iHUMAN CASE STUDY
Case 4
Scratch Sheet
Patient: Justin Johnson
Age: 19 years
Clinical Case Study Worksheet Confidential
, iHuman Case 4 | Justin Johnson, 19 y/o | Scratch Sheet
1. Patient Demographics
Complete all fields below based on the iHuman patient introduction.
Patient Name: Justin Johnson
Age: 19 years
Gender:
Date of Birth:
Allergies:
Code Status:
Chief Complaint:
Setting:
2. History of Present Illness (HPI)
Document the HPI using the OLDCARTS mnemonic. Gather details from the patient interview in the iHuman
case.
OLDCARTS Assessment
Onset When did symptoms begin? Sudden or gradual?
Location Where is the symptom located? Does it radiate?
Duration How long does each episode last? Constant or intermittent?
Character Describe the quality (sharp, dull, burning, aching, etc.)
Aggravating Factors What makes it worse? Activity, food, position, stress?
Relieving Factors What makes it better? Rest, medication, position?
Timing Time of day? Related to meals, activity, sleep?
Severity Rate pain 0-10. How does it affect daily activities?
Notes:
3. Past Medical History
Review the patient chart and interview responses for historical medical data.
Medical History
Past Medical History (PMH) Chronic illnesses, hospitalizations, previous surgeries?
Past Surgical History (PSH) Surgical procedures with dates and outcomes?
Medications Current medications (name, dose, frequency, route)?
Allergies Drug, food, environmental allergies and reaction type?
Page 1
Case 4
Scratch Sheet
Patient: Justin Johnson
Age: 19 years
Clinical Case Study Worksheet Confidential
, iHuman Case 4 | Justin Johnson, 19 y/o | Scratch Sheet
1. Patient Demographics
Complete all fields below based on the iHuman patient introduction.
Patient Name: Justin Johnson
Age: 19 years
Gender:
Date of Birth:
Allergies:
Code Status:
Chief Complaint:
Setting:
2. History of Present Illness (HPI)
Document the HPI using the OLDCARTS mnemonic. Gather details from the patient interview in the iHuman
case.
OLDCARTS Assessment
Onset When did symptoms begin? Sudden or gradual?
Location Where is the symptom located? Does it radiate?
Duration How long does each episode last? Constant or intermittent?
Character Describe the quality (sharp, dull, burning, aching, etc.)
Aggravating Factors What makes it worse? Activity, food, position, stress?
Relieving Factors What makes it better? Rest, medication, position?
Timing Time of day? Related to meals, activity, sleep?
Severity Rate pain 0-10. How does it affect daily activities?
Notes:
3. Past Medical History
Review the patient chart and interview responses for historical medical data.
Medical History
Past Medical History (PMH) Chronic illnesses, hospitalizations, previous surgeries?
Past Surgical History (PSH) Surgical procedures with dates and outcomes?
Medications Current medications (name, dose, frequency, route)?
Allergies Drug, food, environmental allergies and reaction type?
Page 1
