Month: November 2019

Scribe Series: HPI Practice Case 2

Hello medhatters!

I have another case for you all! Like the previous post, I will give you a scenario with a few questions to answer. The goal is to improve your HPI writing. Again, since this isn’t audio recorded, this will not help with your listening & typing skills. It will however, help you improve your flow and if you can properly pick out which elements are what. Since looking at the problem is easier when trying to solve it than listening to it, we will do that again today.

Like the last practice, I have a practice worksheet for you. Please feel free to either copy it and pull it up and work on it, or print it out. I will not be allowing editing access simply so it stays blank for others when they come across it. Worksheet Here.

Courtesy of giphy.com

Case: Chest Pain

Complaints:

  • 61 y/o
  • M
  • Chest pain while watching television earlier tonight
  • Sharp
  • Substernal
  • Squeezing
  • 9/10
  • Goes to left arm
  • Goes up to jaw
  • Nausea, he vomited once.
  • Has not improved with drinking water. Nothing made it better or worse at home.
  • Called EMS, they gave him some medicine that he doesn’t know the name of that seemed to help a little bit, but now his chest pain is back.
  • He has never had this before.
  • H/o HTN, CAD.

Task 1: Can you pick out the elements of this HPI?

Age/Sex
Chief Complaint
Onset
Location
Duration
Characteristic
Alleviating factors
Aggravating factors
Associated Symptoms
Radiation
Timing
Severity
(anything else you can add at the bottom of your paragraph).

Now, there are actually two problems here. But we are going to lump the lesser problem into the main problem, simply because I’m going for one caused the other.

Answer:

Age/Sex: 61 y/o M
CC: Chest pain
Onset: earlier tonight while watching television
Location: substernal
Duration: constant (implied here).
Characteristic: sharp and squeezing
Alleviating factors: nothing at home, including attempting to drink water. But some improvement with EMS medication administration
Aggravating factors: none
Associated symptoms: nausea & vomiting x1
Radiation: to left arm and jaw
Timing: since pain is constant we don’t really have a timing specific element in this story.
Severity: 9/10
Everything else: We have some backstory here. The main thing to look at is the history of (h/o) hypertension (HTN) and coronary artery disease (CAD). We also know he has never had this before.

I want you to stop and think about what this might be.  What might the medication have been that EMS gave?

Task 2: Write an HPI!

Write an HPI so that your order, flow and story makes sense. Use medical terminology as if you were writing this in a chart. The blessing is this is text, and you aren’t converting it from what you are hearing down into text form.

My version of this HPI:

Patient is a 61 y/o M with a h/o HTN and CAD, presenting for sudden onset substernal chest pain while sitting down watching television tonight. He describes his pain as a sharp and squeezing sensation, rated a 9/10 which radiates to his L arm and jaw. He has had nausea and vomiting x1. The patient noted no improvement with drinking water at home, but upon EMS arrival he was given sublingual NTG with brief improvement before his pain returned. No reported aggravating factors. He denies having this previously and has no other concerns or complaints.

Bonus!

On exam, he is diaphoretic, tachycardic, and in distress. You immediately hook him up to an EKG and find he is in normal sinus rhythm. His heart rate is 105 BPM. On his strip, he has ST depression in leads 2,3, and AVF.

His radial and DP pulses are 2+ and equal. His lungs are clear to auscultation bilaterally. Abdomen is benign. He is alert and oriented, but nervous.

You order a chest X-ray (CXR), a troponin, CBC, & CMP. You start him on oxygen, IV morphine, and give him a baby ASA. He was started in a Nitro drip.

Task 3: Can you guess what happened?

This is a pretty classic case here. I hope even if you don’t know what some of this medical treatment is, you would be able to guess it!

Answer:

He is having a STEMI, or an ST elevated myocardial infarction. This is an inferior MI, which means it is likely affecting the RCA or right coronary artery. So we are essentially not getting enough blood flow to the right atrium and right ventricle right now. Not good!

Since we started his initial treatment, and the doctor gave him pain medications and more nitroglycerin in attempts to relax his arteries to get more blood flow to the heart. The next step is to call the cardiologist in hopes of getting him to the Cath lab. We want to open those arteries up as quickly as possible before damaging more tissue.

So our diagnoses (or Assessment!) is as follows:

  1. Chest pain, Inferior STEMI
  2. H/o HTN
  3. H/o CAD

You may also hear the terms ACS or acute coronary syndrome which encompasses both MI’s and angina.

Hopefully you enjoyed this practice HPI post! Let me know if this helped in the comments below.

Cheers!

Scribe Series: HPI practice Case 1

Hey all,

Since I do peruse what piques peoples interest on this site, I’ve noticed a lot of interest in general on HPI practice. So today, I figured I’d give ya’ll some practice. This will be text practice; I’m not technologically fancy enough to do a voiceover. These cases are long, so I will do 1 per post. Let me know if you find this helpful in the comments below!

Also, here is a drive worksheet you can use. Feel free to make a copy of it or print it out so you can work through this on your own. I will not be giving edit access out simply to allow others to come across a blank worksheet. Worksheet here.

Cough

Here are the list of complaints given to you in no particular order.
– 73 y/o
– F
– h/o COPD, recent pneumonia which got better on abx a few weeks ago.
– Has had pneumonia 3x this year.
– Has a rescue inhaler and a long acting inhaler. Noticed that she is having to use her rescue inhaler more, 6 times or more a day.
– Cough onset 1 week ago, productive. white-yellow sputum. Coughing bouts occur all throughout the day, making it difficult to do her normal activities. Cough keeps her up at night.
– Fatigued.
– Don’t feel well. Hasn’t checked her temp at home.
– Cough syrup makes it slightly better. Activity and deep breathing makes it worse. She’s been shallow breathing because of it.
– Also has a sharp pain to her R rib cage that is much worse with deep breathing. Noticed 2 days ago. pain is a 7/10. Feels slightly better when compressing the area.

Task 1: Can you pick out the elements of this HPI?

Age/Sex
Chief Complaint
Onset
Location
Duration
Characteristic
Alleviating factors
Aggravating factors
Associated Symptoms
Radiation
Timing
Severity
(anything else you can add at the bottom of your paragraph).

Now, there are actually two problems here. But we are going to lump the lesser problem into the main problem, simply because I’m going for one caused the other.

Answer:

Age/Sex: 73 y/o F
CC: Cough
Onset: 1 week ago
Location: chest
Duration: constant (in a sense).
Characteristic: productive of white-yellow sputum.
Alleviating factors: cough syrup helps slightly
Aggravating factors: activity. deep breathing
Associated symptoms: fatigue. malaise. No reported temp, but we are unsure.
Radiation: None. In general, usually only pain radiates.
Timing: all throughout the day.
Severity: None. In general, usually only pain radiates.
Everything else: Lots here!
– In regards to the cough, she is having to use her rescue inhaler more. This is an important fact. It means she is not well controlled and her current cough (whether from COPD or another infection) is needing a lot more medication.
-Cough is keeping her up at night, likely causing her fatigue.
-She was recently on antibiotics for a bout of pneumonia.
-Rib pain! Her rib pain started after her cough began. It is pleuritic (or hurts when she breaths) and 7/10 in sharp pain. It feels better when she compresses it.

Now, we could ask more information on the rib pain, and do a second OLDCAAARTS on this complaint. However, your provider decides not to ask more.

Why might that be?

Task 2: Write an HPI!

Write an HPI so that your order, flow and story makes sense. Use medical terminology as if you were writing this in a chart. The blessing is this is text, and you aren’t converting it from what you are hearing down into text form.

My version of this HPI:

Patient is a 73 y/o F with a h/o COPD presenting c/o 1 week of a productive cough with yellow-white sputum. She has noted her cough to be constant and interfering with her daily activities and sleep. Because of this, she has been fatigued more than usual. The patient recently had pneumonia which improved on antibiotics, but has had 3 other bouts of pneumonia this year. Deep breathing worsens her cough and causes pleuritic pain. Cough syrup has slightly improved her symptoms. Other associated symptoms include malaise and right sided rib pain which presented after her coughing started. Rib pain is pleuritic and rated a 7/10. This improves with manual compression of the area. Of note, she has both a rescue inhaler and long-acting inhaler at home. She has needed her rescue inhaler more this past week, reporting using it upwards of 6x or more a day.

Bonus!

On exam, she is febrile at 102’F, tachycardia at 110. She appears ill. Breath sounds are muffled in the RLL. Her R 5th rib has minor step off to the anterior axillary line area. Tenderness over this area of her chest.

Xray shows you barrel chested, hyperinflated lungs with a flattened diaphragm.  Consolidation in the RLL noted. Trachea appears midline. The R 5th is fractured at the anterior axillary line. No other fractures seen. All other bones appear normal.

Task 3: Can you guess what happened?

Now this is just for funsies as I certainly didn’t give you all of the clues or everything that I would order for this patient. You also wouldn’t be asked to do this as a scribe! But just for fun, what do you think this patient has?

Answer:

Well, first off by her history she has as cough, with mucopurulent sputum. We are thinking infection. She didn’t point us to a fever at home, but she certainly has one here. She is also a bit tachycardia and ill looking: all signs of infection. We are worried about whatever she has progressing to sepsis.

What else points to infection? Well she is not in great health (COPD can cause a lot of problems), but the biggest thing here is that they were recently on antibiotics for pneumonia and have had pneumonia multiple times this year. On X-ray, I told you there was a consolidation, or Dr. speak for pneumonia.

The other issue here is the rib pain. I was going for that they fractured their rib due to coughing so hard. This happens in pertussis due to coughing so hard, BUT can happen in pneumonia as well. Usually someone with osteoporosis may have a much higher incidence of this happening, but it can occur in anyone who repeatedly coughs very hard. Xray confirmed the rib fracture.

The last thing here is the COPD. Now, this would explain why she is on an inhaler regimen. In someone who has pneumonia that does not have underlying lung disease, we would prescribe just a rescue inhaler. Because this person also has a long acting inhaler, this points us to underlying disease. The X-ray also confirms this with the barrel chest, flattened diaphragm, and hyperinflation. All classic signs of COPD on X-ray exam. I could have also said increased AP diameter.

So our diagnoses (or Assessment!) is as follows:

  1. Pneumonia, recurrent
  2. Rib fracture, likely from pneumonia
  3. H/o COPD

Hopefully you enjoyed this practice HPI post! Let me know if this helped in the comments below.

Cheers!