or this weeks assignment, you are going to find a patient with an acute CC. Complete a History and Physical (H&P) on a patient with an acute complaint. 3. Pick one of the acute chief complaints (CC) below. Unintentional weight loss 4. Document subjective data: (Include Identifying data – age, gender) Chief complaint (CC) – must be in patients own words – use quotation marks History of Present Illness (HPI) – Include a symptom analysis for CC using the OLDCART acronym. List the HPI using each term of OLCART for practice and clarity as follows: Onset: Location: Duration: Characteristics: Aggravating factors: Relieving factors: Treatments: Past Medical History (include date of diagnosis) Past Surgical History (include year of surgery and any complication) Family History (FH): Include only the FH that would contribute to the development of the differential diagnoses for the CC. Social History (SH): Include only those components that will contribute to the development of the differential diagnoses for the CC. Be sure to include employment, type of dwelling and whom patient lives with. Medications, OTC, supplements Allergies (medications, food, other) and reaction Review of Systems (ROS): Include systems related to CC as well as constitutional ie nausea, vomiting, diarrhea, weight loss, weight gain. Follow ROS template provided. The ROS is NOT the same as PE. Use term denies or patient states… for negative or positive responses to questions, respectively. If there are positive findings in any system, you must inquire using OLDCART and document accordingly. Explanatory Model: Use BATHE Technique 5. Document objective data to include: Vital signs: General Survey: PE: Examine only those organ systems that are pertinent to the CC but always assess respiratory and cardiac systems on all patients. The PE is not the same as ROS; is a hands-on head to toe assessment performed by the provider. You will not be performing a genitourinary examination for this assignment. Use textbook – follow proper written documentation verbiage. Use the IPPA (Inspection, Percussion, Palpation, Auscultation) and document your findings as a chart worthy document. 6. Pick one possible diagnosis. 7. Identify one diagnostic study (lab, x-ray or maneuver) that will help to confirm the diagnosis you have chosen. Cite and reference your work using a clinical guideline, peer reviewed article, textbook, or other reputable source as evidence from the literature. Look for the gold standard diagnostic study to confirm the diagnosis.
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