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An H&P Contest Results

July 29, 2018
by Mark David Siegel

Hi everyone: 

With the help of five ruthless residents, I am returning a copy of last week’s HPI, which now resembles a wounded high school essay, oozing red (in bold since this site doesn't accommodate color):

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CC: Abdominal pain (Express the chief concern in a full sentence. Include the patient’s name, age, gender, relevant history, and the problem that brought her to attention.)  

Where did you get this information?  

HPI: (Begin each HPI by describing the patient’s usual state of health and symptom onset.) The patient is a 57-year-old female (Don’t call people “male” or “female.” Honor their humanity; use “man” or “woman.”)  with DM, HTN, COPD, ESRD, temporal arteritis, corneal transplant, CAD s/p LAD DES, IBD, and OCD. (Don’t list the whole medical history in the HPI.  Just include the diagnoses that pertains to the current illness. Relegate the rest to the PMH).  On July 14 (Don’t use dates. Reference time in relation to her admission) she developed 5/10 (Use ordinary terms to describe severity; patient’s don’t use Likert Scales) abdominal pain (Details please. Tell us about the onset, location, duration, character, radiation, exacerbating and relieving factors, and associated symptoms).  The day before (Before what? Before symptom onset? Before admission?), she ate mussels and coleslaw (Provide a precise timeline relating the meal to her symptoms).  She has a 5-year history of Crohn’s disease and takes azathioprine (This history may prove relevant, so include it in the CC and beginning of the HPI, along with a description of disease activity). On ROS, (The “ROS” NEVER belongs in the HPI.  Just list pertinent positives and negatives that speak to the current illness.  The ROS goes in a separate section after the Family and Social Histories where it serves as a screening inventory to be asked of ALL patients). she endorsed (“Endorsed” sounds like she’s nominating a candidate for governor. “Described” is better). N/V x 1 (This isn’t multiplication; say she had “one episode”), diarrhea x 2 (“two episodes”), and itchy elbows (Itchy elbows are almost certainly irrelevant to the HPI; put them in the ROS).    

On July 15 (Use “On the day of admission”) she came to the ER (Why?). In the ER, the temperature was 98.6oF, P76, RR12, BP 120/80 (Don’t list stable vitals. Just describe key highlights from the ER). The lungs were clear, heart RR, abdomen tender with old surgical scars, extremities without edema (List only relevant physical exam findings, documented by the ER clinician; you’ll describe your own thorough physical exam later).  Did she have any laboratory tests that contributed to the decision to admit? She was given 1L NSS (Why?), had a CT of the abdomen and pelvis (Why? Were there important findings?), and was admitted to Fitkin (Why? And state the type of service, not the name. Not all readers will recognize the name).

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Here’s a better admission note. For now, we’ll just include the CC, Source of information, HPI, PMH, and PSH:

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CC: Ms. Smith is a 57-year-old woman with a history of Crohn’s disease, presenting with one day of crampy abdominal pain, nausea, vomiting, and diarrhea.  

Source of information: The patient and prior records  

HPI: The patient has a history of Crohn’s disease which has been quiescent for five years on azathioprine, well-controlled DM, stable CAD, and ESRD treated with hemodialysis. She was in her usual state of health until one day prior to admission when she suddenly developed moderately severe, crampy, non-radiating lower abdominal pain, six hours after eating mussels and coleslaw in a local restaurant that had previously been closed by the health department.  The symptoms came on in waves, without exacerbating or relieving factors, and were accompanied by nausea, one episode of vomiting of undigested food, and two episodes of watery diarrhea.  She denied fever, chills, sweats, chest pain, shortness of breath, hematemesis, rectal bleeding, dysuria, back pain, or previous similar episodes.  Her husband, who shared dinner with her, also vomited once but soon felt better.  

The patient attempted to sleep the night before admission but woke up frequently because of the pain.  In the wake of persistent symptoms and because she couldn’t eat, drink, or take her medications, she came to the YNHH ER, where her exam was notable for dry mucus membranes and lower abdominal tenderness without peritoneal signs.  Laboratories were notable for a WBC count of 17.6K without a left shift, a hemoglobin of 14 (baseline 12), sodium 149, and a BUN/Cr of 30/1.2 (baseline 12/0.9).  An abdominal CT showed possible thickening of the descending colon without free air or fluid collections.  She was given 1L of NSS to treat volume depletion and was admitted to the medicine service for further evaluation and management.  

PMH:

Crohn’s Disease (Diagnosed 5 years previously, well-controlled on azathioprine, no surgery required, no recent steroids, has a single daily soft BM at baseline)

Type II DM (last Hgb A1C 6.5)

HTN

COPD

CAD (s/p LAD DES 6 years previously, recent stress test without ischemia, EF WNL)

ESRD (on HD- M, W, F, last dialyzed the day before admission)

Temporal arteritis (in remission, treated 5 years previously)

Obsessive compulsive disorder  

PSH:

Corneal transplant (10 years previously)

Appendectomy (as a child)

Two Caesarian Sections

Cholecystectomy ____________________________________________________________________________________________________________________________________________________________________________________________________________________ 

Hopefully you agree that the revised H&P reads better, provides context and relevant detail, and will make it easier for the team to diagnose and treat the patient’s medical problem.  

A special thank you to Corey O’Brien, Erin Gombos, Melanie Hundt, Solmaz Ehteshami Afshar, and Yiduo Hu- you collectively identified all the errors in the HPI and found many I hadn’t noticed.  To be honest, I lost count of the shortcomings listed and can’t pick a winner, but you should all come by my office for a prize.  

Enjoy your Sunday, everyone! I’m headed out for a bike ride, then down to Milford for brunch (at a safe place I can vouch for).

Mark  

Submitted by Mark David Siegel on July 29, 2018