Transcript History of Present Illness

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