Scott Becker shadow health Subjective Data Collection

Scott Becker shadow health Subjective Data Collection

This document summarizes the subjective data (information gathered from the patient themself) collected by Scott Becker during a patient encounter.

Chief Complaint:

Fatigue

History of Present Illness:

Worsening fatigue over several weeks

Vomiting once this morning, with dark flecks

Stomach pain in the upper left abdomen for 3-4 months

Gnawing or burning

Worsens after eating

Increasing over the past week

Takes antacids daily, moderately effective

Past Medical History:

No allergies (food, environmental, latex, medication)

Hypertension

High cholesterol

Coronary artery disease

Osteoarthritis

Scott Becker’s Social History

This section details the social history aspects of Scott Becker’s patient encounter.

Living Situation:

Lives with family

Substance Use:

No tobacco use

Drinks coffee every morning (2-3 cups)

Drinks alcohol 1-2 nights a week (1-2 glasses per sitting)