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THE HISTORY AND PHYSICAL (H & P). I. Chief Complaint. Why the patient came to the hospital. Should be written in the patient's own words. II. History of Present Illness (HPI) a chronologic account of the major problem for which the patient is seeking medical care according to Bates' A Guide to Physical Examination, the
Jan 19, 2010 HPI: PRT is a 24?year?old woman who reports that she has had difficulties periodically with anxiety and low mood for a good part of her life since age 13.She has been treated in the past with 6 months of counseling (age 15) and sertraline 100mg qd (ages 16?23). Her current difficulties began 9 months ago
Surgery H&P. CC: The patient is a 62 yo old female with a 2 day history of worsening abdominal pain and distension. HPI: The patient states that for the past five days she has felt bloated and has had a decrease in appetite. Two days ago she began having intermittent abdominal pain that initially felt like gas pains but it has
Jun 2, 2004 final written H&P, (and just list a final problem list. 3. History of HTN (4 years) shown below), it is useful to make an initial list simply. 4. History of TAH/BSO to keep track of all problems uncovered in the interview. 5. History of peptic ulcer disease. (#1-9 in this list) and exam (#10-13). 6. Penicillin allergy. 7.
II. Parent as Historian. A. Parent's interpretation of signs, symptoms. 1. Children above the age of 4 may be able to provide some of their own history. 2. Reliability of parents' observations varies. 3. Adjust wording of questions - “When did you first notice Johnny was limping"? instead of “When did Johnny's hip pain start"?
Initial visit H&P. CC: The patient is a 62 year old male with a history of mild COPD who complains of cough, shortness of breath, fatigue, and fever progressively worsening for the past week. HPI: The patient believes the fatigue and dry cough began just over one week ago. Shortly thereafter the cough became productive of
If an injury, where did it take place? Home__ School__ Work__ Other__ PHARMACY (Name/City). CURRENT or CHIEF PROBLEM. Area of body to be examined: Which side? Left___ Right___. How does it affect you, i.e. Swelling Bruising Numbness Weakness ECT? When does it affect you most and how long does it last?
SAMPLE H&P. Chief Complaint (CC): chest pain (patients' presenting complaint(s) in his own words). History of Present Illness (HPI): (details of patients' presenting complaints). This is the first Hospital admission for this 52 year old lawyer with a past history of hypertension. Mr. A noted the abrupt onset (timing) of a dull
Sample H&P for Complicated Patient*. Note the date, time, and fact that this is a medical student note are clearly labeled. 6/21/2002. Medical Student H&P. 11:00. CC: Mr. Jones is a 72yo white, retired farmer, who presented to the ER because “I fainted 3 times in the last 2 days." CC is specific, gives key pt demographics,
History and Physical Examination (H&P) Examples. Info. The links below are to actual H&Ps written by UNC students during their inpatient clerkship rotations. The students have granted permission to have these H&Ps posted on the website as examples.
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