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Write up Suggestions
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Write-Ups

One of the goals of the Internal Medicine Clerkship is for you to learn how to communicate medical information and your assessment via thorough, well-developed medical documentation.  Writing H&Ps is an important skill and learning tool.  Think of writing your H&P as a means for integrating all of the information you gather about your patient with what you know and what you know about certain illnesses to form a coherent, informed argument of what you think is happening with the patient, why it is happening, and what you want to do.

Each new patient you see will have a full evaluation completed by you.  This document will be part of the patient’s permanent medical record.  Residents and faculty will use your write-up for information about your patient and to evaluate your ability to gather, interpret and communicate clinical data and your clinical reasoning.  Some hints for writing notes are listed below.

History

Chief Complaint:  This may be a symptom, a laboratory abnormality (e.g. “my doctor sent me in because my potassium was high”), or another person’s observation (“Mom was acting confused”).

HPI:  Think of the HPI as a narrative, as if you are telling a story.  The HPI should be a sequential (chronological) description of the patient’s illness.  It should include a description of the patient’s baseline health, a narrative of the events leading up to hospitalization, and pertinent positives and negatives.  It should not be a checklist, and it should not include a full PMH or review of systems.  Although you will find that your HPI becomes more concise with time, the goal is clarity, not brevity.  The HPI should give the reader a clear picture of the patient’s story and the diagnostic possibilities you are considering.

PMH:  This is a thorough list of active and inactive problems.  You may include some of these problems in the HPI if they are relevant to the patient’s presenting complaint.

Meds:  Make sure you have a complete list of your patient’s medications.  This may involve verifying prescriptions with the patient’s pharmacist.  Make sure you understand why your patient is taking each of these medications.  Mentally linking each medication with a problem in the PMH is helpful. 

Soc:  The psychosocial history should include (but is not limited to) the patient’s living situation (including caregivers and home nursing/aides), advanced directives.  Drugs of abuse (including tobacco and alcohol) are better suited to the PMH. 

Fam:  Make sure you ask about whether a disease in your differential diagnosis also runs in the family.

ROS:  This should be thorough.  You do not need to repeat information that you included in the HPI.

Physical Exam

Your initial physical exam should be thorough.  Like the HPI, the physical exam should also expand on areas of abnormality.  For example, in the sample write-up that follows, a patient with a headache has an expanded neurologic exam.  Likewise, a patient with abdominal pain would have an expanded abdominal exam, including maneuvers like a Murphy’s sign, which would not be necessary to do in all patients.  Always include vital signs.

Data

The data section should include labs, imaging studies, and other testing from the current episode.  Note important trends.

Assessment and Plan

The assessment starts with a summary statement.  In the summary statement, put foreground issues first (i.e. presenting complaint and important findings from your history, physical, and data sections) and then state the background issues (age, pertinent past medical history).  The assessment should include a discussion of the differential diagnosis and your clinical reasoning.  Divide your differential diagnosis into categories of “likely”, “less likely”, “less likely but immediately life-threatening”, and “unlikely” diagnoses (as you learned in 2nd year).  .  List the most likely diagnoses first.  As you weigh your differential diagnosis, you should support your reasoning with findings from your history, physical, and work-up, and information you gathered from your reading.  The assessment is a discussion of your patient, NOT a reiteration of your reading.  This is your opportunity to show how you are thinking about a caseReferences should be used for every patient and noted at the end of your write-up.

Problem Lists

All problem lists should be problem-based, not organ system-based, regardless of how your residents structure their notes.  In some cases, the problem will be a symptom (abdominal pain); in other cases, when a diagnosis is established by the data you have already collected, it will be a diagnosis (pancreatitis).  For example, the headers for your discussion in the problem list would be:

Problem-Based (Correct)

Organ System-Based (Incorrect)

Chest Pain

Cardiovascular

Pneumonia

Pulmonary or ID

Hypokalemia

F/E/N

          

Develop a plan for each problem in your list.  Your plan may be fairly basic initially and will become more sophisticated as your learn more.  Your problem list should include a section on prevention (especially DVT prophylaxis for hospitalized patients, influenza and pneumococcal vaccinations, tobacco cessation, etc.) and a disposition plan (where and when you anticipate the patient to go upon leaving the hospital, home care and follow-up needs, etc.).



Sample:  Initial History and Physical

July 27, 2007

2:00 pm

cc:  “I can’t see, and my head hurts”

HPI:  Mrs. Dana Bartok is a 67 yo Caucasian female with a history of hypertension and tobacco abuse who was active and feeling well until three weeks ago, when she developed the gradual onset of fatigue and a headache over her right temple.  She does not recall what she was doing when the headache started, but it has been constant and dull, without throbbing or radiation.  Initially, she thought she had the flu and felt slightly better with ibuprofen, which she takes 2-3 times a day.  Over the past two weeks she notes that the headache is worse with brushing her hair and chewing her favorite caramels.  It is also worse at night, and she avoids lying on her right side.  Bright lights and loud noises do not bother her.  She had no fever or chills, but she occasionally felt warm.  She had no nausea, but her appetite is not as good as it normally is.  Last week she visited her daughter in Texas and forgot to take her blood pressure medicines with her.  Her headache did not change during her visit, and she had no chest pain or difficulty breathing.  She returned home last night and took her blood pressure medicines and 600 mg ibuprofen before she went to bed.  When she awoke this morning she was unable to see clearly.  She noticed that if she closed her right eye, she could see fairly well, but if she closed her left eye, everything was gray and blurry.  The headache has not changed, and she has had no confusion, nausea, dizziness, weakness, numbness or tingling, trouble speaking, or difficulty walking around the house, aside from the having difficulty seeing on the one side.  When she called her primary care physician, he sent her to the emergency room.

ED Course:       In the ED, her initial blood pressure was 210/105.  Her headache pain on arrival was 7/10.  She was given lobetalol 10mg IV and morphine 8mg IV.  Currently, she rates her pain 4/10.  Her blurry vision has not changed.

Past Medical and Surgical History:

  • Hypertension – diagnosed 7 years ago.  Initially managed with Atenolol; added Hydrochlorothiazide 8 months ago; does not know her usual BP
  • Pneumonia 7 years ago- required hospitalization but no intubation
  • Tobacco abuse: 1/2ppd x 17 years; quit 7 years ago when hospitalized for pneumonia
  • s/p cholecystectomy 1981

Medications

Hydrochlorothiazide 25mg PO daily

Atenolol 50mg PO daily

Ibuprofen 600mg PO q8h PRN

                       

Allergies

Penicillin causes rash

Preventive Health:

Last cholesterol check last year, results were “fine”.

Pneumovax 5 years ago

Flu shot yearly

Yearly mammograms- all normal

No screening colonoscopies

 

Family History

Father died age 51 MVC

Mother 87 with DM II, HTN

Sister 65 alive and well

No family members with early CAD, autoimmune diseases, or cancers

Social History:

Widow, former dental technician.  Lives with friend in Avon.  Has a small dog and enjoys gardening.  She feels that this keeps her very active, as she tends her own garden and raises vegetable plants for the town garden.  One glass of wine with dinner per week.  No intimate relationships since husband died 4 years ago of stroke.  No difficulty walking or performing ADLs.

R.O.S.

General:  denies weight loss, fatigue, fevers, chills

HEENT:  last eye check <2yrs ago, no hearing loss, tinnitis, mouth sores, sees dentist regularly, no voice change, sinus congestion.

Pulmonary:  No cough, pneumonia, tuberculosis exposure, shortness of breath, orthopnea, paroxysmal nocturnal dypsnea

Cardiac:  No known murmur, rheumatic fever, palpitations, chest pressure/pain

GI:  No dysphagia, odynophagia, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, or change in stool caliber

GU:  no h/o STD, no urinary symptoms of pain, burning, blood, nocturia, no sexual dysfunction/dissatisfaction

Heme:  no bruising, bleeding problems

Endo:  no thyroid disease, hot/cold intolerance, polyuria/polydipsia

Vasc:  no leg pain with walking

Neuro:  See HPI

Derm:  no rashes, skin lesions

Psychiatric:  no anxiety or depression, notes she had a difficult time adjusting to her husband’s untimely death, but now feels she is doing fine.

Physical Exam

Vitals: T 36.8             BP 172/94 (both arms, sitting)   P 75     RR 14   SaO2 99% R/A Pain 8/10

Gen:     Comfortable, fit elderly female sitting up in bed in no acute distress.

HEENT: 

Head:   NCAT.  Tenderness to palpation over R. temple; decreased pulse in R. temporal artery compared to the L. 

Eyes:  No conjunctival icterus or injection.  Optic disc margins slightly blunted on right, normal disc on left

            External ears normal, canals normal, tympanic membranes normal

            Nose:  normal, patent airways

            Mouth:  no lesions, pharynx normal, dentition excellent

Neck: supple, thyroid normal, no mass, nodules; JVP 6 cm; normal carotid pulsations; no carotid bruits

Lymphatic:  No cervical, supraclavicular, axillary or inguinal adenopathy.

Lungs:  Clear bilaterally.  Resonant to percussion.

Heart:  Normal PMI, regular rate and rhythm with normal S1 and S2, no murmur, rub, gallop

Abdomen:  Soft, nontender, nondistended, normal bowel sounds.  No hepatosplenomegaly.  Well-healed scar RUQ.

Rectal/GU:  Normal sphincter tone.  Stool sent to lab for occult blood testing.  Foley in place.

Back:    No spinal deformities or tenderness; no CVA tenderness

Extremities:  no clubbing; no leg or hand edema; peripheral pulses normal

Skin:  No rash or petechiae

Musculoskeletal:  ROM full in neck, shoulders, elbows, wrists, hands, spine, hips, knees, ankles, and toes.  No joint deformities, swelling, erythema, or warmth.

Neuro: 

Mental Status:  a, a, and o x 3.  MMSE:  30.

Cranial Nerves:

II          R. pupil sluggish, L. pupil reactive, R. eye acuity 20/400 with R. visual field cut; L. eye acuity 20/30. 

III, IV, VI EOM’s full. 

V:        Facial sensation intact to PP

VII:      Face symmetrical

VIII:     Hearing intact

IX, X:   Palate rises symmetrically

XII:      Protrudes tongue symmetrically

Motor:  Muscle bulk and tone normal. 

Strength (R/L):

BI        5/5

TRI      55

WF       5/5

WE      5/5

HF       5/5

HE       5/5

KF       5/5

KE       5/5

AT       5/5

PT        5/5

EHL     5/5

Sensation:        Intact to light touch and PP intact.  Vibratory sensation intact in extremities. 

Reflexes (R/L)

BI        2/2

TRI      2/2

PAT     2/2

Ankle   2/2

Toes down going bilaterally

Coordination: Fà N normal bilaterally.  Heel to shin intact bilaterally.

Gait normal.

Kernig’s and Brudzinski’s signs negative.

 

Data    (OK to use diagrams for electrolytes and CBC)

Na 135 Cl 110              BUN 22            Glc 101

K 4.0                CO2 24 Cr 1.0

WBC:   10.0  76%seg; 20%lymph; 4% mono

HCT     37                    Platelets  241

Urinalysis:  1.015,  -urobil, - pro, - WBC, - RBC, – LE, - Nitrate

ESR 115

CT head – Pending


Assessment

This is a case of acute onset of unilateral vision loss following 3 weeks of constant ipsilateral headache and fatigue in 67 yo female with past history notable for hypertension and former tobacco abuse.  Work-up is notable for uncontrolled hypertension, blunted disc margin and decreased visual acuity in the right eye, right temporal artery tenderness and decreased pulses, and an elevated erythrocyte sedimentation rate.  The differential diagnosis of Mrs. Bartok’s headache includes giant cell arteritis, intracranial hemorrhage or other hypertensive emergency, and intracranial mass.  The combination of right temporal pain and tenderness for several weeks, along with decreased temporal artery pulse, points to giant cell arteritis. She is in the appropriate age and ethnic group, as the average age of onset is 65-70 years, and people of north European descent are most commonly affected.  Giant cell arteritis is a vasculitis that affects medium to large arteries, but the clinical manifestations are usually due to affected extracranial arteries, such as the temporal artery.

Ms. Bartok’s headache may be due to tenderness of the temporal artery, since it is worse with hair brushing and chewing, which causes traction on the inflamed artery.  Her acute visual loss is probably due to involvement of the ophthalmic artery or posterior ciliary artery, causing retinal ischemia or amaurosis fugax.  This is a concerning finding for Mrs. Bartok, because it represents progression of the illness and may result in permanent blindness.  She also has an elevated ESR, although this is a nonspecific finding.  Although many patients with GCA have a fever, she may be suppressing this with the ibuprofen she has been taking for her pain.

The other major diagnosis in the differential is intracranial hemorrhage due to uncontrolled hypertension.  She could have a subarachnoid hemorrhage or, less likely, an intraparenchymal hemorrhage.  Her blood pressure has been elevated due to running out of her medications while traveling.  However, the duration of her headache is less consistent with a hypertensive bleed, and while a subarachnoid hemorrhage could cause a severe headache, it would not cause tenderness to palpation of the temple.  Although intracranial hemorrhage is less likely, it is potentially immediately life threatening and should, therefore, be ruled out. 

An intracranial mass could cause a constant headache and unilateral blindness with blurring of the disc margins due to mass effect.  However, she has no other neurologic deficits to support this; her neurologic abnormalities are limited to the loss of vision in the R. eye.  She has no nausea to suggest mass effect, and an intracranial mass would not account for tenderness to palpation of the temple.  This is a less likely, but potentially immediately life threatening, diagnosis (if she has mass effect), so this should be ruled out.

1.         Acute vision loss

-Ophthalmology consult for dilated eye exam

 

2.         Headache

-Temporal artery biopsy

-Since giant cell arteritis can leave her permanently blind if untreated, we will treat her empirically with corticosteroids (Prednisone 60mg PO daily) while waiting for a temporal artery biopsy.  Patients can be treated for 3-4 days, but longer treatment may impair the interpretation of the biopsy. 

-If biopsy is positive for GCA, will consult Rheumatology to help with management

-Head CT with IV contrast to rapidly rule out intracranial hemorrhage and intracranial mass

-Serial neurologic exams

-Tylenol #3, 2 tabs PO q4H PRN pain; will not use NSAIDS until hemorrhage is ruled out, as these impair platelet function and may worsen bleeding


3.         Uncontrolled Hypertension   Will treat as hypertensive emergency until hemorrhage ruled out:        

-Lobetalol 10mg IV; repeat until BP controlled

-Restart Atenolol and hydrochlorothiazide

-Monitor BP closely

-Telemetry to monitor heart rate while beta-blocking

-Low sodium diet

-Counseling on importance of packing extra pills when traveling

 

4.         Prevention

Although her age qualifies her for DVT prophylaxis, uncontrolled hypertension is a contraindication to heparin, and hemorrhage has not been ruled out yet.  Also, prolonged corticosteroid use can cause ulcers, GI bleeds, and osteoporosis.

Plan:   

-Ambulate, SCD’s

-Start heparin 5000units subcutaneous TID once intracranial hemorrhage is ruled out and blood pressure controlled

Plan:   

-Ranitidine 150mg PO BID

-CaCO3 1500mg PO QD

-Vitamin D  800 IU PO QD

-Will search literature on use of a bisphosphonate in prevention of steroid-induced osteoporosis.

-Advised to schedule outpatient routine screening colonoscopy. 

5.         Disposition

-D/C Foley catheter (no indication)

-Anticipate discharge to home in 1-2 days; no home services needed.  Will ask opthalmologist to comment on her safety driving.

References

Fauci AS et al.  Harrison’s Principles of Internal Medicine, 4th ed. 

Salvarani C et al.  Medical Progress:  Polymyalgia Rheumatica and Giant-Cell Arteritis.  New England Journal of Medicine.  347(4):261-271, July 25, 2002

Attending:        Dr. Marino

Full Code

Leslie Truman, CC3     




 

Sample:  Progress Note

On the days following an admission, you will write daily progress notes on your patients.  These are more brief, including a focused history and physical.  Use your problem list from the admission as a template for each day’s problem list; add new problems to the list if they arise.

July 29, 2007

9 am

Headache is much improved.  R. eye vision is improved, but not back to baseline; most objects are still gray and blurry.   No new complaints.  No nausea since Tylenol with codeine was stopped. 

Exam:              T 37.1  BP 121/74         P 62     R 20     SaO2  99% R/A  Pain 1/10 (R. temple)

General:           NAD

Head:               Minimal R. temple tenderness, biopsy site without bleeding or erythema

Lungs:              CTA Bilaterally

Card:                Reg, Normal S1 and S2; no rubs/murmurs/gallops

Neuro:              a,a,o x3  Visual Acuity 20/200 on R.  20/30 on L.  EOMs full; face and palate symmetrical

                        Strength and sensation intact; reflexes symmetrical

Ext:                  No edema; peripheral pulses normal

Data:                Temporal artery biopsy: Consistent with giant cell arteritis (Preliminary)

                        CT Head:  No intracranial hemorrage or mass (non-contrasted).

                        WBC:   15.5

                        Hct:      36

                        Platelets 260

Medications:

Prednisone 60 mg PO daily

Hydrochlorothiazide 25mg PO daily

Atenolol 50mg PO daily

Heparin 5000units subcutaneous TID

Ranitidine 150mg PO BID

CaCO3 1500mg PO daily

Vitamin D 800 IU PO daily

Alendronate 10mg PO daily

Assessment/Plan:      Giant cell arteritis with amaurosis fugax in 67 yo female with history of HTN.  Responding to high-dose corticosteroids.  Intracranial hemorrhage ruled out by head CT.  Blood pressure now controlled on home antihypertensive regimen.

1.         Giant Cell Arteritis with amaurosis fugax:  

-Continue prednisone 60mg PO daily

-Follow up in ophthalmology clinic in 2 weeks.

2.         Hypertension:

-Continue Atenolol and hydrochlorothiazide

-Follow up with primary care physician (Dr. Alexander Kim) one week after discharge for blood pressure check. 

-Patient to buy home blood pressure machine

3.         Leukocytosis: Likely due to demargination of leukocytes with corticosteroids.  No evidence of infection.

4.         Prevention

GI prophylaxis:  Ranitidine

Osteoporosis prophylaxis:     Continue CaCO3 and Vitamin D

Since alendronate prevents the development of corticosteroid-induced osteoporosis and decreases the incidence of new vertebral fractures with a relative risk of 0.6, will initiate alendronate 35mg PO weekly.  Outpatient DEXA scan for baseline.  May need higher dose (70mg) if she already has osteoporosis.

5.         Disposition:    Probably discharge home today; will discuss with attending.  Follow up with primary care physician in one week.

(Reference:  Saag KG et al.  Alendronate for the prevention and treatment of glucocorticoid-induced osteoporosis.  New England Journal of Medicine 339(5):292-9, July 30, 1998)

Leslie Truman, CC3

 
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