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writing hpi. anyone good with this crap?

Discussion in 'Medical Students - MD' started by YouDontKnowJack, Feb 14, 2006.

  1. YouDontKnowJack

    YouDontKnowJack I no something you don't 5+ Year Member

    Apr 21, 2005
    I've written several h/p papers in the past. but each time, I get different and conflicting comments about my writing. I mean, an HPI is how the patient tells his story. How does an instructor tell me the hpi isn't good enough if that's how the patient told the story?
    Could someone comment on this hpi? The instructor said that when you have a 1 paragraph HPI like the one below, you know you've farked up. :sleep: :sleep: How can I improve this hpi?

    About 3 years ago, DA walked down a hallway to visit her cousin, who was her neighbor at her former residence nearby, after doing her laundry. Before she got to her cousin’s door, she tripped on what she assumed was a rock, and fell forward onto the ground, breaking her fall with her left knee and left wrist. Her bones broke in these 2 areas. This was the first time she had broken her bones. She was treated at Mt. Sinai for 2 weeks following the incident. Her wrist and knee were bound up in a cast, and subsequently, she was given physical therapy to improve mobility of her wrist and knee. Last May, after her former residence was demolished, her family brought her to -omitted- Home for care. She has been asthmatic since she was in her 60’s and had taken cortisone inhalers for many years for treatment of asthma. She currently uses a walker and cane to walk outside her room.
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  3. trudub

    trudub Senior Member 7+ Year Member

    Oct 23, 2003
    I think it is just way too wordy. I don't think it should be in story format. Get what the patient told you in the HPI but condense it. Basically, just like I said, it is too wordy.
  4. YouDontKnowJack

    YouDontKnowJack I no something you don't 5+ Year Member

    Apr 21, 2005
    Here is a sample HPI i grabbed off the internet. it's supposed to be good, according to several doctors

    Yesterday morning while eating lunch patient had the sudden onset of sharp, R eye pain accompanied by decrease in vision. Pain was worse with coughing, unchanged by position, unrelieved by tylenol, aspirin or percocet. When the pain started, he "couldn't see the clock." He also had difficulty determining the numbers on the telephone. No blurred vision or diplopia. Vision is the same whether he covers right or left eye. He had nausea and vomiting x2--NB/NB at the onset of the pain. Was unable to give niece directions to hospital--unable to decide whether to make right or left turns. Pain and visual changes persisted through the night. No photophobia. No dizziness, weakness, dysarthria, CP, palpitations.

    So, in this case, the patient gave the interviewer a lot more information.

    My dilemma is, i don't wanna write BS, but the assh0le prof says it's too short. WTF?

    My patient fell and broke her bones just this once. one time deal! she's been on glucocorticoids for extended periods of time, and she's got osteoporosis. That's it. I can't write more than one paragraph for this crap.
    We've all read Bates. We know what questions to address. What aggravates it? How long? this was an acute case, and the patient healed up nicely. these questions don't apply.
    here's another place where they encourage using story format for hpi.
  5. angel80

    angel80 Senior Member 7+ Year Member

    Jan 27, 2006
    What you wrote isn't really an HPI. It's more like a PMH, but in a story rather than list format. The HPI is supposed to expand upon the chief complaint. If the patient doesn't give you enough info, you need to ask the appropriate questions until you get the whole story.

    What was this patient's chief complaint?
  6. StickMe

    StickMe Registered Loser 5+ Year Member

    Jan 15, 2005
    Here's how I learned to do an HPI. Yes, it's subjective information but it doesn't have to be the patient's "Story."

    Identifying information: age, gender, history of serious illnesses/diseases
    Attributes of Chief Complaint: duration, location, severity, quality, setting, what makes it better, what makes it worse, associated symptoms
    Identify Risk Factors: (personally not too sure about this subsection.)
    Pertinent Positives and Negatives:

    Mrs. Smith is a 42 year old White Female with Type 2 DM presenting today with R ear pain x 4 days. Patient describes pain as constant with a level of 7. She was at a party and was in a hot tub approximately one week ago. Takes tylenol for the pain and warm compresses. Also complains of purulent discharge from R ear. Complains of some hearing loss to R ear. No vision changes or facial weakness.

    Take the patient's story and include what the medical team wants to know while leaving out the filler as much as possible.
  7. YouDontKnowJack

    YouDontKnowJack I no something you don't 5+ Year Member

    Apr 21, 2005
    essentially, there was no real CC. We were just there for a check up & for practice.

    my case was a hard one.
    my pt is 86y.o. Broke her wrist and knee like 3 years ago. She moved into the nursing home just half a year ago, and we were just there to interview her.
    her wrist and knee were all healed up by that time.

    Anyhow, the whole purpose of the paper was to document why my pt had been admitted to the nursing home. According to her records, she was admitted for treatment of or osteoporosis. so the chief complaint revolved around that.

    my HPI was supposed to document all the crap since her fall, all the way up to the time she was admitted to the nursing home. that was the assignment handed to us

    She fell. she was old. she cracked some bones. way way post menopause. she used steroid inhalers (hint to med team: causes osteoporosis). What else could a doc wanna know....
  8. Krazykritter

    Krazykritter Senior Member 7+ Year Member

    Nov 4, 2005
    We are taught to use OPQRSTA criteria under the HPI so that you get the critical infomation in a precise way;
    O = Onset
    P = Provoking/Palliative factors
    Q = Quality (i.e. dull or sharp)
    R = Radiation
    S = Severity/Scale
    T = Timing
    A = Associated symptoms (that the pt. associates to their CC)

    Having a quick reference always helps me to remember to get everything I need. Hope this helps.
  9. noncestvrai

    noncestvrai Member 5+ Year Member

    Feb 18, 2005
    No matter how I changed the way my HPI was written, there is always something "better"...even if I get honours in after consideration, I found that each prof has his/her own subjective appraisal. Don't fret, check HPI's in charts, you'll see how condensed they are...especially in surg, that's what I'm finding out now...

    Now, if I can get this case report done...

  10. jennyboo

    jennyboo Senior Member 7+ Year Member

    Jun 11, 2004
    Follow-up outpatient visits are tough when the attending seems to want you to write a "classic" H&P with chief complaints (when there clearly aren't any). But in your case, the chief complaint could be "fall."

    CC: fall

    HPI: "86F with history of asthma maintained on inhaled steroids and osteoporosis, who was admitted to ______ Nursing Home three months ago for inability to perform ADLs secondary to unsteadiness on her feet. She has a history of a fall after tripping three years ago, resulting in left knee and wrist fractures. She has since received physical therapy and uses a walker and cane when outside her bedroom."

    She states that her fall three years ago occurred when she tripped over a rock while walking along a sidewalk. She fell on her outstretched left hand and knee and describes immediate sharp localized pain after the impact with increased swelling and pinpoint tenderness after an hour. The pain was constant and not improved with Tylenol or Percocet. She was driven to the emergency room by her cousin, where she was x-rayed and admitted to the orthopedic service........"

    PMH: 1. Osteoporosis s/p wrist, knee fractures in 2003. 2. Asthma (on inhaled steroids) since 1960s.

    That is what would go in a practical note. But since your attending is probably trying to teach you to document a history of symptoms, go with the OPQRSTA thing. Next time, just pretend that this isn't a nursing home visit but an acute visit, and make up the OPQRSTA.
  11. SurfingDoctor

    SurfingDoctor "Hooray, I'm useful" Physician Faculty 10+ Year Member

    Indeed, it's not the information collected, but the presentation of it.

    "About 3 years ago, DA walked down a hallway to visit her cousin, who was her neighbor at her former residence nearby, after doing her laundry. Before she got to her cousin’s door, she tripped on what she assumed was a rock, and fell forward onto the ground, breaking her fall with her left knee and left wrist. Her bones broke in these 2 areas. This was the first time she had broken her bones. She was treated at Mt. Sinai for 2 weeks following the incident. Her wrist and knee were bound up in a cast, and subsequently, she was given physical therapy to improve mobility of her wrist and knee. Last May, after her former residence was demolished, her family brought her to -omitted- Home for care. She has been asthmatic since she was in her 60’s and had taken cortisone inhalers for many years for treatment of asthma. She currently uses a walker and cane to walk outside her room"

    CC: "I'm here for a check up" <-- Cheif complaint's should be in the patient's words

    HPI: DA is 86 y.o female who comes to clinic for routine follwup. Pt.'s main issue began approx. 3 years ago when she fell at a neighbors house, breaking her L knee and wrist. She was hospitalization at Mt. Sinai for 2 weeks with (what type of breaks, open, closed, comminuted ?) and received PT/OT. Currently (what ever her current status is with these breaks, okay, pain, limited mobility?)

    PMHx: Asthma - approx 60 years. Well controlled
    Osteoporosis - s/p fall w/ fractures, uses walker

    Meds: Inhaled corticosteroids

    Allergies: None

    Fam Hx: Asthma

    Social Hx: Lives in nursing home after her previous house was closed down.

    You get the idea. You had different parts of the history all in the same section. The HPI should be essentially a condensed chronological narrative of the current complaint or medical issue. Other medical issues that aren't relevant to the cheif complaint should be address in the past medical history.
  12. footcramp

    footcramp Senior Member 5+ Year Member

    the hpi is not how the pt tells the story. if you did that, your hpi would be 10 pages with a bunch of stupid irrelevent comments about how she farted on the drive over to the hospital, how the weather sucks, and how rocky her marriage is. the hpi is how you tell the story, while integrating pertinent information and presenting in a logical order.

    reading this HPI, i have no idea why she is seen, no idea what her issues are, no idea why you mention these past incidents, and no information about many other details. why does she use a walker - does she have osteoarthritis? is it secondary to injury to the knee? why did she fall - did she have syncope, dizziness, or decreased proprioception? is this an isolated incident or has she fallen other times? where exactly were the fractures, especially for the knee? if she is being taken care of at home, are her medical needs being met? has her cortisone use led to any side effects? any complications, such as oral candiasis, pneumonia, opportunistic infections? (usually inhaled steroids do not lead to systemic complications though it is possible.) why does she use a walker? due to pain, loss of balance, etc?

    in essense your HPI presents a bunch of random facts in hapzard order and displays no processing of information, no synthesis, and no critical thought.
  13. robotsonic

    robotsonic Senior Member 5+ Year Member

    Oct 10, 2005

    When you are starting out writing HPIs it's difficult to know what is important and what isn't. When I read your HPI, it was clear that you had no idea what you should or should not include. The fact that she was visiting a neighbor who happened to be a cousin is completely irrelevant - and yet you mention it in the first sentence! That first sentence is very valuable territory, and it should pretty much summarize the entire focus of the H&P. It should give the reader/listener a very clear idea of what they should be focusing on. When you go on and on about visiting a neighbor and assuming there was some rock on the ground, I have no idea where you are going. As others mentioned above, a good first sentence goes like this: "DA is an 80 year old woman living at ___ Nursing Home with a history of asthma and osteoporosis who presents today for a routine visit." Just from this sentence, you pretty much know where I'm going, and you know what things you should start thinking about. You should be expecting me to elaborate on her main issues, even if there is no actual "chief complaint" from the patient.

    Also, the HPI is not the patient's story, but your "story" of the patient. There is a difference. Patient's often give you a ton of useless information - it is your job to put it together into a coherent whole, into a standardized format that physicians use to communicate important information. Like cliched fairy tales, HPIs are stories with pretty structured formats. Although you might not really understand the logic in this yet, you will understand once you start reading tons of H&Ps written by residents - it's so nice to get a well-organized H&P, with all of the relevant information exactly where you expect it.
  14. liveandlearn

    liveandlearn Senior Member 5+ Year Member

    May 26, 2005
    here's an example that i wrote. i hope this helps. Learning by example is about the only way i can think of to help you. Just literally say almost the same thing. Dont forget pertinent negatives and pertinant postives etc. There should be essentially a laundry list of complaints that you asked about that normally go in your ROS but since they are relevant you move them to you HPI so people dont have to go flipping through 7 pages to find out if the patient had nausea. (e.g. in the example you posted about eye pain. the provider should have listed whether the patient had nausea or not. you should be able to essentially make a diagnosis from the HPI)

    heres my example

    "Mr. Cook is a 51 year old male complaining of “burning chest pain for the past two days.” The patient states that a burning pain began when he woke up two days ago, and since then, the pain has intensified. He rates the pain a 5 out of 10, 1 being no pain, and 10 being unbearable pain. Mr. Cook says that the pain is now constant and it is only slightly alleviated when he lies down with his upper body elevated by two pillows. The patient states that the pain is most intense at the middle of his chest, but radiates down to his belly button. Mr. Cook mentioned that he has been experiencing mild shortness of breathe upon exertion that started at the onset of the chest pain. He has been taking 500 mg of Advil tablets by mouth as needed for the past two days to alleviate the chest pain, but states that the Advil is no longer helping. Patient denies any loss of appetite, nausea and vomiting, irregular bowels, hemorrhoids, hematemesis, changes in stool, flatulence, jaundice, and any history of previous gastrointestinal work-up. Patient denies any palpitations, shortness of breath, paroxysmal nocturnal dyspnea, edema, hypertension, myocardial infarctions, exercise intolerance, phlebitis, and denies ever having a electrocardiogram. The patient denies any fatigue, malaise, night sweats, weight change, or chills. He denies any taste changes, sore throat, difficulty swallowing, mouth sores, tooth problems, or tongue pain. He denies any enlargement, soreness, swelling, or masses of the lymph nodes. The patient denies any family history of similar episodes. Mr. James states that he is in generally good health and denies any history of any type of chest pain before this episode. He denies taking any other medications or herbal remedies for his current symptoms. His primary care physician is Dr. Jones."
  15. azzarah

    azzarah sleepy! 10+ Year Member

    Jul 19, 2003
    This is a xyz year old WF with a PMH significant for asthma x 30 yrs now on chronic steroids, blah, blah, and blah who presents here today with a chief complaint of blah blah....She states that she was in her usual state of health until XYZ days ago when blah blah happened and she blah blah.....

    Here are some questions I thought of as I was reading your HPI....maybe answering these will help you beef it up.....

    Why did the patient trip and fall? Did she have vertigo? Did she trip over something? Does she peripheral neuropathy? Did she "faint?" Did she fall b/c her vision is poor because she has cataracts from the steroids, etc.

    How do you know she has osteoporosis from using steroid inhaler for asthma? Could she have other risk factors? How old is she? What does she do? What was her activity level before this incident?

    What kind of fracture did she have? what do you mean she broke her knee? What bones did she break in her wrist? Did the radiographs show evidence of osteoporosis?

    How long did she have PT? What is the range of motion in her joints now that she has to use a walker?

    Hope this helps! good luck!
  16. YouDontKnowJack

    YouDontKnowJack I no something you don't 5+ Year Member

    Apr 21, 2005
    Hey people. great tips. very enlightening. But I still have a small problem... I already know the diagnosis even before I write the H&P.

    I know she has osteoporosis because she's taking fosamax as ongoing treatment. Her medication gives the diagnosis away.
    (Had I not known about the fosamax, I would've used osteoporosis as a differential-- She's 86 years old. no estrogen + steroid inhalers.)

    So.... If your Chief Complaint is: 86yo cuban female, admitted for treatment of osteoporosis.
    What do you talk about in the HPI? fall, fracture, use of inhalers? History of osteoporosis?
    Can you even write an HPI on something that has been diagnosed?

    CC: Tx of osteoporosis?
    HPI: history of osteoporosis? "X years ago, her doctor said she had osteoporosis"??
    PMH: past Dx: osteoporosis

    This kind of paper just seems funky.

    I've written H&P's about acute problems like chest pain and HTN, where you don't know the diagnosis beforehand. I've never been given this kind of assignment, where I'm told the diagnosis beforehand. :mad: :mad: :thumbdown: This is why I had trouble with this HPI.
  17. footcramp

    footcramp Senior Member 5+ Year Member

    it's not just about the diagnosis. you should also put it in context. as others have mentioned already, you need to dig deeper. so say a person has osteoporosis... what caused it? are there any other causes that you should account for as well? does she have any fractures? does she have future risk of fractures? (i.e. what's her bone density) when was her last DEXA? what medications is she on? are they effective, any side effects? what exercise regimen? is there a danger in the home? does she have ongoing issues that may exacerbate further bone loss (such as steroid use).

    your HPI isn't just about the diagnosis. it's about framing the pertinent information to not only communicate the main issues, but also put it in context so that it is clear what needs to be done.

    ask yourself, what information can you get from this:

    CC: tx of osteoporosis, HPI: hx of osteoporosis, PMH: osteoporosis...

    from the information there i have no context, i have no idea what medications or adjustments i should do. you need to give as much information as possible to justify your course of action, or to guide it for others. i think from your frustration it's likely that you just let the attending handle all the management after dumping some basic info to them. you should think of yourself in the role of the caretaker and try to anticipate what kind of information will help you make the right decision, not just the right diagnosis.
  18. liveandlearn

    liveandlearn Senior Member 5+ Year Member

    May 26, 2005
    and NEVER, NEVER put "cuban" female. she is a female. you are asking to get sued.
  19. YouDontKnowJack

    YouDontKnowJack I no something you don't 5+ Year Member

    Apr 21, 2005

    :thumbup: :thumbup:
  20. azzarah

    azzarah sleepy! 10+ Year Member

    Jul 19, 2003
    I second that! :thumbup:
  21. azzarah

    azzarah sleepy! 10+ Year Member

    Jul 19, 2003
    Also, read a bit about osteoporosis on E-medicine or up-to-date, to make sure you've covered all the main points in your HPI. GOOD LUCK! :luck:
  22. emack

    emack Senior Member 5+ Year Member

    Oct 30, 2005
    I've heard "use the patient's own words", too, and different people will expect different levels of subjectivity. That being said, you still have to do a lot of filtering. I believe it's appropriate to use direct quotes sometimes, for example when describing the patient's pain: 'Pt describes a sharp RUQ pain, "like a toothache in my belly."' Or in the above case, it might be appropriate to mention that this woman believes her fall was caused by tripping (and then mention pertinent negatives: "Denies pre-syncope, dizziness, etc prior to fall.")
  23. YouDontKnowJack

    YouDontKnowJack I no something you don't 5+ Year Member

    Apr 21, 2005
    ok. round 2. HPI's are easier read than done.
    I have another patient to write about.
    Apparently, the paper graders don't like concise and short HPI's.

    Can anyone help me improve this hpi?
    Basically, this pt has a foot ulcer.... and I have to describe the crap :mad:

    "FS is a 42 y.o female with a history of IDDM who presented with a sore on the dorsum of the left foot, which began 4 days ago. She was well until 4 days ago. She denies ever having such injury prior to this incident. She believes that the abscess might have started as a blister from shoe friction. She applied Neosporin to the wound without improvement. However, the wound has not worsened or changed in size. The abscess is accompanied by persistent stinging pain, rated 5/10, especially in contact with foot apparel while walking (which she doesn’t do much) or standing (which she frequently does as a hotel maid). The pain goes away when the foot is immobilized and not in contact with anything. She took 2 tablets of adult strength Tylenol to try to relieve the pain, but without improvement.
    Other significant factors: She was diagnosed with IDDM in 1993, and has been taking insulin since then. She denies any illicit drug use. She mentioned wearing socks and stockings at the time of injury onset. She complained of frequent swelling in the calf and feet of both legs. For the past 4 days, she has been wearing slippers instead, and has had some rest with feet elevated. This relieved the leg swelling. Her previous physician mentioned that she has poor vascular circulation in her legs. Varicose veins are present from the thigh down. She has a chronic condition of dry, scaly, hyperpigmented skin in the distal third of her legs. She frequently applies lotion, but it fails to improve the condition.

    Thanks for reading, peeps
  24. Blue Dog

    Blue Dog Fides et ratio. Physician Gold Donor SDN Advisor Classifieds Approved 10+ Year Member

    Jan 21, 2006
    Provided all relevant information is present, short and concise always beats long and wordy. ;)

    FS is a 42 y/o African-American* female with a 16-year history of insulin-requiring diabetes who presents with a four-day-old ulceration to the dorsum of her left foot. She has a history of "poor circulation" and varicose veins with chronic dependent edema and xerosis. She has no history of prior foot ulcers. There is no history of trauma, although she did note an antecedent blister, arising from her job as a housekeeper. The wound is painful, "stinging", rated 5/10, worse with contact and walking, improved with rest and elevation. OTC analgesics and Neosporin have not been helpful.

    That's six sentences to your nineteen, encapsulating essentially the same relevant information.

    I put "poor circulation" in quotations because this is presumably in the patient's own words. It's not clear whether she suffers from peripheral arterial disease or chronic venous insufficiency, although it's probably the latter.

    Resist the temptation to throw physical exam findings into the HPI.

    *Regardless of what some people tell you, race/nationality is frequently relevant, and should usually be included.
  25. azzarah

    azzarah sleepy! 10+ Year Member

    Jul 19, 2003
    Also whenever someone has diabetes, it might be useful to mention her glycemic control (last HgBA1C) and if the patient has a history of peripheral neuropathy or other -pathies (retinopathy, etc.) so people get an idea of how far advanced her diabetes is and her level of sugar control. Good luck!

    BTW, this one is much more thorough and easy to understand than the first one you posted! See, you are getting so much better! Practice makes perfect! :thumbup: :thumbup:
  26. 8744

    8744 Guest

    Dec 7, 2001

    CC: Difficulty walking and opening jars.

    HPI: Mrs. Smith is a 70 y.o. woman with no significant PMH presenting for followup from Mt Sinai hospital for an osteochodral fracture of the patella and an ulnar styloid fracture sustained on 2/3/06. The patient recieved physical therapy to improve the mobility of her wrist and knee after they had healed but still requires a walker or a cane for her activities of daily living.


    1. Asthma, mild persistant.

    PSH: None


    1. Flovent 44 mcg/spray 2 puffs INH BID
    2. Albuterol 90 mcg/spray 2 puffs INH q4-6H prn

    etc. Tripping on rock is irrelevant most of the time unless, well, it is relevant.
  27. 8744

    8744 Guest

    Dec 7, 2001
    I definitely think we need to rethink how we write our HPIs. By careful choice of words you can make them shorter, more concise, more informative, and thus more likely to be read.
  28. YouDontKnowJack

    YouDontKnowJack I no something you don't 5+ Year Member

    Apr 21, 2005
    thanks for the tips again.
    you guys rock.

    funny thing is, a handful of people in my class have 2-3 page HPI's, 12pt font, single spaced. it's ridiculous. Panda Bear is right. I wouldn't want to read that.

    Honestly, if i turned in this 4-line hpi, they'd give me an F.
    But it's a stupid exercise they torture us with. When we get to the wards, we won't have to write this lengthy crap anymore, thankfully.
  29. flop

    flop Junior Member 7+ Year Member

    Jan 17, 2006
    I hated writing these as well as a second and third year. I complained all the time and just never understood how it was useful.

    That being said, you get to a point where you are no longer scrutinized and you just know what to write (it's almost automatic). I think it becomes a blend of the full H+P (full ROS and all) and your knowledge of medicine. When your knowledge (clinical) improves you'll find H+P's become much easier. FYI all the BS they teach about these in 2nd and third year is actually mandated by billing, hippa etc. It is useful to know, but painful, I agree.
  30. Writing H&Ps just takes practice. I remember starting off as an MSI, trying to make sure they were as comprehensive as possible - I would include minutae like the patient's descriptions of every single hospitalization for unrelated illnesses, previous occupations, etc. As I went through med school I learned to pare it down, and going through surgery internship I really learned to be concise, succinct and to-the-point (NOT lazy and rushed). I also had to re-remember what extra things to add for different rotations:

    Peds surg - APGARs, complications after birth, NICU stays, etc.
    Gyn onc - Age at menarche/menopause, menstrual triad, etc.
    Ortho - Full musculoskeletal/neuro exam of pertinent extremity
  31. Zweihander

    Zweihander Billygoat Gruff Gold Donor Classifieds Approved 10+ Year Member

    Jun 8, 2003
    maximum effort
    The "use the patient's words" point refers to the chief complaint, not the HPI. The HPI is a chronological presentation of what brought the patient to see you at the present time.
  32. azzarah

    azzarah sleepy! 10+ Year Member

    Jul 19, 2003
    I serioulsy doubt that! His HPI is excellent and captures all the information, which is the most important thing. :thumbup:
  33. eternalrage

    eternalrage Even Kal has bad days... 10+ Year Member

    Jun 22, 2005
    Long Island, NY

    Location, intensity, quality, onset, radiation, associated symptoms, aggravating factors, alleviating factors.

    Throw in PERTINENT crap from PMH and your ROS and you're gold.
  34. GoBuckeyes913

    GoBuckeyes913 Intoxicating 7+ Year Member

    Jan 23, 2007
    A lot of good advice here. You will get better with time, it just takes practice.

    My advice is mneumonics
    C: Chief complain
    H: HPI - with OPQRST as described in previous posts
    A: Allergies
    M: Meds
    P: PMH (past medical hx)
    P: PSHX (past surgical hx)
    S: Social/sexual history- include "TACOS" - T= Tobacco, A= alcohol,
    C=caffeine, O= occupation, S= sex/substance abuse
    F: Family Hx

    Then, include ROS.

    BONUS: Add a soap note to the above, and you now know how to write a consult :thumbup: (HPI+SOAP note= consult)
    Hope this helps:luck:
  35. lcsar


    Nov 5, 2008
    You will get very good at doing these (very quickly!) in third year. But when you start it's hard and confusing. Don't worry, once you're doing your clerkship and you have others notes to look at it makes it much easier.

    On the other hand, we had to do these in 1st and 2nd year and they were *expected* to be extremely comprehensive, minimum 2-3 pages long (most were much longer). Without any guidance, I wrote up the PMHx part in paragraph form! (As a note, this is WAY better done in bullet form).

    Everyone who posted above me is right - on the wards, concise and relevant is golden! And it varies by clerkship - in medicine my admissions were quite extensive (partly because you're getting the most complicated patients), but in surgery they were quite brief. Regardless, the format is usually the same:

    One sentence with the pt's age, sex, reason for showing up, and significant PMHx. (Ie, if they have chest pain I want to hear about their previous MI, multiple TIAs, DM, HTN and dyslipidemia in the first sentence, but don't care so much that they had their tonsils out when they were 7). This is the sentence that "sets the scene".

    Next is the HPI: Include all relevant info in a concise way. I do the OPQRST AAA for evaluation of symptoms, but you also need to know things like have they had it before, etc. Often it's the third (or 4th or 7th or 32nd) time they've been in, so you can compare this to previous events (Note: if you know you'll be pimped about this condition without having time to read up on it, think of this as your chance to learn on the fly! Ask them how it was treated, what the course of illness has been like, etc. Often you will find these questions will come in handy not only for pimping purposes, but that the attending wants to know these things about the patient!). Don't just ask "What makes it better, what makes it worse" - do you know if they've even *tried* anything to make it better? If you ask "Does anything make it feel better?" and they say "no", there's a big difference between if they simply haven't tried anything and if they've been popping T3's from their last surgery. You'll learn this as you go.

    Next is PMHx. Do this in point form with dates - remember it should be easy to read! I want to glance at it and see what's important. As someone above said, it should be noted how severe each thing is. Have they had 10 recurrences of their gout, or none? Do they have severe nephropathy from their diabetes, or is it well-controlled? If they say it's well-controlled, how do they know? Do they know their last A1C? Do they self-monitor their BG at home? Etc. You will do more talking than writing for these things.

    Don't forget: Past Surg Hx, Meds, Allergies (and what the reaction is!), CODE STATUS (if you're admitting a pt), Social Hx (esp - where are they returning when they're discharged? Is it safe/appropriate? Also smoking/drugs/etoh/sex/etc.), Fam Hx.

    Follow this with Review of Systems, then your physical exam, then any labs/imaging you have back. After this it's important to write an Impression: In a few short sentences, sum up what is wrong with the patient, and what your working Dx is (+/- your top differential if appropriate). Then, make a list of the patient's issues (ALL of them), and what your plan is to address these issues. Interestingly, your plan is also where you figure out what you need to order! :) This is a typical admissions hx/px for internal medicine, so it's more comprehensive than some other services. And let's not even talk about peds...
  36. 45408

    45408 aw buddy 7+ Year Member

    Jun 13, 2004
    everybody I had in medicine wanted a story format for an HPI. I've written an entire page-long HPI - typed.
  37. mjl1717

    mjl1717 Senior Member 10+ Year Member

    May 24, 2003
    Excellent--thats what I hear...In medicine be it H/P or rounds..Being able to tell a near Shakespearian STORY (many residents cant do this) is more profound then telling a gray, drab, random, (sleeepy-time) collection of medical sentences..

    [Then again some guys will NEVER know how to communicate properly, concisely, and at the right time]
    [And although discounted on this forum, I still say communication is a BIG deal in medicine]

    How did Osler say it?.. Medicine is an art based on a science..
    Last edited: Nov 6, 2008

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