Scribe Series: HPI Practice Case 3

Hey all,

I’m back with some more HPI 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.

Diarrhea

Here are the list of complaints given to you in no particular order.

• 27 y/o M
• Diarrhea, having several episodes a day
• Watery, not much mucus. No blood.
• Stomach hurts all over. 
• Some nausea and vomiting. Vomited 2 times.
• Symptoms started 3 days ago. 
• Having abdominal cramps that seem to get better after going to the bathroom. Cramps and pain are a 6/10. 
• He’s been taking pepto bismol with slight relief of cramps and diarrhea. He hasn’t been eating much as he just gets sick when he does. 
• He doesn’t have a thermometer at home to take his temperature. 
• He was travelling recently before he got sick.

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).

Answer:

Age/Sex: 27 y/o M
CC: Diarrhea
Onset: 3 days ago
Location: Abdomen
Duration: episodic. Having several episodes a day.
Characteristic: watery, no mucous or blood.
Alleviating factors: going to the bathroom to relieve himself. pepto bismol. Not eating.
Aggravating factors: eating
Associated symptoms: abdominal pain and cramping. Nausea and vomiting x2.
Radiation: None.
Severity: 6/10
Everything else: He recently travelled prior to symptoms seeming to start.

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 27 y/o M presenting with 3 days of diarrhea. It is watery, but no mucous or blood noted. He is experiencing several episodes a day with associated cramps and generalized abdominal pain rated a 6/10. This improves briefly with bowel movements. Patient is also experiencing nausea and has had vomiting x2 since onset. He has been taking pepto bismol and not eating as much with some improvement in symptoms. Of note, he was recently traveling before symptoms started.

Bonus!

On exam, he appears uncomfortable. HR is 103, RR is 18, Temp is 99.7’F, BP is 115/87. Conjunctiva are pink. Mucous membranes are slightly dry. Heart is slightly tachycardia, but regular rhythm. No murmurs, rubs, or gallops. Pulses equal and bilateral to upper and lower extremities. Abdomen: Generalized tenderness without rebound or guarding. Hyperactive bowel sounds noted. in all four quadrants. Negative Murphy’s and McBurney’s sign. The remainder of exam is non-contributory.

Labs show a slightly elevated white count. But normal hemoglobin. Slightly elevated hematocrit. BMP shows a slightly elevated BUN and creatinine, but still within normal range. Negative liver panel. Stool studies were sent off and are pending.

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:

I was going for a viral gastroenteritis here. There are lots of different presentations for this and it could be viral or bacterial. This is a very common thing to get in the winter (viral) and popular in the summer at cookouts (bacterial). You see this frequently in both outpatient clinics, urgent cares, and ER’s. Since this one is likely viral from his recent travel, he will probably get some fluids and some anti-emetics and left to ride it out. The biggest concern with diarrhea is dehydration. Depending on someones baseline of hydration will depend on how much diarrhea will cause dehydration to that patient.

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

1. Diarrhea, likely viral.
2. Gastroenteritis, likely viral.
3. Mild dehydration.

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

Cheers!