SLEEPING TROUBLE I-HUMAN CASE STUDY

Reason for nunntc;
Ttou0fe sleeptng

Location

'.•tav, ECG. ane

ICStOÄ:

,
,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
Clinic Notes
I am having trouble sleeping and
I feel so tired. came to see it you CC SX HOW Can I you today?
could give me sornething to help
me sleep better.
Yes. a bit nervous... sort 0!
jumpy if you know what I mean.
but I
Assoc sx Have or worried you been about nervous, something?anxk.us dont the problem really know
sleeping... why. Maybe Life isit's
good. have been enjoying
retirement with my friends.
Sometimes, but seem to just be
Assoc sx DO You awaken frequently frorn sleeping very light. I hear sleep?

Yes actually now that you ask...
I used to really battle
constipation. Now i am having
bowel
X Assoc sx Any change in the frequency 01 movements twice daily.
They are your bowel movements? really soft, not well
formed. I guess at times they border on diarrhea consistency. but
not realty diarrhea.
Do you have any other symptoms I feel a bit gittery or nervous and I
Assoc sx

, or concerns we should discuss? seem to be loosing weight.
How is your appetite? Any recent Yes, it seems I am hungry all the
Etiology
change? time.


OLD-CARTS for the HPI