Demographic Data
Patient : A 46 year old Mexican American female
Subjective
Chief Complaint (CC)
History of Present Illness (HPI) in paragraph form (remember OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment)
Past Med. Hx (PMH) : Medical or surgical problems, hospitalizations, medications, allergies, iImmunizations , and preventative health maintenance
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Family Hx
Social Hx : Including nutrition, exercise, substance use, sexual hx , occupation, school, etc.
Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy )
Objective
Physical findings listed by body systems, not paragraph form
Assessment (the diagnosis)
Three (3) differential diagnosis (if applicable) with rationale
Final diagnosis with rationale and pathophysiological explanation
Plan
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Dx Plan (lab, x-ray)
Tx Plan ( meds )
Pt. Education, including specific medication teaching points
Referral/Follow-up
Health maintenance (including when screenings, immunizations, etc., are next due):
Reference
Compare care given to the patient with the National Standards of Care/National Guidelines. Cite accordingly.
*** This patient is a 46 year old Mexican American female complains of fainting with shortness of breath and dizziness 2 wks ago.I would say Bradycardia for diagnosis***
Can you please make up the rest of papers.
Dx: with Brady Cardia
MODEL ANSWER
Demographic Data
This patient is a 46-year-old Mexican American female complains of fainting with shortness of breath and dizziness 2 wks. ago. She presented to the emergency setting with the acute shortness of breath. The symptoms begun weeks ago and had progressively become worse without any notable relieving | PLACE YOUR ORDER NOW AT writtask.com | reports that she had reported almost similar symptoms a year ago which resulted in chronic obstructive pulmonary disease that required her to be hospitalized | PLACE YOUR ORDER NOW AT writtask.com | sleeping, the patient often uses a BiPAP ventilatory support. She had requested to use the same in the emergency setting especially due to the shortness | PLACE YOUR ORDER NOW AT writtask.com | denies experiencing fever, chills, coughing as well as wheezing. She also doesn’t experience any abdominal pain, vomiting or nausea. Often, the heart …
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