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Writing an HPI

Writing an HPI. Mr. Smith is a 48 year old man who presents with chest pain.

phyllis-warren
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Writing an HPI

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  1. Writing an HPI

  2. Mr. Smith is a 48 year old man who presents with chest pain. The pain began 3 weeks ago and has been slowly getting worse. It lasts for 5-10 minutes at a time and comes on several times throughout each day. It is located in the middle of his chest and does not radiate. At its worst it is a 5/10 in severity. Resting seems to make the pain get better. He can not describe the quality further; he says “it just hurts”.

  3. Mr. Smith is a 48 year old man who presents with chest pain. The pain began 3 weeks ago and has been slowly getting worse. It lasts for 5-10 minutes at a time and comes on several times throughout each day. It is located in the middle of his chest and does not radiate. At its worst it is a 5/10 in severity. Resting seems to make the pain get better. He can not describe the quality further; he says “it just hurts”. 3. Characterization

  4. Mr. Smith is a 48 year old man who presents with chest pain. The pain began 3 weeks ago and has been slowly getting worse. It lasts for 5-10 minutes at a time and comes on several times throughout each day. It is located in the middle of his chest and does not radiate. At its worst it is a 5/10 in severity. Resting seems to make the pain get better. He can not describe the quality further; he says “it just hurts”. 3. Characterization OPPQRST Pertinent positives

  5. Mr. Smith is a 48 year old man who presents with chest pain. The pain began 3 weeks ago and has been slowly getting worse. It lasts for 5-10 minutes at a time and comes on several times throughout each day. It is located in the middle of his chest and does not radiate. At its worst it is a 5/10 in severity. Resting seems to make the pain get better. He can not describe the quality further; he says “it just hurts”. 4. Pertinent negatives

  6. Mr. Smith is a 48 year old man who presents with chest pain. The pain began 3 weeks ago and has been slowly getting worse. It lasts for 5-10 minutes at a time and comes on several times throughout each day. It is located in the middle of his chest and does not radiate. At its worst it is a 5/10 in severity. Resting seems to make the pain get better. He can not describe the quality further; he says “it just hurts”. 3. Characterization OPPQRST Pertinent positives 4. Pertinent negatives

  7. Mr. Smith is a 48 year old man who presents with chest pain. The pain began 3 weeks ago… 3. Characterization He denies any… 4. Pertinent negs

  8. Mr. Smith is a 48 year old man with DM, HTN and tobacco abuse who presents with chest pain. The pain began 3 weeks ago… 3. Characterization He denies any… 4. Pertinent negs

  9. Mr. Smith is a 48 year old man with DM, HTN and tobacco abuse who presents with chest pain. The pain began 3 weeks ago… 3. Characterization He denies any… 4. Pertinent negs 1. Opening sentence

  10. Mr. Smith is a 48 year old man with DM, HTN and tobacco abuse who presents with chest pain. The pain began 3 weeks ago… He denies any…

  11. Mr. Smith is a 48 year old man s/p appendectomy who presents with chest pain. The pain began 3 weeks ago… He denies any…

  12. Mr. Smith is a 48 year old man with DM, HTN and tobacco abuse who presents with chest pain. The pain began 3 weeks ago… He denies any…

  13. Mr. Smith is a 48 year old man with HIV who presents with chest pain. The pain began 3 weeks ago… He denies any…

  14. Mr. Smith is a 48 year old man with HIV with recent CD4 count of 22 who presents with chest pain. The pain began 3 weeks ago… He denies any…

  15. Mr. Smith is a 48 year old man with DM, HTN and tobacco abuse who presents with chest pain. The pain began 3 weeks ago… He denies any…

  16. Mr. Smith is a 48 year old man with known CAD who presents with chest pain. The pain began 3 weeks ago… He denies any…

  17. Mr. Smith is a 48 year old man with known CAD who presents with chest pain. The pain began 3 weeks ago… He denies any… 2. Context

  18. Mr. Smith is a 48 year old man with known CAD who presents with chest pain. He first presented with chest pain 4 years ago. Cath demonstrated 90% LAD lesion and he received a bare metal stent. He has been asymptomatic since then. 3 weeks ago… 2. Context

  19. Mr. Smith is a 48 year old man with known CAD who presents with chest pain. He first presented with chest pain 4 years ago. Cath demonstrated 90% LAD lesion and he received a bare metal stent. He has been asymptomatic since then. Baseline 3 weeks ago… 2. Context

  20. Mr. Smith is a 48 year old man with known CAD who presents with chest pain. He first presented with chest pain 4 years ago. Cath demonstrated 90% LAD lesion and he received a bare metal stent. He has been asymptomatic since then. Baseline 3 weeks ago… Is pain the same as before? 2. Context

  21. Mr. Smith is a 48 year old man who presents with chest pain. The pain began 3 weeks ago and has been slowly getting worse. It lasts for 5-10 minutes at a time and comes on several times throughout each day. It is located in the middle of his chest and does not radiate. At its worst it is a 5/10 in severity. Resting seems to make the pain get better. He can not describe the quality further; he says “it just hurts”.

  22. Mr. Smith is a 48 year old man with known CAD who presents with chest pain. He first presented with chest pain 3 years ago. Cath demonstrated 90% LAD lesion and he received a bare metal stent. He has been asymptomatic since then. 3 weeks ago… He denied any… 1. Opening 2. Context / baseline 3. Characterization 4. Pertinent negatives

  23. Mr. Smith is a 48 year old man with known CAD who presents with chest pain. He first presented with chest pain 3 years ago. Cath demonstrated 90% LAD lesion and he received a bare metal stent. He has been asymptomatic since then. 3 weeks ago… He denied any… In the ED… 5. Other tests (not diagnoses) if will change management 1. Opening 2. Context / baseline 3. Characterization 4. Pertinent negatives

  24. Mr. Smith is a 48 year old man with known CAD who presents with chest pain. He first presented with chest pain 3 years ago. Cath demonstrated 90% LAD lesion and he received a bare metal stent. He has been asymptomatic since then. 3 weeks ago… He denied any… In the ED… 5. Other tests (not diagnoses) if will change management 1. Opening 2. Context / baseline 3. Characterization 4. Pertinent negatives

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