This H&P format is rather extensive and should, if closely followed portray a very good medical picture of the patient. This is the type of picture needed for a general medicine service. Surgery, OB/GYN, etc. may not need quite as complete a picture as exams tend to be more focused. You should always, however keep this format in mind with any H&P you do. Keep this in mind also - your write up in the chart needs to be concise enough to say all you need to say but your dictation should include negatives as well. Get with your attending about how much detail is needed.

Patient:

Age:

Gender:

Room #:

Date of admit:

Attending:

Dictating Physician (student Dr. xxx): Yes scut monkey, you will do the dictation. You don't think the attending is going to do this do you?

CC/HxCC: Try to get this in the patients own words - use quotes in your writeup. Follow the CC by the history of the CC and any circumstances involved with the CC. Don't forget - character, location, onset, radiation, intensity, duration, associated events, palliative, provocative factors (in other words PQRSTUAdocs and drugs).

PMH: This is medical hx beyond the chief complaint - arthritis, asthma, blood disease, bronchitis, cancer, diabetes, emphysema, epilepsy, flu, gout, hepatitis, heart disease, HTN, liver disease, mental disorders, mononucleosis, pneumonia, RF, seizures, thyroid disease, TB, ulcers, UTIs,
just to name a few.

PSH: (include injuries) - type, date, where treated, doctor.

FMH: include medical info about 1st degree relatives, living or deceased.

Meds: drug name, dosage, frequency.

Allergies: we are specifically looking for drug allergy(s) here.

Social Hx: cigarettes, alcohol, illicit, type of work, home life, etc.

REVIEW OF SYSTEMS

General: recent changes in general health, wt. appetite, sleeping habits. State where ROS is derived, eg. ROS is taken from pt. who appears to be a good historian. The patient denies any recent changes in general medical condition, weight, appetite, or sleeping habits.

In general the pt. will have a hx. or deny a hx of (by body system) the following: Don’t forget this - if a patient states a past hx of removal of a basal cell carcinoma lesion of the L cheek then on your PE you should make note of the fact that "Pt demonstrates a scar on the L cheek from excision of lesion."

Integument: skin lesions, rashes, skin grafts, etc.

Head: cephalgia, trauma, or migraines.

Eyes: bluriness, cataracts, diplopia, photophobia, or any vision changes.

Ears: discharge, hearing changes, tinnitus, childhood tubes.

Nose: chronic sinusitis, decreased smell, excessive rhinorrhea, or unexplained epistaxis, nasal fractures.

Mouth/Throat: tenderness or lesions in oral cavity, frequent sore throats, dysphagia, or persistant hoarseness.

Neck: injury, masses, pain, or stiffness.

Pulmonary: asthma, bronchitis, COPD, chronic cough, hemoptysis, SOB, TB, tachypnea.

Cardiovascular: angina, CHF, claudication, CVA, cyanosis, dizziness, exertional dyspnea, hypertension, orthopnea, PND, phlebitis, precordial pain, or TIAs.

Gastrointestinal: cramping or pain, constipation, clay or fatty stools, diarrhea, dysphagia, gallbladder disease, hematemesis, hematochezia, hemorrhoids, hepatitis, hernias, indigestion, jaundice, melena, N/V, pancreatitis, rectal bleeding.

Genitourinary: anuria, dysuria, hematuria, nocturia, discharge, frequency, hesitancy, incontinence, chronic UTIs, STD, lesions, prostatitis (caution - women don't get prostatitis!), renolitiasis.

OB/GYN: G T P A L, difficulties, last pap/breast exam: _____________,

Contraceptive use: (Y/N), menstrual cycle, increased bleeding?, regular?, FDLMP:_____________, or menopausal?

Breasts: discharge, enlargement, pain, tenderness, prior surgery or biopsy.

Neuromuscular: anesthesias, paresthesias, arthralgias, or myalgias. No hx. of nervousness, syncope, vertigo.

Endocrine: hot & cold intolerance, polydipsia, polyphagia, polyuria, anemia, excessive bruising or bleeding, diabetes or thyroid problems.

PHYSICAL EXAM

Vitals: Temp, Pulse, Resp., B/P, Ht. & Wt.

General: overall appearance, nutritional status, weight, height, communication skills, behavior, awareness, orientation, cooperation with exam.

Example: This is a 32 y/o G3P1102 lady who presents to labor and delivery in active labor at 38+2/7 weeks. She appears to be well hydrated, properly nourished  and her appearance is appropriate with the stated age. The patient is alert, cooperative, and except for pain of active labor is in no acute distress at this time. The patient appears to be a good historian. Nurse Smiley is present during the examination.

Skin/Integument: color, integrity, texture, temperature, hydration, diaphoresis, edema, lesions, hair and nails.

Example: Skin texture, tugor, and pigmentation appear normal. No rashes, cyanosis, or petechiae noted. Normal hair pattern for sex and age. Tattoos are noted distributed over the upper torso, however, no pathologic lesions are demonstrated.

Head: size, contour, scalp appearance, symmetry and spacing of facial features, edema, puffiness, erythema, other lesions.

Example: Head is atraumatic, normocephalic, features are symmetrical, evenly spaced, and without deformities.

Eyes: appearance of orbits, conjunctivae, sclerae, eyelids, eyebrows, extra occular movements, corneal light reflex, pupil shape, consensual response to light and accommodation, visual fields (acuity optional), opthalmoscopic findings, retina, optic disc, macula, retinal vessel size, caliber, AV crossings

Example: PERRL, EOMI bilaterally. No conjunctival injection, ptosis, or scleral icterus. Fundoscopic exam reveals no AV nicking, papilledema, retinal hemorrhages or retinopathy. (caution here: unless you specifically test for accomodation you cannot say PERRLA).

Ears: configuration, position, and alignment of auricles, otoscopic findings (canals and typmpanic membranes), hearing assessment.

Example: External ear exam reveals no abnormalities. External ear canals patent, TM intact bilaterally with normal cone of light and without injection.

Nose: external appearance, nasal patency, discharge, crusting, flaring, internal exam - appearance of turbinates, polyps, septal alignment, presence of sinus swelling or tenderness, odor discrimination.

Example: No septal deviation, turbinates appear normal without hyperemia or exudates. Moist nasal mucosa without discharge.

Mouth/Throat: appearance of lips, tongue, buccal and oral mucosa, condition of teeth, presence of dental appliances, floor of mouth, pharynx, tonsils, hard and soft palates, uvula, tongue deviation with protrusion?, gag reflex, voice quality.

Example: Gums pink without bleeding. Oral mucosa moist. Teeth condition _______. Uvula midline, no pharyngeal or tonsillar hyperemia or exudate. There is no deviation of the tongue on protrusion.

Neck: carotid pulses, bruits, trachea, JVD?, Thyroid palpable?, cervical lymph nodes, neck stiffness.

Example: Carotid pulses are equal and adequate bilaterally with no bruits auscultated. Trachea is midline and freely mobile. No JVD. Thyroid not palpable or enlarged. No cervical lymphadenopathy or nuchal rigidity.

Lungs/Thorax: lungs sounds, intensity, chest excursion, fremitus, lymphadenopathy.

Example: Lungs are clear to auscultation without adventitious sounds: rales, ronchi, or wheezes. Breath sounds are of good intensity without prolonged expiratory phase. Respirations normal/labored with good chest excursion. Tactile & vocal fremitus are equal in all fields. No supraclavicular nor axillary lymphadenopathy  noted.

Heart: rate, rhythm, intensity, PMI (include quantitative/qualitative assessment).

Example: Regular rate  without murmurs: no clicks, gallups, rubs or extra heart sounds (S3/S4/snaps). Heart sounds of normal intensity. PMI is at the 5th IC space and lateral to the MC line. (caution here: rhythm is an EKG finding. Unless you look at an EKG strip you cannot say regular rate and rhythm).

Abdomen: contour, texture, palpatory findings, auscultory findings, percussive findings.

Example: Inspection reveals (flat,distended, obese, gravid) soft , nontender abdomen. No masses, organomegaly, or rebound tenderness. ______ scars are noted. Active bowel sounds noted in all 4 quadrants. No pulsations, bruits or flank pain noted.

Extremities: condition of nails, check for edema, varicosities, pulses (radial, dorsal pedal at a minimum - grade +x/4).

Example: No clubing, cyanosis, edema, or varicosities noted. Pulses equal and adequate, +_/4 in both upper & lower extremities. No cutaneaous temperature difference bilaterally. -Homens, Moses, straight leg raising test. There is no evidence of cutaneous vascular change.

Neurological: general mental status, affect, speech, CNs, DTRs upper and lower, JP and 2PD, cerebellar fx.,

Example: Pt. is oriented x 3. DTRs equal and adequate in upper and lower extremities. Good grip strength noted bilaterally with no involuntary movements. Sensation is intact to pain and & light touch. Cerebellar fx intact with finger-to-finger/finger-to-nose, heel to shin, and normal rapid alternating movements and with normal gait. CN II-XII grossly intact. Babinsky  is appropriate. Mental Status: Pt. speech has normal rate and rhythm and responds to questions appropriately. The pt' s affect is (flat, blunded, appropriate) and mood is (sad, happy, etc.). Romberg is appropriate. Memory is intact to immediate, recent, and remote recall - able to recall 3 of 3 objects in 5 min. The pt's thought content (delusions, phobias, OC, etc) and thought processing (goal directed, loose) appear to be WNL. Pt. denies any auditory or visual hallucinations or any homicidal or suicidal ideation.

Breast Exam: general appearance, symmetry, masses, scars, discharges, tenderness to palpation, lymphadenopathy. Note - In the H&P it is appropriate to document the presence of a nurse during female exams. See the general comment above.

Example: Breasts are of normal symmetry, no discrete masses, scars, nipple discharge, dimpling, introversion, or tenderness noted. No axillary lymphadnopathy noted. You could also say that breast exam is not done per pt. request.

Genitalia: general appearance, masses, discharge, lesions.

Example: Genitalia are normal in appearance. There is no discharge, inflammation, or evidence of infection. You can also say genital exam is not done per pt. request.

Vaginal Exam: lesions, uterine assessment (for a gravid female it is appropriate to mention fundal height above/below umbilicus), tenderness, masses.

Example: Speculum exam reveals no vaginal or cervical lesions. Uterus is normal size and position (ante, retro). Bimanual exam reveals no adenexal tenderness or masses. If you did not do a speculum exam document why.

Rectal Exam: external exam, masses, lesions, fissures, blood, polyps, prostate.

Example: No masses, polyps, hemorrhoids palpated. Sphincter tone adequate. No blood on exam glove. Hemoccult ______. Prostate had no nodules and was not tender or palpably enlarged. Stool ______.

Osteopathic Exam (obviously DOs only will do this): See example statement below.

Example: Pt. examined in both (supine, sitting, standing) positions. No gross AP or lateral assymmetry in posture or spinal curves. Gait & movement appear to be accomplished with ease & symmetry (except). Nor gross or segmental abnormalities of the spinal column, pelvis, or extremities noted (except). No tissue texture changes or somatic dysfunction noted.

LABS: Imaging, EKG, etc. If labs were ordered in the ED but not posted get results! Don't forget to make a note of things like serum CK, Troponin I, glucose, etc. Call the radiology dept. and have them fax up a report not in the chart - your attending will be happy with you.

Assessment:
   Before we go to far with writting down a bunch of fancy stuff let me comment that you first need to talk to your attending about what sort
   of detail he/she wants in the chart. While on a surgery rotation as an intern I had a surgeon and a great guy tell me that he didnt want a
   detail. His premise was that "The lawyers just love all that writing."

1. Principle diagnosis (just because a dx was made in the ED doesn't mean you cannot make your own). NOTE: R/O (rule out) is not a diagnosis.
   If you are not sure what you are dealing with considerwriting something like - Chest pain of unknown etiology. After you have made this
   comment be sure you put some appropriate differentials down like - consider MI, PE, costochondritis, blunt trauma, malignancy ....

2. etc. - note all historical problems in past history which might be significant. For instance, DM-I by history, metastatic carcinoma by history,
   MI by history.  These types of things may have a significant bearing on treatment, furthermore a history of DM means by definition that
   the patient still has DM. Also put down any incidental items found on physical exam. It is realy cool to find a skin lesion (which turns out to
   be melanoma) on a patient who present to the hospital for something like pneumonia. Also be sure to put down abnormallabs,  for instance
   thrombocytopenia, possibly related to previous hx myeloplastic disease. Last but not least put down the simple things like morbid obesity,
   nicotine dependent.

Plan:

1. ATSO Dr. xxx

2. medications per admit order.

3. additional meds.

4. additional test(s), procedures, etc.

Dictation noted in progress note?

DON'T FORGET TO WRITE ADMIT NOTE and ORDER IF NOT ALREADY DONE!!!