The Following Is An Example Of An Excellent HPI- Thorough And Concise

The following is an example of an excellent HPI- thorough and concise. Does nice job of highlighting PERTINENT details in addition to OPPQRST!

HPI: Yesterday NR woke up with pain on the ball of her left foot which she describes as feeling like a bruise. Soon after, she noticed a rash on the ball of her left foot which began to rapidly spread from the foot to the toes and then up her leg. Shortly after, the rash presented on the right leg. As the rash spread, NR felt that she could not wait until morning to seek care from her primary care physician so she presented to the hospital at 10:30 pm. By the time she was in her hospital gown the rash had spread up both of her legs to the inner thighs and appeared on her right arm. She is not aware of anything that makes the rash or the joint pain worse. She attempted to treat herself with naproxen and hydrocortisone but neither was effective. Upon presentation, NR describes her rash as a stinging pain which was a 6/10 on the pain scale. Since being admitted and treated with Norco the rash does not sting anymore and she rates it at a 4/10, but says she only experiences pain when she moves. The rash radiated as previously described but currently is isolated to the feet and ankles with a small segment on the right inner thigh and a small segment on the right inner arm. The pain presented with edema in the feet which was alleviated by elevating the legs. She is also experiencing a foul smelling, dark vaginal discharge which began 2 days ago. NR is currently finalizing a divorce and has begun a new sexual relationship with another man as of 2 months ago.The patient believes that her current symptoms are either caused by an STI, either gonorrhea or Chlamydia, or from an exposure she had working as a nurse. Below is an excellent and thorough example of ROS:

Review of Systems:

General: reports +fatigue, +weight loss; denies fever, chills, weakness, or trouble sleeping.

Skin: +lumps, denies rashes, itching, dryness, or color changes

Head: denies headache or head injuries

Ears: reports decreased hearing in right ear and earache, denies tinnitus

Eyes: denies blurry or double vision, pain, discharge or redness

Nose: denies stuffiness, discharge, nosebleeds or sinus pain

Throat: denies sore throat, dry mouth, hoarseness, or bleeding.

Neck: denies swollen glands, pain or stiffness

Respiratory: denies cough, hemoptysis, shortness of breath, or wheezing

Cardiovascular: denies chest pain, tightness, palpitations, orthopnea, paroxysmal nocturnal dyspnea and edema

Gastrointestinal: complains of constipation, positive for nausea, vomiting, melena, denies diarrhea or hematochezia, denies hematemesis.

Urinary: denies frequency urgency, burning, hematuria or incontinence

Musculoskeletal: +back pain, +joint pain, denies swelling, stiffness

Neurologic: +numbness, +tingling on fingers and toes, denies dizziness, fainting, seizures

Endocrine: denies polyuria, polydypsia, sweating, or heat or cold intolerance

M2 Physicianship Applied Physical Diagnosis Excellent examples of H&Ps part 1