AUC Macros: HPI

HPI General F/U

*** y/o fe/male presents to clinic to follow up from (date) visit regarding (CC). Pt has been using (medications) with/without complications. Pt reports minimal/moderate overall improvement in Sx since last visit. Pt currently experiencing sx of (Sx). Denies (Sx). Pt has been following (treatment plan) as advised at last visit. No other concerns today.


N95 mask, gloves, and face shield worn during visit.

HPI Annual Physical 1

Female patient:
*** yo Female presents to clinic for annual physical. Also patient wants to follow up on his/her symptoms.
Patient's last annual physical was year/s ago.
Pt has been using (medications) with/without complications or any side effect.
Allergy? Trigger? Kind of reaction?
Patient just got annual blood work and wants to learn the results.
Patient did not get the annual blood work yet but wants to get it after today's visit.
Last TDap vaccination was in
Last Flu vaccination
Last COVID 19 vaccination
50+
Pneumonia shots 1 or 2
Shingles shotLMP: *** Her periods are regular/irregular, for ** days. Uses **pads/tampon each day, heavy/ normal flow, with/without pain.
Her last mammogram/breast US ***years ago. Denies/reports abnormal results or biopsy.
Her last pap smear was **years go. Denies/reports abnormal results or biopsy. No/history of hysterectomy.
sexually active, partner male, female condom yes, no,
Her last colonoscopy was*** years ago and needs to repeat in***years. Denies/reports abnormal results or biopsy.

Male
*** yo Male presents to clinic for annual physical. Also patient wants to follow up on his/her symptoms.
Patient's last annual physical was year/s ago.
Pt has been using (medications) with/without complications or any side effect.
Allergy? Trigger? Kind of reaction?
Patient just got annual blood work and wants to learn the results.
Patient did not get the annual blood work yet but wants to get it after today's visit.
Last TDap vaccination was in
Last Flu vaccination
Last COVID 19 vaccination
50+
Pneumonia shots 1 or 2
Shingles shot
sexually active male female ,condom yes, no
patient last colonoscopy was*** years ago and needs to repeat in***years. Denies/reports abnormal results or biopsy.
Last PSA was in *****.


Pt reports minimal/moderate overall improvement in sx since last visit. Pt currently experiencing sx of (Sx). Denies (Sx). Pt has been following (treatment plan) as advised at last visit. No other concerns today.


N95 mask, gloves, and face shield worn during visit.

HPI Eye Infection

*** y/o (gender) comes in with complaint of (possible pink eye, eye discharge, stye, etc.) x () days. Pt has been experiencing Sx of (drainage [color?], redness in eye, scratchiness, watery eyes, swelling around eye, decreased vision [blurriness?], sensitivity to light, itching in eye [ask about any cough, nasal congestion, sinus pressure]). Does pt have allergies seasonally? Does patient wear contacts or correctional lenses? Pt has been taking (insert medications).
His last tetanus vaccine was (date or length of time).

HPI General F/U with Lab Results

*** y/o fe/male presents to clinic to follow up from (date) visit regarding (CC). Pt has been using (medications) with/without complications. Pt reports minimal/moderate/overall improvement in sx since last visit. Pt is currently experiencing sx of (Sx). Denies (Sx). Pt has been following (treatment plan) as advised at last visit. Here to discuss lab/imaging results. No other concerns today.


N95 mask, gloves, and face shield worn during visit.

HPI Back Pain

Mr.____ is a pleasant ___-year-old male with history of _____ pain. He has experienced the pain for the past _____. He states the pain started after an injury _____/with no inciting incident. The pain is located in the _____ with radiation to UE/LE with tingling/numbness, weakness, no bowel or bladder incontinence. At today's visit, he rates his pain ___/10 on a scale of 0-10, 0 being no pain and 10 being the worst pain possible. He describes the pain as burning, sharp-shooting, tingling, numbness, pinprick, stabbing, deep-pressure, tightness, spasms. The pain is aggravated by _____. The pain is mildly alleviated by _____. The impact of the pain has been significant on his physical and emotional life. He states that the pain impairs his ability to perform household chores, office work, drive, walk, run, play sports. It also has had a negative impact emotionally causing problems with concentration, depression, anxiety, mood, appetite, sleep, relationships. In the past, he has had MRI, X-ray, CT, EMG, Bone Scan, blood/lab tests. He has tried epidural injections, physical therapy, TENS unit, heating pad, ice, injections, exercise, steroids, surgery, massage, medications, acupuncture, hypnotherapy.

HPI Abd Pain, N/V

*** year old male/ female came into clinic with complaint of abdominal pain (cramping, sharp) to (quadrant: RLQ, LLQ, RUQ, LUQ, entire abdomen, lower or upper?) x *** days. Pt notes associated symptoms of nausea/vomiting/diarrhea/loss of appetite, fever, chills, night sweats. Pt has vomited *** times today and other days. Pt has had diarrhea episode *** times today and other days. Pt notes blood in stool, or vomit? Pt has been using (insert meds here) and has been staying hydrated. Pt last ate at ** AM/PM. Pt notes eating something different, sick contact. Has had flu shot?

HPI Animal Bite

*** year old male/ female came into clinic with complaint of animal bite to (region) which occurred (date/time). How did it happen (place of occurrence, circumstance).Provoked or Unprovoked attacks. Type of animal, name, breed, color. Owner of animal? Up to date on tetanus shot? Pt reports (pain, bleeding, swelling, rash, fever, chills).

HPI Chest Pain/SOB

*** y/o (gender) comes in with complaint of chest pain or SOB x () days/hours. Time of occurrence. Hx of cardiopulmonary disease/ conditions [patient and family]. Pt is experiencing Sx of (SOB, hyperventilation, chest pain [1-10 pain], tightness, heaviness, swelling in throat, fast pulse, slow pulse, fatigues, lightheadedness/dizziness, vision changes). Does pt have Hx of anxiety disorder? What medications has patient been using [OTC and Rx]?

HPI Ear Pain

*** y/o (gender) comes in with complaint of earache x () days. Pt has been experiencing Sx of (ear pain [numerical scale], sharp or dull pain, drainage [color], ringing in ears, tenderness on outside ear, decreased hearing, sinus pressure, nasal congestion/drainage). Has pt been swimming or on a airplane recently? Pt has also been experiencing Sx of (fever [temp], chills and night sweats, muscle aches, fatigue, productive or non-productive cough [color phlegm], congestion [chest or head], headache, N/V/D, swollen lymph nodes, sore throat [pain 1-10], headache, SOB, chest pain[tightness], dehydrated [fluid intake]. Has pt received flu shot and covid this year? Pt has been using (insert medications).

HPI Headache

Pt with complaint of headache
Onset prior to evaluation:
Rapid or Gradual
Onset while: active/sleeping/working

Associated Pain (0=none, 10=severe)
Location: nuchal/occipital/crown/parietal/temporal/frontal
Radiation: yes/no and if yes then to which area?
Neck Pain: yes/no
Severity now (0-10):
Severity at worst (0-10):
Duration: minutes/hours/days
Characterized as dull, sharp, stabbing, pulsating, throbbing, burning, pressure.
Worst headache of your life? yes/no
Previous headaches of this nature? yes/no
Neurological deficits? speech changes, visual changes, numbness or tingling in face or extremities
Distal extremity cramping, swelling or pain? yes/no

Pain modifiers
Relieved with sleep, NSAIDs, triptans, opiates, cold compress
Worse with activity, bright light exposure, sound, movement, laying down, standing up

Associated Symptoms:
no <-- nausea/vomiting
no <-- preceding aura before the headache (e.g. vision change, scotomata)
no <-- blurred vision
no <-- fever
no <-- sinus pressure or nasal drainage
no <-- extremity weakness

Pertinent PMH
no <-- Migraine Headache
no <-- frequent Sinusitis
no <-- Glaucoma
no <-- Head Trauma
no <-- Serious CNS risks (e.g. active cancer, immunosuppression, HIV)
no <-- Exposures (e.g. Tick bites, carbon monoxide)

no <-- Family history of cerebral aneurysm or stroke
no <-- Family history of autoimmune disorders or connective tissue disorders?

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Onset of Pain

Timing of onset of pain is a key factor in headache evaluation. A sudden onset of pain in the head or the neck should put subarachnoid hemorrhage in the differential diagnosis. TSG research indicates that this piece of historical information is missing in over half of headache charts.

Severity of the Pain

The subarachnoid hemorrhage can present with mild or severe pain. However, it is the severe headache that leads to the diagnostic evaluation for SAH. TSG research indicates that documentation of the severity of pain is documented in less than half of headache medical records.

Risk Factors for SAH

In general, risk analysis documentation by practitioners is inadequate. Risk factor analysis can provide invaluable clinical clues, and provides evidence that the practitioner considered a differential diagnosis. There are many missed diagnostic opportunities in this area. Risk factors for SAH are addressed at length in this program.

Headache History

The practitioner should elicit a historical evaluation for headaches. This is critical.

HPI Croup

*** year *** mo old male/female came into clinic with (parents, mother, father, guardian) with complaint of possible croup. Noted symptoms include cough (productive or dry?), (difficulty breathing, fast breathing, noisy breathing, shortness of breath, or wheezing), fever, chills, night sweats, fatigue, rhinorrhea, nasal congestion. (parents, mother, father, guardian) note the child has been more irritable, has not been sleeping well and has been crying often. Pt has been using (insert meds here) and was last given ***ml/mg of *** at *** AM/PM.

HPI Influenza

*** y/o (gender) comes in with complaint of possible flu x () days. Pt has been experiencing Sx of (fever [temp], chills and night sweats, muscle aches, fatigue, productive or non-productive cough [color phlegm], congestion [chest or head], headache, N/V/D, swollen lymph nodes, sore throat [pain 1-10], headache, SOB, chest pain[tightness], dehydrated [fluid intake]. Has pt received flu shot and covid this year? Been around anyone with flu Sx? Pt has been taking (insert medications).

HPI Laceration

{{dob}} {{gender}} c/o injury to (named body part)
more specifics on body part injured: (left/right, no. of digit, UE, LE)
that occurred (hours since event)
Injury occurred while (name activity)
He is currently experiencing:
no other symptoms
no loss of sensation related to the injury
full range of motion of involved body part
no symptoms of vascular compromise
loss of sensation distal to the injury

His last tetanus vaccine was (date or length of time)

Alternate Questions:
if head injury: LOC, dizziness, visual changes, anticoagulants
If taken any medication for pain: what? when? how much? did it help?

HPI Med Refill

y/o presents with request for medication refill. Pt has been previously prescribed ____ by another provider, and has run out. He/she denies any acute symptoms today and feels healthy. PCP is Dr. _____.

HPI Motor Vehicle Accident

Date and Time of incident:
Type of Vehicle: car/motorcycle/bicycle/boat
Position in vehicle: driver, front passenger, back passenger
Belted: yes/no
Hit head: yes/no
LOC: yes/no
Air bags deploy: yes/no
Police at scene: yes/no
Injuries reported at scene: yes/no
Extrication from vehicle: yes/no
Transported by ambulance: yes/no
Main body part(s) injured: head/extremity/torso/neck/low back/hands/
His last tetanus vaccine was (date or length of time)

HPI Musculoskeletal Injury

*** y/o (gender) comes in with complaint of (back ache, poss, broken bone, sprain, etc). Time and date of occurrence [how it happened]. Pt has been experiencing Sx of (back pain [1-10, sharp, shooting, radiating, dull], ROM limitations, discoloration, swelling, tingling/numbness, muscle spasms). What makes it worse [sitting, lying down, walking, etc..]. What makes the pain better [ice, rest, sleep, lying down, elevated, OTC meds]. Pt has been using (insert medications).

HPI Pharyngitis/Sore Throat

((age}} y/o {{gender}} comes in with complaint of sore throat x () days. Pt has been experiencing Sx of (sore throat [pain 1-10], (cough [productive or non-productive], color phlegm (if applicable), sinus pressure, headache, ear ache, wheezing, lightheadedness, SOB, chest pain [tightness], nasal drainage [color], fever, chills, night sweats, N/V/D). Hx of asthma, bronchitis or pneumonia? Pt has been taking (insert medications). What makes it better? What makes it worse?

HPI Psych

{{age}} y/o {{gender}} presents with complaint of

Pt lives at home with * who is emotionally supportive

Pt reports feeling well

Pt reports the medication has been working well

Pt has not noticed any change in symptoms since starting/increasing medication

Pt reports good mood

Pt reports depressed mood

Pt rates mood 5/10, up from 2/10 last visit

Mood ranges from 3- 5/10

No suicidal ideation/homicidal ideation/intent or plan

Sleep is good, Appetite is good

Sleep is hard to start and interrupted. Pt sleeps an estimated * hrs per night

Appetite is fair/poor/unchanged, with weight loss/gain

No AH/VH/paranoia/manic symptoms

Pt is tolerating medication without side effects.

HPI Rash/Skin Condition

*** y/o (gender) comes in with complaint of rash [reaction, blistering, burn, redness]. Pt is experiencing Sx of (area of body affected [where it started; did it spread] raised rash, fluid filled pustules, warmth to touch, itchiness, burning, tingling sensation, swelling, redness, discharge [color or odor?], fever, chills, N/V/D). New lifestyle changes, diet, pets, environment (outside). Any allergies? Hx of reactions. Pt has been using (insert medications).
His last tetanus vaccine was (date or length of time)

HPI Sport Physical

{{age}} year old {{gender}} comes into clinic with mother/father/guardian for a sports PE, pt will be playing the sport of *** and has been playing for *** years. History of problems with the sport or in the sport? History of asthma, cardiac or other respiratory conditions? History of heart disease, sudden deaths or respiratory disease in the family? Up to date on vaccinations?

HPI UTI

*** y/o (gender) comes in with complaint of possible UTI x () days. Pt has been experiencing Sx of (Pain [numerical scale], burning upon urination, increased hesitancy/ frequency/ urgency when urinating, unusual odor to urine, blood in urine, abdominal pain [cramping or sharp], fever, chills, lower back pain [check CVA tenderness]. Pt has had x amount of UTIs in the past or recently. Pt (is/isn't) sexually active. Pt has been taking (insert medications).

HPI Asymptomatic Covid Consult

*** y/o (fe)male presents to clinic with request for preventative Covid-19 testing. Pt is currently asymptomatic at this time. Denies cough, fever, chills, sob, chest [tightness], headache, nasal congestion/drainage, N/V/D at this time. Denies/Reports hx of asthma, bronchitis, or pneumonia. Pt denies/reports known exposure to persons with Covid-19.


N95 mask, gloves, and face shield worn during visit.