H&p ADM ASSMT – INPT/HISTORY

CHIEF COMPLAINT/SUMMARY OF INDICATIONS FOR ADMISSION:
Establish why is the Patent seeking medkel attention. 
Pt's own words of actual symptoms and timing, ("use quotation marks liberally'). 
Use open-ended questions and active listening. 
This m-year-old-race-gender, complaining of... (e.g. SOB) for... (e.g. 3 months). 

HX OF PRESENT ILLNESS:


The HPI should include: Highly directed & Hypothesis-driven    information    
Onset, date and mode, sudden/gradual, etc. 
Symptoms (nature and course). 
Precipitating events
Frequency and severity
Current manifestations. 
Character and quality

Diagnoses/Meds 
All information related to the system (s) involved. 
(recorded as a paragraph, logicaland chronological rder, it should be written In full sentences)

PAST MEDICAL HISTORY & REVIEW OF SYSTEMS:

Illnesses: Adult .p Childhood (dates, Dx, Sx, Rx, Complications, MD, litigation) CAD, HTN, DM, dyslipidemia, COPD, Cancer, asthma, depression, TB, SIDS, Bleeding Disorder, stroke,    etc 
Hospital Admissions
Surgeries 
Trauma/Injury
Blood transfusions (date, reason, reactions) 
Immunizations /Vaccinations 
Psychiatric Hx 
Travel Hx
Atherosclerotic CVD Risk Factors 
smoking, dyslIpidemia, HTN, Inactivity obesity/ overweight, DM +FH of CHD, male stres?) 

Health Maintenance 
BP Breast ex, SBE, Pap smear, Mammography, FOBT, flex sigkolonoscopy, Vax, Flu shot, Pnumovax, etc.

Social    History
Provides information about the social-cultural background and educationa/economical status. 
Smoking (packs per year) 
ETOH (type,quantity,    duration) 
IDU, IVDA, (illicit drugs) 
Life style (habits) 
DIET 
Exercise & Sports 
Job, Education, activities 
Military Hx
Satisfaction/frustration (typical day)
Sex Life (libido, frequency, discharge, dyspareunia, anorgasmia) 

#    Family    History
For each family member record age and state of health/major illnesses. 
Parents / Children / Relatives (cancer, DM, HTN, CAD, obesity, TB, COPD, asthma, stroke, bleeding diathesis, similar Sx, depression, thyroid, etc.) 

#    OBGYN    Hx    (If    Relevant)
LMP -last menstrual period- ( x x ) (frequency, regularrity, duration, flow) 
Age @ menarche 
Pregnancies (Gravida, Para, Abortion, Still    Birth,    Living Children, c-sections, twins, macrosomia) Breastfeeding (x, duration) 
Contraception (type, duration) 
Pap smear (results, dates) 
Menopause (onset, Sx)

#    Review    of    Systems
The ROS should be complete and systematic. 
Do Not repeat, do not omit. 
If the CC and HPI involve a particular System (e.g CV), that system should logically be included in the HPI. 
If a symptom is Included In the HPI, simply write 'see HPI'.

GS:    Weight (change,loss/gain) 
Appetite (anorexia) hyporexia, polyphagia thirst (polydipsia) 
Fever / Chills 
diaphoresis (sweats) 
fatigue / malaise 
strength / weakness 
overall status 
HEENT:    
headache, dizziness 
Visual acuity (rx, lens/type/duration) 
Vision, blurred, diplopia (double), floaters 
pain (itching, burning) 
ocular discharge 
photophobia 
Presbyopia 
Xerophthalmia (dry, itching, sand sensation) 
amaurceis fugax
blindness (night/color) 
scotomata, asthenopia
exophthalmos (bilateral?, proptosis) 

VITALS
PHYSICAL EXAM
DIAGNOSTIC STUDIES
DIAGNOSTIC IMPRESSION:
TREATMENT PLAN
CHIEF COMPLAINT/SUMMARY OF INDICATIONS FOR ADMISSION:
Establish why is the Patent seeking medkel attention.
Pt's own words of actual symptoms and timing, ("use quotation marks liberally').
Use open-ended questions and active listening.
This m-year-old-race-gender, complaining of... (e.g. SOB) for... (e.g. 3 months).

HX OF PRESENT ILLNESS:


The HPI should include: Highly directed & Hypothesis-driven information
Onset, date and mode, sudden/gradual, etc.
Symptoms (nature and course).
Precipitating events
Frequency and severity
Current manifestations.
Character and quality

Diagnoses/Meds
All information related to the system (s) involved.
(recorded as a paragraph, logicaland chronological rder, it should be written In full sentences)

PAST MEDICAL HISTORY & REVIEW OF SYSTEMS:

Illnesses: Adult .p Childhood (dates, Dx, Sx, Rx, Complications, MD, litigation) CAD, HTN, DM, dyslipidemia, COPD, Cancer, asthma, depression, TB, SIDS, Bleeding Disorder, stroke, etc
Hospital Admissions
Surgeries
Trauma/Injury
Blood transfusions (date, reason, reactions)
Immunizations /Vaccinations
Psychiatric Hx
Travel Hx
Atherosclerotic CVD Risk Factors
smoking, dyslIpidemia, HTN, Inactivity obesity/ overweight, DM +FH of CHD, male stres?)

Health Maintenance
BP Breast ex, SBE, Pap smear, Mammography, FOBT, flex sigkolonoscopy, Vax, Flu shot, Pnumovax, etc.

Social History
Provides information about the social-cultural background and educationa/economical status.
Smoking (packs per year)
ETOH (type,quantity, duration)
IDU, IVDA, (illicit drugs)
Life style (habits)
DIET
Exercise & Sports
Job, Education, activities
Military Hx
Satisfaction/frustration (typical day)
Sex Life (libido, frequency, discharge, dyspareunia, anorgasmia)

# Family History
For each family member record age and state of health/major illnesses.
Parents / Children / Relatives (cancer, DM, HTN, CAD, obesity, TB, COPD, asthma, stroke, bleeding diathesis, similar Sx, depression, thyroid, etc.)

# OBGYN Hx (If Relevant)
LMP -last menstrual period- ( x x ) (frequency, regularrity, duration, flow)
Age @ menarche
Pregnancies (Gravida, Para, Abortion, Still Birth, Living Children, c-sections, twins, macrosomia) Breastfeeding (x, duration)
Contraception (type, duration)
Pap smear (results, dates)
Menopause (onset, Sx)

# Review of Systems
The ROS should be complete and systematic.
Do Not repeat, do not omit.
If the CC and HPI involve a particular System (e.g CV), that system should logically be included in the HPI.
If a symptom is Included In the HPI, simply write 'see HPI'.

GS: Weight (change,loss/gain)
Appetite (anorexia) hyporexia, polyphagia thirst (polydipsia)
Fever / Chills
diaphoresis (sweats)
fatigue / malaise
strength / weakness
overall status
HEENT:
headache, dizziness
Visual acuity (rx, lens/type/duration)
Vision, blurred, diplopia (double), floaters
pain (itching, burning)
ocular discharge
photophobia
Presbyopia
Xerophthalmia (dry, itching, sand sensation)
amaurceis fugax
blindness (night/color)
scotomata, asthenopia
exophthalmos (bilateral?, proptosis)

VITALS
PHYSICAL EXAM
DIAGNOSTIC STUDIES
DIAGNOSTIC IMPRESSION:
TREATMENT PLAN

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0, 415 boilerplate words
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