The document provides guidance on writing a history of present illness (HPI) for patient encounters, including templates for documenting chief complaints, symptoms, duration, severity, treatments tried, and pertinent medical history; it also gives examples of HPIs for common complaints like chest pain, cough, and anxiety.
The document provides guidance on writing a history of present illness (HPI) for patient encounters, including templates for documenting chief complaints, symptoms, duration, severity, treatments tried, and pertinent medical history; it also gives examples of HPIs for common complaints like chest pain, cough, and anxiety.
The document provides guidance on writing a history of present illness (HPI) for patient encounters, including templates for documenting chief complaints, symptoms, duration, severity, treatments tried, and pertinent medical history; it also gives examples of HPIs for common complaints like chest pain, cough, and anxiety.
The document provides guidance on writing a history of present illness (HPI) for patient encounters, including templates for documenting chief complaints, symptoms, duration, severity, treatments tried, and pertinent medical history; it also gives examples of HPIs for common complaints like chest pain, cough, and anxiety.
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HOW TO WRITE AN HPI
HPI - HISTORY OF PRESENT ILLNESS, WHY PATIENT COME HERE
TODAY? - foundation of patient encounter
HPI TEMPLATE
The patient states that she has been experiencing (chief
complaints) for the past(duration), which has been (timing). The patient described her pain as (character). She rates her pain(intensity). She affirms(Associated sysmptoms). She has tried (treatment before arrival). She denies(other symptoms). She affirms(medical history). She denies(past medical/social history).
OTHER SYMPTOMS - Anything denied during "rapid fire"
questioning example: Patient denies having sore throat, sob, cough etc.
SAMPLE HPI HPI: The patient is a 34-year-old male who reports a history of Celiac disease and now presents with abdominal pain CC. The pain started 8 months ago ONSET, and typically last for 2 hours at a time. Over the past week DURATION, the pain occurred once a day. He describes the pain as "burning" and "gnawing" CHARACTER, says it located in the epigastrium LOCATION, and reports the pain has been "quite sever"CHARACTER and "quite bothersome" CHARACTER in the past week. It does not radiate.RADIATION It is associated with eating food. It typically occurs around 10-30 minutes after starting to eat. MODIFYING FACTORS/ ALLEVIATING AND AGGRAVATING FACTORS It usually come on suddenly. It is not associated with bowel movements ASSOCIATED SYMPTOMS. The pain is somewhat relieved by reducing stress(MODIFYING FACTORS/ ALLEVIATING AND AGGRAVATING FACTORS. The pain does not awaken him from sleep. He does no report satiety. He does no report diabetes, gallstones, GERD, pancreatitis, or peptic ulcer.(DENIES ASSOCIATED SYMPTOMS He does not take aspirin or NSAIDs.
He also reported diarrhea and bowel incontinence ASSOCIATED
SYMPTOMS. The patient does not report dsyphagia, heart burn, bloating, constipation, nausea, or vomiting. He does not report blood in his bowel movements, black stools, vomiting blood, unintended weight loss, diminished appetite, or fevers. He has no history of abdominal surgeries. There is a family of colorectal cancer.
HPI examples.
CC - Chest pain
A 40-year old man presented to me with the complaint of acute
central chest pain for 12 hours, which he describes as sharp, compressing pain, predominantly localized to the central portion of the chest and does not radiate. His chest pain worsens when he breathes deeply or lie down in bed and relieve to some extent when he sits up or leans forward, and taking pain killer had helped him a lot. He stated that he got his pain while jogging in early morning. He describes his pain as 8 out of 10 on scaling.
CC- Cough, fever, dyspnea and wart like growth on neck
35 year-old otherwise healthy, nonsmoker, male presents to the clinic with complaints of intermittent cough, low-grade fever, and difficulty breathing that has persisted for the past few months. Additionally, he has noticed a nontender wart-like growth on his neck that has increased in size over this period. He reports 5lb weight loss and has experienced some occasional joint stiffness throughout the day. He drinks 2-3 beers a week, tried marijuana 5 years ago, and denies any IV drug use or time spent in jail. He has worked as a landscaper for the past 10 years and recently moved from Missouri.
A female patient presents today experiencing vomitting for the past 36 hours. She states that she's been feeling overwhelmed and feeling anxious. She attributed her anxiousness due to lack of sleep and nightmares of her dying. She also reported having suicidal ideation one time, her husband took her to a dr one time which prescribe her Ativan for her anxiety. Denies any medication other than mentioned. She denies blood in her vomit(Hematemesis),diarrhea, constipation, abdominal pain, fever, runny nose, cough, congestion, chest pain, palpitations, denies pregnancy. Denies pregnancy. Heart: Regular Lungs: Clear Abdominal: Good bowel sounds, no tenderness, rebound or guarding.
A female patient present today in the hospital with a cheek
laceration and other minor scratches after she fell of her bike in a curb side walk. Also experiencing minor frontal headache, stiff neck and a little nauseous. Denies any medical problems. Denies problems breathing,couugh fever, sob She reported taking baby aspirin. Left cheek longhitudinal laceration 6cm length, minimal active bleeding. Mild frontal tenderness Some pain with motion in the neck Right paracervical tenderness No terness in the back and kidneys. 2 over 6 little murmur No pain on her upper and lower extremities
Suturing CAT scan no contrast CTC spine no contrast
Medication pain Morphine sub Q Tylenol ibrupofen anesthitized one percent epinephrine sutured 6 o nince one no complication. sutures will have to be 5- 7 days. PAtient should be clening ------------------------------------------------------------------------------------ GALING SA TIKTOK Patient’s Name: Rachel
DOB (Date of birth): ***
AGE: 68
SUBJECTIVE(Galing sa bibig ng pasyente):
HPI-ROS:
HPI:
Pt. is a 60 year old female and presents with abdominal pain/diarrhea.
Pt. states that this has been going on for about a month. Pt, states that she had a very bad“episode” of diarrhea yesterday it made her feel disoriented and had to leave work. Pt. states that the pain is located in her lower abdomen and both the left and right side and also has pain in her URQ.
Pt. states that there are days when she has regular bowel movement and there are days when it’s watery color yellow, but lately it’s green. She states that eating does not trigger it. It happens randomly. She’s not on any new medication, she’s also been eating still the same. She states that she feels like raw spinach makes it happen more. She also states that berries and cherries cause it as well. She does not know if it’s food allergies. She states that there are episodes when she’s afraid that she won’t make it to the bathroom and when she does not go immediately, it would be explosive.
She tried Pepto Bismol, she feels like it does control the episodes but yesterday it did not. She does not take it daily though. She tested for COVID and it was negative. She does not have blood in stools, no fever.
REVIEW OF SYSTEMS:
General: Generally healthy, no change in strength or exercise tolerance.
Head: No headaches, no vertigo, no injury.
Eyes: Normal vision, no diplopia, no tearing, no scotomata, no pain
Ears: No change in hearing, no tinnitus, no bleeding, no vertigo.
Nose: No epistaxis, no coryza, no obstruction, no discharge.
Mouth: No dental difficulties, no gingival bleeding, no use of dentures.
Neck: No stiffness, no pain, no tenderness, no noted masses.
Chest: No dyspnea, no wheezing, no hemoptysis, no cough
Heart: No chest pains, no palpitations, no syncope, no orthopnea.
Abdomen: ADMITS DIARRHEA, ADMITS ABD, PAIN, DENIES BLOOD IN STOOL.
GU: No urinary urgency, no dysuria, no change in nature of urine.
Musculoskeletal: No muscle pain, no painful joints, no weakness.
Neurologic: No headache, no dizziness, no fainting.
Psychiatric: No depressive symptoms, no changes in sleep habits, no changes in thought content.
OBJECTIVE:
General: Awake, alert, and oriented in no acute distress. Conversant and friendly affect.
Head: Normocephalic, no lesions.
Eyes: Pupil equal round and reactive, extraocular muscle intact. Conjunctiva clear no injection or discharge, sclera non-icteric.
Ears: EAC’s clear, TMs normal bilaterally.
Nose: Mucosa normal, no obstruction, no discharge.
Throat: Clear, no exudates, no lesions, no erythema.
Neck: No JVD, no masses, no thyromegaly, trachea midline, ROM normal; no meningeal signs.
Heart: Regular rhythm and rate, no murmurs, no rubs, no gallops.
Chest: Lungs clear bilaterally, no rales, no rhonchi, no wheezes, normal chest movement, no use of accessory muscles of respiration.
Abdomen: SOFT, NO MASSES, DIFFUSELY TENDER OVER THE COLON AREA
Back: Normal curvature, no tenderness.
Extremities: No edema, no clubbing, no cyanosis.
Neuro: No localizing findings. Mentation appropriate. Short-term memory intact. Speech normal. CN 2- 12 intact. No cognitive dysfunction. No sensory or motor deficits. Gait normal.
ASSESSMENT:
1. DIARRHEA
PLAN:
LAB ORDERS: COMP. METABOLIC PANEL, STOOLCULTURE, CBC, OVA AND PARASITES SMEAR Will order to rule out several conditions. Will prescribe patient with Lomotil while waiting on lab results. If Pt. has extreme pain and blood in stools, if Pt. isn’t able to eat and drink, advised to go to the ER for immediate care, pt voices understanding. Will FU with the patient once her results are in. Stay on bland diet, avoid milk products, and try to stay hydrated.
