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Florence Blackman (49 y/o female) – Chest Pain. CC: Intermittent squeezing chest pain iHuman Case Study : Comprehensive Study | Analyzed by An Expert | Latest Analysis$22.49
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Key Findings
History b Feedback Create one entry for each
problem you identify during your +
Below you will see the strategy for selecting the "required” questions in this patient encounter using the OLD-CARTS mnemonic HEP.
for the HPI
{ Chest pain 8/10 -
Reason for Encounter
7 Shortness of Breath -
Start with open-ended patient-centric questions. e
® Asked X Not asked 2 Pain radiating down left arm -
y
Graded Approach Question Response oInformation Obtained * Nausea _
It's my heart.... was having really bad
® CCSx Howcan! help youtoday? chest pain. Its bit better, but stil 2 Sweating -
hurts.
Yes. I've had chest pain before, but . Hx smoking -
nothing like this. | almost fee! lie |
X Assoc Sx | Do you feel anxious? might not make it. Am | just being ~ Pain with exercise -
silly and over reacting? Is it Serious v
this time?
2 Hx stent -
® AssocSx Doconcems
you have any other symptoms
we should discuss?
or | Just started feeling short of breath
strange ... | I'm lying down.
v
N2 Hx CAD -
OLD-CARTS for the HPI ~2 4 Anxious -
@ Asked X Not asked N
2 Diaphoretic -
Information
Graded Approach Question Response Obtained
Notes Clinic a1
2 Type your P key findings here... =
Was going uphill on cross country ski A Pale _
course. Done it many times .. in the v
® |onset What are the events surroundingthe | past. Couple of weeks ago, no
start of your chest pain? problem. Just a bit out of breath then 2 RRR possible ST -
Today ... a bit colder than before.
Entire course felt . more difficult A
£ B
Hypertension -
® Location Does the painelse?in your
someplace chestradiate
Where? yog jt aqiates to my left arm ~ B 150/88 _
Duration
What does the pain/discomfort in Pulse 120 -
your chest feel like? (squeezing,
® Characteristics | pressure, crushing, bumning, Squeezing
stabbing, aching, tingling,
suffocating, tingling)
Aggravating
Relieving
Timing/Treatments
® severiy How severe (1-10 scale) is the pain Now i's an 8. On the mountain felt
in your chest? like 2 12. (weak smile)
HPI
PMH, FH, SH as Needed
® Asked X Not asked
Graded Approach Question Response Information
o Obtained
X | PMH Any new or recent change in No.
medications?
, PMH, FH, SH as Needed
® Asked X Not asked
Graded Approach Question Response Information Obtained
" Clinic Notes
. Any new or recent change in No.
medications?
PMH Do you have any allergies? Not that | know o
Yes. Listin my wallet. (Doctor gets
list: Metoprolol 25 mg extended-
Are you taking any prescription release daily, Hydrochlorothiazide
X PUH medications? 12.5 mg daiy, Atorvastatin 80 mg
daily, Aspirin 81mg daily, clopidogrel
bisulfate 75 mg daiy)
Review of Systems (ROS)
Select the major body systems that have not been touched on during the interview process for the HPI
® Asked X Not asked
Graded Question Response Information
e Obtained Clinic
Have you noticed any bruising, bleeding
X gums, nose bleeds, or other sites of Nope.
increased bleeding?
Do you have problems with heat or cold
intolerance, increased thirst, increased
X | sweating, frequent urination, o change in
appeite?
Do you have problems with dizziness,
o fanting, spinning room, seizures,
weakness, numbness, tingling, or
tremor?
Do you have any problems with an itchy
X scalp, skin changes, moles, thinning hair, Nope.
or britte nails?
Do you have any problems with
nervousness, depression, lack of
@ interest, sadness, memory loss, or mood Nope.
changes, or ever hear voices or see
things that you know are not there?
When you urinate, have you noticed any
pain, burning, blood, dificuty starting or
X stopping, dribbling, incontinence, urgency No.
during day or night, or any changes in
frequency?
Do you have any problems with
headaches that don't go away with
aspirin or Tylenol (acetaminophen),
@ double or blurred vision, difficulty with Nope.
night vision, problems hearing, ear pain,
sinus problems, chronic sore throats, or
difficulty swallowing?
Have you noticed any breast discharge,
X lumps, scaly nipples, pain, sweling, or No.
redness?
Do you have problems with nausea,
vomiting, constipation, diarrhea, coffee Yes, I'm a bit nauseated now... just
@ grounds in your vomit, dark tarry stool, started.
bright red blood in your bowel
movements, early satiety, or bloating?
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