What brought you here
today…(eg. headache)
Patient states that she is here for a physical exam as she is starting a new
job.
History
of
Pre
s
e
nt
Illn
e
s
s
Chronological order of events, state of health b
...
What brought you here
today…(eg. headache)
Patient states that she is here for a physical exam as she is starting a new
job.
History
of
Pre
s
e
nt
Illn
e
s
s
Chronological order of events, state of health before onset of CC, must include OLDCARTS in
paragraph form
Onset Patient presented for a pre-employment physical for insurance purposes.
She is starting a new job as an accounting clerk for Smith, Stewart, Silver,
and Company. She states that she feels “all of my health stuff is better now.
I feel like my diabetes is in control, I’m in better shape, I’m eating
healthier. I’m less stressed. Things are going really well.” She reports that
she last saw her primary care physician 5 months ago and was started on
Metformin for her diabetes. She states that when she quit taking Metformin
before it made her feel sick and gassy, now she eats yogurt and it seems to
help. She has since lost 10 pounds by eating better, she is active in a blog
for diabetics where she finds new recipes to try. She is exercising, walking
30-40 minutes 4-5 times a week and goes swimming at the Y once a week
also. Since her last visit she has been to the eye doctor and was prescribed
glasses which she wears. She has also visited a dentist five months ago, and
no cavities or problems were found at that visit. She has also visited an
OBGYN and was diagnoses with PCOS for which she was started on YAZ,
4 months ago. Her cramps have been much less since starting the birth
control and her menstrual cycles are regular coming every 4 weeks and
lasting 5 days. She visited an eye doctor 3 months ago and received glasses
for her near-sightedness. Her headaches have been fewer and she has not
had one for 6 months. She no longer has back pain, since she hurt her back
and was seen in our clinic, she went to physical therapy and completed their
recommended stretches and exercises. The sore that she had on her foot
has healed and she has no recurrent problems from that. She was also
started on Flovent daily and since starting that medication she has
experienced a reduction in her asthma symptoms. She has only had to use
her rescue inhaler once in the last three months when she visited a friend
who had a cat that she is allergic to. She no longer has a problem with her
asthma when climbing stairs. She no longer has sleeping problems that
were associated with her stress. She has not had any heart palpitations
since she stopped drinking energy drinks and excessive caffeine. She is
much happier and looking forward to her new job, new apartment, and new
relationships.
Location
Duration
Character
Aggravating/associate
d factors
Relieving factors
Temporal factors –
other things going on
Severity
P
a
st
M
e
dic
al
History
Adult Illnesses,
childhood illnesses,
immunizations,
surgeries, allergies,
current medications
Adult Illnesses: PCOS, Diabetes Mellitus II, Near-sightedness, Asthma
(diagnosed at age of 2 ½), Gerd
Childhood Illnesses: Chicken pox
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