Bare Essential H&P

ID: 35 YO female architect from Moose Jaw  brought to ER by a co-worker

(age) (sex) (occupation) ( location) (where and how they arrived)

CC: comes in with back pain for 1 day

(presenting complaint) (duration)

HPI: History gathered from patient. She was lifting a carton at work on Jan 15, 2000 (yesterday) when she felt sudden pain in lower back. Pain level was 8 on a scale of 10. Had to leave work and go home to rest.  Sharp stabbing pain initially but now a dull ache that is present all the time. Wakes her from sleep. Worse with prolonged sitting. Ibuprofen initially helped with pain. Radiates down right leg to side of foot. Returned to work today but was unable to lift because of pain. She had gradual worsening of pain this afternoon and a co-worker brought her to ER when she was unable to walk because of the pain.  Patient otherwise feels well. Has never had back pain before and has not had any other joint problems - no history of other injuries to back. She thinks the pain was directly a result of lifting the carton.

(from who history was obtained) (mechanism and time of onset) (pain intensity, quality of pain, pain waking her from sleep?) (aggravating and alleviating factors) ( radiation of pain and other associated symptoms)  (functional impairment) (history of similar problems, injuries or associated symptoms in the past) (patient's opinion on initiating cause of problem)

PMHx:

Patient has history of HTN since 1996. Also has childhood asthma but no recent flare-ups. No hospitalizations for medical illness. 

Prior history of major depressive episode in 1985 with minor recurrences but no suicide attempts. Went through alcohol rehab program in 1993. No hospitalizations for psychiatric condition.

History of MVA in 1988 with brief LOC and fractured left femur treated with cast, not hospitalized, no sequelae.

G3 P2 A1 with normal vaginal deliveries. Abnormal PAP with colposcopy and cryotherapy treatment in 1990. No further abnormal PAP's.

(brief summary of medical problems, psychiatric history, previous trauma, obstetric and gynecologic history. Often, the surgical history is also included in medical history rather than a separate heading. Patient should be asked if they have ever been admitted to hospital with the reasons for hospitalization described - ex: hospitalized 5 times for COPD - most recently in 2000 - never intubated )

SurgHx: remote hysterectomy for functional bleeding, remote appy, left inguinal hernia repair in 1999

Meds: lisinopril 10 mg QD, Prozac 20 mg QD, ibuprofen 600 mg TID PRN (just started)

(name, dose, frequency, and duration if relevant - probably the most important section after the HPI - needs to be complete and accurate which may require many different sources of information)

Allergies: sulpha drugs (rash and dyspnea), erythromycin (N & V)

(drug name or class of drugs, nature of allergic reaction or adverse event)

Health Maintenance: Tetanus shot in 1996, prior Hep B vaccination, Normal PAP 2 years ago. Childhood immunizations were done. Uses seat belts and bike helmet.

(pertinent immunizations, screening procedures, life style choices)

FmHx: 

- Dad had MI at 57 YO and died. Mother alive but in poor health. 

-Dad and Uncle with MI's. No DM type II, no HTN, no strokes, no hypercholesterolemia, history of breast Ca in mom at age 48, no colon Ca / rectal Ca / bowel Ca, no melanoma, no ovarian cancer, no prostate Ca, no asthma, no thyroid disease, history of leg clot and lung clot in GM, no bleeding disorders, no migraine headaches. History of depression in sister, no history of schizophrenia, history of alcoholism in brother, no dementia. No other FmHx of significant disease.

(basic family history should screen for the basic illnesses listed above as well as specific illnesses relevant to HPI – family includes siblings, mother and father , grandparents and uncles and aunts. Genetic screening for pregnancy is much more extensive and a separate history. Mention whether parents are alive and what type of health they are in)

SocHx: married with good support from husband, 2 children at home, works as an architect. Originally from Poland now living on a farm near town. Spent 2 years in military as a medic. No history of asbestos exposure, is physically active, no history of STD. She does chew tobacco - does not want to quit, 2 ETOH drinks / week - prior history of alcohol problems. No current drug abuse. No history of IV drug abuse, blood transfusion , nor high risk sexual activities. Has never traveled outside the country.

(current relationship, kids, occupation, place of birth, living situation, military experience, occupational risk exposure, physical activity, sexual history, tobacco and alcohol use, drug use, history of IV drug use / transfusions/ high risk sexual contacts, travel history)

Functional Level: Lives independently in her own house. No impairment in mobility. Drives a car.

(Functional Level would probably not be included in this particular history but should be included in histories of the elderly and of people with disabilities. Function includes capability of doing ADL's (activities of daily living such as personal hygiene, continence, dressing, ability to feed self, ability to transfer from a chair to bed, etc.), mobility (wheel chair, bed-ridden, uses a walker, unable to go outside of house, drives car, etc), exercise capacity (able to walk 1/2 block at slow pace, etc), fall risk, significant visual and hearing impairments, and ability to function independently in the community (IADL's - instrumental activities of daily living). If dementia is present, the most recent mini-mental state score could be mentioned along with risk of wandering and whether 24 hour supervision is needed)

ROS: normal sleep, recent 10 lb weight gain, normal appetite, no history of diet drug use, no history of eating disorder, normal energy, no fevers or chills; no history of diabetes nor high blood sugars, no history of cancer, no history of TB nor exposure to same, no history of HIV nor possible exposure to same, no history of anemia nor other blood disorder; no depression nor anxiety at present, no prior suicide attempts; normal vision, no eye difficulties, normal hearing, no ringing in ears, normal balance, no sore throat, no problems with hoarseness, no dental problems, no neck pain nor stiffness; normal exercise tolerance - able to run 3 miles, no history of heart attack, heart problems, high BP nor elevated cholesterol, no chest pain / discomfort, no dyspnea, no history of syncope, no palpations nor arrhythmias, no history of Rheumatic Fever nor heart valve abnormalities; no difficulties with breathing, no cough, no history of bloody cough, no history of asthma nor wheezing; no breast lumps /pain /tenderness / other changes, no nipple discharge nor rash; occasional heartburn / indigestion controlled with tums, no difficulty with eating nor swallowing, no nausea nor vomiting, no abdominal pains, no history of hepatitis nor jaundice, no history of ulcers nor UGI bleeds, no change in BM’s, no history of blood in stool nor of black tarry stools; normal urination, no increase in urinary frequency / nocturia, normal menstrual cycle, no menstrual difficulties, normal onset of menarche, normal sexual function; no headaches other than occasional mild ones, no history of seizure /convulsion /epilepsy, no history of stroke or stroke-like episode, no history of major head injuries nor LOC (loss of consciousness), no unusual sensations /numbness / weakness in limbs; no leg pain or swelling, no joint pains nor stiffness; recent back pain - discussed in HPI. No skin problems, rash nor moles of concern, no concern about lumps in the body. Patient denies any other health concerns at this time.

(brief screening ROS by system - positive answers will bring out more details and questions. Recording the negative responses confirms that you asked the questions. Some of the questions ask for history of significant disease which would then be put in the PMHx if the answer is positive. For clarity, positive responses can be highlighted. Detailed ROS pertaining to presenting complaint should be covered in the HPI)

PE: Healthy appearing 35 year old woman who was carried into ER. Hgt - 5 ft 4 in ; Wgt - 180 lb; BMI- 31; BP 140/78 ; HR - 72 (regular rhythm); Temp 96.8

(brief overall description of patient with VS’s; be careful of how you describe patient; giving actual wgt and hgt is more accurate and less offensive than stating that patient is obese – putting in BMI also gives a picture; remember that patients have complete access to read their own records)

Remaining Physical Exam

LAB and X-Ray: minimal spondylolithesis of L5 on S!, no compression fracture

ASSESS:

1.) Lower Back Pain secondary to injury on Jan 15, 2000; right leg pain

2.) Hypertension well-controlled

3.) Smoker with strong family history of CAD

4.) 35 YO woman with strong family history of Breast Ca

(the problem list in the assessment summarizes the HPI and subsequent findings. It also mentions ongoing medical problems that are being treated and pertinent ongoing health concerns)

PLAN:

1.) Started on Lodine 500 mg BID for 10 days. Warned about possible GI bleed from medication and to seek immediate medical assessment if onset of black tarry stools, severe epigastric pain, or dizziness with standing up - Lower back exercises described - Immediate follow-up if onset of stool or urine incontinence or onset of numbness on inner thighs. Follow-up in 2 weeks if no relief of symptoms.

2.) recheck BP in 3 months

3.) patient advised of need to quit smoking given family history of CAD.

4.) patient advised to start having yearly mammograms which she will arrange in the next few months.

(the plan discusses the course of action for the problems in the assessment list. Potential serious side effects of drugs must be mentioned to the patient including what to look for and what course of action to take. Also, patient follow-up in the event of onset of serious complications must be discussed. Finally, future follow-up should be discussed with patient)

Oral presentation of patient should include complete coverage of ID, CC, and HPI. Brief coverage of PmHx should be given. Complete Med list should be mentioned along with Allergies. Pertinent FamHx and SocHx should be mentioned as well as pertinent positives of ROS. Physical exam should only highlight significant positive and negative findings. The same goes for lab and X-ray. The assessment and plan should be presented in their entirety

NB:this is just a framework on which you can build / subtract as you progress :)

Rick Howe