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HISTORY:

• Patient interview reminder sheet- document in key findings
• “Good Question” means you asked a required question

Step 1: Start by asking 2 open ended patient centric questions:

1. How can I help you today?
2. Any other symptoms or concerns?

Step 2: Obtain an HPI using “OLDCARTS”

• O = Onset; circumstances surrounding start of symptom
• L = Location, radiation
• D = Duration
• C = Characteristics (sharp, dull, cramping)
• A = Aggravating
• R = Relieving
• T = Treatments
• S= Severity Step 3: PMH

• No patient record – Obtain history
• Have patient record – Update allergies, medications, OTC drugs

Step 4: FH

• No patient record – Obtain history

Step 5: SH

• No patient record- obtain history
• Have patient record- Update if major changes in living situation, death of partner, loss of job etc.

Step 6: ROS

• Questions for systems not addressed in HPI
• Choose ROS for the body systems you do not have information on. Use the large multipart questions

Physical Exam

• Do those physical assessment maneuvers as needed
• Choose ROS for those body systems you do not have information on. Use large multipart questions.

Assessment

• Organize key findings list by selecting the MSAP (Most significant active problem).
• Mark other findings as; related, unrelated, unknown, PMH/resolved.

Problem Statement

• Short summary of patient’s presentation. Should contain: 1. Demographic description, 2. Chief complaint, 3. Hx and PE key findings, 4. Risk factors. Keep it concise.

Differential Diagnosis

• List disease you are considering Prior to ordering tests.

Tests:

• Determine what tests are needed to rule in or rule out each diagnosis on authors corrected list.
• Review authors corrected list of test results.

Final Diagnosis

• Select a final diagnosis or diagnoses.

Treatment plan

• Write a treatment plan following your instructors’ guidelines.

Gear head exercises

• Complete exercises found throughout the case (look for the brain with gears icon in steps of the case)

Summary

• Proceed all the way to the “Summary” tab.
• Submit your case and press the “see evaluation” button to see your first evaluation.

Paisley Ward

16 y/o

5’5 (165cm)

150.0lb (68.2kg) BMI 25

A&Ox4

Reason for encounter: Cough and SOB

Vital Signs

Temp: 37.0 (98.6)

Pulse: 88 bpm, rhythm: regular, strength: normal

BP L/arm 112/82, R/arm 114/80, assessment: normal, pulse pressure: normal RR:26 bpm, rhythm: regular, effort: unlabored

SpO2: 94%

3 yr ago visit:

Reason: For Physical examination

Psych: stress at home with financial situation of family. No anxiety or SI PMH: Eczema: uses moisturizer daily no flares for several yrs.

Hosp/Surg: Normal birth, full term, no medical problems. No major accidents or injuries. No surgeries. Prev health: last check up 1 yr ago. UTD on all immunizations

Meds: None Allg: NKDA Social:

Lives at home with mother and father. Only child. Father lost job, works odd jobs to pay bills. Mother works at fast food restaurant. Evicted from home looking for place to live.

Denies past/present use of alcohol, tobacco, or illicit drugs. Never been sexually active. States she does get sad sometimes due to her family’s recent financial and living situation but she does not feel like she is depressed. She denies SI.

FHX: Father: Eczema, otherwise healthy, Mother: no medical problems, No other significant family history.

HISTORY Questions:

Skin: pink, warm, moist

1. How can I help you today?

Cough for the last three weeks which has been getting worse. I’ve also had SOB when walking to my next class at school. I have to stop and take a break.

2. Do you have any other symptoms or concerns we should discuss?

No, but I did have a runny nose and congestion 3 weeks ago. The congestion went away in a week but the cough is still there.

HPI: Cough:

3. Are you coughing up any sputum?

No

4. Does anything make your cough better or worse?

Not really, it has been constant but has been getting worse over the past three days and seems to be worse at nights.................... Continue