Department of Internal Medicine
History and Physical Guidelines
The basic format for the history and physical is outlined in the Blue Book each student received in the Physical Diagnosis Course. (Camden students are also allowed to use the Red Book, a modified version of the Blue Book.)
The Red Book can be downloaded as a MS-Word Document or an Adobe PDF file (Adobe Acrobat Reader is required). In additions, PDA users can download a PDB (for Isilo or other PDB file readers) or create an AvantGo channel (channel address is http://www4.umdnj.edu/rwjcweb/docs/redbook/redbook2001.html)
The two most important parts of the history and physical are the history of present illness and the assessment at the end of the exercise. The HPI should be complete unto itself and should present the patient's problem and the problems related to that organ system in roughly chronological fashion. All details pertinent to that particular organ system should be included in the HPI.
Of even more importance is the assessment at the end of the H&P. You are expected to write a detailed discussion of the patient's major problem and to at least mention all of the patient's other problems. Your discussion of the main problem will usually be a differential diagnosis, which is not simply a list of possibilities, but a discussion of which possibility you feel is most likely and the reason you believe that diagnosis takes precedence over the others. In other words, you should summarize those features of the history and physical that support your diagnosis and that tend to mitigate against the other diagnoses.
Keep in mind that a student H&P should always contain a complete review of systems. In addition, nothing in the H&P should be listed as "noncontributory." The physical exam should contain every organ system with the exception of the rectal, genital, and breast exams (unless these are pertinent to the patient's problems). Describe your exam findings as you found them; if you did not hear a murmur, write down "no murmurs," even if you see that the intern's note described a 2/6 SEM. If part of an exam was done by someone other than you, note this in your write-up (e.g., "Rectal exam: nl tone, heme negative [per ER resident]"). Describe the location of your findings; "DTRs 2+" or "strength 4/5" is not helpful if you do not specify which DTRs or muscle groups you checked.
We have provided examples of UNACCEPTABLE and ACCEPTABLE write-ups:
History and Physical Write-Up: Unacceptable
CC: Orthopnea
HPI: The patient is a 49 yo white male who was awakened from sleep because he could not breathe. He had to sleep sitting up in a chair. The patient noted some chest pain with this episode but it eventually went away. Nothing made his symptoms better or worse. He thinks that the episode was similar to his heartburn, only worse. The day before yesterday he felt fine.
PMH: GERD, HTN
Surgery: Appendectomy
Allergy: PCN
Meds: HCTZ
Social hx: Social ETOH; Married/2 childen
FHx: noncontributory
ROS: noncontributory
PE:
VS: p 130/70 p 70 RR 14
GEN: WDWN W male alert oriented x 3 NAD
HEENT: PEERLA/EOM ok Sclerae not jaundiced
Mouth without lesions
Ears - normal hearing
NECK: No bruits, trachea midline, thyroid normal
CHEST: Clear A & P
COR: S1 S2 no m, gallops or rubs pulses equal
ABDOMEN: Nontender
EXT: No c/c/c
RECTAL: heme -
NEURO: Nonfocal, 2+ DTRs
LABS:
urine negative except 2+ glucose
P7 glucose 310; CBC WNL
1st set of cardiac enzymes negative
EKG: NSR
Assessment/Plan:
-ROMI: Check enzymes & ECG; stress as outpatient
-DM: Insulin sliding scale
History and Physical Write-Up: Acceptable
CC: "I woke up choking last night"
HPI:
The patient is a 49 year old man with a past medical history significant for HTN, tobacco abuse, and GERD who was feeling well until the day prior to admission when he returned home from a wedding reception feeling full from a late dinner. He went straight to bed and describes being awakened from a sound sleep with a choking sensation in his throat and a sour taste in his mouth. He immediately got out of bed and paced around the room trying to clear his throat. He denies any actual chest pain, but states that he did have some epigastric "burning." He took some Maalox, but the sensation did not go away. He denies any associated palpitations, lightheadedness, or diaphoresis. Eventually, he fell asleep while sitting in a chair. The patient presents today at the insistence of his wife. He is now feeling well and has not had any chest discomfort since last night. He states that this episode was similar to his GERD, but those symptoms are usually much milder, and are quickly relieved with antacids. He has not had any nausea, vomiting, BRBPR, or melena. He has had no diarrhea or constipation and has not experienced any weight loss. He golfs regularly and has not had any chest pain or shortness of breath while walking on the green.
PMH:
HTN x 5 years, well-controlled on HCTZ
GERD x 5 years; normal endoscopy last year
No history of diabetes
Medications:
Hydrochlorothiazide 25 mg po qd
OTC antacids prn
Surgery:
Appendectomy age 17
Family hx:
Father died age 50 MI
M HTN, died age 78 s/p CVA
1 sister with DM Type II, 1 brother A&W
2 children healthy
Social hx:
+ tobacco 35 pack years, currently 1ppd
4-5 beers on a weekend; CAGE = 0
Lives with wife and 2 children
Works as an assistant manager of a grocery store
No travel in past 2 years
No occupational exposures
No current street drugs, no IVDU ever
ROS:
Skin: Cystic acne as a teenager
Head: Occasional tension headache; denies syncope, dizziness, or hx of trauma
Ears: No hearing problems
Eyes: No blurred vision, no photophobia
Nose: Occasional post-nasal drip
Mouth/throat: No problems
Lymphatic: No swollen lymph nodes
Respiratory: No cough, no wheezing, no shortness of breath; no snoring or episodes of apnea
Cardiac: Hx of hypertension x 5 yrs, controlled on hydrochlorothiazide; denies exercise-related chest discomfort, palpitations, orthopnea, paroxysmal nocturnal dyspnea or edema
Abdominal: See HPI
Genitourinary: Denies dysuria, hematuria, penile discharge or erectile dysfunction
Neuromuscular: Denies weakness, tremor, hx of seizures or problems with coordination
Psych: No history of depression, anxiety, or panic attacks
General: Denies fever, rigors, change in appetite or weight
PE:
VS: BP 130/72 P 74 Reg. Supine RR 14 unlabored
136/78 P 78 Reg. Standing T 37.4 oral O2sat 98% RA Weight 95kg Height 67" (BMI 32.8)
GEN: Well-developed, obese white man, appears comfortable, cooperative
Skin: Warm, dry, well-perfused
Lymphatics: No cervical, axillary, or inguinal lymphadenopathy
HEENT: Atraumatic/normocephalic; PERRL (accommodation not tested); EOM full; sclerae and conjuctivae clear; fundi - no papilledema; tympanic membrances clear with normal light reflex; OP normal dentition, MMM
NECK: Supple; no thyromegaly
CHEST: Clear to auscultation and percussion
CARDIOVASCULAR: PMI in the 5th ICS midclavicular line; RRR, no M/R/G; no JVD or hepatojugular reflex; no carotid bruits; DP and radial pulses 2+ bilaterally
ABDOMEN: Obese, well-healed scar right lower quadrant; bowel sounds normoactive; nontender; no aortic or renal bruits;
liver percussed to 10 cm in MCL; spleen nonpalpable
EXTREMITIES: No clubbing, cyanosis, or edema
GENITALIA: Circumcised male with no testicular masses; no hernia present
RECTAL: Skin tag present, normal sphincter tone, prostate normal in size and texture, no masses, stool brown and guaiac negative
NEUROLOGIC: A&O x 3
Cranial nerves II-XII intact
Biceps & patellar DTRs 2+/equal, ankle DTRs 1+/equal
Toes downgoing bilaterally
Strength 5/5 bilaterally in biceps, grip, hip flexors, quadriceps
Sensation intact to light touch in feet, LEs, & UEs bilaterally
Normal gait, negative Romberg
LABORATORY:
Hgb/HCT 15/46 wbc 7.5 normal diff.
Platelets 280
UA: Clear, SG 1.030, pH 6, no protein, no blood, 2+ glucose
CK: 93
troponin <0.1
136 99 BUN 16
3.8 30 Cr. 1.0
Glucose 349
CXR: No active disease
EKG: Normal sinus rhythm, axis -30 degrees P-R 0.12 QRS 0.10
SUMMARY:
49 year old man with several cardiac risk factors, admitted with an episode of a choking sensation/epigastric pain and new hyperglycemia
IMPRESSION:
Choking Episode/Epigastric Pain
Assessment: The differential diagnosis for this episode centers on ischemic cardiac disease versus symptoms related to his history of GERD. The patient's age, family history, and history of tobacco use put him at higher risk for cardiac disease, though the absence of typical chest pain or any associated symptoms and the lack of ECG changes make this diagnosis somewhat less likely. The timing of the episode (after eating a large meal just before bed), the sensation of sour taste, and the similarity of this attack to earlier episodes of GERD make this diagnosis more likely. Given the seriousness of the potential diagnosis of cardiac ischemia, however, it is important to rule this possibility out before attributing his symptoms to GERD. There are a few other much less likely etiologies for this episode. Pulmonary disease can cause a choking sensation, though the absence of coughing, wheezing, or shortness of breath makes this diagnosis very unlikely, and this diagnosis has been essentially ruled out by the patient's normal CXR, normal pulmonary exam, and normal oxygen saturation. Heart failure can cause paroxysmal nocturnal dyspnea and orthopnea, but can be ruled out in this patient by the absence of any physical or radiological evidence for heart failure; in addition, the patient has no history of any heart disease. Sleep apnea can awaken patients from sleep with a choking feeling, and this patient is obese, but the history is not consistent with this diagnosis and the patient denies any history of snoring. Panic attacks can awaken a patient from sleep with shortness of breath and throat tightness, but this patient has no history of panic attacks or anxiety, and did not have any symptoms of anxiety during this episode. The sour taste in the mouth and epigastric burning also point away from panic attack as an etiology.
Plan:
Follow cardiac enzymes
Follow serial ECGs
Consider stress test if patient rules out
Start empiric PPI
Elevate head of bed
Avoid eating before bed
Hyperglycemia
Assessment: The patient's plasma blood glucose level of 349 is consistent with a diagnosis of diabetes mellitus Type II, which he is at risk for given his obesity and his family history. However, it is possible that this is an isolated or spurious reading, especially since the patient has had none of the typical symptoms of diabetes such as fatigue, weight loss, polyuria, polydipsia, or blurred vision. Formal diagnosis of diabetes mellitus requires two separate elevated serum blood glucose measurements, either >125 fasting or >200 random (or post oral glucose tolerance test).
Plan:
Check fasting serum glucose level
No-concentrated-sweets diet
FSBG bid
Sliding scale insulin if needed
Diabetic teaching
Encourage weight loss
Consider starting an oral hypoglycemic agent; metformin would be appropriate given the patient's weight and his normal renal function
Hypertension
Assessment: Well-controlled on current antihypertensives
Plan:
Continue HCTZ
Smoking
Assessment: 35 pack-years, currently 1 ppd; patient tried to quit in the past but was unsuccessful
Plan:
Discuss quitting smoking
Referral to tobacco cessation class
Consider medication
Discharge Planning
Assessment: The patient has good home support and no physical limitations
Plan:
Discharge to home once acute medical issues are resolved
For questions about our programs contact;
Anna Headly , MD, Medicine Director of Undergraduate Education
or Safa Preston, Student Programs Coordinator at 856-757-7903 |
