Sample H&P Each person’s H&P is a little different so find your own style and what works best for you. A lot of people make a template of which they keep several copies with them and use it when interviewing patients then rewrite the note more clearly in the chart.

Date, Service (UAB IM Student H&P), Time (military)

CC: “My chest hurts”

HPI: (Who, what, when, where, how bad, how long, better?, worse?, ROS)

Mr. Smith is a 56 yo white, obese male with a hx of CAD, DM-II, HTN who presents to the ER with sub-sternal chest pain. Pain began 6 hours ago while the patient was watching television in his chair. The pain was unremitting, crushing in nature, 10/10 in intensity and radiated to the left arm and jaw. The pain was made worse by walking and somewhat relieved by rest. Also c/o diaphoresis, and nausea. Positive for (insert pertinent ROS here), but negative for (Insert pertinent ROS here).

PMH: (Include illness, when diagnosed, treated by. Also surgery, meds, allergies and hospitalizations)

HTN (1988, Dr. Meenie), CAD (1990, Dr. Miny), DM-II (1991, Dr. Moe)

Surgeries: Appy (1976, Dr. Larry), Vasectomy (1980, Dr. Curly)

Hospitalizations: 1976 (Appendicitis)

Meds: HCTZ (dose), Labatolol (dose), Glucotrol (dose)

Allergies: NKDA

FH: (Include immediate family and grandparents if applicable)

Mother (Deceased 77): CAD, DM, HTN, Breast CA

Father (Deceased 85): Prostate CA, HTN, CVA

Sister (Living 49): Breast CA, HTN

Brother (Deceased 60): CAD, HTN

SH: (Include as much as pertinent, job, living situation, children, drugs, EtOH, tobacco, sexual hx if pertinent.)

Lives in Madison, AL with wife of 30 years and two children ages 24 and 30. Worked for the railroad since 1972 and completed the 10th grade. Smoked 2 ppd for the past 20 years, drinks a fifth of whiskey a night for 30 years, and smokes crack for 5 years.

PE: (I will include a normal exam, except vitals)

Vitals: 99.2, 145/90, 112, 30 (temp, BP, HR, RR)

Gen: 56yo WM appears stated age, well dressed and groomed, A&O X4, NAD

HEENT: NC/AT, PERRLA, OP clear, No TTP, No LAD, trachea midline

Pulm: CTAB, No w/r/r, No pain with respiration.

CV: RRR, No m/g/c/r, No JVD

Abd: Soft NT/ND, BS + in all quads, No guarding, rebound or organomegaly.

Ext: Skin warm and moist, peripheral pulses present, No clubbing or edema.

GU: Normal tone, Heme negative.

Neuro: No lateralizing signs, CN II-XII intact, Strength 5/5 throughout, DTR 2+ in all extremities, No cerebellar signs, Gait and Station normal. Normal sensation at all levels.

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