HPI – history of present illness. This is subjective data that the patient or parent is telling you about the illness. It is the “story” of why the patient is coming to see you, include anything that is relevant (such as co-morbidities).
Example: 5yo female with history of asthma brought to the clinic by mother for c/o cough for 5 days, worse at night. Cough sounds barky. Mother also reports the patient is wheezing and short of breath when engaging in activity. Also has a runny nose and sore throat. Had a fever of 102 yesterday but none today. Cough is worse at night. Drinking well, urinating normally. Siblings are also sick.
History of Present Illness
PMH – past medical history (include gestation prematurity and delivery problems if pertinent),
Surgical history
Family history,
Medications (name of medication dose indication) use prescriptive format,
Immunizations
Social or Home situation – who do they live with siblings pets (pertinent for respiratory or allergy complaints) smoking. For the well visit you would go over the developmental milestones.,
ROS-review of systems: review all of the pertinent body systems (even if you covered it in the HPI). For the well visit you will need to do a complete ROS.,
Physical exam: complete if a well child pertinent systems for a specific complaint., However EVERY patient should have a Respiratory and Cardiovascular assessment., You will include vital signs and the results of any diagnostic testing.,
Include age appropriate developmental assessment, including milestones and stages.
Differential Diagnoses: What disease do you think is causing the symptoms? List your primary or working diagnosis first. Include 3 differentials with supporting pathology. You can put pertinent positives and negatives to support your diagnosis.
History of Present Illness
Plan of Care: Include everything that you will do for this patient. Medications, written in prescriptive format (dose, route, frequency, duration, indication). Any lab work or diagnostic testing that you will order. Non pharmacologic therapies. Patient teaching including things the patient can do to prevent disease transmission, symptoms that you would want the patient to watch for and what to do if they occur. Follow up directions – including a time frame and who/where they should go. Remember for your Well Visit you will need to discuss anticipatory guidance!
History of Present Illness
Reference your sources using APA format. Use your advanced practice journal article for pathophysiology or treatment plan information for the diagnosis.
Follow the grading rubric. Some of these case studies will be long. As always, speak to your assigned faculty if you have any questions.