Ms Hopkins Sick Visit: Management of Endocrine Conditions Shadow health
Model Documentation:
Chief Complaint: “I’m losing hair and feel tired.”
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History of Present Illness (HPI): Maureen, a 79-year-old female, presents to the clinic with atraumatic hair loss persisting for three weeks and ongoing fatigue for the past month. She notes non-pruritic dry skin on her hands, arms, and elbows that began three weeks ago, temporarily relieved by lotion. The symptoms are constant but do not hinder her daily activities. Mrs. Hopkins reports taking all prescribed medications, including Synthroid, which she takes early in the morning, at least 60 minutes apart from other medications or food. She mentions a change in her Synthroid medication three months ago, with the pill bottle now labeled as levothyroxine sodium and the pill shape transitioning from circular to oblong. Sleep remains consistent at 7-8 hours per night, with no new reported anxiety or stress.
Fatima Khan Endocrine System Hourly Rounds Shadow health Transcript
Home Medications:
– Multivitamin QHS
– Calcium tablet QD
– Vitamin D tablet QD
– Synthroid 125 mcg QAM
Allergies:
NKDA, denies all other allergies
Past Medical History (PMH):
Hypothyroid, osteopenia
Past Surgical History (PSH):
Denies
Social History:
Denies tobacco or recreational drug use, occasional alcohol use on special occasions but none recently.
Subjective (Student Documentation):
Ms. Hopkins, a 79-year-old woman, presents with fatigue and hair loss lasting nearly four weeks. She notes dry skin, alleviated minimally by lotion, and maintains independence in daily activities. With a history of hypothyroidism and osteopenia, she adheres to Synthroid and supplements, recognizing the recent name change to levothyroxine. Ms. Hopkins believes her current conditions are managed and unrelated to her current symptoms. She denies allergies and lists her medications as Levothyroxine 125 mcg, Calcium tablet QD, and Vitamin D QD.
Past Medical History reveals hypothyroidism diagnosed 15 years ago and osteopenia diagnosed four years ago. The family history includes a deceased mother from a stroke and a father who passed away due to COPD complications. Living alone in retirement, Ms. Hopkins reports a self-sufficient lifestyle.
Model Documentation
Chief Complaint: “I’m losing hair and feel tired” History of Present Illness (HPI): Maureen is a 79-year-old female presenting to the clinic today with concerns of atraumatic hair loss for three weeks, and fatigue, which has been ongoing for the past month. She reports no aggravating factors for her symptoms. She also reports non-pruritic dry skin on her hands, arms, and elbows that began three weeks ago Sick Visit: Management of Endocrine Conditions Shadow health Documentation / Electronic Health Record. Lotion temporarily relieves this dryness. Her symptoms are constant, but do not affect her activities of daily living. Patient reports that she is taking all of her medications as prescribed, including taking her Synthroid in the early AM, at least 60 minutes apart from any other medications or food. Mrs. Hopkins reports her Synthroid medication changed three months ago. The medication name on the pill bottle changed to levothyroxine sodium, and the pill shape changed from circular to oblong. She sleeps her usual 7-8 hours per night with no reported new anxiety or stress. Home Medications: • Multivitamin QHS • Calcium tablet QD • Vitamin D tablet QD • Synthroid 125 mcg QAM Allergies: NKDA, denies all other allergies Past Medical History (PMH): Hypothyroid, osteopenia Past Surgical History (PSH): Denies Social History: Denies tobacco or recreational drug use, endorses rare alcohol use on special occasions, but none recently. Reports eating
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| Student Documentation | |
|---|---|
SubjectiveMs Hopkins a79-year old woman presents to the client with a chief complaint of fatigue and hair loss. She reports to have been experiencing the symptoms for almost four weeks. She also states to have noted her skin is dry. She has been using lotion with little or no relief. She reporta she can do all things by herself. She has hypothyroidism and osteopenia. She reports to taking synthroid for her hypothyroidism and supplements for her osteopenia. She also reports to have nited her synthroid name change to levothyroxine. She believes her current conditions have been managed and are not related to the symptoms she is presenti g with. Allergies; Denies of any allergy Medications; Levothyroxine 125 mc, Calcimu tablet QD, vitamin D QD. Sick Visit: Management of Endocrine Conditions Shadow health Documentation / Electronic Health Record Past medical history; Hypothyroidism diagnised 15 years ago and osteopenia diagnosed 4 years ago. Family history; Mother deceased from stroke and father deceased due to COPD complications. Social Hx;Patient is retired and lives alone. She reports to have a Dont wait until the last minute.Provide your requirements and let our native nursing writers deliver your assignments ASAP. |