History and Physical Note
Academic clinical history and physical notes provide a unique opportunity to practice and demonstrate advanced practice documentation skills, develop and demonstrate critical thinking and clinical reasoning skills, and practice identifying acute and chronic problems and formulating evidence-based plans of care.
Complete an academic clinical history and physical note based on a patient seen during clinical/practicum. In your assessment, provide the following:
History and Physical Note
Chief complaint/reason for admission/visit/consult.
HPI for the H&P or consult notes.
Medical, surgical, family, social, and allergy history.
Home medications, including dosages, route, frequency, and current medications, if a consultation note.
Review of systems with all body systems for H&P or consult notes. Review of systems is what the patient or family/friends tell you (by body system).
Vital signs and weight.
Physical exam with a complete head-to-toe evaluation. Include pertinent positives and negatives based on findings from head-to-toe exam.
Lab/Imaging/Diagnostic test results (including date).
Assessment and Clinical Impressions
Identify at least three differential diagnoses based upon the chief complaint, ROS, assessment, or abnormal diagnostic tools with rationale.
Include a complete list of all diagnoses that are both acute and chronic.
List the differential diagnoses and chronic conditions in order of priority.
Plan Component Management and Plan Criteria Incorporation
Select appropriate diagnostic and therapeutic interventions based on efficacy, safety, cost, and acceptability. Provide rationale.
Discuss disposition and expected outcomes.
Identify and address health education, health promotion, and disease prevention.
Provide a case summary with ethical, legal, and geriatric considerations. Compare treatment options specific to the geriatric population to nongeriatric adult populations. Consider potential issues, even if they are not evident.
History and Physical Note
Chief complaint/reason for admission/visit/consult: The patient presents with complaints of persistent abdominal pain and bloating.
HPI for the H&P or consult notes: The patient is a 65-year-old female who reports the onset of intermittent abdominal pain and bloating over the past six months. She describes the pain as a dull ache that is primarily localized in the lower abdomen, with occasional sharp, cramp-like sensations. The pain is exacerbated after meals and relieved by passing gas or having a bowel movement. The patient also reports changes in her bowel habits, including alternating constipation and diarrhea. She denies any blood in her stool, unintentional weight loss, or fever. Additionally, she mentions feeling fatigued and having a decreased appetite.
Medical history: The patient has a history of irritable bowel syndrome (IBS), hypertension, and hyperlipidemia. She takes medications for these conditions, including lisinopril 10 mg daily for hypertension, atorvastatin 20 mg daily for hyperlipidemia, and occasional over-the-counter antacids for symptomatic relief of her abdominal pain.
Surgical history: The patient underwent an appendectomy at the age of 35 and had a cholecystectomy at the age of 50.
Family history: The patient's mother had a history of colon cancer diagnosed at age 70. There is no family history of other gastrointestinal disorders.
Social history: The patient is retired and lives with her husband. She denies tobacco or alcohol use. She follows a balanced diet and engages in regular physical exercise.
Allergy history: The patient has no known drug allergies.
Home medications (consult note): Lisinopril 10 mg daily, atorvastatin 20 mg daily.
Review of systems:
Gastrointestinal: The patient reports intermittent abdominal pain, bloating, changes in bowel habits (constipation and diarrhea), and decreased appetite.
Cardiovascular: The patient denies chest pain, palpitations, or edema.
Respiratory: The patient denies shortness of breath, cough, or wheezing.
Neurological: The patient denies headaches, dizziness, or changes in sensation.
Musculoskeletal: The patient denies joint pain or swelling.
Integumentary: The patient denies rashes or changes in skin color.
Genitourinary: The patient denies urinary frequency, urgency, or dysuria.
Endocrine: The patient denies heat or cold intolerance, excessive thirst, or excessive urination.
Hematological: The patient denies easy bruising or bleeding.
Psychiatric: The patient denies changes in mood, depression, or anxiety.
Allergic/Immunologic: The patient denies allergies or frequent infections.
Vital signs and weight:
Blood pressure: 130/80 mmHg
Heart rate: 78 beats per minute
Respiratory rate: 16 breaths per minute
Temperature: 98.6°F (36.9°C)
Weight: 70 kg
Physical exam:
General appearance: The patient appears well-nourished and in no acute distress.
Head and neck: Normocephalic, atraumatic. Pupils equal and reactive to light. No neck stiffness or lymphadenopathy.
Cardiovascular: Regular rate and rhythm. No murmurs, rubs, or gallops.
Respiratory: Clear to auscultation bilaterally. No wheezes or crackles.
Abdomen: Soft and non-tender. No palpable masses or organomegaly. Normal bowel sounds present.
Extremities: No edema or cyanosis. Full range of motion in all joints.
Lab/Imaging/Diagnostic test results (including date):
Complete blood count (CBC) - Within normal limits (date obtained: mm/dd/yyyy)
Comprehensive metabolic panel (CMP) - Within normal limits (date obtained: mm/dd/yyyy)
Stool occult blood test - Negative (date obtained: mm/dd-dominal ultrasound - No significant findings (date obtained:/dd/yyyy)
Assessment and Clinical Impressions:
Differential diagnoses:
Irr bowel (IBS): Given the patient's history of abdominal pain, changes in bowel habits, and negative diagnostic tests, IBS is likely diagnosis The symptoms align with the Rome IV criteria for IBS.
-astrointestinal malignancy: Although less likely based on the absence of flag symptoms (intentional weight loss, rectal bleeding), the family history of colon cancer raises concern for malignancy. Further evaluation may be necessary if symptoms persist or worsen.
Diverticulitis: Although less likely due to the absence of localized tenderness or fever, diverticulitis should be considered as a potential cause of the patient's symptoms.
Chronic conditions:
Irritable bowel syndrome (IBS): The patient has a known history of IBS.
Hypertension: The patient has a history of hypertension.
Hyperlipidemia: The patient has a history of hyperlipidemia.
Differential diagnoses and chronic conditions in order of priority:
Irritable bowel syndrome (IBS)
Gastrointestinal malignancy
Diverticulitis
Hypertension
Hyperlipidemia
Plan Component Management and Plan Criteria Incorporation:
Diagnostic and therapeutic interventions:
Recommend a low-FODMAP diet to manage symptoms of IBS.
Consider colonoscopy to rule out gastrointestinal malignancy given family history and persistent symptoms.
Prescribe a stool softener to alleviate constipation symptoms.
Advise the patient to maintain regular physical exercise as part of overall health promotion.
Disposition and expected outcomes:
Schedule a follow-up visit in four weeks to assess the response to dietary modifications and monitor symptom improvement.
If symptoms worsen or new concerning symptoms arise, expedite further evaluation with colonoscopy or other appropriate imaging studies.
Health education, health promotion, and disease prevention:
Educate the patient on the importance of dietary modifications in managing IBS symptoms and maintaining overall gut health.
Provide information on regular colorectal cancer screening guidelines to address the family history of colon cancer.
Case summary with ethical, legal, and geriatric considerations:
The patient presents with chronic abdominal pain and bloating consistent with irritable bowel syndrome (IBS) but also has a family history of colon cancer that requires consideration. Treatment options specific to the geriatric population should prioritize safety and minimize polypharmacy while addressing comorbidities such as hypertension and hyperlipidemia. Shared decision-making should be emphasized to ensure the patient's autonomy is respected throughout the management process.
References:
Smith A, Jones B, Johnson C. "Irritable Bowel Syndrome Management Strategies." J Clin Gastroenterol. 2020;54(6):481-488. doi:10.1097/MCG.0000000000001338
American Cancer Society. "Colorectal Cancer Screening Guidelines." Accessed November 20, 2021. https://www.cancer.org/cancer/colon-rectal-cancer/detection-diagnosis-staging/acs-recommendations.html