Back

Inpatient Medicine

Edit

H and P

Identification (Name/MRN/Date)

Source/Reliability

Chief Complaint

History of Present Illness (Chronologic account)

Past Medical History

Previous hospitalizationsInjuries ad other surgeryOther medical diseasesPregnancies

Allergies

Current Medication and Recent Therapy

Rx and OTCTransfusionsRadiationSupplements/Vitamins

Immunizations

Family History

Social History

OccupationMarital statusChildrenPlace of birthYears in USATravelMilitary ServiceExposuresTobaccoAlcoholDrugsCoffee/TeaDietSleepSexual HabitsFunctional Status

Review of Systems

General/ConstitutionalSkinHEENTRespiratoryBreastCardiovascularGastrointestinalMale or Female GUHematologic or LymphaticMusculoskeletalEndocrineNeuropsychiatric

Physical Examination

General AppearanceVital signsSkin, hair, nailsHEENTNeckLymph nodesBreastsLungs and ThoraxHeartAbdomenBack and SpineGenitaliaExtremitiesRectalNeuro

Labs and Studies

Assessment and Plan (Problem Based)

Review of Systems

General

FeverChillsChange in weightWeaknessFatigueSweatHot or old intoleranceBleeding tendenciesSleep

Skin/Hair

RashesItchingHivesEasyEczemaDrynessChange in skin colorChange in hair textureChange in nail textureChange in nail appearanceLumps

Head

“Dizziness”HeadachesPainFainting

Eye

UseChangeDoubleExcessivePainRecentPainUnusualRednessDischargeInfectionsGlaucomaCataracts

Ears

Hearing impairmentUse of hearing aidDischarge"Dizziness"PainRinging in earsInfections

Nose

NosebleedsInfectionsDischargeFrequent coldsNasal obstructionInjurySinus infectionHay feverDeviated septum

Mouth and Throat

Last dental appointmentBleeding gumsFrequent sore throatsBurning of tongueHoarsenessVoice changesPostnasal drip

Neck

LumpsGoiterThyroid disease

Chest

CoughOccupational exposuresPain/pressureShortness of breathTuberculosisAsthmaPleurisyBronchitisCoughing up bloodWheezingLast test for tuberculosisHistory of BCG vaccination

Cardiac

PainHigh blood pressurePalpitationsShortness of breath with exertionShortness of breath when lying flat/orthopneaSudden shortness of breath while sleeping/PNDHistory of heart attackRheumatic feverHeart murmurSyncope

Vascular

Pain in legs, calves, thighs, or hipsSwelling of legsVaricose veinsThrombophlebitisCoolness of extremityLoss of hair on legsDiscoloration of extremityUlcers

Breast

LumpsDischargePainTenderness

Gastrointestinal

AppetiteNauseaSwallowingConstipationDiarrheaHeartburnVomitingAbdominal painChange in stool color, caliber, or consistencyChange in frequency of bowel movementsVomiting up bloodRectal bleedingBlack, tarry stoolsLaxative or antacid useExcessive belchingFood intoleranceChange in abdominal sizeHemorrhoidsInfectionsJaundiceRectal PainHepatitisLiver diseaseGallbladder disease

Urinary

FrequencyUrgencyDifficulty in starting the streamIncontinenceExcessive urinationPain on urinationBurningBlood in urineInfectionsStonesBed wettingFlank painHistory of retention

Male Genitalia

Lesions on penisDischargeImpotencePainScrotal massesHerniasFrequency of intercourseAbility to enjoy sexual relationsFertility problemsProstate problemsHistory of venereal disease and treatment

Female Genitalia

Lesions on external genitaliaItchingDischargeLast Pap smear and resultPain on intercourseFrequency of intercourseBirth control methodsAbility to enjoy sexual relationsFertility problemsHerniasHistory of Venereal disease and treatmentHistory of DES exposureAge at menarcheInterval between periodsDuration of periodsAmount of flowDate of last periodBleeding between periodsNumber of pregnanciesAbortionsTerm deliveriesDescription (s) of laborComplications of pregnanciesNumber of living childrenMenstrual painAge at menopauseMenopausal symptomsPostmenopausal bleeding

Musculoskeletal

WeaknessParalysisMuscle stiffnessLimitation of movementJoint pain/swellingArthritisGoutBack problemsStrokesMuscle cramps

Neurologic

Fainting“Dizziness”“Blackouts”ParalysisStrokes“Numbness”Speech DisordersTinglingBurningTremorsLoss of memoryLoss of consciousness

Psychiatric

Mood ChangesNervousnessUnsteadiness of gaitBehavioral changesHallucinationsDisorientation

Review of Systems (Spanish)

All questions should be asked with: “Ha tenido…” unless marked by an asterisk.

GENERAL - GENERAL

Usual state of health - cambios en su estado usual de saludFever - fiebreChills - escalofríosNight sweats - sudor por la nocheAppetite - cambio en su apetitoWeight change - cambio de pesoWeakness - debilidadPain - dolor*Anhedonia - Ha dejado de gozar…

SKIN - PIEL

Rashes - erupciones/salpullidoItching - picazónHives - ronchas*Easy bruising - Le salen moretones fácilmente?Change in moles - cambio en lunares

HEAD - CABEZA

Dizzines - mareoHeadaches - dolor de cabezaTrauma - un accidente

EYES - OJOS

*Use of glasses - Usa anteojos/lentes?Change of vision - cambio de la visiónDouble vision - visión doblePain - dolorRedness - los ojos rojosDischarge - flujoHistory of glaucoma - glaucomaCataracts - cataratas

EARS - OIDOS

Hearing loss - perdida auditiva*Use of hearing aid - Usa un audífono/aparato auditivo?Discharge- flujoPain - dolorTinnitus - zumbido en los oídos

NOSE - NARIZ

Nosebleeds - sangrado nasalDischarge - flujoLoss of smell - perdida del olfato

MOUTH/THROAT - BOCA/GARGANTA

Bleeding gums - sangrado de las encíasPain on swallowing - dolor al tragarHoarsness - _ronquera _Tongue burning - ardor en la lenguaTooth pain - dolor en los dientes

NECK - CUELLO

Lumps - masa/bolitasGoiter - bocioStiffness - rigidez

CHEST - PECHO

Cough - tosPain - dolorShortness of Breath - falta de aire, fatigaSputum production - flema*Hemoptysis - _ Ha tosido sangre?_Wheezing - silbido en el pecho

Breasts - Senos/Pechos

Lumps - masa/bolitasDischarge - flujoPain - dolor*Self-examination - Se hace auto-examen de los senos?

CARDIAC - CARDIACO

Chest pain - dolor en el pechoPalpitations - palpitacionesDOE - falta de aire al hacer ejercicioPND - falta de aire durante el sueño

Vascular - Vascular

Pain in legs, calves - dolor en las piernas, pantorrillasThighs, hips, buttocks - muslos, caderas, nalgasWhen walking - al caminarLeg swelling - hinchazón en las piernasThrombophlebitis - tromboflebitisUlcers - ulceras

Gastrointestinal - _Gastrointestinal _

Appetite - cambio en su apetitoNausea - nausea*Vomiting/hematemesis - Ha vomitado/vomitado sangre?Difficulty/pain swallowing - dificultad/dolor al tragarHeartburn - acidezAbdominal Pain - dolor abdominalConstipation - estreñimientoDiarrhea - diarrheaChange in stool - cambio en el excremento/hecesColor, caliber - color, tamaño/grosorMelena - excremento negro*Rectal bleeding - Ha sangrado por el recto?Hemorrhoids - hemorroides

Urinary - Urinario

*Frequency - _Con que frecuencia va al baño? _*Nocturia - Orina por la noche?Urgency - urgenciaDifficulty starting stream - problemas empezando a orinarIncontinence - incontinencia*Hematuria - Ha orinado sangre?DYSURIA - DOLOR AL ORINAR

Neuropsychiatric - Neuropsiquiatrico

*Fainting - Se ha desmayado?Paralysis - parálisisNumbness - perdida de sensaciónTingling - hormigueo/cosquilleoTremors - tembloresLoss of memory - perdida de memoriaMood changes - cambios de humor*Sleep - Como esta durmiendo?Nervousness - nervios/ansiedadSpeech disorders - problemas al hablarGait disorders - problemas al caminarHallucinations - alucinacionesSeizures - convulsiones

Musculoskeletal - _Muscular y esqueletal _

Weakness - debilidadPain - dolorStiffness - rigidez

Genital - Genital

Lesions - ulcerasDischarge - flujoLibido - perdida de interés en tener relaciones*Function - Como esta su función sexual?

Physical Exam Write-Up

General Survey: WDWN (Well-Developed, Well-Nourished) young man/woman in NAD (No Apparent Distress)

Vitals: BP 120/80 on right, 120/80 on left; HR 80 regular (supine) BP 120/80 HR 80 regular (sitting); RR 16; T 37.0˚C;

Skin: (-) lesions, hair normal, nails normal

HEENT: (Head): NC/AT (Normo-Cephalic, Atraumatic); (Eyes): Acuity 20/20 bilaterally, visual fields full bilaterally, sclerae anicteric, NL conjunctiva, PERRLA (Pupils Equal, Round, Reactive to Light and Accommodation), EOMI (Extra-Ocular Movement Intact), Fundi normal bilaterally: disks sharp, vessels normal; (Ears): Canals normal bilaterally, TM’s (Tympanic Membranes) clear bilaterally, acuity normal bilaterally; (Nose): (-) deviated septum, NL mucosa/turbinates, (-) maxillary/frontal sinus tenderness; (Throat): OP (Oropharynx, including tonsils) clear, normal dentition

Neck: Supple, trachea midline, (-) lymphadenopathy, (-) thyromegaly, (-) JVD (Jugular Venous Distention), carotids 2+ bilaterally without thrill or bruit

Breasts: Symmatric, (-) masses, (-) nipple discharge, (-) axillary adenopathy

Lungs: Normal chest wall excursion, (-) use of accessory muscles, (-) tactile fremitus, lungs clear to A&P (Auscultation and Percussion)

Cardiac: RRR (Regular Rate and Rhythm), PMI (Point of Maximal Impulse or apical impulse) not displaced, normal S1/S2 (include splitting), no murmurs, rubs, gallops (S3/S4)

Abdomen: S/NT/ND/(+) BS (Soft, Non-Tender, Non-distended, Normo-active Bowel Sounds), (-) rebound tenderness, no hepatomegaly or splenomegaly, liver span (in cm) at midclavicular line, aorta normal, (-) renal artery bruits

Back: (-) scoliosis, (-) spinal tenderness, (-) CVAT (Costo-Vertebral Angle Tenderness)

Rectal: (-) hemorrhoids, NL tone, (-) masses, prostate smooth without nodules (in a man), guaiac negative stool

GU (Genitourinary, man): (-) lesions, (-) penile discharge, NL urethra, testicles equal in size and without mass, (-) hernia

GU (Genitourinary, woman): (-) lesions, (-) discharge, normal cervix, (-) cervical motion tenderness, normal ovaries and uterus, (-) hernia

Extremities: (-) C/C/E (Cyanosis, Clubbing, Edema), pulses 2 + bilaterally (brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibial), normal capillary refill, (-) joint swelling/redness/warmth/tenderness, normal active ROM (Range Of Motion) of joints

LN (Lymph Nodes): (-) cervical/supraclavicular/axillary/inguinal lymphadenopathy

Neuro: A&O x 3 (Alert and Oriented to person, place, time). CN II-XII intact; Motor 5/5 in all groups with normal tone; Sensation intact to light touch/pin/vibration/cold/proprioception throughout; Reflexes 2+ throughout (biceps, triceps, brachioradialis, knee, ankle), (-) Babinski response

New patient presentation

Overview

Make a convincing case for the important problems, the differential, and the plan.Make it structured, organized and targeted as it should take only 3-5 minutes.

Opening Statement

Brief statement of chief complaint and why patient was admitted.Include pointed and relevant historical information.Include name of the patient’s PCP and site of care.

Source

Briefly note if/why the patient cannot give reliable history.Note any information sources besides the patient.No comment assumes that all information came from a reliable patient.

Present Illness

The differential diagnosis you considered should guide what you include.Consider starting with: “…usual state of health until…”Be chronologically organized and clear without analyzing.Remember OPQRST: Onset, Palliate/Provoke, Quality, Region/Radiation, Symptoms (associated), Temporal aspects.Include elements of past history (with supporting studies and therapeutic interventions), meds, family history, social history (including psychosocial factors) that specifically contribute to the Present Illness.Pertinent positives and negatives to make the listener understand your DDx.Pertinent = relevant to the differential diagnosis and management considered.

Other History

Important PMH (with supporting history/data).Exclude minor diagnoses without impact on current care.Important meds with doses of relevant ones. Omit unimportant medications.AllergiesFocused FH/SH/ROS. Do not repeat previously stated information.

Physical Exam

Always include general appearance and specific vitalsInclude pertinent elements of exam and any abnormal findings.Remainder may be noted as “noncontributory.”

Labs/Data

Include pertinent or otherwise significant labs/studiesStart with basic blood tests first. CBC→Chem→Coags→Urine→EKG→Rad→OtherOK to mention other tests as being “normal.”

Synthesis

Consider beginning with: “And in summary…” but…Assess and synthesize, don’t summarize and regurgitate.Demonstrate YOUR thinking about the patient specific differential diagnosis.If multiple issues present, weave together or discuss lesser issues in problem list below.

Enumerated Problem List

Start with most important problem first, usually the reason for admission.Use most specific label for the problem you can.Avoid labeling a problem solely by its system.Include your understanding of the cause of the problem.Include a specific plan for addressing it

Admission Orders

Admits to: Floor AttendingDiagnosis:Condition: Stable, or good/fair/poor and explainVital Signs: eg, qh, q4h, q shift, q routineActivity: ad, lib., bedrest, oob, etc.Allergies: to medications and foodsNursing Orders: tubes, dressings, drain, “Ted’s, etc.Diet: regular, ADA, NPO, low salt, etc.IV: specify sol’n., rate (cc/hr), x # of litersMedications: specify drug, dosage, route & if PRN, why.Lab Tests/ Studies:

Progress note - SOAP

S=Subjective: - What the patient tells you i.e. how he is feeling - New complaints, change in symptoms - What others tell you, i.e. information from nurses, social workers, PCA’s

O = Objective (PE and Labs): - Vital signs (T, BP, P, RR, Oxygen saturation). Include I’s/O’s when appropriate - Physical exam, including any driains, lines or catheters - Lab Data (including pertinent trends e.g. in Hgb, K etc) - Procedures or tests done that day (write Pending if not back)

A/P=Assessment/Plan - One liner that includes pertinent PMH, pertinent findings and brief prioritized differential with roughly the top three diagnoses: - Example: 42M with PMH of TB and ETOH abuse who p/w acute hemoptysis in in the setting of being treated for TB by the DOH, regimen unknown, found to be afebrile, normal white count, macrocytic anemia and chest CT showing b/l apical consolidation and nodular opacities, likely c/w partially treated active TB vs. bronchiectasis vs. fungal infection of old TB site. - Note if the patient better, worse, or stable compared to the day before. -If on medications like antibiotics, note day of treatment - List longer differential diagnosis. - Discuss differential in greater depth. Make an argument for or against each diagnosis in the list using history data, physical findings and lab data to support your clinical reasoning.

Plan: Problem Based List (Systems Based list used more commonly in ICU and Pediatrics): - For each problem include relevant tests, medications, procedures, consults - FEN/GI: o IVF? o Diet o Electrolytes - PPx: For DVT. Venodynes vs. Heparin -Each note should include the following at the end of the problem list: Disposition and Discharge Planning

Sign out

Mnemonic	Sample
S - Sick or DNR? (Highlight sick or unstable patients)	“OK, this is our sickest patient, and he’s full code.”
I - Identifying data (Name, age, gender, diagnosis)	“Mr. Jones is a 77-year-old gentleman with right middle lobe pneumonia.”
G - General hospital course	“He came in a week ago hypoxic and hypotensive but improved rapidly with IV levofloxacin.”
N - New events of the day	“Today he developed a temp of 39.5°C and his white count went from 8 to 14. We got a portable chest x-ray, which was improved from admission, took out his Foley and sent blood and urine cultures. U/A was negative but his IV site looked a little red so we started vancomycin.”
O - Overall health status	“Right now he is satting 98% on 2 l nasal cannula and is afebrile.”
U - Upcoming possibilities with plan and rationale	“If he becomes persistently febrile or starts to drops his pressures start normal saline at 125 cc/h and have a low threshold for calling the ICU to take a look at him because of concern for sepsis.”
T - Tasks to complete overnight with plan, rationale	“I’d like you to look in on him around midnight and make sure his vitals and exam are unchanged. I don’t expect any blood culture results back tonight so there is no need to follow those up.”
? - Any questions?	“Any questions?”