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Critical Analysis-Health Issues

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Subjective&Data • Patient!demographic: name!(use!initials!or!pseudonym) age sex reliable!historian? • Chief!complaint (Brief!description) • History!of!present!illness (“OLD!CARTS”!onset,!location,!duration,!character,! aggravating/associated!factors,!relieving!factors,!temporal!factors,!severity!of!symptoms).!! Include!pertinent!negatives. • Past!medical!history: 1.! General!health!and!strength 2.! Childhood!illnesses 3.! Major!adult!illnesses/diagnosis 4.! Immunisations • Past!surgical!history 1. Transfusions • Current!medicat...

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Subjective&Data • Patient!demographic: name!(use!initials!or!pseudonym) age sex reliable!historian? • Chief!complaint (Brief!description) • History!of!present!illness (“OLD!CARTS”!onset,!location,!duration,!character,! aggravating/associated!factors,!relieving!factors,!temporal!factors,!severity!of!symptoms).!! Include!pertinent!negatives. • Past!medical!history: 1.! General!health!and!strength 2.! Childhood!illnesses 3.! Major!adult!illnesses/diagnosis 4.! Immunisations • Past!surgical!history 1. Transfusions • Current!medications • Allergies • Family!history!(genogram).!! • Social!history 1.! Personal!status!(may!include:!birthplace,!where!raised,!home!environment,!education,!,! general!life!satisfaction,!hobbies,!sources!of!stress U as!appropriate). 2.! Habits:!(nutrition!and!diet,!regularity!of!eating!and!sleeping habits,!exercise,!alcohol use,!coffee,!tea,!tobacco;!illicit!drugs;!breast!or testicular!selfUexam) 3.! Sexual!hx 4.! Home!conditions 5.! Occupation!(description!of!work;!exposure!to!occupational!hazards/risks – as! appropriate). 6.! Religious!preference 7.! Financial!concerns (family) • Review!of!systems (this!is!a!list!of!current complaints!not!related!to!history!of!present!illness,! not!medical!history!or!diagnosis). 1.! General!constitutional!symptoms 2.! Appetite,!weight!loss 3.! Skin,!hair,!nails 4.! Musculoskeletal;!pain,!functional!changes,!falls 5.! Head!and!neck: 5.1! Eyes;!visual!changes!etc 5.2! Ears 5.3! Nose 5.4! Throat!and!mouth;!dysphagia,!difficulty!chewing!etc 6. Endocrine!(heat!or!cold!intolerance,!weight!changes,!hx!diabetes,!polydypsia,!polyuria,! changes!in!facial!or!body!hair,!skin!striae) 7. Chest!and!lungs;!SOB,!cough!etc. 8. Heart!and!blood!vessels;!angina,!chest!pain 9. Hematologic;!easy!bruising,!bleeding 10. Lymph!nodes 11. Gastrointestinal;!appetite,!bowel!functions,!dyspepsia 12. GenitoUurinary;!urgency,!frequency,!nocturia 13. Neurologic;!headaches,!dizziness,!syncope!memory!etc. 14. Psychiatric;!depression,!anxiety!etc. • Concluding!questions:!(Is!there!anything!else!that!you!think!is!important!for!me!to!know?!! What!concerns!you!the!most?!!What!do!you!think!is!the!matter?) • Physical!exam 1. Head!to!toe,!organised!by!systems 2. Accurate!terminology!and!abbreviations 3. Accurate!description!of!abnormal!findings • Assessment 1. List!all!health!problems!in!order!of!priority.!!Include!if!problem!is!new!onset,!controlled,! or!resolved. • Plan 1. DX!– justify!tests,!evidence!based,!costs,!pt.!comfort 2. RX!– Medications!– why 3. Education 4. FollowUup!plan

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Chief complaint: Kaira experiences difficulty in breathing. She experienced several coughing, wheezing and breathlessness episodes during previous days and began to cough while playing with her friends. Furthermore, the attack was so severe that she coughed even more when she cried. The young girls’ chest retracted severely on inspiration. Her mother informs that she has had an upper respiratory tract infection (URI). These recurrent attacks of breathlessness and wheezing vary in severity in different episodes

•Past medical history 
 General health and strength
 Childhood illnesses: Kaira has no history of childhood illness
 Major adult illnesses  / diagnosis
 Immunisations: She has completed all her childhood immunizations
 

 

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