Instructions:
- Indicate key symptoms (Sx) you have identified from the history. Start with the patient’s reason(s) for the encounter and add additional symptoms obtained from further questioning.
- Characterize the attributes of each symptom using “OLDCARTS”. Capture the details in the appropriate column and row.
- Review your findings and consider possible diagnoses that may correlate with these symptoms. (Remember to consider the patient’s age and risk factors.) Use your ideas to help guide your physical examination in the next section of the case.
HPI Symptoms:
- Abdominal Pain
- Onset: 6-8 months ago, usually happens an hour after eating
- Location: Epigastric, sometimes radiates to the back
- Duration: Ongoing, pain comes and goes
- Characteristics: Awakens him at night, feels like burning, occasionally stabbing
- Aggravating: More often after he drinks beer
- Relieving: TUMS, not eating, not drinking beer
- Timing/Treatments: Antacids used to help the pain but lately are not working as well
- Severity: Severe
- Weight Loss
- Onset: Past few months
- Location: Generalized
- Duration: Ongoing
- Characteristics: Poor appetite, does not feel like eating much
- Aggravating: Unknown
- Relieving: Unknown
- Timing/Treatments: Unknown
- Severity: Mild, concerning
- Heartburn
- Onset: Unknown
- Location: Chest, epigastric
- Duration: Ongoing, chronic
- Characteristics: “Worse than usual”
- Aggravating: Unknown
- Relieving: TUMS
- Timing/Treatments: Antacids
- Severity: Moderate
- Black Stools
- Onset: Twice in 3 weeks
- Location: Stool
- Duration: Ongoing, chronic
- Characteristics: Black tarry stool, “stinky”
- Aggravating: Unknown
- Relieving: Unknown
- Timing/Treatments: Unknown
- Severity: Bothering