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)
