ERIN BRADLEY (ENDOCRINE) CC; NAUSEA AND VOMITING, FEELING SHAKY AND HOT ALONG WITH A
FLUTTER IN CHEST COMPLETE EXPERT FEEDBACK (SOLUTIONS)
[Document subtitle]
[DATE]
[COMPANY NAME]
[Company address]
, Chief complaint: Nausea and vomiting, feeling shaky and hot along with a flutter in chest
1. Identifying data:
Name: Erin Bradley
Age: 21
Sex: Female
Source: Patient who is a reliable historian.
2. HPI:
Ms. Bradley is a 21 years old college student who appears to be moderately distress with
complaints of worsening weakness, nausea, vomiting, increase in frequency of bowel
movement 3-4 times, hot feeling, heart palpitations, increase appetite, shaky, new onset
of productive cough, non-bloody sputum, unintentional weight loss of approximately 10
pounds, insomnia sleeping only 3 hours, oligomenorrhea x 6 months and recently missed
one period. In addition, patient reports she recently recovered from the flu and was
feeling better then however she started to experience the forementioned symptoms which
has progressively got worse impacting her ability to perform her daily routine. Pt also
endorses fever in which Tylenol provides some relief and shortness of breath which has
gotten worse. She appears anxious denies recreational drug use.
3. ROS:
a. General/Constitutional: Pt reports fatigue, insomnia, unintentional weight loss, increase
appetite, fever and chills
b. HEENT: Pt denies blurry vision, difficulty swallowing/speaking, denies, photophobia,
hearing problems or sinus problems.
c. Cardiac: Report’s palpitations and decreased exercise tolerance. Denies chest pain
d. Respiratory: Reports productive cough and shortness of breath on exertion. Denies
wheezing.
e. Gastrointestinal: Report’s nausea, vomiting, increase frequency in bowel movement,
increase appetite. Denies abdominal pain
f. Genitourinary: Denies hematuria, bladder incontinence, urgency or dysuria.
g. Musculoskeletal: Denies muscle or joint pain, muscle cramps, redness, swelling or joint
stiffness.
h. Neurological: Denies dizziness, fainting, weakness, seizures or tremors.
i. Endocrine: Reports increase appetite and heat intolerance.
FLUTTER IN CHEST COMPLETE EXPERT FEEDBACK (SOLUTIONS)
[Document subtitle]
[DATE]
[COMPANY NAME]
[Company address]
, Chief complaint: Nausea and vomiting, feeling shaky and hot along with a flutter in chest
1. Identifying data:
Name: Erin Bradley
Age: 21
Sex: Female
Source: Patient who is a reliable historian.
2. HPI:
Ms. Bradley is a 21 years old college student who appears to be moderately distress with
complaints of worsening weakness, nausea, vomiting, increase in frequency of bowel
movement 3-4 times, hot feeling, heart palpitations, increase appetite, shaky, new onset
of productive cough, non-bloody sputum, unintentional weight loss of approximately 10
pounds, insomnia sleeping only 3 hours, oligomenorrhea x 6 months and recently missed
one period. In addition, patient reports she recently recovered from the flu and was
feeling better then however she started to experience the forementioned symptoms which
has progressively got worse impacting her ability to perform her daily routine. Pt also
endorses fever in which Tylenol provides some relief and shortness of breath which has
gotten worse. She appears anxious denies recreational drug use.
3. ROS:
a. General/Constitutional: Pt reports fatigue, insomnia, unintentional weight loss, increase
appetite, fever and chills
b. HEENT: Pt denies blurry vision, difficulty swallowing/speaking, denies, photophobia,
hearing problems or sinus problems.
c. Cardiac: Report’s palpitations and decreased exercise tolerance. Denies chest pain
d. Respiratory: Reports productive cough and shortness of breath on exertion. Denies
wheezing.
e. Gastrointestinal: Report’s nausea, vomiting, increase frequency in bowel movement,
increase appetite. Denies abdominal pain
f. Genitourinary: Denies hematuria, bladder incontinence, urgency or dysuria.
g. Musculoskeletal: Denies muscle or joint pain, muscle cramps, redness, swelling or joint
stiffness.
h. Neurological: Denies dizziness, fainting, weakness, seizures or tremors.
i. Endocrine: Reports increase appetite and heat intolerance.
