I present here the more formal version of a patient assessment, to be used when 1) there is a diagnostic dilemma, and 2) time is your friend, not your enemy.  When the battle lines are reversed, you need shortcuts to look for the most likely problems, and the Trauma assessment is one of those.

This format is used universally in hospitals, mainly because all the components you see below are mandated to be present by the various insurance companies, or you won’t get paid.  Even doctors like to get paid.

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A formal History & Physical consists of the following parts:

1. Patient identifiers (name, DOB, whatnot)

2. Chief complaint

3. History of Present Illness

4. Review of Systems (often skipped or ignored)

5. Past Medical History

6. Past Surgical History

7. Family History (also often skipped, even in formal H&Ps)

8. Social History

9. Current medication list, with names, doses, frequency

10. Vital signs and physical exam.

11. Objective data, often broken into Labs & Imaging

12. Overall assessment

13. Plan (which includes plan for diagnosis, treatment, and follow up)

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No big deal, right?  Just a few, measly bits of info.

Actually, it’s not that bad.  Even the formal version can be done in 30 minutes, 60 if they are very complex.

Point by point, then:

 

1. Patient ID is obvious stuff, but it’s not nearly as fun when you write the entire H&P and drop orders in, only to realize you’ve just ordered a bunch of stuff on the wrong patient.  Wrong med at the wrong time to the wrong person–gets people killed. Ask me how I know.  On second thought, don’t.  I’ve too many examples to choose from.

2. Cheif Complaint: is what brought the patient in the door. I ask “So, what brought you here today?” and that’s what I put here.  It’s short and sweet: abdominal pain, chest pain, ugly feet, etc.

3. History of Present Illness (HPI): This is where you get the story of the chief complaint. My mnemonic is:

OLD: Onset, Location, Duration;  CARTS: Characterization, Aggravating factors, Relieving factors, Temporal associations, other Symptoms.

I sometimes throw in “Happened before?” in the CARTS to make CHARTS, which kinda makes sense; most of this can be pulled from a patient’s old chart, and is often much more complete.

This mnemonic is geared toward the chief complaint of “pain” as that is by far the most frequent thing that gets people in the door.  But it works for most things.  As you saw in IvyMike’s SOAP post, there are as many mnemonics as there are brains.  Use mine, use your own, just use it.

An example:

“So, Mr. XYZ, what brought you here today?”

CC: “Doc my chest really hurts.”

HPI: When did it start? About 3 hours ago.  Where does it hurt? Right here in the middle of my chest. Does it hurt other places [radiate] too? Yes, seems to go into my left arm and jaw. How long [onset] has it been hurting? about 2 hours, then went away when I took my nitro pills. (Snuck in a relieving factor there).  What does this pain feel like [characterization]? Is it crushing, stabbing, electric? Crushing, doc, like an elephant on my chest. Anything make it worse [aggravating factors]? moving around, exerting myself. Other than nitro, anything make it better [relieving factors]? That morphine the EMS guys gave me.  Has this happened before? Feels just like my last heart attack. What was going on at the time [temporal factors]? were you exercising, eating, sitting still watching football? Minding my own business watching TV.  Any other symptoms at the time? Got a little short of breath and started sweating a lot. Felt a little dizzy. Now I have a wicked headache after that stupid nitro pill.

Now, we don’t put all of that in the medical chart, it would go like this:

68 year old male presents with 3 hour history of non-exertional, sudden onset, crushing left sided substernal chest pain, radiating to left arm and jaw, relieved by nitro and morphine and worsened by exertion. This was associated with dizziness, dyspnea, and diaphoresis, and felt the same as prior heart attacks.

That’s a lot more compact.

But it still tells the same story.  Most diseases come with some form of predictable pattern.  Pneumonia doesn’t give you leg pain; torn ACL doesn’t cause fuzzy vision.  The pattern of those factors tells the story of the disease, and the job of medical training is to help you remember the stories, and then teach you how to respond.

Review of Systems:

As the name implies, this is a review of all the organ systems.  You ask questions about everything, top to bottom, to see if you or the patient missed anything .

A fine example can be had here, from Wikipedia.  I’ll not clutter this post with all the possible questions.

Past Medical History:

This is a list, with some detail, of all the medical problems a patient has.  Some reasonable level of detail is necessary, especially if your patient has something that directly relates to his current illness.

A not-acceptable list:  Diabetes, cancer, heart failure.

The reason this list sucks is that it tells you nothing.  Allow me some illustrations:

“Diabetes” could mean either 1) type II, poorly controlled despite 3 oral medications and insulin.  Has suffered loss of one leg, has severe kidney disease (nearing dialysis), and has very poor vision as complications, OR it could be 2) type I diabetes and has been diabetic since age 4, has an insulin pump, has never been in the hospital for complications, and his Hgb A1C (a measure of chronic diabetes control) is normal.

“Cancer” could be 1) basal cell skin cancer, removed 5 years ago with no other complications, OR 2) malignant melanoma, removed 1 year ago but they didn’t get it all, with known spread to his liver, lungs, heart, and brain.  Failed initial chemotherapy and has been traveling back and forth to WellKnown Cancer Hospital for experimental treatments.

“Heart failure” could include 1) Isolated heart failure as a result of a viral infection 3 years ago, takes all his medications and is now back to running 5Ks at 7 minute/mile pace, OR 2) longstanding history of progressive heart failure due to a combination of 3 different heart attacks and ongoing smoking, has been in the ICU 4 times in the last 6 weeks for flare-ups of his disease, doesn’t take his medications, and his heart doctor has been talking to him about hospice/end of life care as he is not a candidate for heart transplant.

So get the details.

Past Surgical History:  What surgery, when, any problems with the anesthesia, any complications afterwards?

“5 vessel coronary artery bypass grafting, done in 2010, no issues with anaesthesia and had typical uncomplicated post-op course.”

“Above the knee amputation in 2008, due to chronic bone infection in the feet from uncontrolled diabetes.  Difficult intubation but no problems with anaesthesia.  Post op course complicated by surgical site infection, post-operative bleeding, and atrial fibrillation (a heart arrythmia).”

Family History:

What runs in the family?

“Don’t know, I’m adopted.” “Every person in my family has had a heart attack before age 50, and only one has survived to age 60”. “We have a history of cystic fibrosis that runs in the family.”  “Well, der, doc, ya know that sumtimes back in the holler, the family tree has sum funny branches ‘n such.”–this last means you are about to get a real earful of which cousin is banging which.

Sometimes there is a genetic disease that runs in the family. The pedigree below shows the members of the English Royal family that were afflicted with hemophilia, a blood disorder that makes you more prone to bleed. In grid-up medicine, this is a reason to call the genetics folks, they really geek out over this kind of stuff.

 

Social History

This is where you ask the embarrassing questions.  Tobacco? how many packs, how many years? Drugs? what type? IV, pills, smoke? Huff anything? Alcohol? how many cases per day? hard liquor too? how many 5ths per day? are you sexually active? boys, girls, both, or other (and you’ll be surprised who falls into which category here)? Unprotected sex? Ever exchanged money for sex, or purchased sex? and etc.  The point here is not to provide fodder for Jerry Springer, but to determine risks for various diseases that are acquired or spread via the above mechanisms. Lung cancer, mouth cancer, bladder cancer; hepatitis C or HIV, liver failure, syphilis, etc.  It’s considered very unprofessional to judge or otherwise give grief to your patient based on the responses to these questions.

There are some non-embarrassing questions, as well: what do you do for a living? any exposures to dust, fumes, Agent Orange, asbestos, beryllium, etc? Any hobbies that would cause exposures?

Recent travel? Oh, you’ve been to eastern Libera and gone to the funeral of a Ebola victim? did you touch the body? Oh, someone threw up on you, who later died of Ebola?  (Not a fictional example.  And it’s amazing how quickly you jump into the gear you just complained were too hot, stifling, and sweaty when you hear that story. And no, she tested negative.)

Do you have any animals or pets? What kinds? Any birds? Lizards? etc.

And on, and on.  There are so many things you can ask here.

Allergies:

Specifically we are interested in allergies to medications, and what the reactions were.  Many folks list as allergies, intolerances.  If taking aspirin makes your farts especially rank, that’s an intolerance.  If it makes your throat swell to the point you can’t breathe, a rash break out, your blood pressure drop through the floor, that’s an allergy.

Current Medication List:

This is broken down as follows: Name of med, dose, route, frequency, and sometimes duration and holding parameters.

1. Lisinopril 20 mg by mouth daily

2. Plavix 75 mg by mouth, every day, for next 3 months.  Hold if uncontrolled bleeding and call your doctor immediately.

3. Metoprolol 100 mg by mouth, twice daily, on an empty stomach. Hold for systolic blood pressure less than 100 or heart rate less than 60.

This is also the place to find out about all the different vitamins, herbal meds, home remedies, and over the counter meds they take.  They should be listed in the same format, and some effort should be made to determine where they were purchased.

Physical Exam:

Will be saved for a future post.  This is an incredibly long and detailed part of the exam.  Whole textbooks have been written on this topic.  Vital signs go here, too.

Objective data:

Chest xrays, lab data, ultrasound imaging, EKGs, MRI reports, cardiac catheterizations, etc.  Grid down, this section will be quite small. Grid up–oh boy.  Folks, this is where the meat and potatoes of Western Medicine is found.  One could even argue that this kind of information is what defines Western Medicine.  It’s why American doctors struggle without all the labs and toys.  It’s not that physical exam is bad, but a CT scan or MRI is just so much better.

Overall assessment:

Depending on your style, this is either a paragraph-style summary of your overall impression, or a list of diagnoses designed to make the billing department happy.  Or some mix of the two. I apologize for the NerdyDoctorSpeak inherent in this section.

“In summary, we have a 58 year old male with signs, symptoms, lab values, and an EKG consistent with a heart attack.  This appears to be complicated by cardiogenic shock, acute kidney injury, alterd mental status, and particularly pungent smelling feet.”

“In summary, we have a 42 year old female with ongoing difficulty breathing.  The precise cause is unclear, but the differential diagnosis (see below) includes COPD, asthma, vocal cord dysfunction, central airway obstruction. or morbid obesity. ”

Differential Diagnosis:

This “differential diagnosis” bit is important enough to rate its own category, even though it’s not a formal aspect of an H&P.  It is a list of all the possible things that could cause the symptoms your patient has. If you take your time, it’s typically quite long.  There are a host of online sites and apps that can help with this.  The list is a a critical component of how I approach a patient.  Once you have your list, you then try to determine what things you can take off the list, Sherlock Holmes-style, and once you have eliminated all but one, that’s what your patient has.  An example, frequently used in my residency:

The 7 Deadly Causes of Chest Pain:

1. Heart attack

2. aortic dissection

3. tension pneumothorax

4. pericardial effusion/cardiac tamponade

5. Pulmonary embolism

6. esophageal rupture

7. Penetrating thoracic trauma (GSW, knife wound, etc).

This is an incomplete list, but it is adequate for illustration.  All of these things cause chest pain and can kill your patient.  Some of these things can be taken off the list, just based on your HPI or exam.  No chest trauma? Cross off #7. Now, what test or lab can I do that would help me cross others off the list? Let’s grab a chest xray.  If it’s normal, then you cross #3 off the list, it makes #2, #4, and #6 less likely but you don’t cross them off the list yet. What about a heart attack? An EKG and troponins (a lab test that is very specific for heart damage) are next.  If either of these two are abnormal, you essentially have the diagnosis and you stop looking; if they are normal you keep going.  If still normal, the next test is likely a CT scan, looking for evidence of #2-#7.  And yes, the fact that it gives you info about so many things is why a chest CT is one of the most popular things ordered in the ER.  We joke that you can’t get out of the ER without a chest CT.

If all of the above is normal, then you can feel pretty comfortable that your patient is not going to immediately die.  The next step is typically admission to the hospital so that the inpatient team can do a more careful evaluation. They do this by expanding the list of differential diagnoses to the Not Deadly but Highly Annoying Causes of Chest Pain, and then testing as above.  They may even have to expand the list to the Really Wierd and Unusual Causes of Chest Pain, or if something strange comes up, to the Just Where Did You Stick That Bottle? Causes of Abdominal Pain, or the Wow She’s Freaking Crazy Causes of Leg Pain.

 Plan:

This presents how you will move forward.  If you have a diagnosis, this is where you spell out how you are going to fix what is wrong.  For many diagnoses, there is a set of things you need to do to provide high quality care, and you have to be very sure you have checked off all the items.  If you don’t know, then you spell out what tests/labs/imaging you plan on doing to make the diagnosis.  You can make this diagnosis based, or organ systems based.  Again, apologies for the NerdyDoctorSpeak;

“Heart attack: Patient  has NSTEMI based on labs and EKG.  She has received aspirin and heparin in the ER.  Cardiology has been consulted, and they plan on a cardiac cath in the morning.  We will start a statin and beta blocker as well, and obtain an echocardiogram in the morning.”

“Diabetes: will continue the patient’s home dose of Lantus (long acting insulin) and humalog (short acting insulin). Will check HgbA1C in the morning (a measure of chronic diabetes control).

“Septic Shock: the source appears to be left lower lobe pneumonia.  We will give 2 more liters of IV fluids to a goal systolic blood pressure of >100, and watch  for urine output of at least 100 cc/hour.  If these goals are not met, we will place a central line and start norepinephrine, and likely attach a Vigeleo system for non-invasive monitoring of cardiac output.  We will continue the antibiotics started in the ER (Vancomycin and Zosyn) and will modify these as culture results come back.  We will check the left pleural space and perform a thoracentesis if there is significant fluid.  Finally, should her respiratory status worsen, we will move directly to intubation.”

Your plan won’t sound as nerdy as those above.  A simple, “We’ll try some benadryl and have him check back tomorrow to see if the itching goes away” will do.

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So those are the big sections of a formal H&P.  This is the bread and butter of everyone you know with an MD after their name.  A huge chunk of medical training is trying to learn what to ask, what elements in the HPI point you to which diagnoses, which tests are useful in what situations, and what to do once you have the diagnosis.  It’s a lifelong process, so don’t worry too much if you don’t have it all on day 1.

 

–Grouch