Here’s the CC and HPI from a badly written H&P. How many stylistic errors can you find?
CC: Abdominal pain
HPI: The patient is a 57-year-old female with DM, HTN, COPD, ESRD, temporal arteritis, corneal transplant, CAD s/p LAD DES, IBD, and OCD. On July 14 she developed 5/10 abdominal pain. The day before, she ate mussels and coleslaw. She has a 5-year history of Crohn’s disease and takes azathioprine. On ROS, she endorsed N/V x 1, diarrhea x 2, and itchy elbows.
On July 15 she came to the ER. In the ER, the temperature was 98.6oF, P76, RR12, BP 120/80. The lungs were clear, heart RR, Abdomen tender with old surgical scars, extremities without edema. She was given 1L NSS, had a CT of the abdomen and pelvis, and was admitted to Fitkin.
We’ll review the next part of this terrible H&P soon…
For now, see how many stylistic mistakes you can find. The intern or resident who finds the most mistakes wins a prize. Submissions are due to me by Friday, July 27, at 5PM.
And don’t worry- none of you wrote this HPI. I’ve attached a copy of the “Yale Way” in case you need a refresher.
Enjoy your Sunday everyone; I’m on my way to round on Fitkin,
Mark D. Siegel, MD