Ms Hopkins Sick Visit: Management of Endocrine Conditions Shadow health
Documentation / Electronic Health Record
Chief Complaint: “I’m losing hair and feel tired” History of Present Illness (HPI): Maureen is a 79-year-old female presenting to the clinic today with concerns of atraumatic hair loss for three weeks, and fatigue, which has been ongoing for the past month. She reports no aggravating factors for her symptoms. She also reports non-pruritic dry skin on her hands, arms, and elbows that began three weeks ago Sick Visit: Management of Endocrine Conditions Shadow health Documentation / Electronic Health Record. Lotion temporarily relieves this dryness. Her symptoms are constant, but do not affect her activities of daily living. Patient reports that she is taking all of her medications as prescribed, including taking her Synthroid in the early AM, at least 60 minutes apart from any other medications or food. Mrs. Hopkins reports her Synthroid medication changed three months ago.
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Interaction of Nurse Informaticists with Other Professionals
The medication name on the pill bottle changed to levothyroxine sodium, and the pill shape changed from circular to oblong. She sleeps her usual 7-8 hours per night with no reported new anxiety or stress. Home Medications: • Multivitamin QHS • Calcium tablet QD • Vitamin D tablet QD • Synthroid 125 mcg QAM Allergies: NKDA, denies all other allergies Past Medical History (PMH): Hypothyroid, osteopenia Past Surgical History (PSH): Denies Social History: Denies tobacco or recreational drug use, endorses rare alcohol use on special occasions, but none recently. Reports eating
| Student Documentation | |
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SubjectiveMs Hopkins a79-year old woman presents to the client with a chief complaint of fatigue and hair loss. She reports to have been experiencing the symptoms for almost four weeks. She also states to have noted her skin is dry. She has been using lotion with little or no relief. She reporta she can do all things by herself. She has hypothyroidism and osteopenia. She reports to taking synthroid for her hypothyroidism and supplements for her osteopenia. She also reports to have nited her synthroid name change to levothyroxine. She believes her current conditions have been managed and are not related to the symptoms she is presenti g with. Allergies; Denies of any allergy Medications; Levothyroxine 125 mc, Calcimu tablet QD, vitamin D QD. Sick Visit: Management of Endocrine Conditions Shadow health Documentation / Electronic Health Record Past medical history; Hypothyroidism diagnised 15 years ago and osteopenia diagnosed 4 years ago. Family history; Mother deceased from stroke and father deceased due to COPD complications. Social Hx;Patient is retired and lives alone. She reports to have a
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Sick Visit: Managing Endocrine Conditions Shadow Health Documentation / Electronic Health Record
– Flowsheets
– My Provider Notes
– Diagnostic Notes
My Provider Notes
Model Documentation
Chief Complaint: “I’m losing hair and feel tired”
History of Present Illness (HPI): Maureen, a 79-year-old female, visits the clinic with concerns of non-injury-related hair loss persisting for three weeks and fatigue lasting for a month. She reports that her symptoms have no specific triggers. Additionally, she mentions experiencing dry, non-itchy skin on her hands, arms, and elbows for the past three weeks, with temporary relief achieved using lotion. These symptoms are constant but have not hindered her daily activities. Maureen confirms that she adheres to her prescribed medication regimen, including taking Synthroid in the early morning, at least an hour apart from other medications or food. She notes that her Synthroid medication underwent a change three months ago, with the pill bottle now labeled “levothyroxine sodium,” and the pill’s shape transitioning from circular to oblong. Her sleep patterns remain consistent at 7-8 hours per night, and she reports no recent occurrences of anxiety or stress.
Home Medications:
– Multivitamin QHS
– Calcium tablet QD
– Vitamin D tablet QD
– Synthroid 125 mcg QAM
Allergies: No known drug allergies, denies any other allergies
Past Medical History (PMH): Diagnosed with hypothyroidism and osteopenia
Past Surgical History (PSH): Denies any surgical history
Social History: She denies tobacco or recreational drug use and mentions occasional alcohol consumption during special events, but none recently.
Student Documentation
Subjective
Ms. Hopkins, a 79-year-old woman, presents to the clinic with a chief complaint of fatigue and hair loss, which she has been experiencing for nearly four weeks. She also notes dry skin, for which she has been using lotion with limited relief. She states that these symptoms do not impede her daily activities. Ms. Hopkins has a history of hypothyroidism and osteopenia and reports taking Synthroid for hypothyroidism and supplements for osteopenia. She is aware that her Synthroid medication was rebranded as levothyroxine, but she believes her current conditions are well-managed and unrelated to her current symptoms.
Allergies: Denies any allergies
Medications: Levothyroxine 125 mcg, Calcium tablet QD, Vitamin D QD.
Past medical history: Diagnosed with hypothyroidism 15 years ago and osteopenia 4 years ago.
Family history: Mother passed away from a stroke, and father died due to complications from COPD.
Social History: Retired and living alone. She reports having a
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