Complete H & P


HISTORY

CC: Must be documented by physician (required)

HPI: Severity, Quality, Location, Duration, ↓↑ Factors, Associated Si/Sx, Timing, Context. 8/8 (4 required) or 3 chronic illness w/status indicated (3 required).

Example:
__ yr old pt with Hx of HTN, DM II, HL, COPD, present to ER complaining of 8/10, substernal, pressure like chest pain radiating to his left arm which started about 6 hrs ago. Pain exacerbated with exertion, relieved with rest. Associated symptoms include nausea, vomiting and SOB. Denies lightheadedness, blurred vision, or fever.

PFSH: (all 3 required)
    1. PMH:
        PSH:
        ALLERGIES:
        MEDS:
   
     2. FH:    
     3. SOC
: T.E.D, Home situation, occupation, insurance

ROS

Review of all 14 systems negative except HPI

    OR    

10 bullets (do all 14)

ROS: (10/14 required) only one element for each system required.

  1. Constitutional: fever, weight change, Malaise
  2. Eyes: vision change, scotoma, photophobia
  3. ENT: otalgia, vertigo, rhinorrhea, Sore throat, Hoarseness
  4. CV: Chest pain, SOB, PND, Orthopnea, edema, palpitations, claudication.
  5. RESP: Cough, sputum, hemoptysis, wheezing, pleurisy
  6. GI: abd pain, N/V, hematemesis, dysphagia, GERD, Diarrhea, hematochezia, melena
  7. GU: Dysuria, hematuria, incontinance,  
    1. FEMALE: LMP, vaginal dc, dyspareunia, contraception.
    2. MALE: penile dc, testicular pain/mass.
  8. MS: Joint pain, stiffness, swelling, ROM
  9. SKIN: rash, lesion, pruritis, lumps, Mole changes
  10. NEURO: syncope, seizure, focal numbness or weakness, speech, HA
  11. PSYCH: ↓↑ mood, SI, anxiety, memory.
  12. ENDO: polydipsia, polysuria, heat/cold intolerance, diaphoresis.
  13. HEMATOLOGIC/LYMPHATIC: bruising/bleeding, swollen glands.
  14. ALLERGY/IMMUNOLOGY: Hepatitis, HIV Risk factors, Anaphylaxis.

PHYSICAL EXAM

1997 Guidelines (18 elements from 9 systems required)
  1. CONSTITUTIONAL: VS x 3; normal habitus. 2/2.
    [Well developed, well nourished, in NAD].
    {frail, anxious, confused, unkept, elderly, in distress}
  2. EYES: Conjunctiva clear; PERRLA; Discs Sharp. 3/3.
    [EOMI]
  3. ENT: Normal ext. ear & nose, External Auditory Canal & TMs clear; Nares Clear; OP Clear ?; Hearing intact; Dentition good. 6/6.
    [No deformity/significant septal deviation; normal mucosa; moist mucus membranes; no erythema/exudates]
  4. NECK: Supple; Trachea midline, No thyromegaly. 2/2
  5. RESPIRATORY: CTAB; Normal effort; No dullness to percussion, no tactile fremitus. 4/4
    {wheeze, crackles, crepitation}
  6. CARDIO: RRR no MGR; PMI non-displaced, no carotid/aortic/femoral bruits, pedal pulses 2+, no edema. 7/7
  7. CHEST/BREAST: Breast bilaterally symmetric w/o mass. 2/2
  8. GI/ABD: No masses, tendreness, guarding or rebound. No HSM, No hernia.
    {Murphy's sign- gall bladder.    Psoas / Rovsing/ Obturator sign - Appendicitis}
    1. RECTAL: normal ST, No masses or hemorrhoids, Guiac: neg. 5/5
  9. GENITOURINARY:
    1. FEMALE: Normal ext. genitalia, urethra, vagina & bladder.
      Cervix: No dc, non-tender.
      Uterus: Retroverted w/ normal size, shape, consistency, non-tender,
      Adnexa: No masses, non-tender. 6/6.  
    2. MALE: ↓↓Testes no masses, non-tender, normal circumcised penis.
      Prostate: No masses, non-tender. 3/3
  10. LYMPHATIC: No cervical, axillae, Inguinal or other LAD. 4/4
  11. MSK: Normal gait/station, No clubbing/cyanosis. Joints/bones/muscles in extremities x4: Full ROM. Normal inspection & palpation, Normal stability, Normal strength & tone. 6/6.
    [No hot, red or tender joints. No obvious deformaties, dislocaion or fracture. Full ROM of neck & back, No CVA tendrness].
  12. INTEGUMENT: No rash or atypical lesion, No induration or nodules. 2/2
    {? severe acne, rosacea, actinic keratosis, warts}
  13. NEURO: CN 2-12 grossly intact. DTRs 2+ globally, sensation intact to light touch. 3/3
    [No gross focal deficits, No nuchal rigidity]
    {? weakness, rigidity, cogwheeling, hypersthesia, tremor, hyporeflexia, hyper-reflexia, abnormal gait, MENINGITIS:kernig sign, brudzinski's sign}.
  14. PSYCH: A&O x 3, euthymic, appropriate affect, judgment & insight intact, recent & remote memory intact. 4/4
    [Thought content appears normal, maintains good eye contact].
    {? anxious, Agitaded, depressed. SIG EM CAPS}
Assessment /Plan:
  1. Chest Pain R/O ACS -- O2, Morphine, Nitroglycerine, Aspirin, Lisnopril, Metoprolol, Simvastatin, Serial Cardiac enzymes and EKG, CXR, CBC, BMP, Mg, Phos, UA, TSH, HbA1c, Fasting lipid panel, Stress test in AM, Echocardiogram, Cardiology consult (Spoke with Dr. Zia - Suggested starting Heparin per pharmacy).
  2. Dehydration -- IV fluids
  3. Nausea/Vomiting - IV fluids, Zofran
  4. Depression -- Continue celexa
  5. GERD -- Pepcid 20mg PO bid.
  6. Prophylaxis -- Heparin per pharmacy protocol.