Writing a history of present illness templates
Past Medical History PMH : This includes any illness past or present that the patient is known to have, ideally supported by objective data. The number of HPI elements that are needed to characterize the clinical condition, and are included in the document.
She develops horizontal diplopia in all directions of gaze especially when looking to the left. Other: travel, pets, hobbies.
Example of hpi documentation
When multiplied this is referred to as "pack years. So, maintain a healthy dose of skepticism when reviewing notes and get in the habit of verifying critical primary data. The temporal aspects of the history are presented in an easy to follow fashion, starting with the most relevant distant event and then progressing step-wise to the present. Unless this has been a dominant problem, requiring extensive evaluation, as might occur in the setting of secondary hypertension. Muscle bulk and tone are normal. Only negative statements belong in the pertinent negatives section. Temperature is There is no history of diabetes or hypertension. She is not aware of a change in her appearance, but her husband notes that her right eye seems to protrude; he thinks that this is a change in the last few days. Strength is full bilaterally. History of present illness: Mrs. A comprehensive list can be found here: ROS Physical Exam: Generally begins with a one sentence description of the patient's appearance. Smith is a 70 year-old male admitted for the evaluation of increasing chest pain.
Dosage, frequency and adherence should be noted. In order to gain insight into what to include in the HPI, continually ask yourself, "If I was reading this, what historical information would I like to know?
This highlights "pertinent negatives" i. Items which were noted in the HPI e. Work History: type, duration, exposures.
History of present illness example
Events which occurred after arrival can be covered in a summary paragraph that follows the pre-hospital history. The pain lessened somewhat when she took Vicodin that she had lying around. It lasted perhaps 1 minute. There is no history of diabetes or hypertension. The double vision was most prominent when she looked to the left, but was also present when she looked straight ahead, up, down, and to the right, and went away when she closed either of her eyes. She develops horizontal diplopia in all directions of gaze especially when looking to the left. Also, get in the habit of looking for the data that supports each diagnosis that the patient is purported to have. The patient's blood pressures have fluctuated significantly based on the patient diary and are suboptimally controlled on her current regimen.
Past Medical History Include all medical problems active or remote.
based on 105 review