SAMPLE HISTORY & PHYSICAL EXAMINATION

Your Name:
Name: Bridget Smith Place: University Hospital
Age: 34 Admission: 07/01/2009
Address: Evans, GA. Date of Exam: 07/01/2009
Source of History: patient Attending: Fall
Reliability: excellent Room Number: 862
Hosp. #: T8330000

Chief Complaint: (In their own words) "I have been short of breath for 1 week now”

HPI: (The first sentence should include past medical history that is pertinent to chief complaint i.e. h/o asthma.
It should be a clear, chronological narrative including the onset of the problem, setting it developed in,
manifestations, and treatments. Symptoms should be described with location, quality, quantity or severity,
timing, onset duration, frequency, setting, aggravating and relieving factors, effect on function and associated
manifestations. Negative data may have diagnostic significance.)

Ms. Smith is a 34 y/o African-American women with a history of asthma “for as long as I can remember” who
presented to the ER with a worsening asthma attack. She has had a history of asthma since early childhood. (Start at
the very beginning and work your way up to the CC.) She has occurrences of her asthma almost weekly and needs
to be seen in the ER on a monthly basis. She claims her asthma is initiated by a wide variety of allergens including
foods, pollens, animals, and exercise. She has had numerous hospitalizations for her asthma, however she has never
required intubation. Her most recent hospitalization was 6 mos. ago. She was discharged on Albuterol and
Beclamethasone nebulizers and oral Prednisone. (Include all pertinent medications.) She was tapered off the
Prednisone a month later.
She was in her usual state of health until one week ago when she ran out of her nebulizers. She felt as if she
had a fever and she complained of chills (she never actually took her temp). Her breathing worsened to where she
could not walk across a room without getting SOB and wheezing. She normally can walk 3 blocks before she will get
SOB. She also had a cough productive of green sputum. She complained of sub-sternal chest pain when she coughed.
This pain would last a few minutes. The pain could be relieved by rubbing. Nothing made the pain worse except
coughing.
(ROS, both positives and negatives, that are pertinent to HPI.) She has no nasal congestion, no post-
nasal drip, and no sore throat. She denies a history of reflux. She denies hemoptysis, nausea, vomiting. She felt weak
and lethargic but denies dizziness or tinnitus. She has had no weight loss or night sweats. She does not know her
normal peak flow. She has never smoked or used any type of illicit drug (Include all pertinents from PMH/SH/FH.)

Past Medical History

Childhood Illnesses: For adults only childhood diseases that have health sequelae are important (e.g. Rheumatic
fever)

Medical Illnesses:

You should know the date the diagnosis was made. For diseases that are active you need to go beyond just
listing. If pertinent include negatives here or in ROS.

1. HTN dx 1999: Patients blood pressure has been well controlled,

2. Asthma 1988 (In this case since it is relevant to the CC/HPI it will be in the 1st line of the HPI not here.)
(-) coronary artery disease, CVA, renal failure (pertinent negatives in view of history of HTN)

Past Surgical history: tubal ligation elective, 1991

Medications: You should know the medication, the dosage, frequency and reason it is being used

Medication Beclamethasone Albuterol Lisinopril Motrin

2 puffs q 4h
Dosage 2 puffs q 4h (ran out) 40 mg daily 400 mg q 6h
(ran out)

Date Years Years years

Prescribed for Asthma Asthma HTN Aches

Doctor ? ? Jones OTC

Allergies: ASA (it makes her have a rash) These items can
occasionally be deleted if
Social History: include tobacco, alcohol, drugs and related substances, occupation not pertinent.
Travel: never been out of the country, visited friends in Detroit once

Habits: never smoked, no IVDA, drinks beer occasionally socially

(Can be in Social History)

Exercise: very limited, it triggers asthma attacks

Diet: eats fruit, vegetables and meat. Can't eat seafood, the smell causes an asthma attack

Immunizations: All childhood immunizations. tetanus shot 1 year ago, no pneumovax or Hep B.

Transfusions: none

Screening Tests: PPD, has had a yearly breast exam and pap smear that were both neg. does not do self breast
exams

OB-GYN: G3P3 -- All NSVD. LMP 11/9/96

Sexual: heterosexual, is divorced, currently has no boyfriend and no sexual relations

Screening Tests: PPD, has had a yearly breast exam and pap smear that were both neg. does not do self breast exams
SOCIAL HISTORY: Ms. Forrest was born on Oct. 22, 1966 in New Orleans, LA. She finished high school in New
Orleans and worked in the Art Department at Loyola University. She was married and had 3 children, 2 boys and 1 girl.
They are 5, 7, and 9 years old. She became divorced after the last child was born. She currently lives with her sister
and is unemployed due to her persistent asthma attacks.

FAMILY HISTORY: This can be written out and not diagrammed.

REVIEW OF SYSTEMS (Those not included in HPI or relevant to CC):

General: no weight loss, felt like she had a fever and chills (see HPI)
Skin: no dryness, itching, or irritation
Head: says she has occasional headaches that are relieved by Tylenol, no dizziness or vertigo
Eyes: no changes in vision, no blurring of the vision, no auras or spots
Ears: no tinnitus, no discharge, no change in hearing
Nose and Sinuses: see HPI, no nose bleeds, no nasal polyps
Mouth and Throat: no bleeding gums, no sores in the mouth, no sore throat
Neck: no lumps or pain
Respiratory: (see HPI)
Cardiac: no heart palpitations
Gastrointestinal: no changes in bowel habits, no blood, no N/V
Genitourinary: no changes in urination, no burning or itching, no urgency or frequency, no hematuria or discharge
Peripheral Vascular: no edema or claudication
Musculoskeletal: pain in left knee for 1 month, hurts when standing on it for a long period of time, no warmth or
redness, no memory of any trauma to the knee
Neurological: no parasthesias, dizziness, or weakness
Hematologic: no bruising or bleeding
Endocrine: no heat or cold intolerance
Psychiatric: no phobias, nervousness, or anxiety
PHYSICAL EXAM – Ensure a detailed exam, of organ system responsible for the chief complaint.
General: Ms. Smith is a mildly obese BF sitting up on the side of bed in moderate respiratory distress with nasal flaring
and use of accessory muscles.

Vitals: Temp: 37 RR: 32 P 116 BP 136/78 – paradox 8, no orthostasis

Weight 166 pounds. Height 5 feet 3 inches BMI 29.4

Skin: several small patches 2-3 cm scaling lesions on elbows bilaterally

HEENT: NC/AT; Visual acuity 20/25 with correction, conjunctiva mildly injected bilaterally, sclera anicteric, Visual fields
full to confrontation, PERRLA, EOMI; hearing excellent, EAC w/o lesions, TM’s clear; nasal turbinates not swollen,
single nasal polyp visible on the left; Teeth in fair repair, oral pharynx w/o lesions, no candida noted.

Nodes: No cervical, axillary, inguinal or femoral adenopathy.

Neck: Thyroid not enlarged w/o nodules; trachea midline

Chest: RR 32, audible wheezing noted, (+) intercostal retractions, chest expansions appears symmetrical,
diaghragmatic excursion 2 cm, Chest appears hyperresonant to percussion, diffuse inspiratory and expiratory wheezes
on auscultation, no crackles or rhonchi noted.

CV: Carotids: 2+ without delay. Upstroke normal

JVP < 5 cm
Heart: Tachycardic rate 116, PMI 5th ICS 1 cm medial to MCL. S1 S2 normal. 1/6 crescendo decrescendo
murmur heard best at the 2nd L ICS.
No S3 or S4 heard.
Peripheral Vascular

Radial Brachial Femoral Popliteal Dorsalis Pedis Posterior Tibial

Right 2+ 2+ 2+ 2+ 2+ 2+
Left 2+ 2+ 2+ 2+ 2+ 2+

2+ = normal ; No bruits heard

Breasts: symmetric, no deformity noted, no masses palpated

Abdomen: mildly obese, (+) BS, Liver 8 cm by percussion, No splenomegaly, no masses, No tenderness.

Back: FROM, normal lumbar lordosis, no CVAT

Pelvic:
External : no lesions
Vagina: no discharge or lesions
Cervix: Parous w/o lesions
Adnexa: no masses, no tenderness

Rectal: good sphincter tone, no masses, stool heme negative

Musculoskeletal: FROM all extremities, no deformity, no swelling of joints. No muscle atrophy

Neuro: MS: O x 4, affect appropriate, long and short term memory intact
CN: II-XII intact
Motor: 5/5 all groups, no atrophy
Sensation: intact to pain, light touch, proprioception, negative romberg
Cerebellar: F-N intact, no dysdiadokinesia, heel to shin intact
Gait: narrow base
DTR’s

2+ 2+ 2+ 2+
2+ 2+

2+ 2+

2+ 2+

Labs

Na 135 K 4.8 Cl 98 HCO3 22 BUN 16 Creatinine 1.0 Glucose 164

WBC 9.8 64 P 18 L 6 M 12 E

Summary: 30 year old with long history of asthma presents with exacerbation. Exam shows evidence of
bronchospasm. Patient has classic triad of asthma, aspirin sensitivity and nasal polyps.

Assessment/Plan: You MAY consider using the following to outline your critical thinking. This does not substitute for
a discussion on each active problem. Your differential should be no more than 3
 PROBLEMS DDX DX PLAN RX PLAN

1. SOB 1. Asthma 1.CXR 1. IV Steroids

exacerbation 2. aspergillus 2. inhaled beta-agonists
2. Allergic percipitins 3. inhaled ipratroprium
bronchopulmonary 3. ABG
aspergillosis
3. Pneumonia
4. Pulmonary
embolus(unlikely)

2. hyperglycemia 1. Diabetes mellitus 1.Fasting glucose 1.Low carb diet

2. impaired fasting 2. consider 2 h ogtt
glucose 3. Hgb A1C 2. Dietary counseling for
weight reduction

3. HTN 1.essential 1. None 1. Monitor BP

2. possibly steroid 2. Adjust meds to keep
induced BP <140/90

1. (Main Problem is # 1) SOB : Asthmaà Acute exacerbation. Will treat with IV solumedrol to decrease
inflammatory component along with inhaled beta-agonists for bronchodilation. The role for ipratropium in
asthma is unclear. Aproximately 50% of patients will respond so it is worth trying. In view of the eosinophilia
we need to consider the posibility of allergic bronchopulmonary aspergillosis à will send aspergillus
precipitins and check IGE levels. It is unlikley that she has an underlying bacterial bronchitis will not treat with
ABX.

Because she has frequent attacks will add a leukotriene inhibitor after she resolves this episode. Will also
switch to a long acting beta-agonist at discharge. Other considerations are the use of cromolyn sulfate to
prevent histamine release. Anti IGE antibodies are far too expensive to use in this case.
The plan should be divided into diagnostic and therapeutic. These should be justified or explained in the
assessement.

Diagnostic Plan:
a. CXR
b. aspergillus precipitins
c. ABG
d. IGE level

Therapeurtic Plan
a. Solumedrol 60 mg IV q 6h
b. albuterol 2 puffs q 4h
c. ipratropium 2 puffs q 6h
d. follow spirometry

Other Problems (These are problems picked up in history, physical or abnormal labs not related to the HPI and
stable outpatient problems. Continue current meds is not adequate)

2. Hyperglycemia: Random blood sugar elevated. Patient is overweight as per BMI. She is also under stress;
both of which may lead to diabetes. She does not meet ADA criteria for Diabetes. We will check fasting
glucose and if > 126 this would make diagnosis. However, patient will be on high dose steroids so this may
cloud the picture. Would check HgbA1C and if elevated it would point toward DM and need for more
aggressive management. Will have nutrition see her and counsel on weight reduction and low glycemic diet.
Consider repeat labs when off steroids. For now follow sugars especially with steroid boluses.

Diagnostic Plan
1. Follow glucoses
2. HgbA1C

Therapeutic Plan
1. Nutrition consult
2. Follow up as outpatient while on steroids.

3. Hypertension: Patient is African-American with family history, which points to this being essential hypertension.
Patient is at goal as recommended in JNC 7. If she has evidence of renal dysfunction or refractory
hypertension would consider the possibility of fibro-muscular dysplasia

Diagnostic Plan
a. None
Therapeutic Plan
a. monitor BP
b. low salt diet
c. continue lisinopril

If the attending can’t figure out if you have read about the given problems then you did not do a good job. Furthermore
you will be expected to be able to answer questions related to your diagnostic plan as well as assessment and plan. If
you can’t it is not ‘A” quality.

ANY MED Student Y3