history and physical

1. history and physical speaker:万冕

2. www.themegallery.com case The writing The goal

3. www.themegallery.com The goals of all the differing styles of the H&P are the same • communicating the important aspects of the patient's presentation • Providing thorough background information about the patient • Leading the reader through the information in an organized manner so he or she can understand what you were thinking when you made treatment decisions

4. www.themegallery.com Sections of the H&PConventionally,the H&P is broken downinto the following thirteen major sections 1)Source 2)Chief complaint(cc) 3)History of the present illness(HPI) 4)Past medical history(PMH) 5)Medications(Meds) 6)Allergies(All) 7)Family history(FHx) 8)Social History(SHx) 9) Review of Systems(ROS) 10)Physical Exam(PE) 11)Laboratory and Data(Lab/Data) 12)Assessment/Impression/Summary 13)Plan

5. www.themegallery.com Source • very brief • identify the source(s) of information • comment on the credibility of the source

6. www.themegallery.com source • Information obtained from the patient and his spouse,who seemed clear and coherent • Information obtained from5-year-old son who acted as interpreter for the patient,who doesn't speak English.Son seemed to understand only part of questions.

7. www.themegallery.com Chief complaint(cc) • Drief statement of why the patient present-ed • Identifies patient and relevant"context"related to presenting compl-aint • Focuses attention of reader(s)

8. www.themegallery.com Chief complaint(cc) • 34-year-old male with advanced AIDS complaints of a"bad cough" and fevers developing over the last 8days. • 81-year-old African-American female with a history of hypertension and diabetes complains of "pain in mychest"while walking up the stairs yesterday

9. www.themegallery.com History of the present illness(HPI) • Lead the reader toward the conclusions you draw in the Assessment and Plan that follows • Write in full sentences • Do not make up abbreviations • Organize and edit the patient's information • Give the time course • Be descriptive,not analytic,regarding all features of the primary complaint(s) • Include all relevant information about the complaint • Note other coexisting illnesses/situations that may contribute("context") • Guide the reader through the appropriate differential diagnosis with pertinent positives and negatives

10. www.themegallery.com History of the present illness(HPI) • Present illness: • The patient felt upper bellyache about ten days ago. He didn’t pay attention to it and thought he had ate something wrong. At 6 o’clock this morning he fainted and rejected lots of blood and gore. Then hemafecia began. His family sent him to our hospital and received emergent treatment. So the patient was accepted because of “upper gastrointestine hemorrhage and exsanguine shock”. • Since the disease coming on, the patient didn’t urinate.

11. www.themegallery.com Past medical history(PMH) • Thorough listing of prior medical illnesses or events • Include supporting data(e.g.,biopsies,PFTs,echos,CTs,if available) • Avoid chart lore • Consider separating past surgical,obstetric,and psychiatric histories

12. www.themegallery.com Past medical history(PMH) • Status post cholecystectomy 4/94 for gallstones. • Hypertension.Wellcontrolled for 5 years. • Status post hysterectomy-deatails unknown-approx 1990 at Boston Hospital.

13. www.themegallery.com Medications(Meds) • List all meds,doses,routes,intervals • Include over-the-counter meds • Include recently stopped or changed meds

14. www.themegallery.com Medications(Meds) • Lisinopril 10mg po qd • Lanoxin 0.125mg po qd • Vitamin B12100Xg im q month • Pravastatin 40mg (increased from • 20mg 3week ago)po qhs • Multivitamin 1 po qd

15. www.themegallery.com Allergies(All) • List all meds to which patient has reacted • List the reaction

16. www.themegallery.com Allergies(All) • 1.Sulfa drugs-rash • 2.Ampicillin-anaphylaxis • Note: • This is not the place for seasonal allergies, hay fever,or contact allergies.They belong in the PMH.

17. www.themegallery.com Family history(FHx) • List or diagram family members • List major illness,causes of death for each family members

18. www.themegallery.com Family history(FHx) • Family history: His parents have both died.

19. www.themegallery.com Social History(SHx) • Occupation,hobbies,personal interests • Marital status,number of children,social support network,living situation • Alcohol,cigarette,and illicit drug use • Sexual history

20. www.themegallery.com Social History(SHx) • SHx: Married 22 years with 3 children • Taking correspondence course to get B.A. • Coaches Little League baseball • Occ Hx:Does construction work (no asbestos exposure known) • Only chemical exposure is paint thinner • Was previously a meat packer during his 30s and 40s • Habits: Denies tobacco and illicit drug use • Admits to 2-3 u alcohol twice weekly with friends CAGE questions 0 of 4 • Monogamous relationship with since married

21. www.themegallery.com Review of Systems(ROS) • Comprehensive head-to-toe or system-by-system checklist of symptoms • If relevant (positive or negative) to HPI, it belongs in HPI-not here • Any significant findings require follow-up in Assessment and Plan sections below

22. www.themegallery.com Review of Systems(ROS) • Respiratory system: No history of respiratory disease. • Circulatory system: No history of precordial pain. • Alimentary system: No history of regurgitation. • Genitourinary system: No history of genitourinary disease. • Hematopoietic system: No history of anemia and mucocutaneous bleeding. • Endocrine system: No acromegaly. No excessive sweats. • Kinetic system: No history of confinement of limbs. • Neural system: No history of headache or dizziness.

23. www.themegallery.com Physical Exam(PE) • Describe,don't interpret,findings • Be systematic,e.g., General Appearance,Vitals,HEENT,Neck, Lungs,Cardiac,Breast,Abdomen,Rectum,Genitals,Extremities,Skin,Musculoskeletal,Neuro

24. www.themegallery.com Physical Exam(PE) • T 36.4℃, P 80/min, R 20/min, BP 90/60mmHg. She is well developed and moderately nourished. Active position. The skin was not stained yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pitting edema. Superficial lymph nodes were not enlarged.

25. www.themegallery.com Laboratory and Data(Lab/Data) • Common labs first(CBC,chemistries,liver functions,coagulation profile) • Other blood tests obtained • Urinalysis • Chest X-ray(and other radiology studies) • ECG • Other data obtained

26. www.themegallery.com Laboratory and Data(Lab/Data) • Blood-Rt: Hb 59g/L RBC 1.90T/L WBC 0.8G/L PLT 55G/L • Blood cytology: A few immature lymphocytes could be seen.

27. www.themegallery.com Assessment/Impression/Summary • Demonstrate your thinking process • Don't summarize;synthesize • Include key elements of H&P in a guided fashion to lead the reader through the differential diagnosis and land the reader on your conclusion(s) • Generate a problem list (primary and secondary) with explanations considering why and how this situation occurred • Write in full sentences

28. www.themegallery.com Assessment/Impression/Summary • Patient was female, 14 years old • Pharyngalgia and fever for four days. • No special past history.

29. www.themegallery.com Plan • This may be integrated into Assessment section • Enumerate a specific problem list as above • Be as specific with your plans as possible • Address all issues

30. THANK YOU! Class of The Dental Speaker : 万冕 PPT Maker : 夏添.王静,胡熹 Material collecter : 徐丹丹,刘政文,秦媛,朱艳玲 Review : 钱雷,章文轩 The End