Ebony Gray Week 1 Case 1

Case Help 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” • = 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