Download
1 / 74

Write Ups The written History and Physical (H&P) - PowerPoint PPT Presentation


  • 162 Views
  • Uploaded on

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)

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' Write Ups The written History and Physical (H&P)' - benita


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Write ups the written history and physical h p

Write Ups The written History and Physical (H&P)

Dr H.A.Soleimani MD. Gasteroentologist


Write ups
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 ups1
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
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 purposes1
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 purposes2
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 planof attack.


Write ups2
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 ups3
Write Ups

  • If you were unaware that chest pain is commonly associated with coronary artery disease, you would be unlikely to mention other coronary risk-factors when writing the history.


Write ups4
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
Chief Complaint or Chief Concern (CC)

  • One sentence that covers the dominant reason(s) for hospitalization..

  • whypatient here--use patient's own words


History of present illness
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 illness1
History of Present Illness

  • Physician asks questions to discussing the details of the chief complaint.


History of present illness answers questions of
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 illness2
History of Present Illness

  • Ask about the nature of the symptoms (for pain, is it sharp or dull, localized or generalized).


History of present illness3
History of Present Illness

  • Things that the patient has done to improve the symptoms

  • Are any associated symptoms.


History of present illness4
History of Present Illness

  • Very brief… pain after hitting their finger with a hammer

  • More detailed…. abdominal pain


History of present illness5
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

10

15

Abdominal pain

Fever and chills

jaundice


History of present illness pain
History of Present Illness (PAIN)

  • Location

  • Quality

  • Severity

  • Duration

  • Timing

  • Context

  • Modifying factors

  • Associated signs and symptoms.


55 yr old men with chest pain

55-yr-old Men With Chest Pain

History of present illness

LIQORAAA


L Location of the symptom (forehead, wrist...)


I Intensity of the symptom (scale 1-10, 6/10)


QQuality of the symptom (burning, pulsating pain...)


OOnset of the symptom + precipitating factors


R Radiation of the symptom (to left shoulder and arm)


AAssociated 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

40-yr-old Women With Headache

History of Present Illness


History of present i llness 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?

History of Present Illness Headache


Past medical history pmh
Past Medical History (PMH)

  • This should include any illness (past or present) for which the patient has received treatment.


Past medical history pmh1
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 pmh2
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 pmh3
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 pmh4
Past Medical History (PMH)

  • Items which were noted in the HPI do not have to be re-stated.

  • You may simply write "See above" in reference to these events.


Past medical history pmh5
Past Medical History (PMH)

  • All other historical information should be listed.

  • Detailed descriptions are generally not required.


Past medical history pmh6
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 pmh7
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
Past Surgical History (PSH)

  • All past surgeries should be listed, along with the rough date when they occurred.


Past surgical history psh1
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
Medications (MEDS)

  • Includes all currently prescribed medications as well as over the counter and non-traditional therapies. Dosage and frequency should be noted.



Medications meds1
Medications (MEDS)

  • Do they take any prescription medicines?

  • If so, what is the dose and frequency?


Medications meds2
Medications (MEDS)

  • Medication non-compliance/confusion is a major clinical problem, particularly when regimens are complex, patients older, cognitively impaired or simply disinterested.


Medications meds3
Medications (MEDS)

  • If patients are, in fact, missing doses or not taking medications altogether, ask them why this is happening.


Medications meds4
Medications (MEDS)

  • Don't forget to ask about over the counter or "non-traditional" 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 meds5
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
Allergies/Reactions (All/RXNs)

  • Identify the specific reaction that occurred with each medication.


Allergies reactions all rxns1
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
Social History (SH)

  • Alcohol Intake

  • Cigarette smoking

  • Other Drug Use

  • Marital Status

  • Sexual History

  • Work History

  • Other …. travel


Smoking history
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
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
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
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 other1
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
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 history1
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…

Family History (CIRCLE ANY CONDITION WHICH YOU OR ANY BLOOD RELATIVE HAVE HAD)


Obstetrical history where appropriate
Obstetrical History (where appropriate)

  • Have they ever been pregnant?

  • If so, how many times?

  • What was the outcome of each pregnancy


Review of systems
Review of systems appropriate)

  • 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
Review of Systems (ROS) appropriate)

  • 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 ros1
Review of Systems (ROS) appropriate)

Characterize patient's overall health status

Review systems/symptoms from head to toe


Review of symptoms
REVIEW OF SYMPTOMS appropriate)

PURPOSE – A WAY TO MAKE SURE YOU DID NOT MISS A PROBLEM


Review of symptoms1

HEAD appropriate)

EYES

EARS

NOSE

THROAT

MOUTH

CHEST

HEART

ABDOMEN

MUSCULOSKELETAL

NEUROLOGICAL

ENDOCRINE

SKIN

REVIEW OF SYMPTOMS


Review of systems ros2
Review of Systems (ROS) appropriate)

  • 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 ros3
Review of Systems (ROS) appropriate)

  • 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 appropriate)

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 examination


Physical exam

Neurologic: appropriate)

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

Physical Exam



Problem list appropriate)


Assessment and appropriate)Plan


ad