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.

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!