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Which belongs in the Social History?

You document: “Mood: ‘sad’; affect constricted, congruent with stated mood.” Which domain of the mental status exam does this represent?

Given S: “reading trouble up close,” O: VA near decreased; fundus normal; age 47.Best Assessment phrasing?

Which entry belongs in the Subjective section of a focused SOAP note for “cough × 3 days”?

Which ROS is most appropriate for a focused cough visit?

In the HPI using OLDCARTS, “worse after working on a computer for 2 hours” maps to:

Which documentation best reflects an appropriate Chief Complaint (CC)?

A 52-year-old man arrives to the clinic for evaluation of arthritis and leg swelling. The patient reports that the joint pains began 8 months ago. He has tried acetaminophen and ibuprofen without significant improvement. He reports the leg swelling began within the past 2 months and has gotten progressively worse. The patient’s medical history is significant for diabetes. His medications include metformin and aspirin. The patient works as an accountant. He smokes cigars socially. The patient’s temperature is 99°F (37.2°C), blood pressure is 130/78 mmHg, pulse is 70/min, and respirations are 14/min with an oxygen saturation of 98% on room air. Physical examination notes a deeply tanned appearing, overweight male with 2+ edema of bilateral lower extremities. Which of the following tumor markers is associated with a known complication of this patient’s condition?

A 24-year-old female presents for evaluation and reports experiencing fevers, drenching night sweats, and weight loss for past month. Patient notices an area in the right side of her neck that develops a “dull ache” after drinking alcohol. The patient reports that fevers range from 101.3F to 104.0F and occur almost daily. She has lost 15 pounds in past month unintentionally and has had several episodes of generalized pruritus with no associated skin lesions. On exam, there is a 1 x 2.5 cm firm LN in right cervical area palpable on exam; no other palpable adenopathy; no organomegaly. Initial laboratory test results include: normal CBC with diff, elevated ESR, normal CMP, and negative HIV test. What is the most likely diagnosis for this patient?

A 35-year-old woman presents to the emergency room with fatigue, dyspnea, and palpitations. A week earlier, the patient had received a dose of prophylactic cefotetan before an uncomplicated laparoscopic appendectomy. She has no other significant past medical history. She denies any family history of hereditary conditions. Her temperature is 98.1°F (36.7°C), blood pressure is 130/85 mmHg, pulse is 110/min, and respirations are 20/min. Jaundice and splenomegaly are noted on physical exam. Her hemoglobin is 7.1 g/dL, down from 13.2 g/dL 1 week ago. Additional laboratory tests are as follows:Leukocyte count: 7,000Platelet count: 300,000Mean corpuscular volume (MCV): 90Reticulocyte count: 9%Lactate dehydrogenase: 480 U/L (Normal: 140-280 U/L)Haptoglobin: 10 mg/dL (Normal: 41-165 mg/dL)Indirect bilirubin: 2.7 mg/dLD-dimer < 250 ng/mL (Normal: < 250 ng/mL)The peripheral blood smear shows reticulocytosis and microspherocytes. After appropriate therapeutic interventions, which of the following is the most appropriate next diagnostic test?