lOMoARcPSD|64126434
Wi
lliam Fredericks
42 y/o male
, lOMoARcPSD|64126434
6’0’’ (183 cm)
215.0 lbs (97.7kg)
Reason for encounter: worsening headaches and facial pain, fever
Hx:
Hx of present illness:
OLDCARTS mnemonic
Onset:
Location:
Duration:
Characteristics:
Aggregating:
Relieving
Treatment
Severity
PMH:
HTN: 6 YEARS, Hypercholesterolemia x 6 years psoriasis since childhood
Sx hx: appendectomy at 29 y/o hospitalization appendectomy
Medications: Hctz 25 mg po DAILy
Multivitamin daily OTC as needed
Tylenol ES Tylenol cold and flu advil naproxen
Allergies: grass, trees. Seasonal pollen, dust & mold with symptoms of itchy watery eyes, scleral
injections, sneezing, runny nose, nasal congestion
Preventative health:
Fitness, no exercise routine except for activey on job nutrition: typeical American diet high in meats and
carbs,
Stress reduction: nothing works 50+ hours a week
Daily sleep 6-7 hrs with additional on weekends
Previous ½ pack x 20 years, quit 4 years ago, no relapse alcohol intake 1-3 beers during the weeks, 2-4
beers, weekend no recent fecal occult blood sample or prostate exam
Childhood immunization: up to date does not receive seasonal flu shot or adult vaccination S
, lOMoARcPSD|64126434
Prior visit documented- update allergies, medications, OTC drugs.
Family Hx: father 71/yo obese, CAD mother 69 y/o obeses, hx of DM maternal GM. Hx DM; deceased 72,
sepsis r/t LE amputation maternal GF: hx CV dz, decreased age 78 MI paternal GM; no PMH, decrased 82
. MI paternal GF: hx HTN, decease age 80, MI brother 47 y/o DM sister 39 y/o HTN
Social Hx:
Married wife 37 y/o HTNN child; son 11 y/o and daughter 16 y/o both health tobacco ½ pack per day x
20 years quit 4 years ago without relapse
ETOH 1-3 during the week; 2-4 on weekends drug use: non currently; experiment with marijuana in HS
and early adulthood
Review of Symptoms:
Questions for system not addressed in HPI
Choose ROS for those body system you do not have info on. Use large multipart question
Exercises:
- Complete any clinical exercise found that follow various case play sections
- When you’ve completed the exercises and clicked proceed, you will be taken to the next .
Current Visit:
1. How can I help you today? – good question
I am here because I feel really sick and am not getting better. I have this HA which started about 2 weeks
ago. I was just getting over a cold at that time. Over the last 2 weeks my headache got worse and more
of my heart hurt. It now hurts to move my eyes.
2. What other symptoms or concerns we should discuss?
yes, maybe 3 or 5? Days ago my runny nose, which had resolved, has restarted and changed from clear
to creamy. Then over the last day or two I started having low grade fever- around 99.5 to 100 F. I also
have this strange tooth pain/sensitivity and ear pain. I feel like I am falling apart. Its one thing after
another. What a wreck I am!
When did HA start?
- I guess about 14 or more days ago
Is this the worst HA of your life?
Not really. I got hit in the head during little league practice when I was a child. That was the worse HA I
ever had
Does the HA awaken you from sleep?
- No
Dose HA keep you from sleeping?
Wi
lliam Fredericks
42 y/o male
, lOMoARcPSD|64126434
6’0’’ (183 cm)
215.0 lbs (97.7kg)
Reason for encounter: worsening headaches and facial pain, fever
Hx:
Hx of present illness:
OLDCARTS mnemonic
Onset:
Location:
Duration:
Characteristics:
Aggregating:
Relieving
Treatment
Severity
PMH:
HTN: 6 YEARS, Hypercholesterolemia x 6 years psoriasis since childhood
Sx hx: appendectomy at 29 y/o hospitalization appendectomy
Medications: Hctz 25 mg po DAILy
Multivitamin daily OTC as needed
Tylenol ES Tylenol cold and flu advil naproxen
Allergies: grass, trees. Seasonal pollen, dust & mold with symptoms of itchy watery eyes, scleral
injections, sneezing, runny nose, nasal congestion
Preventative health:
Fitness, no exercise routine except for activey on job nutrition: typeical American diet high in meats and
carbs,
Stress reduction: nothing works 50+ hours a week
Daily sleep 6-7 hrs with additional on weekends
Previous ½ pack x 20 years, quit 4 years ago, no relapse alcohol intake 1-3 beers during the weeks, 2-4
beers, weekend no recent fecal occult blood sample or prostate exam
Childhood immunization: up to date does not receive seasonal flu shot or adult vaccination S
, lOMoARcPSD|64126434
Prior visit documented- update allergies, medications, OTC drugs.
Family Hx: father 71/yo obese, CAD mother 69 y/o obeses, hx of DM maternal GM. Hx DM; deceased 72,
sepsis r/t LE amputation maternal GF: hx CV dz, decreased age 78 MI paternal GM; no PMH, decrased 82
. MI paternal GF: hx HTN, decease age 80, MI brother 47 y/o DM sister 39 y/o HTN
Social Hx:
Married wife 37 y/o HTNN child; son 11 y/o and daughter 16 y/o both health tobacco ½ pack per day x
20 years quit 4 years ago without relapse
ETOH 1-3 during the week; 2-4 on weekends drug use: non currently; experiment with marijuana in HS
and early adulthood
Review of Symptoms:
Questions for system not addressed in HPI
Choose ROS for those body system you do not have info on. Use large multipart question
Exercises:
- Complete any clinical exercise found that follow various case play sections
- When you’ve completed the exercises and clicked proceed, you will be taken to the next .
Current Visit:
1. How can I help you today? – good question
I am here because I feel really sick and am not getting better. I have this HA which started about 2 weeks
ago. I was just getting over a cold at that time. Over the last 2 weeks my headache got worse and more
of my heart hurt. It now hurts to move my eyes.
2. What other symptoms or concerns we should discuss?
yes, maybe 3 or 5? Days ago my runny nose, which had resolved, has restarted and changed from clear
to creamy. Then over the last day or two I started having low grade fever- around 99.5 to 100 F. I also
have this strange tooth pain/sensitivity and ear pain. I feel like I am falling apart. Its one thing after
another. What a wreck I am!
When did HA start?
- I guess about 14 or more days ago
Is this the worst HA of your life?
Not really. I got hit in the head during little league practice when I was a child. That was the worse HA I
ever had
Does the HA awaken you from sleep?
- No
Dose HA keep you from sleeping?
