Comprehensive H&P Note Template for Phase 1 Spring Assessment 2016

8/18/2019 Comprehensive H&P Note Template for Phase 1 Spring Assessment 2016

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Comprehensive H&P Write-Up TemplateFoundations of Doctoring Phase 1 Spring ssessment

Universit! of Colorado Denver School of "edicine

Su#$ective

Patient Identification:

Chief Complaint (CC):“I hurt all over and feel like my feet are on fire”.

History of Presenting Illness (HPI):Patient is a !y"o female #ho presents #ith $ody aches all over% and states that she feels like her

feet are on fire. &he symptoms $egan (' day) onday% and the pt. stayed home from #ork

&uesday. Pt reports taking I$uprofen and ay*uil to alleviate the pain #hich #orks only

temporarily. &he pain is descri$ed pain as dull and diffuse throughout the entire $ody and even

more pronounced in the lo#er lum$ar region. Pt reports feelings of dyspnea upon minimale+ertion including #hile #alking from the kitchen to the dining room. Pt. is seeking medical

care to alleviate her symptoms so she may get $ack to her everyday activities. &he e+perience#ith the disease is significantly de$ilitating. Pt. suspects pneumonia and e+pects% if the

diagnosis is confirmed% to $e treated appropriately.

Past edical",urgical History (PH"P,H):

&-o# /itamin

epression

0$esityHypertension1 #rist pain (dates)

edications:2ly$uteride (dosages% route)

Plictosa

iraglotideay*uil

I$uprophen

3llergies: 4o kno#n food or drug allergies

5amily History (5H):,ons #ith 3sthma

,ocial History (,H):

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Pt does not smoke or drink alcohol.

1evie# of ,ystems (Complete 10,):

6 7 2eneral: fever% $ody aches% cough%headache% and snee8ing. 4o #eight loss or

gain.

- 7 /ision: 4o /ision oss"Changes% no

Pain% no 9lurry or dou$le vision

' 7 Head and 4eck ars: 4o facial pain or ;a# pain.

enies hearing changes and no reportedhead in;uries.

4ose: rhinorrhea% congestion%

snee8ing

&hroat: sore throat

4eck: 4o neck pain.

7 Pulmonary: Pt complains of coughing up

green sputum. enies coughing up sputum%

hemoptysis% asthma% or $ronchitis.

< 7 Cardiovascular: dyspnea on e+ertion =denies history of murmurs% angina%

palpitations% or edema

“4on remarka$le”

> 7 2astrointestinal: no changes in appetite%

dysphagia% changes in 9 fre*uency%

constipation% $leeding% pain% or ;aundice

? 7 @rinary: 4o dysuria or hematuria.

A 7 usculoskeletal: B lo#er 9ack pain andglo$al ;oint and skeletal pain.

7 4eurologic: enies loss of sensation%

num$ness% tingling% tremors% #eakness% paralysis% sei8ures or $lackouts.

6! 7 Hematologic: enies history of anemia%

easy $ruising% $leeding% petechiae% purpura%or transfusions.

66 7 ndocrine: &-% denies sensitivity tocold% e+cessive s#eating polyuria%

polydipsia% polyphagia% or thyroid issues.

6- 7 Psychiatric: enies changes in mood%

an+iety% depression% tension% or memory.

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6' 7 ,kin: unremarka$le #ith no $ruising or

rashes%#$ective

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Physical +am (Complete Core +am):

/itals:6-'"A% .A AD 13

2eneral 3ssessment: 5emale% Hispanic% in no apparent distress% Patient looks un#ell and is

#earing a mask in an effort not to spread germs. Patient is supine and draped to maintainmodesty.

H4& +am: Head is normocephalic% skull is normal is shape and symmetry. 4ormal hair

distri$ution and te+ture% no tenderness to palpation% no s#ellings% no masses. &hyroid is

symmetrical #ith no nodules% enlargement or tenderness. 3nterior cervical and supraclavicularnodes are not &&P. ips are pink and moist% teeth are in good repair% and $reath is non offensive.

&ympanic mem$ranes pearly and #hite. 5rontal sinuses are non &&P. &ongue is midline #ithoutdeviation. 4o &&P of mastoid. ar canal looks normal &ympanic mem$rane is pearly and #hite.

Cardiac +am: PI is focal and not diffuse. 4o precordial heaves% lifts or thrills noted. 4omurmurs% ru$s or gallops% ,6 and ,- noted. 11 is regular. 4o edema. /ascular: Carotid pulse

B-% no $ruits% 1adial% $rachial% popliteal% posti$ial and dorsalis pedis e*ual $ilateral% B-

Pulmonary +am: In no apparent respiratory distress. 5ront% $ack% and ri$s are of normal si8e%shape% and symmetry. ungs clear to auscultation. 4o accessory muscle use. 1esonance on

percussion% e*ual $ilaterally. 4o sign of clu$$ing or cyanosis. 4o &&P of sternal notch% sternal

angle% or thoracic muscles. 1espiratory rate is 6< $reaths per minute.

3$dominal +am: 4o lesions% scars% or dilated veins. Pt is o$ese $ut normal contours and

symmetry noted. 3$domen is soft% and rounded #ith no muscle separation% 4ormal $o#elsounds present% no &&P% guarding or re$ounding% normal liver edge. urphyEs sign% no &&P at

c9urneyEs point. ,pleen is not palpa$le.

@pper and o#er usculoskeletal +am: usculoskeletal: o#er e+tremity 7 no musclehypertrophy or atrophy. 4o &&P of ,I ;oints% spinal processes% paraverte$ral muscles% or sacrum.

5ull range of motion of neck and spine. &1 present at the knee and ankles. ,traight leg raising

test negative.

,kin% Hair% 4ails +am: ,kin is healthy in color #ith no lesions% scars% or dilated veins.

ssessment


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,ummary ,tatement:

(more specific no patient reports)

Patient is a !y"o female #ho presents #ith $ody aches all over% and states that she feels like her

feet are on fire. Pt. suspects she has pneumonia and #ould like to $e tested. &here are no personal circumstances that #ould impact the patientEs a$ility to comply #ith any recommended

treatment plan. If the pneumonia diagnosis is confirmed% a prescription should also $e made

availa$le to each family mem$er in the household. In addition% safe hand#ashing and techni*uesto minimi8e further spread of infection should $e discussed #ith everyone in the household.

Documents

Comprehensive H&P Note Template for Phase 1 Spring Assessment 2016