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history and physical
speaker:万冕
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case
The writing
The goal
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The goals of all the differing
styles of the H&P are the
same
•communicating the important aspects of
the patient's presentation
• Providing thorough background informa
tion about the patient
• Leading the reader through the informat
ion in an organized manner so he or she
can understand what you were thinking w
hen you made treatment decisions
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Sections of the H&P
Conventionally,the H&P is broken down into the following thirteen major sections
1) Source
2) Chief complaint(cc)
3) History of the present illness(HPI)
4) Past medical history(PMH)
5) Medications(Meds)
6) Allergies(All)
7) Family history(FHx)
8) Social History(SHx)
9) Review of Systems(ROS)
10)Physical Exam(PE)
11)Laboratory and Data(Lab/Data)
12)Assessment/Impression/Summary
13)Plan
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Source
• very brief
• identify the source(s) of inf
ormation
• comment on the credibility
of the source
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source
•Information obtained from the
patient and his spouse,who seemed
clear and coherent
•Information obtained from5-yearold son who acted as interpreter for
the patient,who doesn't speak
English.Son seemed to understand
only part of questions.
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Chief complaint(cc)
• Drief statement of w
hy the patient presented
• Identifies patient and
relevant"context"relate
d to presenting compl
-aint
• Focuses attention of
reader(s)
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Chief complaint(cc)
•34-year-old male with advanced
AIDS complaints of a"bad cough"
and fevers developing over the last
8days.
•
81-year-old African-American
female with a history of
hypertension and diabetes
complains of "pain in mychest"while
walking up the stairs yesterday
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History of the present illness(HPI)
•Lead the reader toward the conclusions you draw in
the Assessment and Plan that follows
•Write in full sentences
•Do not make up abbreviations
•Organize and edit the patient's information
•Give the time course
•Be descriptive,not analytic,regarding all features of t
he primary complaint(s)
•Include all relevant information about the complaint
•Note other coexisting illnesses/situations that may c
ontribute("context")
•Guide the reader through the appropriate differential
diagnosis with pertinent positives and negatives
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History of the present illness(HPI)
•Present illness:
The patient felt upper bellyache about ten day
s ago. He didn’t pay attention to it and though
t he had ate something wrong. At 6 o’clock thi
s morning he fainted and rejected lots of blood
and gore. Then hemafecia began. His family se
nt him to our hospital and received emergent tre
atment. So the patient was accepted because o
f “upper gastrointestine hemorrhage and exsan
guine shock”.
Since the disease coming on, the patient didn’
t urinate.
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Past medical history(PMH)
• Thorough listing of prior medical illnesses or even
ts
• Include supporting data(e.g.,biopsies,PFTs,echos
,CTs,if available)
• Avoid chart lore
• Consider separating past surgical,obstetric,and
psychiatric histories
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Past medical history(PMH)
•Status post cholecystectomy 4/94
for gallstones.
•Hypertension.Wellcontrolled for 5
years.
•Status post hysterectomy-deatails
unknown-approx 1990 at Boston
Hospital.
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Medications(Meds)
• List all meds,doses,routes,intervals
• Include over-the-counter meds
• Include recently stopped or changed m
eds
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Medications(Meds)
•Lisinopril 10mg po qd
•Lanoxin 0.125mg po qd
•Vitamin B12100Xg im q month
•Pravastatin 40mg (increased from
20mg 3week ago)po qhs
•Multivitamin 1 po qd
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Allergies(All)
• List all meds to which patient
has reacted
• List the reaction
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Allergies(All)
• 1.Sulfa drugs-rash
• 2.Ampicillin-anaphylaxis
Note:
This is not the place for seasonal
allergies, hay fever,or contact allerg
ies.They belong in the PMH.
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Family history(FHx)
• List or diagram family
members
• List major illness,causes of death for
each family members
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Family history(FHx)
• Family history: His parents have b
oth died.
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Social History(SHx)
• Occupation,hobbies,personal interests
• Marital status,number of children,social s
upport network,living situation
• Alcohol,cigarette,and illicit drug use
• Sexual history
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Social History(SHx)
•SHx:
Married 22 years with 3 children
Taking correspondence course to get B.A.
Coaches Little League baseball
•Occ Hx: Does construction work (no asbestos exposure
known)
Only chemical exposure is paint thinner
Was previously a meat packer during his 30s and 4
0s
Habits: Denies tobacco and illicit drug use
Admits to 2-3 u alcohol twice weekly with friends C
AGE questions 0 of 4
Monogamous relationship with since married
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Review of Systems(ROS)
• Comprehensive head-to-toe or system-bysystem checklist of symptoms
• If relevant (positive or negative) to HPI, it bel
ongs in HPI-not here
• Any significant findings require follow-up in
Assessment and Plan sections below
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Review of Systems(ROS)
•Respiratory system: No history of respiratory disease.
• Circulatory system: No history of precordial pain.
• Alimentary system: No history of regurgitation.
• Genitourinary system: No history of genitourinary di
sease.
• Hematopoietic system: No history of anemia and m
ucocutaneous bleeding.
• Endocrine system: No acromegaly. No excessive sw
eats.
• Kinetic system: No history of confinement of limbs.
• Neural system: No history of headache or dizziness.
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Physical Exam(PE)
• Describe,don't interpret,findings
• Be systematic,e.g., General Appearance
,Vitals,HEENT,Neck, Lungs,Cardiac,Breast
,Abdomen,Rectum,Genitals,Extremities,Sk
in,Musculoskeletal,Neuro
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Physical Exam(PE)
• T 36.4℃, P 80/min, R 20/min, BP
90/60mmHg. She is well developed
and moderately nourished. Active p
osition. The skin was not stained ye
llow. No cyanosis. No pigmentation.
No skin eruption. Spider angioma w
as not seen. No pitting edema. Sup
erficial lymph nodes were not enlarg
ed.
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Laboratory and Data(Lab/Data)
• Common labs first(CBC,chemistries,liver
functions,coagulation profile)
• Other blood tests obtained
• Urinalysis
• Chest X-ray(and other radiology studies)
• ECG
• Other data obtained
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Laboratory and Data(Lab/Data)
•Blood-Rt: Hb 59g/L RBC 1.90T/L
WBC 0.8G/L PLT 55G/L
•Blood cytology: A few immature ly
mphocytes could be seen.
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Assessment/Impression/Summary
• Demonstrate your thinking process
• Don't summarize;synthesize
• Include key elements of H&P in a guided fas
hion to lead the reader through the differential
diagnosis and land the reader on your conclus
ion(s)
• Generate a problem list (primary and second
ary) with explanations considering why and ho
w this situation occurred
• Write in full sentences
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Assessment/Impression/Summary
•Patient was female, 14 years old
•Pharyngalgia and fever for four day
s.
•No special past history.
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Plan
• This may be integrated into Assessment
section
• Enumerate a specific problem list as abo
ve
• Be as specific with your plans as possibl
e
• Address all issues
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Speaker :
万冕
PPT Maker :
夏添.王静,胡熹
Material collecter :
徐丹丹,刘政文,秦媛,朱艳玲
Review :
钱雷,章文轩
The End