This was a very early "novice" MS3 H&P I did on my pediatric floors rotation, with that in mind (be gentle)...
Start with ID/CC/HPI
It's also sometimes useful to "kick up" relevant PMH into your one liner to frame the listener's mind. For example:
Instead of
15 y/o Caucasian male complains of epigastric pain since this AM...
say
15 y/o Caucasian male w a h/o Crohn's disease, sclerosing cholangitis, multiple episodes of pancreatitis requiring hospitalizations x many times c/o epigastric pain since this AM
then you can follow this with an HPI including as many of your parameters as you can fit: onset, location, duration, quality, agg/all factors, radiations, timing, severity.
Patient was in his usual state of health until this morning when he awoke with 7/10 sharp pain in the epigastric region without radiations. The pain is described as being persistent with some waxing and waning, worsened by PO intake. He does feel nauseous but has not vomited. Nothing appears to relieve the pain in this instance but similar pain was relieved by Demerol in the past. Patient had an episode of emesis while this writer is writing this H&P without blood or bile present.
In the ED he was worked up for possible recurrence of acute pancreatitis, R/O other etiologies of epigastric pain. In the ED labs ordered were CBC, total CO2, lipase, amylase, AST, ALT, LDH, alkphos, and GGT. In the ED the decision was made to admit the patient for treatment of an episode of acute pancreatitis due to his epigastric pain, clinical presentation, history of presentations, lipase of 2248 and amylase of 523. On arrival of the floor patient claims his epigastric pain is 7/10 sharp without radiations.
This was my written ROS. In an oral ROS you would give pertinent positives and then pertinent negatives.
In the past few days, he denies any changes in the quantity of PO intake, no recent weight loss, no fever or chills, no diarrhea, no rash. He denies having any current oral lesions or anal pain. His normal habitus is one bowel movement per day which is formed stools without hematochezia or melena. Mom claims patient ate "a pound of cheese" 1 day PTA but patient denies such behavior.
Then you can just go through your laundry list of PMH but only relevant bits, probably leave out birth hx, immunizations, WCC, etc.:
Crohn's disease diagnosed age 13, last exacerbation of Crohn's disease more than one year ago
Sclerosing cholangitis diagnosed age 13
Recurrent pancreatitis with 6 recalled exacerbations, last exacerbation 1 year ago
Hospitalizations x 7
Colonoscopy with biopsy in Mar 20xx
Denies having had prior surgery
Birth at 37 weeks NVSD without complications
Immunizations UTD
WCC per AAP guidelines
Then quick medlist/all/FH/SH. Here's what I wrote. I wouldn't spout off all that SH though.
Ursodiol 300 mg by mouth twice daily
Methotrexate 0.8 mL IM once weekly
Folic acid 1 mg by mouth 5 days a week, 2 mg by mouth 2 days a week
MVI once daily by mouth
Celexa 10 mg by mouth once daily
Remicaid Infusion last infused xx/xx given approximately every 8 weeks
Allergies: NKDA, but Toradol, Ibuprofen increase epigastric pain
FH: Cousin with SLE , Cousin with ? IBD vs IBS
SH: Patient is a 10th grader at C------- high school where he is an "As" and "Bs" type student who plays hockey, baseball, and golf. He wears a helmet/mask for hockey and bike helmet (though mom denies bike helmet use). He enjoys surfing at the beach in R-------. He lives in house with mom, dad and sisters aged 17 and 10. Father smokes cigars outside in the woods but there's no exposure to smoke indoors. No pets reside at home. The house has smoke alarms. Patient claims use of seat belts. For diet yesterday patient ate cereal for breakfast, no lunch, chicken nuggets for dinner, and crackers for a midnight snack.
Then your PE: as a med student state your vitals, for things that aren't close to the matter at heart you can say unremarkable. Like cardiac exam was unremarkable. Spend more time talking about your relevant systems, like in this instance your abd exam and rectal.
Physical Exam:
T 98, RR 20, BP 115/53, HR 68, O2sat 98% on RA, weight 69.5 kg
GA: WDWN, uncomfortable, in NAD lying in bed
HEENT: NC/AT; TMs clear B/L; PEERLA, EOMI, RRx2, nonicteric; Nares slightly erythematous, patent; No gross oral lesions, uvula M/L on phonation +MMM
Neck: Supple, no lymph node adenopathy
Resp: CTA B/L without adventitious sounds, good air entry and inspiratory effort
CV: RRR S1 S2 without murmurs; Pulses 2+ rad B/L, 2+ dorsalis pedis B/L
Abd: BS+, soft, ND, +RUQ tenderness, +epigastric tenderness, no rebound, no guarding, no peritoneal signs, no mass, no HSM
Ext: warm and dry; no cyanosis, clubbing, or edema
Neuro: CN II-XII intact, 5/5 strength in all four limbs, sensation intact to sharp and dull
Skin: no rashes, no jaundice
Rectal: heme neg, no visible lesions
State relevant labs then...
can gloss over normal labs like say CBC was WNL, transanimases were normal, bilis normal, e.g.
lipase 2248
amylase 523
AST 24
ALT 17
LDH 235
Alkphos 355
GGT 14
Then your A&P, generally restate pt's age and sex...
15 year old Caucasian male with history of Crohn's disease, sclerosing cholangitis, and recurrent pancreatitis with 6 major episodes in the past exhibits sharp RUQ and epigastric pain as well as increase lipase and amylase tends to favor an acute presentation of pancreatitis consistent with the clinical presentation of previous episodes. WBC is not elevated which suggests a non-infectious etiology. Patient's Crohn's appears to be asymptomatic currently.
Then entertain other things that you might put in a differential:
Acute hepatitis origin: though there is RUQ tenderness no hepatomegaly noted and ALT and AST are not increased
Biliary colic: not generally of a waxing and waning nature, consider U/S to more confidently R/O biliary tree involvement
Biliary obstruction: pain is of constant nature, and somewhat in a corresponding location but bilirubin is not elevated, not suggestive of obstruction, consider US
Sclerosing colangitis: Alkphos is elevated but GGT is not. There also appears to be no bilirubin retention. Consider US to evaluate biliary tree.
Then lastly your plan:
Admit to peds medical/surgical floor
Pancreatitis: Keep NPO for bowel rest, treat pain symptomatically, IVF at 1 times maintenance at approximately 170 cc/h for 70 kg boy
Crohn's disease/GI dz: Patient appears to be in current remission. Recheck rectal. Abd U/S Pending to R/O CBD dilatation and/or obstruction, other ductal involvement
Repeat labs in AM to reassess most likely what is pancreatitis: lipase, amylase (lipase more sensitive). Also order Chem 10 since one was not ordered in ED to assess electrolyte status, renal function
Demerol PCA for pain
GI prophylaxis: IV famotidine 20 mg q 12 h
Nausea treatment/prophylaxis: Zofran IV
GI primary admit, Red inpatient management team to follow
To discuss with resident/team/attending