Scott Becker shadow health Subjective Data Collection

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)
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