Old Carts and ROS Flashcards
“O”ld carts
Onset: setting in which the symptoms started. What were you doing when this started? acute or gradual? stress environmental factor or activity brought it on?
o”L”d carts
Location: where is it occurring? can you point with one finger? is it generalized does it RADIATE anywhere?
ol”D” carts
Duration: does it wax or wane? constant or remitting? when it happens, how long does it last? How much time in between each episode? how frequent does it happen?
old c”A”rts
Associated manifestations: have you noticed any other symptoms with it? does anything else bother you? ex: RASH–> fever, pruritis, chills, joint pain?
old “C”arts
Characteristics: describe the pain, is it sharp, dull achy, electric burning, pressure, shooting? Is it shortness of breath, dizziness? Does it feel like u cant catch your breath?
old ca”R”ts
Relieving/ exacerbating factors: Does anything make it better? what makes it worse?
old car”T”s
Timing: when did it start? be specific. how long has it been going on for? when did it start?
old cart”S”
Severity: on a scale of 1-10 (pain). how much is it affecting your quality of life and ADLs
General
pt denies fever, chills, fatigue, malaise, weight change, sleep changes or night sweats
Skin
pt denies rash, pruritis, pigementation changes, dryness, skin lesions, changes in Quality of hair, texture. Changes in nail growth or thickness, nail pitting, or nail discoloration. or Hx of skin cancer
Neuro
pt denies pt denies headache, migraines, seizures, vertigo (sense of spinning), lightheadedness, syncope/presyncope/loss of consciousness, memory problems, stroke hx, weakness, paralysis, paresthesia (numbness & tingling), involuntary movements, tics, loss of hot or cold sensations, loss of coordination, skull fracture/head injuries, focal weakness, focal sensory change, gait problems, recent falls history of seizures, CVA,
vertigo: perception that the patient/environment is rotating or spinning
Head
pt denies head trauma or shape abnormalities
ears
pt denies hearing loss, hearing aids, changes in hearing, tinnitus, vertigo, dizziness, ear pain, frequent ear infections, discharge
eyes
pt denies eye pain, erythema, changes in vision, photophobia, flashes, floaters, decreased vision, blindness, vision field deficits, diplopia, color blindness, water or discharge, glaucoma, cataracts or use of corrective lenses
nose
pt denies change in sense of smell, frequent colds or sinus infections, nasal congestion, rhinorrhea, postnasal drip, allergies, hay fever, epistaxis, or sneezing
neck
the pt denies pain, stiffness, lumps, lymphadenopathy or thyromegaly
breasts and lymphatics
pt denies changes in skin, dimpling, pain, nipple discharge, lumps, enlarged LNs or LN tenderness
Pulmonary
pulmonary: pt denies SOB (dyspnea @ rest or with exertion), pain with breath (pleuritic chest pain), wheezing, cough (ask: productive, color, amount, hemoptysis), hemoptysis (blood in sputum), sputum production, chest pain or tightness, TB exposure, or recent lower respiratory infection, hx of asthma, emphysema, bronchitis or COPD
Cardiac
pt denies hx of CAD, heart murmur, HTN, Dyslipidemia, chest pain, pleuritic CP, palpitations, orthopnea, PND, edema
Periph vascular dz
pt denies hx of thrombophlebitis or ulcers, DVTs, coldness, numbness, tingling, LE edema, discoloration of hand and feet, varicose veins or intermittent claudication
GI
pt denies abdominal pain, N/V/D, Dysphagia (trouble swallowing) appetite changes/food intolerance, hemorrhoids, heartburn, bloating, belching, flatulence, constipation, changes in bowel habits, blood in stool or melena (Black tarry stool), hematemesis, hernia hx of peptic ulcer disease or gallbladder dz,
GU
pt denies hx of UTI, kidney stones, or stones, dysuria, urgency, oliguria, increased frequency, polyuria, blood in the urine, hesitancy, straining, incontinence, pain in the flank, suprapubic pain, pain in the groins, hernias, dyspareunia, bleeding with intercourse, spotting in bt periods, heavy menses, vaginal discharge or vaginal odor, hernia
Musculoskeletal
pt denies hx of gout, back or neck pain, myalgias, arthralgias, stiffness, swelling, weakness, bone deformities, injury, gait issues, problems with coordination, or joint swelling, warmth or redness
Psychiatric
pt denies nervousness, tension, anxiety, mood changes, problems with memory or sleep or concentration, no overwhelming sadness, depression, suicidal ideations, suicidal plans or attempts, hallucinations, or alcohol or drug substance disorders.
Hematologic
pt denies hx of bleeding disorders, easy bruising, petechiae, purpura, ecchymycosis, blood transfusions
endocrine
pt reports no thyroid issues, heat/cold intolerance, excessive sweating, excessive thirst or hunger, polyuria, or changes in glove or shoe size
Throat
Any hoarseness or voice changes, dry mouth, pain or trouble swallowing (dysphagia), teeth or gum issues, dentures. Hx of sinus infections?
PBI: PMH
Do you have any significant past medical issues? Current diagnoses? Chronic conditions?
PBI: past surgery hx
only if related to CC
PBI: Allergies
always ask if they have any allergies- describe rxn
PBI: Medications
Always ask, dose, route, frequency, reason
PBI: Family history
only include if related to CC
PBI: Social Hx
Always ask:
alcohol- how often do you drink? what kind of alc do you drink?
Tobacco- any tobacco use? what kind/type? how often? how long have you been smoking? Did you ever smoke?
Recreational drugs- any illicit or rx drugs? marijuana? are you taking meds more frequently than normally should?
PBI: Psych hx
always ask. Any problems with emotional or mental health? if yes, have you ever seen a doctor or counselor for that?
Over the past few weeks have you felt down, depressed or hopeless?
Have you felt little interest or pleasure in doing things?
Have you Ever have thoughts about hurting yourself or ending your life?
PBI: Immunizations
always include! including FLu
