¥ R
Jennifer
65 y/o
5'5" (165 cm)
126.0 Ib (57.3 kg)
Reason for encounter
Trouble sleeping
Submitted on 01/18/2022 13:04:18
Case authored by: Judy Kalinyak, MD, PhD
, History Taking Strategy
Below you will see the strategy for selecting the "required" questions in this patient encounter using the OLD-CARTS
mnemonic for the HPI.
Reason for Encounter
Start with open-ended patient-centric questions.
® Asked X Not asked
Information Obtained
Graded Approach Question Response T N
| am having trouble sleeping and |
° CC Sx How can | help you today? feel so ?lred. | came to_ see if you
could give me something to help
me sleep better.
Yes, a bit nervous... sort of jumpy
if you know what | mean, but |
Have you been nervous, anxious | don't really know why. Maybe it's
[ ] Assoc Sx : 2 : S
or worried about something? the problem sleeping... Life is
good. | have been enjoying
retirement with my friends.
Sometimes, but | seem to just be
Do you awaken frequently from . .
[] Assoc Sx sleeping very light. | hear
sleep? =
everything.
Yes actually now that you ask... |
used to really battle constipation.
Now | am having bowel
Any change in the frequency of movements twice daily. They are
X Assoc Sx
your bowel movements? really soft, not well formed. |
guess at times they border on
diarrhea consistency, but not
really diarrhea.
Do you have any other symptoms | | feel a bit gittery or nervous and |
[ ] Assoc Sx g 1 N
or concerns we should discuss? | seem to be loosing weight.
; — .
° Etiology How is your appetite? Any recent Yes, it seems | am hungry all the
change? time.
OLD-CARTS for the HPI
® Asked X Not asked
Information
Graded Approach Question Response Obtained
Clinic Notes
Onset
Location
Duration
o lf.you wake in the middle of the Not always, but mostly | do
[ ] Characteristics night, are you able to fall asleep " "
. eventually... but it takes a while.
again?
Yes. | think | just get so
Does:your insomnia come.and exhausted from not sleeping well
[ ] Characteristics v for 2-3 days that | finally sleep but
an?
| Show Dialogue I
Jennifer
65 y/o
5'5" (165 cm)
126.0 Ib (57.3 kg)
Reason for encounter
Trouble sleeping
Submitted on 01/18/2022 13:04:18
Case authored by: Judy Kalinyak, MD, PhD
, History Taking Strategy
Below you will see the strategy for selecting the "required" questions in this patient encounter using the OLD-CARTS
mnemonic for the HPI.
Reason for Encounter
Start with open-ended patient-centric questions.
® Asked X Not asked
Information Obtained
Graded Approach Question Response T N
| am having trouble sleeping and |
° CC Sx How can | help you today? feel so ?lred. | came to_ see if you
could give me something to help
me sleep better.
Yes, a bit nervous... sort of jumpy
if you know what | mean, but |
Have you been nervous, anxious | don't really know why. Maybe it's
[ ] Assoc Sx : 2 : S
or worried about something? the problem sleeping... Life is
good. | have been enjoying
retirement with my friends.
Sometimes, but | seem to just be
Do you awaken frequently from . .
[] Assoc Sx sleeping very light. | hear
sleep? =
everything.
Yes actually now that you ask... |
used to really battle constipation.
Now | am having bowel
Any change in the frequency of movements twice daily. They are
X Assoc Sx
your bowel movements? really soft, not well formed. |
guess at times they border on
diarrhea consistency, but not
really diarrhea.
Do you have any other symptoms | | feel a bit gittery or nervous and |
[ ] Assoc Sx g 1 N
or concerns we should discuss? | seem to be loosing weight.
; — .
° Etiology How is your appetite? Any recent Yes, it seems | am hungry all the
change? time.
OLD-CARTS for the HPI
® Asked X Not asked
Information
Graded Approach Question Response Obtained
Clinic Notes
Onset
Location
Duration
o lf.you wake in the middle of the Not always, but mostly | do
[ ] Characteristics night, are you able to fall asleep " "
. eventually... but it takes a while.
again?
Yes. | think | just get so
Does:your insomnia come.and exhausted from not sleeping well
[ ] Characteristics v for 2-3 days that | finally sleep but
an?
| Show Dialogue I
