History Feedback
Below you will see the strategy for selecting the "required" questions in this patient encounter using the OLD-CARTS
mnemonic for the
... [Show More] HPI.
Reason for Encounter
Start with open-ended patient-centric questions.
® Asked X Not asked
Graded Approach Question
Orientation
Orientation
Orientation
Orientation
CC Sx
Assoc Sx
Assoc Sx
Assoc Sx
Assoc Sx
Assoc Sx
Assoc Sx
Assoc Sx
What is your name?
Where are you?
What time is it?
What happened?
How can | help you today?
Is there any stiffness in your neck?
Have you had any seizures?
Do you have high blood pressure?
Do you feel confused at times?
Have you been having fevers?
Do you have any other symptoms
or concerns we should discuss?
Do you have any sensitivity to light?
Response
Jessica A Walbertz
In the doctor's office.
..oriented to time when asked..
| have a headache that just won't
go away.
I've had this really bad headache
since yesterday morning and it
hasn't gotten any better.
Not really.
Never in my life, as far as | know.
Not that anyone has ever told me
about -- neither on or off the birthcontrol pill.
Meaning, like, when | have a
headache? No, nothing like that.
No...| haven't been sick, just
stressed.
Yeah, | also feel a bit nauseated.
Yes. That comes with my
headaches. | just want to be in a
dark room.
Information Obtained
Clinic Notes
[} Assoc Sx Do you feel a lack of coordination?
Do you have new weakness in an
i Assoc Sx arm, leg or your face?
. Have you had any more stress in
° Etiology your life lately?
° Etiology Have you had any trauma to your
head?
OLD-CARTS for the HPI
@ Asked X Not asked
Graded Approach Question
When did your nausea and/or
d Onset vomiting start?
What are the events surrounding
hd Onset the start of your headache?
. Where more precisely is the pain in [ J Location your head?
Duration
- Have you had a headache like this @® Characteristics before?
° Characteristics On average, how many hours per
night do you sleep?
Nothing like that.
No, but | would have told you first
thing if | did! Everyone knows about
the signs of a stroke.
I'm trying to get a good job for the
summer and | need to get this
paper written -- the grade will be a
huge percentage of my final grade
in the course. And my boyfriend just
broke up with me. And I've gained a
bunch of weight because | don't
have any time to exercise or eat
right. You bet I'm stressed.
Nope. No accidents.
Information
Obtained Clinic
Notes
Response
The nausea came on as my
headache got worse.
No real event, | was working on a
really important term paper.
It started off here (points to left
temple) but then spread so now my
whole head hurts.
Yes. Similar, but this one is worse
than any of my previous ones.
| am currently getting five to six
hours of sleep each night, but it
varies depending on how much
work | have to do. Lately | have
been working pretty hard on this
paper and have been getting only
about four hours each night. [Show Less]