TEMPLATE
Identifying Data: Age, Gender, Occupation, and Marital Status
27 yo, female, US Navy, and single
Source and Reliability: Patient and medical chart
Subjective
Chief complaint or appropriate health screening visit: The one or more symptoms or
concerns causing the patient to seek care. Need not be the patient’s complete statement
– may be a brief summary of reason patient wanted to be seen for this visit
Patient’s chief complaint of ongoing headaches and cold induced hives.
HPI: Complete subjective description of problem, including “OLDCARTS” findings or
similar, including location, quality severity, duration, timing, context, modifying factors,
associated signs/symptoms, relieving and aggravating factors, related systems.
Patient expresses concern of headaches and hives. Patient states that she
believes her headaches might be due to carbon monoxide exposure. Patient
does not believe it is due to menstruation. Patient states the headache
disrupts sleep with a tightness sensation, but there are no associated
symptoms of nausea or vomiting. Patient states she has noticed changes in
vision including blurriness which was evaluated by an ophthalmologist and
found to be normal. Patient denies any numbness or tingling. She states that
despite attempts at relief with over-the-counter medications such as
Tylenol, Aleve, ibuprofen, midol, and caffeine there are no reducing factors
in the headaches. Patient states this has been going on for approximately a
year. Patient also expresses concern that she experiences widespread full
body hives upon exposure to cold temperatures. Patient states that she
cannot get out to pump gas without breaking into hives. Patient states she
has been managing this condition with Claritin, as recommended by a nurse
from her workplace, but it has not helped. Patient denies throat swelling.
Patient states it lasts around 30 minutes until fully gone after trying to
warm herself up. Patient states that this issue just started this winter.
Medications, including OTC and Herbals Preparation
Amitriptyline 25 mg oral tablet
Cetirizine 10 mg oral tablet
Cyclobenzaprine 5 mg oral tablet
, Famotidine 40 mg oral tablet
Ubrelvy 100 mg oral tablet
Valacyclovir 500 mg oral tablet
Past Medical History:
1. Allergies – NKA
2. Childhood Illnesses – None
3. Adult Illnesses- Cryptic tonsil, genital HSV, hyperlipidemia, hypertrophy of
tonsil, tinnitus
4. Injuries- broken hand/wrist
5. Surgeries – hand/wrist surgery (08/2021)
6. Hospitalizations – none
7. Obstetric/Gynecologic – pap smear and HPV contesting (12/2019)
8. Psychiatric – none
9. Health Maintenance – 6 month follow up with PCP for new medications,
annual wellness exams with labs, pap smear annually, no tobacco use, no
substance abuse use.
10. Immunization status – Up to date on all immunizations. Complete
11. Dental Exams – Yearly, cleanings
12. Last eye exam – 2025, no abnormalities found
13. SBE/Pap/GYN (include results) – negative for intraepithelial lesion or
malignancy (07/17/2024)
Family History: Include presence or absence of specific illnesses in family such as
hypertension, diabetes, or cancer
Diabetes Mellitus- grandmother (M)
Hyperlipidemia- Mother, Father, and grandmother (M)
Thyroid disorder- mother and grandmother (M)
Personal and Social History:
1. Educational level- Attended College but did not finish
2. Personal interests – yoga, pilates, the gym
3. Lifestyle – exercise and diet – exercise daily, good diet with limited fast food
Review of Systems: Pertinent positives and negatives in the differential diagnosis
Objective
1. Vital Signs
Identifying Data: Age, Gender, Occupation, and Marital Status
27 yo, female, US Navy, and single
Source and Reliability: Patient and medical chart
Subjective
Chief complaint or appropriate health screening visit: The one or more symptoms or
concerns causing the patient to seek care. Need not be the patient’s complete statement
– may be a brief summary of reason patient wanted to be seen for this visit
Patient’s chief complaint of ongoing headaches and cold induced hives.
HPI: Complete subjective description of problem, including “OLDCARTS” findings or
similar, including location, quality severity, duration, timing, context, modifying factors,
associated signs/symptoms, relieving and aggravating factors, related systems.
Patient expresses concern of headaches and hives. Patient states that she
believes her headaches might be due to carbon monoxide exposure. Patient
does not believe it is due to menstruation. Patient states the headache
disrupts sleep with a tightness sensation, but there are no associated
symptoms of nausea or vomiting. Patient states she has noticed changes in
vision including blurriness which was evaluated by an ophthalmologist and
found to be normal. Patient denies any numbness or tingling. She states that
despite attempts at relief with over-the-counter medications such as
Tylenol, Aleve, ibuprofen, midol, and caffeine there are no reducing factors
in the headaches. Patient states this has been going on for approximately a
year. Patient also expresses concern that she experiences widespread full
body hives upon exposure to cold temperatures. Patient states that she
cannot get out to pump gas without breaking into hives. Patient states she
has been managing this condition with Claritin, as recommended by a nurse
from her workplace, but it has not helped. Patient denies throat swelling.
Patient states it lasts around 30 minutes until fully gone after trying to
warm herself up. Patient states that this issue just started this winter.
Medications, including OTC and Herbals Preparation
Amitriptyline 25 mg oral tablet
Cetirizine 10 mg oral tablet
Cyclobenzaprine 5 mg oral tablet
, Famotidine 40 mg oral tablet
Ubrelvy 100 mg oral tablet
Valacyclovir 500 mg oral tablet
Past Medical History:
1. Allergies – NKA
2. Childhood Illnesses – None
3. Adult Illnesses- Cryptic tonsil, genital HSV, hyperlipidemia, hypertrophy of
tonsil, tinnitus
4. Injuries- broken hand/wrist
5. Surgeries – hand/wrist surgery (08/2021)
6. Hospitalizations – none
7. Obstetric/Gynecologic – pap smear and HPV contesting (12/2019)
8. Psychiatric – none
9. Health Maintenance – 6 month follow up with PCP for new medications,
annual wellness exams with labs, pap smear annually, no tobacco use, no
substance abuse use.
10. Immunization status – Up to date on all immunizations. Complete
11. Dental Exams – Yearly, cleanings
12. Last eye exam – 2025, no abnormalities found
13. SBE/Pap/GYN (include results) – negative for intraepithelial lesion or
malignancy (07/17/2024)
Family History: Include presence or absence of specific illnesses in family such as
hypertension, diabetes, or cancer
Diabetes Mellitus- grandmother (M)
Hyperlipidemia- Mother, Father, and grandmother (M)
Thyroid disorder- mother and grandmother (M)
Personal and Social History:
1. Educational level- Attended College but did not finish
2. Personal interests – yoga, pilates, the gym
3. Lifestyle – exercise and diet – exercise daily, good diet with limited fast food
Review of Systems: Pertinent positives and negatives in the differential diagnosis
Objective
1. Vital Signs
