An HPI Contest

July 22, 2018
by Mark David Siegel

Hi everyone,

Here’s the CC and HPI from a badly written H&P.  How many stylistic errors can you find? 

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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.

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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

Mark D. Siegel, MD

Submitted by Mark David Siegel on July 23, 2018