Health history,ROS and 3 generation genogram Medicine Coursework (Coursework Sample)
I need an health history with review of systems including 3 generational genogram
A very simple patient
Subject and Section
Date of Submission
Date of Assessment: August 8, 2020
General Information: Name: CY; Age: 57 years-old. Date of Birth: June 30, 1963; Occupation: Bank Teller; Religion: Roman Catholic; Address: Los Angeles, California, USA.
CC: “I have been feeling chest pain and difficulty in breathing especially at night for the past two months.”
HPI: CY is a 57-year-old Caucasian man who came to consult secondary to vague chest pain associated with difficulty in breathing graded 7/10 on the subjective pain scale. The pain is usually felt at night and it cannot be relieved by changing positions but can reduce the pain to 5/10 by taking Ibuprofen. This was also associated with a productive cough (green sputum). He started feeling it 2 months ago when was jogging at a fast speed for over 15 minutes. He does not usually get tired easily or experience SOB. That night, he cannot sleep and felt a vague pain on his chest and difficulty breathing. At first, the chest pain was only at 4/10 so he neglected it. However, 1-month PTC, the pain gradually increased to 7/10. This was already associated with dull, aching, unremitting pain on his left shoulder, medial border of left scapula, and medial side of the left forearm. He also noticed that he started losing weight and cannot tolerate slow walking for 20 minutes 1 month ago. Yesterday, his cough had sputum and a tinge of blood which prompted the consult.
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