Write Ups The written History and Physical (H

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Write Ups The
written History and Physical (HP)

• Dr H.A.Soleimani MD. Gasteroentologist

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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)

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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

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Write Ups serves several purposes

• It is an important reference document a patient's
  history and exam findings at the time of
  admission.

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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.

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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 plan of attack.

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Write Ups

• Knowing what to include and what to leave out
  will be largely dependent on experience and your
  understanding of illness and pathophysiology.

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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.

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Write Ups

• Until you gain experience, your write-ups will be
  somewhat poorly focused. Not to worry this will
  change with time and exposure.

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Chief Complaint or Chief Concern (CC)

• One sentence that covers the dominant reason(s)
  for hospitalization..
• why patient here--use patient's own words

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HISTORY OF PRESENT ILLNESS

• THIS IS THE DESCRIPTION OF THE PATIENTS ILLNESS
  AS TOLD BY THE PATIENT, FAMILY, OLD CHART OR A
  COMBINATION OF THESE.

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History of Present Illness

• Physician asks questions to discussing the
  details of the chief complaint.

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History of Present Illness answers questions of ..

• When the problem began, what and where the
  symptoms are, what makes the symptoms worse or
  better.

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History of Present Illness

• Ask about the nature of the symptoms (for pain,
  is it sharp or dull, localized or generalized).

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History of Present Illness

• Things that the patient has done to improve the
  symptoms
• Are any associated symptoms. 

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History of Present Illness

• Very brief pain after hitting their finger with
  a hammer
• More detailed. abdominal pain

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HISTORY OF PRESENT ILLNESS

• LIST THE EVENTS IN CHRONOLOGICAL ORDER

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Chronological description of the development of
the patient's present illness from the first sign
and/or symptom
0
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Abdominal pain
Fever and chills
jaundice
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History of Present Illness (PAIN)

• Location
• Quality
• Severity
• Duration
• Timing
• Context
• Modifying factors
• Associated signs and symptoms.

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55-yr-old Men With Chest Pain

• History of present illness
• LIQOR AAA

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L Location of the symptom (forehead,
wrist...)
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I Intensity of the symptom (scale
1-10, 6/10)
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Q Quality of the symptom
(burning, pulsating pain...)
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O Onset of the symptom precipitating
factors
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R Radiation of the symptom (to left
shoulder and arm)
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A Associated symptom (
palpitations, shortness of breath)
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A Alleviating factors (sitting with my chest
on my knees)
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A Aggravating factors (effort, smoking,
large meals)
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40-yr-old Women With Headache

• History of Present Illness

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History of Present Illness Headache

• 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?

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Past Medical History (PMH)

• This should include any illness (past or present)
  for which the patient has received treatment.

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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

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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?

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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?

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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.

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Past Medical History (PMH)

• All other historical information should be
  listed.
• Detailed descriptions are generally not required.

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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.

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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).

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Past Surgical History (PSH)

• All past surgeries should be listed, along with
  the rough date when they occurred.

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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.

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Medications (MEDS)

• Includes all currently prescribed medications as
  well as over the counter and non-traditional
  therapies. Dosage and frequency should be noted.

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Current Medications Prescription and
Non-Prescription
Medication
Dose Amount
Frequency




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Medications (MEDS)

• Do they take any prescription medicines?
• If so, what is the dose and frequency?

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Medications (MEDS)

• Medication non-compliance/confusion is a major
  clinical problem, particularly when regimens are
  complex, patients older, cognitively impaired or
  simply disinterested.

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Medications (MEDS)

• If patients are, in fact, missing doses or not
  taking medications altogether, ask them why this
  is happening.

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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?

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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
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Allergies/Reactions (All/RXNs)

• Identify the specific reaction that occurred with
  each medication.

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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.

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Social History (SH)

• Alcohol Intake
• Cigarette smoking
• Other Drug Use
• Marital Status
• Sexual History
• Work History
• Other . travel

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Smoking History

• Have they ever smoked cigarettes?
• If so, how many packs per day and for how many
  years?
• If they quit, when did this occur?
• Pipe, chewing tobacco use should also be noted.

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Alcohol

• Do they drink alcohol?
• If so, how much per day and what type of drink?
• Encourage them to be as specific as possible.
• If they don't drink on a daily basis, how much do
  they consume over a week or month?

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Other Drug Use

• Any drug use, past or present, should be noted.
• Remind these questions to assist you in
  identifying risk factors for particular illnesses
  (e.g. HIV, hepatitis).
• Respect their right to privacy and move on.

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Work/Hobbies/Other

• What sort of work does the patient do?
• Have they always done the same thing?
• Do they enjoy it?
• If retired, what do they do to stay busy?
• Any hobbies?
• Participation in sports or other physical
  activity?
• Where are they from originally?

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Work/Hobbies/Other

• It is nice to know something non-medical.
• This help improve the patient-physician bond.
• It also gives you something to refer back to
  during later visits, letting the patient know
  that you paid attention and really remember them.

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Family History

• In particular, you are searching for heritable
  illnesses among first or second degree relatives.
  
• "Heart disease," valvular disorders, coronary
  artery disease and congenital abnormalities

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Family History

• Find out the age of onset of the illnesses, as
  this has prognostic importance for the patient.
  (MI at age 70 is not a marker of genetic
  predisposition while one who had a similar event
  at age 40 certainly would be).

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Family History (CIRCLE ANY CONDITION WHICH YOU OR
ANY BLOOD RELATIVE HAVE HAD)

• Arthritis
• Cancer
• TB
• Stroke
• Diabetes
• High Blood Pressure

• Epilepsy
• Psychiatric Disorder
• Anesthesia Problems
• Osteoporosis
• thyroid disease
• hepatitis
• Other

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Obstetrical History
(where appropriate)

• Have they ever been pregnant?
• If so, how many times?
• What was the outcome of each pregnancy

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Review of systems

• Questions about common symptoms in each major
  body system which may help to identify problems
  that the patient has not mentioned

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Review of Systems (ROS)

• The most important ROS questioning (i.e.
  pertinent positives and negatives related to the
  chief complaint) is generally noted at the end of
  the HPI.

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Review of Systems (ROS)

• Characterize patient's overall health status
• Review systems/symptoms from head to toe

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REVIEW OF SYMPTOMS

• PURPOSE A WAY TO MAKE SURE YOU DID NOT MISS A
  PROBLEM

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REVIEW OF SYMPTOMS

• HEAD
• EYES
• EARS
• NOSE
• THROAT
• MOUTH
• CHEST

• HEART
• ABDOMEN
• MUSCULOSKELETAL
• NEUROLOGICAL
• ENDOCRINE
• SKIN

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Review of Systems (ROS)

• In actual practice, most providers do not
  document such an inclusive ROS. The ROS
  questions, however, are the same ones that, in a
  different setting, are used to unravel the cause
  of a patient's chief complaint.

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Review of Systems (ROS)

• It is probably a good idea to practice asking all
  of these questions as well as noting the
  responses so that you will be better able to use
  them for obtaining historical information when
  interviewing future patients

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Physical examination

• General appearance
• Vital signs
• HEENT Includes head, eyes, ears, nose, throat,
• Oral cavity
• Neck
• Breasts and axillae

• Thorax and lungs
• CVS and peripheral vascular system
• Abdomen
• Genitalia
• Anus and rectum
• Musculoskeletal system

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Physical Exam

• Neurologic
• 1,Mental Status
• 2,Cranial Nerves
• 3,Motor Strength
• 4,Function, Observed Ambulation

• Neurologic
• 5,Sensation (light touch, pin prick,
  vibration and position)
• 6,Reflexes, Babinski
• Cerebellar

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Lab Results, Radiologic Studies, EKG
Interpretation, Etc.
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• Problem list

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Assessment and Plan
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