In your own words, explain the type and level of this documented past, family, and social history. Explain your rationale
What will be an ideal response?
This 17-year-old patient presents to this pediatrician clinic for an initial visit. Patient's primary complaint is persistent heartburn. Medical record documents recurrent stomach pain but no diagnosed peptic ulcers. Record indicates the patient experienced a history of domestic abuse prior to the age of 12, which culminated in a severe concussion and a three-day hospital stay. The patient's mother is a recovering alcoholic and both the patient and entire family is currently undergoing talk therapy to deal with the mother's abusive behavior of the past. The patient denies alcohol use. The patient currently lives with both parents and admits to smoking tobacco cigarettes.
This documentation supports a new complete PFSH because the following elements are documented:
Past: Medical record documents recurrent stomach pain but no diagnosed peptic ulcers. Record indicates the patient experienced a history of domestic abuse prior to the age of 12, which culminated in a severe concussion and a three-day hospital stay.
Family: Mother is a recovering alcoholic.
Social: The patient denies alcohol use. The patient currently lives with both parents and admits to smoking tobacco cigarettes
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