Question Preview:
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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Question Preview:
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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