Scott Becker shadow health Subjective Data Collection
This document summarizes the subjective data (information gathered from the patient themself) collected by Scott Becker during a patient encounter.
Chief Complaint:
- Fatigue
History of Present Illness:
- Worsening fatigue over several weeks
- Vomiting once this morning, with dark flecks
- Stomach pain in the upper left abdomen for 3-4 months
- Gnawing or burning
- Worsens after eating
- Increasing over the past week
- Takes antacids daily, moderately effective
Past Medical History:
- No allergies (food, environmental, latex, medication)
- Hypertension
- High cholesterol
- Coronary artery disease
- Osteoarthritis
Scott Becker’s Social History
This section details the social history aspects of Scott Becker’s patient encounter.
Living Situation:
- Lives with family
Substance Use:
- No tobacco use
- Drinks coffee every morning (2-3 cups)
- Drinks alcohol 1-2 nights a week (1-2 glasses per sitting)
