Comprehensive H&P Write-Up Template

Foundations of Doctoring Phase 1 Spring Assessment

University of Colorado Denver School of Medicine

Subjective
Patient Identification:
Chief Complaint (CC):
I hurt all over and feel like my feet are on fire.
History of Presenting Illness (HPI):
Patient is a 40y/o female who presents with body aches all over, and states that she feels like her
feet are on fire. The symptoms began (3 day) Monday, and the pt. stayed home from work
Tuesday. Pt reports taking Ibuprofen and Dayquil to alleviate the pain which works only
temporarily. The pain is described pain as dull and diffuse throughout the entire body and even
more pronounced in the lower lumbar region. Pt reports feelings of dyspnea upon minimal
exertion including while walking from the kitchen to the dining room. Pt. is seeking medical
care to alleviate her symptoms so she may get back to her everyday activities. The experience
with the disease is significantly debilitating. Pt. suspects pneumonia and expects, if the
diagnosis is confirmed, to be treated appropriately.
Past Medical/Surgical History (PMH/PSH):
T2DM
Low Vitamin D
Depression
Obesity
Hypertension
R wrist pain (dates)
Medications:
Glybuteride (dosages, route)
Plictosa
Liraglotide
Dayquil
Ibuprophen
Allergies:
No known food or drug allergies
Family History (FH):
Sons with Asthma
Social History (SH):
1

Pt does not smoke or drink alcohol.

Review of Systems (Complete ROS):
1 General: fever, body aches, cough,
headache, and sneezing. No weight loss or
gain.

6 Gastrointestinal: no changes in appetite,

dysphagia, changes in BM frequency,
constipation, bleeding, pain, or jaundice

7 Urinary: No dysuria or hematuria.

2 Vision: No Vision Loss/Changes, no
Pain, no Blurry or double vision

3 Head and Neck

Ears: No facial pain or jaw pain.
Denies hearing changes and no reported
head injuries.

Nose: rhinorrhea, congestion,

sneezing

8 Musculoskeletal: + lower Back pain and

global joint and skeletal pain.

9 Neurologic: Denies loss of sensation,

numbness, tingling, tremors, weakness,
paralysis, seizures or blackouts.

10 Hematologic: Denies history of anemia,

easy bruising, bleeding, petechiae, purpura,
or transfusions.

Throat: sore throat

Neck: No neck pain.
4 Pulmonary: Pt complains of coughing up
green sputum. Denies coughing up sputum,
hemoptysis, asthma, or bronchitis.
5 Cardiovascular: dyspnea on exertion denies history of murmurs, angina,
palpitations, or edema

11 Endocrine: T2DM, denies sensitivity to

cold, excessive sweating polyuria,
polydipsia, polyphagia, or thyroid issues.

12 Psychiatric: Denies changes in mood,

anxiety, depression, tension, or memory.

Non remarkable

13 Skin: unremarkable with no bruising or

rashesObjective

Physical Exam (Complete Core Exam):

Vitals:123/85, 111, 16, 99.8 98% RA

General Assessment: Female, Hispanic, in no apparent distress, Patient looks unwell and is
wearing a mask in an effort not to spread germs. Patient is supine and draped to maintain
modesty.

HEENT Exam: Head is normocephalic, skull is normal is shape and symmetry. Normal hair
distribution and texture, no tenderness to palpation, no swellings, no masses. Thyroid is
symmetrical with no nodules, enlargement or tenderness. Anterior cervical and supraclavicular
nodes are not TTP. Lips are pink and moist, teeth are in good repair, and breath is non offensive.
Tympanic membranes pearly and white. Frontal sinuses are non TTP. Tongue is midline without
deviation. No TTP of mastoid. Ear canal looks normal Tympanic membrane is pearly and white.
Cardiac Exam: PMI is focal and not diffuse. No precordial heaves, lifts or thrills noted. No
murmurs, rubs or gallops, S1 and S2 noted. RR is regular. No edema. Vascular: Carotid pulse
+2, no bruits, Radial, brachial, popliteal, postibial and dorsalis pedis equal bilateral, +2
Pulmonary Exam: In no apparent respiratory distress. Front, back, and ribs are of normal size,
shape, and symmetry. Lungs clear to auscultation. No accessory muscle use. Resonance on
percussion, equal bilaterally. No sign of clubbing or cyanosis. No TTP of sternal notch, sternal
angle, or thoracic muscles. Respiratory rate is 15 breaths per minute.
Abdominal Exam: No lesions, scars, or dilated veins. Pt is obese but normal contours and
symmetry noted. Abdomen is soft, and rounded with no muscle separation, Normal bowel
sounds present, no TTP, guarding or rebounding, normal liver edge. Murphys sign, no TTP at
McBurneys point. Spleen is not palpable.
Upper and Lower Musculoskeletal Exam: Musculoskeletal: Lower extremity no muscle
hypertrophy or atrophy. No TTP of SI joints, spinal processes, paravertebral muscles, or sacrum.
Full range of motion of neck and spine. DTR present at the knee and ankles. Straight leg raising
test negative.

Skin, Hair, Nails Exam: Skin is healthy in color with no lesions, scars, or dilated veins.

Assessment

Summary Statement:
(more specific no patient reports)
Patient is a 40y/o female who presents with body aches all over, and states that she feels like her
feet are on fire. Pt. suspects she has pneumonia and would like to be tested. There are no
personal circumstances that would impact the patients ability to comply with any recommended
treatment plan. If the pneumonia diagnosis is confirmed, a prescription should also be made
available to each family member in the household. In addition, safe handwashing and techniques
to minimize further spread of infection should be discussed with everyone in the household.