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)
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Dr H.A.Soleimani MD. Gasteroentologist
Fever and chills
History of present illness
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)
History of Present Illness
Episodic or constant?
How long lasting?
Intensity of pain?
Quality of pain?
Site of pain?
Photophobia?History of Present Illness Headache
If you receive little/no response
High Blood Pressure
Other…Family History (CIRCLE ANY CONDITION WHICH YOU OR ANY BLOOD RELATIVE HAVE HAD)
Characterize patient's overall health status
Review systems/symptoms from head to toe
PURPOSE – A WAY TO MAKE SURE YOU DID NOT MISS A PROBLEM
SKINREVIEW OF SYMPTOMS
General appearance appropriate)
HEENT: Includes head, eyes, ears, nose, throat,
Breasts and axillae
Thorax and lungs
CVS and peripheral vascular system
Anus and rectum
Musculoskeletal systemPhysical examination
4,Function, Observed Ambulation
5,Sensation (light touch, pin prick, vibration and position)
Problem list appropriate)
Assessment and appropriate)Plan