Old Carts and ROS

Question 1

“O”ld carts

Answer 1

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?

Question 2

o”L”d carts

Answer 2

Location: where is it occurring? can you point with one finger? is it generalized does it RADIATE anywhere?

Question 3

ol”D” carts

Answer 3

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?

Question 4

old c”A”rts

Answer 4

Associated manifestations: have you noticed any other symptoms with it? does anything else bother you? ex: RASH–> fever, pruritis, chills, joint pain?

Question 5

old “C”arts

Answer 5

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?

Question 6

old ca”R”ts

Answer 6

Relieving/ exacerbating factors: Does anything make it better? what makes it worse?

Question 7

old car”T”s

Answer 7

Timing: when did it start? be specific. how long has it been going on for? when did it start?

Question 8

old cart”S”

Answer 8

Severity: on a scale of 1-10 (pain). how much is it affecting your quality of life and ADLs

Question 9

General

Answer 9

pt denies fever, chills, fatigue, malaise, weight change, sleep changes or night sweats

Question 10

Skin

Answer 10

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

Question 11

Neuro

Answer 11

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

Question 12

Head

Answer 12

pt denies head trauma or shape abnormalities

Question 13

ears

Answer 13

pt denies hearing loss, hearing aids, changes in hearing, tinnitus, vertigo, dizziness, ear pain, frequent ear infections, discharge

Question 14

eyes

Answer 14

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

Question 15

nose

Answer 15

pt denies change in sense of smell, frequent colds or sinus infections, nasal congestion, rhinorrhea, postnasal drip, allergies, hay fever, epistaxis, or sneezing

Question 16

neck

Answer 16

the pt denies pain, stiffness, lumps, lymphadenopathy or thyromegaly

Question 17

breasts and lymphatics

Answer 17

pt denies changes in skin, dimpling, pain, nipple discharge, lumps, enlarged LNs or LN tenderness

Question 18

Pulmonary

Answer 18

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

Question 19

Cardiac

Answer 19

pt denies hx of CAD, heart murmur, HTN, Dyslipidemia, chest pain, pleuritic CP, palpitations, orthopnea, PND, edema

Question 20

Periph vascular dz

Answer 20

pt denies hx of thrombophlebitis or ulcers, DVTs, coldness, numbness, tingling, LE edema, discoloration of hand and feet, varicose veins or intermittent claudication

Question 21

GI

Answer 21

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,

Question 22

GU

Answer 22

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

Question 23

Musculoskeletal

Answer 23

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

Question 24

Psychiatric

Answer 24

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.

Question 25

Hematologic

Answer 25

pt denies hx of bleeding disorders, easy bruising, petechiae, purpura, ecchymycosis, blood transfusions

Question 26

endocrine

Answer 26

pt reports no thyroid issues, heat/cold intolerance, excessive sweating, excessive thirst or hunger, polyuria, or changes in glove or shoe size

Question 27

Throat

Answer 27

Any hoarseness or voice changes, dry mouth, pain or trouble swallowing (dysphagia), teeth or gum issues, dentures. Hx of sinus infections?

Question 28

PBI: PMH

Answer 28

Do you have any significant past medical issues? Current diagnoses? Chronic conditions?

Question 29

PBI: past surgery hx

Answer 29

only if related to CC

Question 30

PBI: Allergies

Answer 30

always ask if they have any allergies- describe rxn

Question 31

PBI: Medications

Answer 31

Always ask, dose, route, frequency, reason

Question 32

PBI: Family history

Answer 32

only include if related to CC

Question 33

PBI: Social Hx

Answer 33

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?

Question 34

PBI: Psych hx

Answer 34

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?

Question 35

PBI: Immunizations

Answer 35

always include! including FLu