HISTORY:
• Patient interview reminder sheet- document in key findings
• “Good Question” means you asked a required question
Step 1: Start by
... [Show More] asking 2 open ended patient centric questions:
1. How can I help you today?
2. Any other symptoms or concerns?
Step 2: Obtain an HPI using “OLDCARTS”
• = Onset, circumstances surrounding start of symptom
• L = Location, radiation
• D = Duration
• C = Characteristics (sharp, dull, cramping)
• A = Aggravating
• R = Relieving
• T = Treatments
• S = Severity Step 3: PMH
• No patient record – Obtain history
• Have patient record – Update allergies, medications, OTC drugs
Step 4: FH
• No patient record – Obtain history
Step 5: SH
• No patient record- obtain history
• Have patient record- Update if major changes in living situation, death of partner, loss of job etc.
Step 6: ROS
• Questions for systems not addressed in HPI
• Choose ROS for the body systems you do not have information on. Use the large multipart questions
Physical Exam
• Do those physical assessment maneuvers as needed
• Choose ROS for those body systems you do not have information on. Use large multipart questions.
Assessment
• Organize key findings list by selecting the MSAP (Most significant active problem).
• Mark other findings as; related, unrelated, unknown, PMH/resolved.
Problem Statement
• Short summary of patient’s presentation. Should contain: 1. Demographic description, 2. Chief complaint, 3. Hx and PE key findings, 4. Risk factors. Keep it concise.
Differential Diagnosis
• List disease you are considering Prior to ordering tests.
Tests:
• Determine what tests are needed to rule in or rule out each diagnosis on authors corrected list.
• Review authors corrected list of test results.
Final Diagnosis
• Select a final diagnosis or diagnoses.
Treatment plan
• Write a treatment plan following your instructors’ guidelines.
Gear head exercises
• Complete exercises found throughout the case (look for the brain with gears icon in steps of the case)
Summary
• Proceed all the way to the “Summary” tab.
• Submit your case and press the “see evaluation” button to see your first evaluation.
Ebony Gray
25 y/o 5’6 (168cm) 140.0 lb (63.6kg) A&Ox4
Vital Signs
Temp: 37.1 (98.7)
Pulse: 78 bpm, rhythm: regular, strength: normal
BP L/arm 110/72, R/arm 110/72, assessment: normal, pulse pressure: normal RR:14 bpm, rhythm: regular, effort: unlabored
SpO2: 94%
CC: 25 y/o desires contraception
Good Questions:
2 Open ended questions:
How can I help you today?
Any other symptoms or concerns? [Show Less]