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 planof 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 risk-factors 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.. • whypatient 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 10 15 Abdominal pain Fever and chills 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 LIQORAAA
40-yr-old Women With Headache History of Present Illness
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) • 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 re-stated. • 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 Non-Prescription Medication Dose Amount Frequency
Medications (MEDS) • Do they take any prescription medicines? • If so, what is the dose and frequency?
Medications (MEDS) • Medication non-compliance/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 "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 (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.