Identifying Data: Full Name: T.M. Sex: Male DOB: 09/30/1946 Race/Nationality: Caucasian Marital Status: Married Address: New York, NY Religion: Christian Date & Time: 9:00AM 11/30/2021 Location: New York Presbyterian Queens Hospital Source of Information: Self Reliability: reliable Source of Referral: Self Transportation: Driven by wife to ED Chief Complaint: “I have bad pain in my scrotum and side” x24 hours History of Present Illness: 75 y/o covid-negative male with PMHx of recurrent nephrolithiasis and Crohn’s Disease presented to the ED 6 hours prior with initial complaints of sharp, shooting intermittent 8/10 pain in the left scrotum and flank that first …

Identifying Data: Full Name: I.M. DOB: 02/19/1934 Date & Time: 10:45AM on 09/14/2021 Location: New York, NY Race/Nationality: Caucasian Marital Status: Widowed Religion: Deism Source of Information: Self Reliability: Reliable Source of Referral: Urgent Care Transportation: Brother Chief Complaint: “I noticed my pulse getting high and blood pressure was running lower than normal” x1 week History of Present Illness: 87 y/o covid negative female with PMHx of MI x1, AFib x1, HTN, NIDDM was sent to the ER by Urgent Care 3 days prior for atrial fibrillation Dx on ECG. She was treated with Metoprolol 25 mg PO and subsequently …

The following paper is a personal reflection on my 1st and 3rd History & Physical that I have performed for Physical Diagnosis I: What differences do you note between the two H&Ps? The formatting of my Chief Complaint and History of Present Illness has improved from my 1st to 3rd H&P. The social history section has become more detailed as a result of me asking more specific questions to get a better overall picture of the patient’s social factors. I was able to perform the heart, lung, and abdominal exam on the 3rd H&P which I had not yet learned …

The following History & Physical was obtained from my third hospital visit in the Emergency Department: *Areas marked in red were either not performed/obtained or were obtained by hospital staff but have been written in to show completeness of findings I would document in a complete H&P. Identifying Data: Full Name: X.D. DOB: 01/01/1953 Date & Time: 09:00AM 05/18/2021 Location: NYPQ Hospital Race/Nationality: Chinese Religion: unknown Marital status: Married Address: Queens, NY Source of Information: Self with Mandarin translation services Reliability: Reliable Source of Referral: Cardiology Transportation: Spouse Chief Complaint: “I am having the worst chest pain, back pain, and …

This is my first History & Physical which was taken & performed in the Pre-Admission Testing unit. This assignment is apart of Physical Diagnosis I. *Patient identifiers & personal details, including but not limited to the dates listed below, have been modified for patient privacy. IDENTIFICATION: Patient encounter 9:00am 04/13/2021 Name: J.H. DOB: 01/01/1966 Sex: female race: Hispanic nationality: unknown Age: 55 marital status: divorced address: unknown religion: unknown INFORMANT Source of the history: self, reliable REFERAL SOURCE Orthopedics CHIEF COMPLAINT Surgery clearance for right knee arthroscopy after falling on it in 2018 HISTORY OF PRESENT ILLNESS J.H., 55 y/o …

This SOAP note was written based on a hypothetical patient prompt for Interview & Counseling. CC: Feeling “really sleepy all day” and feels like she isn’t functioning well at work HPI: A 36 y/o female smoker (15 pack-years) and chronic cough x4 years presents to the clinic with complaints of fatigue, visual disturbances described as “wavy lines”, and nausea. Patient has a history of migraines with aura that first began 2 years prior. She reports no headaches since beginning Amitriptyline 50mg qhs and associated prodrome symptoms resolve with use of Zolmitriptan 2.5mg. Prodrome symptoms appear to be interfering with functioning …