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  • Historia Clinica 1

    Transféré par

    viviana
    21 vues3 pages
    1) The patient, Yasmin Arevalo, is a 29-year-old single Indian American woman who presented with a chief complaint of right back pain rated an 8 out of 10. 2) Her medical history and physical exam were documented, including vital signs, height, weight, and Glasgow scale results. 3) The document provides an automated report on the patient's conditions, history, diseases, surgeries, immunizations, family history, genetics, socioeconomics, lifestyle, and physical exam findings.

    Description originale:

    HISTORIA CLINICA

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    1) The patient, Yasmin Arevalo, is a 29-year-old single Indian American woman who presented with a chief complaint of right back pain rated an 8 out of 10. 2) Her medical history and physical exam were documented, including vital signs, height, weight, and Glasgow scale results. 3) The document provides an automated report on the patient's conditions, history, diseases, surgeries, immunizations, family history, genetics, socioeconomics, lifestyle, and physical exam findings.

    Droits d'auteur :

    © All Rights Reserved
    Téléchargez comme ODT, PDF, TXT ou lisez en ligne sur Scribd
    Signaler comme contenu inapproprié
    21 vues3 pages

    Historia Clinica 1

    Transféré par

    viviana
    1) The patient, Yasmin Arevalo, is a 29-year-old single Indian American woman who presented with a chief complaint of right back pain rated an 8 out of 10. 2) Her medical history and physical exam were documented, including vital signs, height, weight, and Glasgow scale results. 3) The document provides an automated report on the patient's conditions, history, diseases, surgeries, immunizations, family history, genetics, socioeconomics, lifestyle, and physical exam findings.

    Droits d'auteur :

    © All Rights Reserved
    Téléchargez comme ODT, PDF, TXT ou lisez en ligne sur Scribd
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    sur 3

    SSN # 1130683878

    ID :1130683878

    Print Date :10/11/2018, 03:42:32

    Patient Name: AREVALO, YASMIN DoB:10/11/1989 Sex: Female


    Age 29y 0m 0d

    Ethnicity: Indian American Marital Status : Single Occupation : Administrator


    Evaluation date: 10/11/2018, 02:00:18 Information Source: Self / Reliability : Seems reliable

    Chief Complaint

    History of Present Illness


    paciente con dolor en el dorso derecho su dolor es interno y pasa a la espalda y se pregunta al pacienta
    cuanto califica usted el dolor que siente de una escala de 1 a 10 responde que 8 .

    Medication History

    Medicament Indication Start End Active

    Personal History
    Automated report about patient important conditions Annotations about the patient conditions & history

    Diseases
    Disease Severity Status Active Infectious Diagnosed Remarks

    Surgeries
    Immunizations

    Vaccine Dose Date Next Dose Observations

    Family History and Genetic Information

    Family Information

    Patient Genetic Abnormalities / “Disease Genes”

    Socioeconomics
    Socioeconomic Status :
    Housing conditions :
    Educational Level : University

    Lifestyle

    Sexuality : . .

    Physical Examination
    Vital Signs

    Temperature Systolic
    Blood Pressure
    Diastolic
    Heart rate Respiratory Oxygen
    Rate Saturation

    Anthropometry

    Height Waist BMI


    Weight Hip WHR

    Level of Conciousness / Glasgow Scale

    Eyes 4/4 Verbal 5/5 Motor 6/6 Total 15 / 15


    Glasgow

    Signs and Symptoms

    Type Clinical finding Comments

    Diagnostics Section
    Other Hypotheses / DDx

    Information about the Diagnosis

    Care Plan

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