphadenopathy, maxillary sinuses tender bilaterally to
light tapping. Enlarged, tender thyroid gland
Eyes & Ears: PEERL. Tympanic membranes normal appearing without inflammation, erythema. Normal light reflex.
Oral Cavity: Posterior pharynx is mildly erythematous.
Cadiovascular: No complaints.
Gastrointestinal: No complaints of dysphagia, nausea, vomiting, or change in stool pattern, consistency, or color. She
complains of epigastric pain, burning in quality, approximately twice a month, which she notices primarily at night.
Genitourinary: No complaints of dysuria, nocturia, polyuria, hematuria, or vaginal bleeding.
Musculoskeletal: She complains of widespread aching within the last 4 months. She complains of no other arthralgias,
muscle aches, or pains.
Neurological: She reports occasional disorientation.
Assessment
DDX: Hypothyroidism
Diagnoses attached to this encounter:
(E03.9) Hypothyroidism, unspecified
Acute
Plan
Order CBC, Thyroid panel, Ultrasound of thyroid gland.
Pending results of lab tests- Levoxyl BID
Referral to specialist may be necessary. Will discuss this during follow-up visit.
Medications attached to this encounter:
Levothyroxine Sodium (Levoxyl) 100 MCG Oral Tablet
Encounter – Office Visit Date of service: 02/05/17 Patient: Jacl… https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
4 of 5 4/6/17, 3:40 PM
Free cloud based EHR
Encounter – Office Visit Date of service: 02/05/17 Patient: Jacl… https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
5 of 5 4/6/17, 3:40 PM
Chief complaint
insomnia
PATIENT
Eric R Rodriguez
DOB 03/01/1965
AGE 52 yrs
SEX Male
PRN EP108956
FACILITY
Northstar Physicians Center
T (999) 999-9999
1234 Sunshine Way
100
Minneapolis, MN 99999
ENCOUNTER
NOTE TYPE SOAP Note
SEEN BY Nazir Ashaad
DATE 01/05/2017
AGE AT
DOS
51 yrs
Not signed
Patient identifying details and demographics
FIRST NAME Eric
MIDDLE NAME R
LAST NAME Rodriguez
SSN
–
SEX Male
DATE OF BIRTH 03/01/1965
DATE OF DEATH –
PRN EP108956
ETHNICITY Hispanic or
Latino
PREF.
LANGUAGE
English
RACE Patient declined
to specify
STATUS Active patient
CONTACT INFORMATION
ADDRESS LINE 1 783 Washington
Ave
ADDRESS LINE 2 –
CITY Hollytown
STATE NH
ZIP CODE 33220
CONTACT BY Home Phone
EMAIL ericr@testpatient
.com
HOME PHONE (555) 555-5555
MOBILE PHONE (555) 555-5555
OFFICE PHONE –
OFFICE
EXTENSION
–
FAMILY INFORMATION
NEXT OF KIN Margie Norotz
RELATION TO PATIENT Sibling
PHONE 5555555555
ADDRESS –
PATIENT’S MOTHER’S
MAIDEN NAME
–
Encounter – Date of service: 01/05/17 Patient: Eric R Rodrigue… https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
1 of 4 4/6/17, 3:19 PM
Active Medications
MEDICATION SIG START/STOP ASSOCIATED DX
Eszopiclone 2 MG Oral Tablet 02/14/17 –
Insomnia
LamoTRIgine 25 MG Oral Tablet 04/06/17 – –
Lisinopril 10 MG Oral Tablet 07/02/14 – Hypertension
Provider comment: Patient reported daily use. Prescribed by prior clinic. by Nazir Ashaad on 04/05/17
Historical Medications
MEDICATION SIG START/STOP ASSOCIATED DX
LamoTRIgine 25 MG Oral Tablet 03/27/17 –
04/06/17
Bipolar disorder,
unspecified
LamoTRIgine 25 MG Oral Tablet – 04/06/17 –
Zaleplon 5 MG Oral Capsule 01/03/17 –
02/14/17
Insomnia
Smoking History
STATUS EFFECTIVE DATE
Never smoker 04/05/2017
Encounter – Date of service: 01/05/17 Patient: Eric R Rodrigue… https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
2 of 4 4/6/17, 3:19 PM
No Family health history recorded
Past medical history
MAJOR EVENTS
MVA 10/31/1978 – Fx femur, full recovery
Patient reports multiple concussions from history as collegiate football career. Did not pursue Tx.
Meningitis as a young child- full recovery
ONGOING MEDICAL PROBLEMS
Hypertension – Dx in 2014, Tx with antihypertensive medications
Weight management
FAMILY HEALTH HISTORY
Father- Hypertension, hypercholesterolemia, died from complications of stroke
Mother- Diabetes Type II, hyperthyroidism
Paternal Grandfather- Hypertension, congestive heart failure
Maternal Grandfather- Dementia, possible Alzheimers disease
Paternal Grandmother- Heart problems (unspecified)
Maternal Grandmother- Died of breast cancer
SOCIAL HISTORY
Education: Some college
Occupation: Financial manager
Disability: None
Substance Use/Abuse: Drinks alcohol (usually beer) 3-5 drinks/week. Does not smoke. No history of smoking.
Marital status: Divorced
NUTRITION HISTORY
Patient was advised to decrease carbohydrate intake in 2014 when a wellness check showed prediabetic levels of blood
glucose. He has monitored BG annually since that visit and BG has been WNL since that time.
Patient is advised to decrease saturated fat intake, increase water intake, and increase green, leafy vegetable intake.
Dietary changes will continue to be assessed. Dietician consult may be needed.
Family health history
DIAGNOSIS ONSET DATE
Subjective
HPI
Eric is a 38 year old man with a history of hypertension here because he has had difficulty sleeping two weeks ago lasting
for 1 week. He states that he thinks he was fine but his wife made him come because he was keeping her up all night.
He said he was staying awake all night because he felt “unstoppable.” He was writing papers during the night although
he notes that he never seemed to finish one because half way through a new topic interested him. He reports that his
wife complains that he was extremely or almost too talkative during dinner, and he says he got in trouble at work for
making a sexual advance on a co-worker, which is very unlike him. He works in human resources at an investment bank.
He denies any weight loss, fevers, chills, or night sweats. He denies any drug use. He also denies any thoughts of
harming himself or others. Of note, he says his mom takes “some sort of metal” for her mood swings. He says today he
Encounter – Date of service: 01/05/17 Patient: Eric R Rodrigue… https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
3 of 4 4/6/17, 3:19 PM
feels “a little down” but denies any suicidal or homicidal ideation. He denies any LOC or syncope.
Review of Systems
Constitutional: per HPI
Neurological: Patient reports paresthesia in bilateral upper limbs.
Respiratory: No chest pain, cough, or shortness of breath.
Cardiovascular: No chest pain
Gastrointestinal: No abdominal pain, distension, or change in bowel movements.
Genitourinary: no painful, increased, or decreased urination
Musculoskeletal: negative
Endocrine: negative
Objective
PE:
General: Sitting down, not making eye contact
Cardiovascular: RRR, no MRG, 2+ radial and DP pulses bilaterally
Abdominal: soft, non-tender
Respiratory: lungs clear
Neurologic: CN2-12 intact, normal gait, reflexes normal and symmetric
HEENT: Atraumatic normocephalic. PERRL. No bleeding from nasal septum. No lymphadenopathy.
Psych: flat affect, no SI&HI
Assessment
Otherwise healthy man with symptoms concerning of bipolar disorder but currently not manic or suicidal
Diagnoses attached to this encounter:
(I10) Hypertension
(F31.9) Bipolar disorder, unspecified
(G47.00) Insomnia
Plan
Referral to psychiatrist for evaluation of possible mood disorder.
Continue hypertension medication b.i.d.
Free cloud based EHR
Encounter – Date of service: 01/05/17 Patient: Eric R Rodrigue… https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
4 of 4 4/6/17, 3:19 PM
