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!