Medical Student Documentation

HPI: Start with “1-liner” to highlight who the patient is and why they are here today.

Must include 4 of the following:
Onset
Location
Duration
Characteristic
Aggravating
Relieving
Timing
Severity

Include pertinent negative historical items.

Include PMH, PSH, medications, and a brief family and social history.

HPI: Provided by the patient, reliable.

Mr. Jones is a 49 year old male with a history of hypertension who presents to the emergency department for evaluation of chest pain. The pain began 3 hours ago gradually at rest, but has since resolved. He describes the pain as sharp and rates it as a 7/10. It is located in the middle of his chest and does not radiate. No other aggravating or alleviating factors. He has never had an episode like this in the past and did not try any medication to relieve the pain. He denies any fevers, cough, nausea, vomiting, light-headedness, abdominal pain, diaphoresis, shortness of breath, numbness, or reflux symptoms. He has not had recent surgeries, hospitalizations, or traumas.

PMH, PSH: Hypertension. ORIF left ankle >5 years ago
Meds: Losartan 50mg daily
FH: Father deceased d/t lung cancer, mother has hypertension and CABG at
age 72. No known family history of DVT or PE.
Social History: Denies tobacco use. Drinks alcohol socially. Denies illicit drug use,
including cocaine.

ROS: : Can use a standard ROS phrase or list by system; recommend 10 systems with 2 symptoms per system. This depends on the region where you practice.

ROS: 
Constitutional, HEENT, respiratory, cardiovascular, integumentary, gastrointestinal, endocrine, psychiatric, genitourinary, neurologic, and musculoskeletal systems were reviewed and negative except where otherwise described in the HPI.

Physical Exam: 8 system physical exam, at least 2 points for each system.

PHYSICAL EXAM:
Vital Signs: Temp 37.2℃, HR 88, BP 140/85, RR 15, SPO2 99% on room air
Constitutional: Alert and oriented. NAD.
HENT: Mucous membranes are pink and moist. EOMI. PERRLA.
CVS: Left sided chest wall tenderness. RRR, normal S1 & S2. No M/R/G. Equal pulses 2+ b/l.
Resp: Clear to auscultation bilaterally. No wheezing, rales, rhonchi.
GI: Abdomen soft, non-tender, non-distended throughout.
Neuro: AAOx3. Moves all extremities spontaneously.
MSK: No lower extremity edema. No calf tenderness. No gross deformities or extremity tenderness.
Skin: Warm and dry

Pertinent Labs, Imaging, and other study results (such as ECGs)

MDM: Brief summary.

DDx - What you think could be going on. Ruling in/out major life-threatening diagnosis.

Narrative - ED course, which includes treatments given and test results.

Discuss final disposition including information such as prescriptions, follow-up instructions, and return precautions if the patient is being discharged.

MDM:

49 y/o male with PMH of HTN who presents with gradual onset of sharp chest pain which resolved prior to arrival.

Differential diagnosis includes but is not limited to ACS, aortic dissection, pneumonia, pneumothorax, and costochondritis. Patient is hemodynamically stable, has no neurologic deficits, and the chest pain is resolved making aortic dissection unlikely. Pulmonary embolism is unlikely based on lack of dyspnea, pleuritic chest pain, and tachycardia. Doubt pneumothorax with normal lung sounds and lack of dyspnea. Esophageal rupture is less likely with no hematemesis and no dysphagia. Patient has no signs of infection with lack of fever, chills, and productive cough, which makes pneumonia unlikely.

Patient was administered 325mg PO aspirin. EKG showed normal sinus rhythm with no ST segment changes. In order to further evaluate for possible ACS, a delta troponin was drawn and also negative. Through the HEART score pathway, the patient is overall low risk with an initial HEART score of 2 and negative delta troponin. CBC shows no anemia or leukocytosis. BMP shows no electrolyte abnormalities or AKI. CXR shows no signs of pneumonia, pneumothorax, pulmonary edema, pleural effusion, or pneumomediastinum.

Upon re-evaluation, the patient reports no return of chest pain. He continues to appear well and a repeat cardiovascular and respiratory exam reveals improved chest wall tenderness. His vital signs have remained stable throughout his ED course. Patient was instructed to follow up with his PCP within 1-2 weeks. He was discharged home in stable condition with appropriate return precautions.

Impression: Can be a series of single words or phrases. Avoid specific diagnoses unless confirmed by laboratory or other studies. May have more than one per patient.

Impression:

1. Chest pain; unspecified

Signature: Sign with your name and title.

Your Name, MS-IV