This is one of a number of H&Ps that I have done for IM; I posted this to help those that are yet to reach clinicals. I believe the CS is woeful at teaching us how to do history and physicals. Frankly, it's a real deficency of the CS dept.
Those further on from me may have some of their own ideas and criticisms, but this example is just to give a heads up, something I wished I had had.
DISCLAIMER: CLINIC NOTE, NOT PERFECT, USE AS A GUIDE ONLY !!!


J. D. #12345566




CC:
Shortness of breath with associated increased heart rate.

HPI:
Pt is known to have CHF, CAD with ejection fx of 35%, HTN, COPD, AICD, past coronary stent and morbid obesity; he was recently admitted for SOB. He spent six days as an inpatient before being discharged six days ago. Within the last three days since d/c he has been suffering increasing SOB despite ATC O2 3L via nc, with associated decreased activity tolerance.
He reveals that he sleeps very poorly because he keeps waking up gasping for air. According to his wife he sleeps for no more than 40 minutes at a time, before waking up in this fashion. Following his last d/c he received a CPAP machine which he said he was “unable to use as water kept backing up into the piping”.
His normal activity level is mobilizing from his bed to the living room, with a cane. He is always out of breath after performing this task. However, with his worsening SOB over the last three days, he has only been able to move from bed to bedside commode with a walker. He denies chest pain, head ache, sweating, nausea/vomiting, abdominal pain but believes he is a little swollen from the mid abdominal area down to his toes. He denies feeling his defibrillator kick in at any time.


Past Medical Hx: CAD, (ej fx 10% 1/09, 35% 7/09), CHF, HTN, CVA
’04,’08, COPD, GERD, Gout, Carpal Tunnel Syndrome and morbid obesity (5’7” 230 kg)

Past Surgical Hx: AICD ’04, cardiac stent ‘06

Allergies: NKDA

Medications: Hydralazine 50mg PO tid, Imdur 30 mg PO qd, Metalozone 5mg PO qd, Carvedilol 6.25 PO bid, Enalapril 5mg PO qd, Digoxin 0.125 mg PO qd, Lasix 80mg PO qam / 40 mg qpm, KCL 20 Meq PO q 12, NTG 0.4 SL prn, Gabapentin 300mg PO bid, Allopurinol 100mg PO qd, Colchicine 0.6mg PO qod, Zocor 20mg PO qd, Mg O dose? PO bid, MVI PO qd, Spiriva 18 mcg INH qd, Ambien dose? PO prn, Tylenol #4 dose? PO q6 prn, Vicodin dose? PO q4 prn


Social Hx: Drank beer socially; quit 11 yrs ago, smoked 1ppd for 20 years, quit 11 years ago, “dabbled” in Crack, quit 11 years ago. The pt became very religious at this time.

Family Hx: Father died, he had ADA, mother died of MI, grandmother and an aunt on his mother’s side died of MI and one brother died of MI also.

ROS:
Pt denies fevers, chills, sweats, palpitations, n/v, arthralgia, myalgia, rash, loss of appetite, weight loss, dysuria, diarrhea or constipation. He admits to SOB on minimal exertion and some general swelling.


Vital Signs: Temp 97.1 BP 127/92 HR 105 RR 18 P.ox 99% on 3L O2

Exam:

HEENT:
No buccal or palpebral cyanosis noted, no nasal d/c or cough, no exopthalmus, jaundiced sclera, adenopathy or enlarged thyroid noted. No JVD was appreciated; the pt’s neck was quite thick.
.

Resp:
Lung sounds difficult to hear d/t pt’s size, no crackles or rhonchi heard; no pursed lip breath was seen or auxiliary effort. The pt was at rest on the gurney since admit to ER.

CVS:
Heart sounds also difficult to hear d/t pt’s obesity, S1 and S2 present and no rub, gallops or murmurs could be appreciated.

Abdo:
Large, NT, ND with faint bowel sounds, no pitting edema was seen on exam.

Extremities:
Although indentations were present on lower legs, ankles and feet when pressing, no edema was believed to be present- the pt’s calves and feet were large in size and were deemed normal for this pt. Strength 5/5 upper limbs and 3/5 lower limbs, sensation and capillary refill were present. The pt had poor toenail hygiene with evidence of a fungal infection between the toes on the left foot.

Skin:
Dry and intact with a hyperpigmented area of skin under the right eye. No lesions were noted; fungal infection between toes.

Neuro:
Deferred




Labs: 1/22 There is a conventional way to write a CBC and Lyte panel, which I cannot show here- I don't have the know how to draw grids- look it up
CBC and Lyte panel here plus e.g Troponin level/s

UA:
Slightly cloudy, >300 protein, blood ++, leukocyte esterase ++, few bacteria

CXR:
1/22 Enlarged heart, AICD, no change to previous CXR prior admission.

A/P:

#1 SOB d/t CHF secondary to insufficient cardiac function - The
pt is probably fluid depleted not overloaded- no edema and lung sounds are dry. i/ Diuretics to be held for now and cautious fluid channel to commence, NS @ 100cc/hr.
ii/ D/C IV Nitro (started in ER), pt is not overloaded.
iii/ Albuterol and Atrovent tx q4 prn
iv/ O2 2 to 3 L via nc
v/ CPAP per respiratory.
vi/ Repeat EKG in am
vii/ PT eval before d/c.
viii/ Dietary consult for weight loss and management



#2 Worsening renal function – possibly related to ADA onset and or ischemia d/t CHF. i/ Repeat lyte panel in am.
ii/ Fasting blood glucose in am.
iii/ Foley catheter for accurate I & O
iv/ Daily weight.
v/ Renal US to r/o hydronephrosis/ enlarged kidneys.
vi/ D/C diuretics.

#3 UTI d/t pt’s size and difficulty with mobilization and hygiene, r/o BPH.
i/ Check PSA
ii/ Urine Cx
iii/ Ciprofloxacin 500 mg IV bid, will revise after sensitivity reported.
vi/ Renal US to r/o hydronephrosis/ enlarged kidneys.


#4 HTN- ongoing, pt morbidly obese; currently controlled.

#5 COPD- longstanding, aggravated by obesity.
i/ O2 ATC as at home.
ii/ Albuterol/Atrovent prn
iii/ ABG

__________________
NO FLY LIAT

Surgery [X] IM [X] Peds [ ] OBGYN [ ] Psy [ ] FP [ ]

I may post one or two more if there is interest.

__________________
NO FLY LIAT

Surgery [X] IM [X] Peds [ ] OBGYN [ ] Psy [ ] FP [ ]

Actually I just started clincals,and would appreciate if you could post a few more examples.

Thanks

going over your note...this is not a note that is adequate for a medical student...intern maybe or resident, but not a med student.

med students note should be more in depth...in your A/P you need to explain why you are choosing to do the things you are doing (and the answer is not because your intern said so...). You need to cite some EBM for the reason say, you are using cipro instead of say moxi or ceftriaxone.

CC:- ONE reason, and only one reason to be listed here...which brought him into the hospital...the SOB or the tachycardia? there is ALWAYS an overriding reason. And you should put it in the pts word...

HPI: how old is this guy? and is it a guy or a girl. "The pt is a 65 yo WM (race isn't always needed) with a hx sig for HTN, CHF (EF10%), s/p AICD placement in 2004......"it sets the stage..i'm going to think of different things if you said instead "This is a 27 yo WF who is post partum day 3..."
Your telling a story and should anticipate the questions that will come up in the attending's head...The pt has been experiencing worsening SOB for the past 3 days with + PND, + Orthopnea and has needed to increase O2 use from his baseline of 2L to 5L. Good info from family member...sometime the pt's is not the best of informants and getting info from other sources is important.

Meds: QD is an illegal abbreviation...qday or daily....there are many illegal abbreviations, mostly because they can be easily confused (QD and QID can get mixed up...and that could be a BIG problem!). PRN should always be followed by for what..pain? fever? nausea?

Social Hx...where do they live...who do they live with? pets in house? smokers in house? what do they do for a living? all of these things can be relevant to care

ROS should be broken down by system and should include both positives and negatives..yours is a bit skimpy

Exam- again a bit skimpy...were the pupils reactive? mucous membranes? how were they (i mean you are saying this guy is dehydrated...clinically HOW do you know?) This guy has CAD (had stents!) and did you hear any carotid bruits? no documentation means you didn't do the exam. Abd exam- fluid thrill? shifting dullness?- pt is telling you his abd is feeling full, but you didn't exam for it? And justify for me how your pt doesn't have trace to 1+ edema when you state that there are indentations..which i'm assuming are hanging around...capillary refill is present, but is it fast, slow, slower than normal? you need to quantify that (> or < 2 sec). And there should be nothing that is deferred...you need to note you were unable to perform the exam or the pt refused...deferrred sound as if you just chose not to do it (lunch for a malpractice lawyer!).

CXR: ABCD...you need to remark on everything...good penetration, good insiratory effort, slightly rotated tothe right, trachea midline, cardiac siloutte enlarged, Costophrenic angles sharp b/l with no evidence of cephalization or airspace disease.

NO EKG?? this guy is a cardiac pt! and you are suspecting a cardiogenic issue!

and labs? are those all that you ordered? where is the BNP (or pro bnp). and vitals are lacking weight...chf pt- don't you want to know if his weight has signifacntly increased? or decreased? and where is the ABG?? exactly how hypoxic is he?- maybe he needs the ICU?

as for A/P- its crap...you have jumped to a conclusion...where is your Diff Dx...what else causes SOB and tachycardia? CHF exacerbation, COPD exacerbation, Sepsis, PE, MI....you as a student need to list out each point of the diff dx AND give reason why its high or low on your list...and what you want to do to rule things in or out.

renal function- you should state whether you suspect pre-renal, intrinsic, or post renal obstruction and what you would do to rule in out...and AKI? no fluids? where is your FeNa ( or since your pt is on diuretics what Fe would you use? and why not FeNa?).

and code status? sick guy...what happens

as a med student, your note should be the most in-depth in ALL aspects...as a student you are responsible for a lot less pts that anyone else on the team...you have the time to spend with the pt and time to craft your note...

you may want to post a better example (or work on this if this is your best work...)

__________________
Vacation [x]..........Wards []
Elective [x]...........MICU []
MICU [x]...............Vacation []
CCU [x]................Elective []
MICU [x]...............Renal []
CCU 6 more days....Wards []

im so happy i have a full EMR in the hospital . i could create a level 5 H & P on a critical patient with a few clicks of a mouse 5-10 minutes max.

__________________
Dr. Scott
Internal Medicine
PGY-2

VMD Moderator

This is a terrible H&P, I don't know how you had the idea that it would be a good example. CAD with associated ejection fraction? The EF should be associated with the CHF rather than CAD. You've done this in both the HPI and the PMH. and, CAD known how? Cath? Well, I guess since this patient has had stents, it is probably through a previous cath.

The CC should be the patient's complaint in his/her own words if possible... "I can't breathe and my heart's beating real real fast"

HPI: You have to include the person's age, sex, and generally race, since a lot of medical conditions (esp cardiovascular) can be race-related.

"65 yo morbidly obese AA man with CHF (EF=35) and COPD [the rest of the PMH can be gleaned in the PMH section, only these two are relevant] returns to the hospital for shortness of breath x3 days after being recently discharged 6 days ago. [answer rest of OPQRST... Able to sleep 40 minutes before waking up gasping for air. His baseline blah is blah, and sleeps with x pillows and can walk y before getting short of breath] You don't really need the "according to his wife" part, or even "he reveals" or anything like that. You haven't even said anything about his heart racing. You haven't really characterized the chief complaint at all. Only after all this you can get into the pertinent positives and negatives, which is your quick review of systems and should be characterized in the second paragraph. The review of systems should be way up at the beginning right after the HPI because that's really part of the interview regarding his current episode. What do you mean by general swelling??? Anasarca?? Ascites? Pedal edema?? Which joints?? I mean, the entire point of the HPI is that it's supposed to lead your head to a differential diagnosis and make certain diagnoses more likely and less likely based on the pertinent positives and negatives... I guess in this case CHF exacerbation vs COPD exacerbation vs OSA vs pneumonia. You need to be more concise in the HPI.

When you have 'prn' written, you have to give an indication. Why the hell is he on Vicodin? Is he actively gouty?

How many stents does he have? Where are they? (He may not know, but some patients know, and it may be in the medical record, this is useful especially when correlating EKG findings)

You'd be reamed by several attendings I know for saying "socially" drinking -- you have to characterize it. You can't say "dabbled" in crack, you have to inquire as to what that means. This is a legal document, a medical record -- not a work of literature.

Why does it matter whether he is religious?

What is his occupation? Retired plumber? (Maybe he could have asbestos exposure...). Who does he live with?

Fam Hx - what's ADA? I had to look this up and the only thing I can think of is alcohol dependence / abuse, but I could be wrong. It isn't a standard abbreviation. You should put down the ages they died, and it should be much more brief and succinct without all the verbiage.

Physical exam... HEENT -- what about his pupils?? "Cough" isn't really a physical finding that you need to say he doesn't have. and exophthalmos (note the spelling) -- most patients don't have this, and you're not suspecting thyrotoxicosis so does it really matter to mention it here? "No scleral jaundice" -- the word is icterus there. "Enlarged thyroid" => thyromegaly is the medical term, which you have to use, since you will be a doctor. "Quite thick" -- how thick?

"The pt was at rest on the gurney since admit to ER." and using no accessory muscles of breathing (not auxiliary) -- both should be under "General" which should be immediately after vitals. I'd say "Obese male resting on gurney, answering in complete sentences without using accessory muscles of breathing" for general, and obviously put something about being AAOx3.

Pitting edema doesn't go in abdominal exam, more for extremities, unless you were thinking of ascites.

"Although indentations were present on lower legs, ankles and feet when pressing, no edema was believed to be present- the pt’s calves and feet were large in size and were deemed normal for this "

way too wordy, and you're not making assessments in the physical exam. you can just say 'no edema' or 'trace pitting edema' (I couldn't tell what you meant by indentations -- actual markings/scars?? or what you see when you examine someone for pitting edema in CHF/kidney disease??)

*intact* sensation, *<2s* (or normal) capillary refill

A/P -- you need an overlying statement such as: "69 yo AA male with dyspnea"

(1) Dyspnea: My differential diagnosis for this includes ____. I believe it is X because ____.

(really, this is where you have your statements about your medical thinking, and as a student, you need to include differential diagnoses here).

and for the kidney function, you've mentioned ADA again... this is something definitely have no idea what you're talking about. Perhaps someone smarter than I am can chime in over here.

I'm really sorry, but this is a terrible H&P, I really don't know what they're teaching you over in grenada and in the hospitals there. This would earn a pretty lousy grade if a US student turned it in, I'm not sure whether your resident/attending OK'd it. I would recommend you purchase First Aid for Step 2 CS so you can get some information about how to write a note, important physical findings, etc... or even purchase something like "Clinical Clerkships: the answer book" which breaks down how to write an H&P, what's important, how to properly document physical findings, etc.

hahahahaha, jinx!

i think you are being too hard on ecela..... after all ecela is only a student. its a learning process. ecela welcomed criticism from the original post....... however chastising a student over and over doesnt help a medical student. be nice and thoughtful when you are teaching students if you are a resident..... after all.... we all were medical students at one point.

while the merits of your criticism may be sound....... making comments like this are completely unnecessary and uncalled for.... not only once, but twice:

if you have interactions like this as a resident with medical students...... all you are going to do is stress the student out. they wont take in your teaching points if you develop a rapport like that. oh and by the way.... ive seen much worse from US students

makes me wonder if you wrote that whole criticism of the h&p to really help the student or to make fun of the student

__________________
Dr. Scott
Internal Medicine
PGY-2

VMD Moderator

Haha... typical medical personality disorder responses.

Someone attempts to help others with what they know and only get this kind of response. I would like some of those who criticized to post a full H&P the fits their requirements.

__________________
Surgery[ ] IM[ ]***** Peds[x] OBGYN[x] Psy[x] Elec[x]

"I would rather try talking suicidal patients down first before suggesting they hurry up and jump" me

The gauntlet is thrown...

__________________
"I got a letter last year asking me if I would donate my brain to a medical school in Grenada. I'll tell you, there are days where I think, yeah, why not just get it over with." ~ Sam Seaborn, The West Wing

SGU '12, Specialization in Professionalism, Fellowship in Your Mother.