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Write Ups The written History and Physical (H&P) Dr H.A.Soleimani MD. Gasteroentologist Write Ups Chief Complaint or Chief Concern (CC) History of Present Illness (HPI) Past Medical History (PMH) Past Surgical History (PSH) Medications (MEDS) Allergies/Reactions (All/RXNs) Social History (SH) Write Ups Family History (FH) Obstetrical History (where appropriate) Review of Systems (ROS) Physical Exam Lab Results, Radiologic Studies, EKG Interpretation, Etc. Problem list ASSESSMENT/PLAN Write Ups serves several purposes It is an important reference document a patient's history and exam findings at the time of admission. Write Ups serves several purposes This information should be presented in a logical fashion that prominently features all data immediately relevant to the patient's condition. Write Ups serves several purposes It allows students demonstrate their ability to accumulate historical and examination based information examination based information, make use of their medical fund of knowledge, and derive a logical plan of attack. Write Ups Knowing what to include and what to leave out will be largely dependent on experience and your understanding of illness and pathophysiology. Write Ups If you were unaware that chest pain is commonly associated with coronary artery disease, you would be unlikely to mention other coronary riskfactors when writing the history. Write Ups Until you gain experience, your write-ups will be somewhat poorly focused. Not to worry; this will change with time and exposure. Chief Complaint or Chief Concern (CC) One sentence that covers the dominant reason(s) for hospitalization.. why patient here-use patient's own words HISTORY OF PRESENT ILLNESS THIS IS THE DESCRIPTION OF THE PATIENT’S ILLNESS AS TOLD BY THE PATIENT, FAMILY, OLD CHART OR A COMBINATION OF THESE. History of Present Illness Physician asks questions to discussing the details of the chief complaint. History of Present Illness answers questions of .. When the problem began, what and where the symptoms are, what makes the symptoms worse or better. History of Present Illness Ask about the nature of the symptoms (for pain, is it sharp or dull, localized or generalized). History of Present Illness Things that the patient has done to improve the symptoms Are any associated symptoms. History of Present Illness Very brief… pain after hitting their finger with a hammer More detailed…. abdominal pain HISTORY OF PRESENT ILLNESS LIST THE EVENTS IN CHRONOLOGICAL ORDER Chronological description of the development of the patient's present illness from the first sign and/or symptom 0 Abdominal pain 10 Fever and chills 15 jaundice History of Present Illness (PAIN) Location Quality Severity Duration Timing Context Modifying factors Associated signs and symptoms. 55-yr-old Men With Chest Pain History of present illness LIQOR AAA L Location of the symptom (forehead, wrist...) I Intensity of the symptom (scale 1-10, 6/10) Q Quality of the symptom (burning, pulsating pain...) O Onset of the symptom + precipitating factors R Radiation of the symptom (to left shoulder and arm) A Associated symptom ( palpitations, shortness of breath) A Alleviating factors (sitting with my chest on my knees) A Aggravating factors (effort, smoking, large meals) 40-yr-old Women With Headache History of Present Illness History of Present Illness Headache How recent in onset? Abrupt onset? How frequent? Episodic or constant? How long lasting? Intensity of pain? Quality of pain? Site of pain? Radiation? Eye pain? Aura? Photophobia? Past Medical History (PMH) This should include any illness (past or present) for which the patient has received treatment. Past Medical History (PMH) Start by asking the patient if they have any medical problems. If you receive little/no response, the many questions can help uncover important past events Past Medical History (PMH) If you receive little/no response Have they ever received medical care? If so, what problems/issues were addressed? Was the care continuous or episodic? Past Medical History (PMH) Have they ever undergone any procedures, X-Rays, CAT scans, MRIs or other special testing? Ever been hospitalized? If so, for what? Past Medical History (PMH) Items which were noted in the HPI do not have to be restated. You may simply write "See above" in reference to these events. Past Medical History (PMH) All other historical information should be listed. Detailed descriptions are generally not required. Past Medical History (PMH) If the patient has hypertension, it is acceptable to simply write "HTN" without giving an in-depth report on the duration of this problem, medications used to treat it, etc. Past Medical History (PMH) Also, get in the habit of looking for the data that supports each diagnosis that the patient is purported to have (for COPD Pulmonary Function Tests). Past Surgical History (PSH) All past surgeries should be listed, along with the rough date when they occurred. Past Surgical History (PSH) Were they ever operated on, even as a child? What year did this occur? Were there any complications? If they don't know the name of the operation, try determine why it was performed. Medications (MEDS) Includes all currently prescribed medications as well as over the counter and non-traditional therapies. Dosage and frequency should be noted. Current Medications: Prescription and NonPrescription Medication Dose Amount Frequency Medications (MEDS) Do they take any prescription medicines? If so, what is the dose and frequency? Medications (MEDS) Medication noncompliance/confusion is a major clinical problem, particularly when regimens are complex, patients older, cognitively impaired or simply disinterested. Medications (MEDS) If patients are, in fact, missing doses or not taking medications altogether, ask them why this is happening. Medications (MEDS) Don't forget to ask about over the counter or "nontraditional" medications. How much are they taking and what are they treating? Has it been effective? Are these medicines being prescribed by a practitioner? Self administered? Medications (MEDS) Encourage patients to keep an up to date medication list and/or write one out for them. When all else fails, ask the patient to bring their meds.Drug Drug Allergies/Reactions (All/RXNs) Identify the specific reaction that occurred with each medication. Allergies/Reactions (All/RXNs) Have they experienced any adverse reactions to medications? what the exact nature of the reaction? Anaphylaxis is absolute contraindication A rash does not raise the same level of concern. Social History (SH) Alcohol Intake Cigarette smoking Other Drug Use Marital Status Sexual History Work History Other …. travel Smoking History Have they ever smoked cigarettes? If so, how many packs per day and for how many years? If they quit, when did this occur? Pipe, chewing tobacco use should also be noted. Alcohol Do they drink alcohol? If so, how much per day and what type of drink? Encourage them to be as specific as possible. If they don't drink on a daily basis, how much do they consume over a week or month? Other Drug Use Any drug use, past or present, should be noted. Remind these questions to assist you in identifying risk factors for particular illnesses (e.g. HIV, hepatitis). Respect their right to privacy and move on. Work/Hobbies/Other What sort of work does the patient do? Have they always done the same thing? Do they enjoy it? If retired, what do they do to stay busy? Any hobbies? Participation in sports or other physical activity? Where are they from originally? Work/Hobbies/Other It is nice to know something non-medical. This help improve the patient-physician bond. It also gives you something to refer back to during later visits, letting the patient know that you paid attention and really remember them. Family History In particular, you are searching for heritable illnesses among first or second degree relatives. "Heart disease," valvular disorders, coronary artery disease and congenital abnormalities Family History Find out the age of onset of the illnesses, as this has prognostic importance for the patient. (MI at age 70 is not a marker of genetic predisposition while one who had a similar event at age 40 certainly would be). Family History (CIRCLE ANY CONDITION WHICH YOU OR ANY BLOOD RELATIVE HAVE HAD) Arthritis Cancer TB Stroke Diabetes High Blood Pressure Epilepsy Psychiatric Disorder Anesthesia Problems Osteoporosis thyroid disease hepatitis Other… Obstetrical History (where appropriate) Have they ever been pregnant? If so, how many times? What was the outcome of each pregnancy Review of systems Questions about common symptoms in each major body system which may help to identify problems that the patient has not mentioned Review of Systems (ROS) The most important ROS questioning (i.e. pertinent positives and negatives related to the chief complaint) is generally noted at the end of the HPI. Review of Systems (ROS) Characterize patient's overall health status Review systems/symptoms from head to toe REVIEW OF SYMPTOMS PURPOSE – A WAY TO MAKE SURE YOU DID NOT MISS A PROBLEM REVIEW OF SYMPTOMS HEAD EYES EARS NOSE THROAT MOUTH CHEST HEART ABDOMEN MUSCULOSKELETAL NEUROLOGICAL ENDOCRINE SKIN Review of Systems (ROS) In actual practice, most providers do not document such an inclusive ROS. The ROS questions, however, are the same ones that, in a different setting, are used to unravel the cause of a patient's chief complaint. Review of Systems (ROS) It is probably a good idea to practice asking all of these questions as well as noting the responses so that you will be better able to use them for obtaining historical information when interviewing future patients Physical examination General appearance Vital signs HEENT: Includes head, eyes, ears, nose, throat, Oral cavity Neck Breasts and axillae Thorax and lungs CVS and peripheral vascular system Abdomen Genitalia Anus and rectum Musculoskeletal system Physical Exam Neurologic: 1,Mental Status 2,Cranial Nerves 3,Motor Strength 4,Function, Observed Ambulation Neurologic: 5,Sensation (light touch, pin prick, vibration and position) 6,Reflexes, Babinski Cerebellar Lab Results, Radiologic Studies, EKG Interpretation, Etc.: Problem list Assessment and Plan