HPI note - Is this way of documenting ok?

[aimskyhigh]

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[Boricua27]

What exactly are you not sure about..the use of slashes? I've never seen so many slashes, and you might as well use commas. In terms of the HPI you have the epidemiology (age and sex) and maybe could include risk factors like recent sick contacts. In terms of clinical presentation you have important positive and (pretty much all) important pertinent negatives. You could also emphasize the most relevant pertinent negatives (respiratory symptoms, lymphadenopathy, muscle pain, nausea, diarrhea, etc) and write them together, and the other less pertinent negatives you can say something like "ROS otherwise negative".

 

[durus0]

Not sure what the question is, but if you think you will be able to ask that many ROS questions for every patient, no way!

 

[Ismet]

You're allowed to say "ROS otherwise negative" for things that aren't pertinent.

You also need to fit past medical history, surgical history, family history, and social history in your HPI.

See the two sample patient notes on the USMLE website here: http://www.usmle.org/practice-materials/step-2-cs/patient-note.html

Also be very careful with what you abbreviate. "C/o" and "HR" are not on the list of abbreviations.

 

[aimskyhigh]

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[aimskyhigh]

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[Ismet]

Here's one that I did, but went over 2-3 minutes. I was typing fast and wasn't correcting spelling or grammar... I plan to use all caps, is that ok?

lol... I just noticed I wrote Aspirin induced Gastritis instead of Ibuprofen. I guess my brain just gives up too in the middle of anxiety attack.
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HPI- 34 YO F C/O ABDOMINAL PAIN
-MIDEPIGASTRIC PAIN STARTED 2 DAYS AGO, INTERMITTENT 1X/DAY, GETTING WOSE, 2-8/10, NO RADATION, BURINIGN\ NATURE WHICH IS ALLEV BY FOOD AND MILK, AND ANTACIDS, AND AGGREV BY EATING FATTY FOOD LIKE PIZZA.
-SHE FELT NAUSEATED AND VOMITEDE 1X YESTERDAY, VOMIT WAS YELLOW WITH MUCOUS, NO BLOOD.
-DENIES CONSTIPATION/DIARRHEA OR STOOL COLOR CHANGE , URNINARY CHANGES, WT AND APPEITIE CHANGES.
ROS- NEGATIVE EXCEPT AS ABOVE, ALL-NONE, MEDS- IBUPROFEN FOR 1 YR FOR ARTHRITIS AND GASTRIC PAIN, AND MALOX FOR ABD PAIN. PMH- UTI RX W/ AMOXICILLIN 1 YR AGO REST AS ABOVE, SXH- SEXUALLY ACTIVE WITH HUSBAND, SH- DENIES TOBACCO, ETOH, ILLICIT DRUGS.

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When is your exam? I'm going to be blunt and honest, because there's a lot of money and time on the line, but if your exam is very soon, I don't think you're ready.

My thoughts:

#1. PLEASE do not use all caps. Ever.

For your HPI:
- You NEED to review the abbreviations list and stop abbreviating so many things. The abbreviations list (here on page 13) is not meant to be a complete list of all acceptable abbreviations, but those are the ones they will be sure to recognize and understand. You should honestly play it safe and just assume that if it's not on the list, you shouldn't use the abbreviation. You get a sheet of the abbreviations at each note-writing station on test day, so you should familiarize yourself with it.
- "C/O" "Allev" "aggrev" are not acceptable abbreviations.
- "All" is not an acceptable abbreviation for allergies.
- The correct abbreviation for Social History is SH or SHx. Sexual history is included in social history
- No one cares that the UTI in the PMH was treated with amoxicillin, and 1 UTI in the past for an adult female is not that pertinent to put in the note. Unless the UTI was recent and you think it may be related to the current illness, but then it doesn't belong in the PMH, it belongs in the HPI.
- What is the "gastric pain" that she has been having? Would you say she has a history of chronic or intermittent abdominal pain and this is an acute pain on top of that?
- CC of abdominal pain - ask about surgical history (especially abdominal/pelvic and cardiac surgeries)
- Need family history too

A more acceptable HPI would be:
34 yo F with h/o intermittent abd pain here with 2 days of worsening mid-epigastric abdominal pain, burning 2-8/10 pain without radiation. Improves with food, milk, and antacids, worse with fatty food. Nausea and emesis x1 yesterday, non-bilious, non-bloody. No constipation/diarrhea, dysuria, anorexia, or weight loss. ROS negative except as above. NKDA. Meds-ibuprofen daily, antacid. PMH- Arthritis, no surgeries. SHx- No tobacco, ETOH, drug use. Sexually active with husband.

For your PE:
- More unnecessary abbreviations. Spell things out.
- "H" and "L" are not acceptable abbreviations for Heart and Lung. It doesn't take that long to write those words.

For your Differential and Plan:
- You would lose MAJOR MAJOR points for not listing cholelithiasis or cholecystitis as your #1. The patient had a positive Murphy's sign, nausea and vomiting, and got worse after eating fatty foods. FAT FERTILE FEMALE FORTY with all of these symptoms = most likely gallbladder.
- Why would you do a pelvic and rectal exam for this???
- What labs other than CBC do you think would be helpful in this situation?
- What imaging study is used to evaluate the gallbladder? You have cholecystitis on your differential and nothing in your plan to evaluate for it.

 

[aimskyhigh]

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[Ismet]

You won't fail for using all caps. You won't fail for a few confusing abbreviations. You won't fail for a few misspelled words. If you do a lot of those things all together, on every note, and it's hard for the reader to make sense of what you're writing, then your ICE score will go down.

You don't have to write about everything the patient says. A single UTI at age 22 is not pertinent past medical history in a 34 year old woman with epigastric pain. Recurrent UTIs, that's a different story.

Re: pelvic and rectal. Only if clinically indicated. Do you honestly do a pelvic and rectal exam on all your patients with abdominal pain? The woman's pain is epigastric. Your differential was PUD, gastritis, and cholecystitis. How would doing a pelvic or rectal exam contribute to your diagnosis of one of those things?

Re: labs. LFTs, amylase/lipase. Could do a UA to eval for renal stones. I'd also do a pregnancy test.
Urea breath test is the one for PUD, not hydrogen breath test. HBT is for malabsorptive disorders and SBO.

 

[aimskyhigh]

Thank you for your help...

 

[Ismet]

Because the pain started after he lifted heavy boxes. It's an acute pain. Worse with movement and coughing, worse when sitting for long periods of time.