Patient, Family, or Population Health Problem Solution, Cheat Sheet of Research Methodology

Download Patient, Family, or Population Health Problem Solution and more Cheat Sheet Research Methodology in PDF only on Docsity! History Feedback Below you will see the strategy for selecting the "required" questions in this patient encounter using the OLD-CARTS mnemonic for the HPI. Reason for Encounter Start with open-ended patient-centric questions. @ Asked X Not asked Information Obtained Graded Approach Question Response Clinic Notes @ Orientation What is your name? Emily Green e Orientation Where are you? In the doctor's office. td Orientation What time is it? oriented to time when asked. XX Orientation What happened? Ihave a headache that just won't go away. I've had this really bad headache @ CCS — Howcan! help you today? since yesterday morning and it hasn't gotten any better. ES X Assoc Sx Is there any stiffness in yourneck? Not really. X Assoc Sx Have you had any seizures? Never in my life, as far as | know. Not that anyone has ever told mo @ Assoc Sx Do you have high blood pressure? about ~ neither on or off the birth- control pill. Meaning, like, when | have a headache? No, nothing like that. No...I haven't been sick, just stressed. X Assoc Sx Do you feel confused at times? @ = = Assoc Sx Have you been having fevers? Do you have any other symptoms or @ = A8800 Sx Concerns we should discuss? Yeah, | also feel a bit nauseated. Yes. That comes with my @ Assoc Sx Do you have any sensitivity to light? headaches. | just want to be ina dark room, Assoc Sx Do you feel a lack of coordination? —_ Nothing like that. No, but | would have told you first thing if | did! Everyone knows about the signs of a stroke. X Asoo Sx D2 YOU have new weakness in an arm, leg or your face? I'm trying to get a good job for the summer and | need to get this paper written — the grade will be a huge a —=—=—=—=B“miyngcgcacc. ore | Have you had any more stress in your life lately? Etiology Have you had any trauma to your OLD-CARTS for the HP! @ Asked X Not asked Graded Approach Question When did your nausea and/or ie [Ores vomiting start? ee lorca What are the events surrounding the start of your headache? - Where more precisely is the pain in summer and | need to get this paper writtan ~ 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 dnsonlalothtnamnmenndanndneiststatt Characteristics night do you sleap? © Charactriics Does the Veet awaken you @ = Characteristics Doos your headache come and go? © | crore | elie bron gr angen © [characteristics [HOW aunty doss yourhasdache B® \cheenxsiaise Dossy footiz aoa to bring the eo | charscwnsscs Drow ar headache keep you from (On average, how many hours per 1am 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. No, this one started when | was awake. I've never had one that has woken me up. Is that what you're asking? Once it starts it lasts quite a while, usually lasting more than a day. I think it's happening more often. It always starts gradually but then gets progressively worse. Sometimes | get headaches after drinking red wine. No. | can usually fall asleep if | can find a dark, quiet room. Some of my friends say they can . a alae ail a e@ SH you drink and haw many drinks per nights. Sometimes wine, sometimes day? a bar drink. | work out about once a week for 30 se: hoe Tell me about daily exercise or minutes on the elliptical. | used to sports that you play, exercise more, but | don't have the time. 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 Information Obtained Clinic Graded Question Response NGEE Have you noticed any bruising, bleeding 5 ost @ cums, nose bleeds, or other sites of eee sounds bad. .Don' fave, increased bleeding? Do you have problems with heat ar cold @ __ iMtolerance, increased thirst, increased sweating, frequent urination, or change in appetite? Nope. Do you have problems with dizziness, ~faintina, spinning room. seizures. Lhaven't passed out or felt ike dizzy or Do you have any problems with nervousness, depression, lack of @ interest, sadness, memory loss, or Nope mood changes, or ever hear voices or see things that you know are not there? Just that college weight gain from eating junk food and not exercising enough. | wish | had more time for some sleep. Do you have any problems with fatigue, @ difficulty sleeping, unintentional weight loss or gain, fevers, or night sweats? Do you experience chest pain discomfort or pressure; pain/pressure @ dizziness with exertion or getting angry; Nope palpitations; decreased exercise tolerance; or blue/cold fingers and toes? Do you experience shortness of breath, @ wheezing, dificulty catching your breath, chronic cough, or sputum production? Do you have problems with nausea, vomiting, constipation, diarrhea, coffee @ grounds in your vomit, dark tarry stool, bright red blood in your bowel movements. early satiety, or bloating? Oh my gosh that's a long list. No bleeding from any end. bu yuu Have provienns will nausea, vomiting, constipation, diarrhea, coffee e grounds in your vomit, dark tarry stool, bright red blood in your bowel movements, early satiety, or bloating? Oh my gosh that's a long list. No bleeding from any end. Do you have problems with muscle or joint pain, redness, swelling, muscle @ cramps, joint stiffness, jaint swelling or Nope. redness, back pain, neck or shoulder pain, or hip pain?  Key Finding Unilateral, throbbing headache of two days' duration; gradual in onset Nausea Photophobia Phonophobia Recent increase in stress and decrease in sleep Disrupted eating habits One similar episode (within the last one year) preceded by “missing vision" and visual "flashes" Ongoing use of oral contraceptive Weight gain Case Problem Statement MSAP Relation MSAP RELATED RELATED RELATED RELATED RELATED RELATED UNKNOWN UNKNOWN The patient is a 22-year-old college student who presents with the complaint of a left-temporal headache that progressed over 30 hours to a throbbing (8/10) headache involving her entire head. She describes associated symptoms of photophobia, phonophobia, and nausea. Acetaminophen and rest had no effect which is different from her typical headaches. PMH is significant for a history of similar headaches over an unspecified number of years; a "scary" one last summer presented with “missing vision" and visual "flashes" lasting for 20 minutes, followed by a headache similar to her current one. Her headaches like this now occur every 4-6 weeks. Recent stressors include: academic, relationship break-up, and poor sleep and eating patterns. FH is significant for sister and mother with similar headaches. Meds include BCP.