Case 1
Chief Complaint (CC)
Subjective Data: I came for my annual physical exam, but do not want to be a burden to my daughter.”
Case 2
“1 am here for my annual physical exam and have been having vaginal discharge.”
Case 3
“Annual physical exam”
History of
Present
Illness (HPI)
At-risk 86-year-old Asian male – who is
physically and financially dependent on
his daughter, a single mother who has
little time or money for her fathers
health needs.
32-year-old pregnant lesbian – her
pregnancy has been without
complication thus far. She has been
receiving prenatal care from an
obstetrician. She received sperm from a
local sperm bank.
[
23-year-old Native American male
comes in to see you because he has
been having anxiety and wants
something to help him. He has been
smoking “pot” and says he drinks to help
him too. He tells you he is afraid that he
will not get into Heaven if he continues
in this lifestyle.
PMH Hypertension (HTN), gastroesophageal
reflux disease (GERD). bl2 deficiency
and chronic prostatitis
PSH S/P cholecystectomy
Drug Hx Current Meds: Lisinopril 10mg daily, Prilosec 20mg daily. B12 injections monthly, and Cipro 100mg daily. Current Meds: prenatal vitamins and takes Tylenol over the counter for aches
and pains on occasion
Current Meds: denied
Allergies No allergies to food or medications.
J
1
500 words
apa style
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