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See an example of a complete H&P write-up. The details and length of a written H&P can vary with the particular problem and with the service to which the patient is admitted.

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History

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  • Identification: Name, age, sex, referring physician, informant (eg, patient, relative, old chart), and reliability of the informant.
  • Chief Complaint: State, in patient’s words, the current problem.
  • History of the Present Illness (HPI): Define the present illness by quality; quantity; setting; anatomic location and radiation; time course, including when the illness began; whether the complaint is progressing, regressing, or steady; whether the complaint is of constant or intermittent frequency; and aggravating, alleviating, and associated factors. The information should be in chronologic order, including diagnostic tests done before admission. Record related history, including previous treatment for the problem, risk factors, and pertinent negative results. Include family history and psychosocial history pertinent to the chief complaint. Other significant ongoing problems should be included in the HPI in a separate section or paragraph. For instance, if a patient with poorly controlled diabetes mellitus comes to the emergency department because of chest pain, the HPI should first include information regarding the chest pain followed by a detailed history of the diabetes mellitus. If the diabetes mellitus is diet controlled or otherwise well controlled, the history of the diabetes mellitus may be placed in the past medical history.
  • Past Medical History (PMH): Current medications, including OTC medications, vitamins, and herbal agents; allergies (drug and other, as well as specific allergy manifestations); operations; hospitalizations; blood transfusions, including when and how many units and the type of blood product; trauma; and stable current and past medical problems unrelated to the HPI. Adult patients: Ask about diabetes mellitus; HTN; MI; stroke; PUD; asthma; emphysema; thyroid, liver, and kidney disease; bleeding disorders; cancer; TB; hepatitis; and STDs. Also ask about routine health maintenance. The questions for this category depend on the age and sex of the patient but can include last Pap smear and pelvic exam; breast exam; whether the patient does breast self-examinations; date of last mammogram; diphtheria/tetanus immunization; pneumococcal, influenza, and hepatitis B vaccines; stool samples for occult blood; sigmoidoscopy or colonoscopy; cholesterol; HDL cholesterol; functioning smoke alarms on each floor at home; and use of seat belts. Pediatric patients: Include prenatal and birth history, feedings, food intolerance, immunization history, hot water heater temperature setting, and use of bicycle helmets.
  • Family History: Age, status (alive, dead) of blood relatives and medical problems of blood relatives (ask about cancer, especially breast, colon, and prostate; TB, asthma; MI; HTN; thyroid disease; kidney disease; PUD; DM; bleeding disorders; glaucoma, macular degeneration; and depression and alcohol or substance abuse). Write out or use a family tree (see Figure in example of a complete H&P write-up).
  • Psychosocial (Social) History: Stressors (financial, significant relationships, work or school, health) and support (family, friends, significant other, clergy); lifestyle risk factors (alcohol, drugs, tobacco, and caffeine use; diet; exercise; exposure to environmental agents; ...

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