I HUMAN COMPREHENSIVE LAURA WOOD CASE STUDY REAL ONE WEEK 9

LAURA WOOD I HUMAN CASE STUDY 41Y/O
REASON FOR ENCOUNTER WELL WOMAN
EVALUATION LATEST CASE LATEST UPDATE




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, LAURA WOOD I HUMAN CASE STUDY 41Y/O
REASON FOR ENCOUNTER WELL WOMAN
EVALUATION LATEST CASE LATEST UPDATE



Step 1: History Taking

Chief Complaint (CC)

 Definition: The main reason the patient has sought medical attention, stated
in their own words.
 Example: Laura says, "I've been feeling really tired and short of breath."

History of Present Illness (HPI)

 Definition: Detailed description of the patient's current symptoms and their
progression.
 Key Aspects: Onset, duration, location, characteristics, aggravating and
alleviating factors, and associated symptoms.
 Example: Laura reports a 3-week history of increasing fatigue and shortness
of breath, worse with exertion and somewhat relieved by rest. No chest pain,
but occasional palpitations.

Past Medical History (PMH)

 Definition: Information about past and current medical conditions,
surgeries, and hospitalizations.
 Example: Laura has hypertension diagnosed 5 years ago, well-controlled on
medication, and a history of seasonal allergies.




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