New York University School of Medicine hypertension, high

cholesterol, cancer,
Department of Medicine diabetes, liver or
Format for Patient Write-Ups by Students heart disease.

Date and time:

Name of patient:
Source and reliability:
Chief complaint (CC)1
Mr. Jones is a 67-year old male who presented to the ER with
“sharp pain in my chest” and night sweats for three days.

History of the present illness (HPI)2 1

Include the patient’s age, sex, and
Mr. Jones has smoked cigarettes continuously since age 17, for ethnicity (if
a total of 118 pack-years. At age 25, he began working in a relevant);
complaints
shipyard and had extensive asbestos exposure over the next (preferably in the
twenty years. He was well until ten years ago, when he patient’s own
developed a cough almost every morning, productive of about a words); and their
teaspoon of greenish sputum, without blood. Presently the duration. The
chief complaint
sputum production clears over the course of the morning and in should include a
general is worst in the spring. When the patient takes antibiotics brief summary of
for any reason, on average once a year, he notes that his sputum the main reasons
becomes clearer and decreases in volume. the patient is
seeking medical
care. Other
Over the past six months, the patient lost 25 pounds without symptoms may be
trying. He has had no change in his appetite. Two months ago, included in the
he noted occasional flecks of blood in his sputum, but no change HPI; those not
related to the
in his chronic cough. Over the past two weeks, sputum present illness
production has increased to three teaspoons per day and now is should be
blood-streaked. enumerated in the
ROS.
Three days prior to admission the patient noted a sharp pain in 2
his right chest. The pain comes on gradually, does not radiate, Tell the patient’s history as a story,
chronologically. Begin with the
is worsened by taking a deep breath, and is not related to earliest event and move in strictly
exercise or meals. He denies shortness of breath, dyspnea on chronological order to the present.
exertion, or peripheral edema. He denies fever, but for the last Report only the evidence. Do not
three nights he has soaked his sheets with sweat. This morning interpret in the HPI.
he saw his private doctor who told him his chest X-ray was Writing an effective HPI requires
abnormal. The doctor also reported that his white blood cell understanding the
count was elevated, and recommended that he come to the ER, differential diagnosis and
where he arrived at 1 PM. Because of his abnormal CXR, he listing the relevant findings. The
actual discussion of the diagnosis
was admitted directly to the medical service with no further must wait until the assessment.
evaluation or treatment. However, consideration of the
differential diagnosis will help
He has no history of tuberculosis, previous hospitalization for guide you through asking the best
questions and writing the history.
pulmonary symptoms or pneumonia, asthma, international Prior hospitalizations, medical
travel, or trauma to the chest. He is unaware of his PPD status. encounters, and lab results related to
There is no history of cardiac illness or cancer. this illness are part of the HPI, and
should be included in their
chronological sequence. Include the
Past Medical History3 most pertinent negatives. Certain
1. Gout. Episodes involving the right great toe in 1975 and symptoms are usually addressed in
1996, effectively treated with allopurinol. the review of systems, discussed
below; however, if the symptom can
2. Major depression in 1980, following the prolonged illness be related to the HPI it should be
and death of his father. Treated with an unknown oral included here.
medication and psychotherapy for two years. No
recurrence.
3. No other history of any major medical illnesses or
hospitalizations since childhood. Specifically, no history of
 he
m
orr
3
The past medical and surgical histories are written in list form in chronological ho
order. Problems should be included only if they have led to medical attention or ids
hospitalization.
.
De
ni
es
na
us
Past Surgical History ea,
Appendectomy at age 19, uncomplicated vo
Left tibia fracture at age 26 mi
tin
Medications4 g,
Allopurinol 300 mg PO daily ch
an
Allergies ge
Tetracycline – caused a rash about 20 years ago. in
ap
Family History pe
Father died at age 70 of colon cancer. tit
Mother alive and well at 85. e,
Daughter, age 39 alive and well. di
Two siblings, brother 59 alive and well, sister 65 with arr
hypertension he
There is no family history of TB, other cancers, premature heart a,
disease, diabetes, or alcoholism. m
ele
Social History na,
Patient retired five years ago after 40 years of work in shipyards co
and a shoe factory.5 He lives in Brooklyn with his wife and nst
daughter who is divorced, both of whom accompanied him to the ip
hospital. He is heterosexual with one partner, his wife. 118 ati
pack-years as above. He drinks 5 cans of beer a week on on
average. Denies any illicit drug use. He receives social security .
and a pension.
GU: Denies history of
Review of Systems (ROS) 6 uri
General: Denies chills or malaise. na
ry
HEENT: Denies head trauma, headaches, or inf
dizziness. Has used eyeglasses for the ect
past 35 years. Denies other problems io
with vision. Denies problems with ns,
hearing, tinnitus. Denies chronic sinus pr
problems, but suffers from hay fever in ob
the fall. Denies frequent sore throats or le
dental problems. ms
uri
Pulmonary: See HPI na
tin
Cardiovascular: Denies congenital heart disease, g,
murmur, rheumatic fever, angina, dy
hypertension, palpitations, MI, su
abnormal EKG, orthopnea, dyspnea on ria
exertion, edema, heart surgery, PVD ,
angiography, syncope. he
m
GI: Denies history of ulcer disease, hepatitis, cholecystitis, at
upper or lower GI bleeding, or uri
 a. history of syphilis, gonorrhea, or
prostate disease. Reports satisfactory
sexual relations.

Heme/Endocrine:

De
ni
es
4
Use scientific, not brand names. his
tor
y
of
an
e
mi
a,
fat
ig
ue,
or
ea
sy
br
uis
5
Occupational history is ab
often relevant to ilit
patient’s illness or
psychosocial situation.
y.
De
ni
es
po
ly
6
The ROS is also an opportunity to uri
pick up past problems that the a,
patient might not otherwise have the po
opportunity to tell you. Include
time-frames. Body systems ly
discussed in the HPI need not be di
repeated in the ROS, you may psi
simply write “See HPI.” Positive a,
symptoms should be elaborated upon
briefly. Significant positive history he
should be moved into the HPI, PMH, at
or PSH, as appropriate. or
co
ld
int
ol
er
an
ce.

Musculoskeletal:

Se
e
P
M
H,
De
 nies other joint, bone, or muscle
problems.

Neurologic: Denies motor or sensory neurologic

problems, difficulties in walking or
balance, seizures, headaches, TIA, or
CVA.

Psychiatric: See PMH

Skin: Denies rashes, lesions, or other skin problems.

Physical Exam
General Appearance7
7
A cachectic male appearing older than his stated age, lying Begin with the patient’s
comfortably in bed, in no acute distress. appearance, which is your first
impression when you enter the room,
Vital Signs and begin to examine the patient.
BP 110/74, pulse 90 and regular while lying Even as you are taking the history,
BP 105/70, pulse 96 and regular while standing you are observing the patient.
Respirations 24 and shallow, temperature 100.8°F orally
Skin8
8
A 2 x 1.5 cm brown, raised, crusted, rough patch on left upper When there is a positive finding,
back, non-tender, non-warm, with irregular borders describe it as completely as possible.
Strive to use quantitative terms and
Head avoid subjective terms such as small,
Bi-temporal wasting, normocephalic, atraumatic mild, etc.
Eyes
Conjunctiva pink, sclerae anicteric, pupils 3mm equally round
and reactive to light (PERRL), fundi demonstrate flat discs,
normal vessels, without hemorrhages or exudates
Ears
External auditory canals normal, tympanic membranes intact,
hearing grossly intact
Nose
Mucosa pink, no discharge or polyps
Mouth
Moist membranes, partial upper dentures, otherwise dentition
normal for age, no oral lesions.
Throat
Non-injected
Neck
Supple, full range of motion (FROM), trachea midline, no a
pulse thyromegaly, carotids 2/2 without bruits, no JVD or HJR
or abnormal pulses or bruits
Nodes9
No cervical, submandibular, supraclavicular, axillary, or 9
List each area examined separately.
inguinal lymphadenopathy 10
For the lung, heart, and abdomen
Breasts examinations, it is particularly useful
to describe the results of:
Normal male, no masses, discharge, or tenderness
Lungs10 Inspection
I: Barrel-chest, unable to take a deep breath due to guarding Palpation
P: No tenderness; tactile fremitus increased right base Percussion
Auscultation
P: Hyper-resonance bilaterally, dull to percussion at right base
A: Rales, bronchial breathing, and egophony at right base,
otherwise breath sounds diminished throughout
Heart
I: No apical heave or
parasternal lift
P: PMI in the 4th
intercostal space in the mid-
clavicular line;
no palpable heave, lift
or thrill
 A: S1, S2 normal; no splitting or loud P2; I/VI low- pitched
early systolic murmur best heard at the lower left sternal
border; no rubs or gallops
Abdomen
I: Abdomen flat, no scars, striae or dilated veins
A: Bowel sounds normal; no bruits
P: Soft, nontender; no guarding or rebound; liver palpable 4 cm
below the right midclavicular line; spleen not palpable; no
masses.
P: Liver span 10 cm by percussion in the right midclavicular line
Back
No spinal or costovertebral angle tenderness
Genitalia
Normal male, circumcised. Testes descended, no masses. No
skin lesions.
Rectal
Good sphincter tone, no masses or tenderness. Prostate smooth,
not enlarged, no masses. Stool guaiac-negative.
Extremities
No clubbing, cyanosis, or edema; no tenderness; joints have full
range of motion; no subcutaneous nodules, no abnormalities of
the great toe, no tophi.
Pulses:
Brach Rad Fem Pop PT DP
R +2 +2 +2 +2 +2 +2
L +2 +2 +2 +2 +2 +2
No bruits
Neuro:
Awake, alert, fully responsive, oriented to person,
place, and time. Normal affect.

CN: I not tested

II visual acuity (corrected 20/20),
full visual fields
III, IV, VI extraocular movements intact
V normal sensation on face
VII no weakness
VIII hearing intact
IX, X gag reflex present bilaterally
XI symmetric trapezius
strength
XII tongue midline
Motor: RUE 5/5 RLE 5/5
LUE 5/5 LLE 5/5
Sensory: intact to pinprick, light touch,
position and vibration
Cerebellar: no dysdiadochokinesis, gait
normal, Romberg’s sign absent
Reflexes: biceps 2+
triceps 2+
patellar 2+
achilles 2+
plantar downward
no snout or glabellar reflexes
Laboratory
Hematocrit 27, MCV 79, WBC cell count 12.8 with 79% PMNs,
4% bands, 13% lymphocytes, 4% monocytes.
Electrolytes, liver function tests, and urinalysis all normal.
Chest X-ray: flattening of
the diaphragms,
hyperlucent throughout.
A 1x 2 cm mass is present
 in the right hilum with a dense right lower lobe alveolar
consolidation and blunting of the right costophrenic angle.

EKG: NSR, rate 90, normal axis, low voltage diffusely, no ST-
or T-wave abnormalities.
11
Summarize the positive findings of
11 the case including symptoms, signs
Summary
and lab findings.
This is a 67-year-old lifelong smoker with a history of chronic
cough from probable COPD, gout, and depression. He presents with List the problems you will address in
25 pound weight loss over six months; two months of hemoptysis, the assessment in order of clinical
increased sputum production, and night sweats; and 3 days of importance at presentation.
pleuritic right chest pain. The physical exam is remarkable for a
pulse of 96, fever of 100.8 degrees, barrel chest with guarding on the
right, and clinical signs of consolidation at the right base. There is a
single skin lesion on the left upper back. Labs show microcytic
anemia and an elevated white count with a normal differential. Chest
12
X-ray reveals an infiltrate in the right lower lobe and a right hilar This is where you present your
diagnostic reasoning and therapeutic
mass. The current problems can be summarized as follows: plan. You are expected to commit to
a diagnosis at the end. Use the data
Problem List you have assembled to expand on
1. Acute pulmonary process your problem list, create a
differential diagnosis for each
2. Right hilar mass problem, consider the pros and cons
3. Chronic cough of each diagnosis, and establish a
4. Weight loss final differential diagnosis in order
5. Anemia of likelihood.
6. Skin lesion Try to estimate and quantitate the
probability of each of the most
Assessment12 important diagnoses you have
considered in your differential for
this specific patient.
1. Acute pulmonary process
Pneumonia is the most likely explanation for the acute Always try to synthesize and
process. This is supported by fever, pleuritic chest pain, consolidate historical, physical exam
hemoptysis, night sweats, signs of consolidation, CXR and laboratory data into a coherent
diagnosis. For each problem, provide
showing lobar infiltrate and pleural effusion, and leucocytosis. an assessment first. This is a written
This probably represents community-acquired pneumonia due formulation, in whole sentences, of
to pneumococcus, but could be due to H. influenzae, S. your reasoning. Then suggest a plan
aureus, B catarrhalis, or L. pneumophila. An alternative of action based on the considerations
in your assessment. This should be
diagnosis causing pleuritic chest pain, hemoptysis and fever is divided into diagnostic and
pulmonary embolism with infarction. Against this diagnosis therapeutic possibilities and
is the patient’s change in sputum production and the presented as lists.
pulmonary consolidation that is not wedge-shaped. Another
possible diagnosis is tuberculosis, which can cause fever,
weight loss, increased sputum, hemoptysis, and infiltrate.
Against tuberculosis are the acute time frame and the location
of the infiltrate. The acute time frame is against other chronic
pulmonary infections. Thus, for the acute process, I favor
community-acquired pneumonia (95% chance), or Plan13
tuberculosis (5% chance). Diagnostic:
1. Sputum for gram
stain, AFB stains,
and culture
2. Blood cultures
3. PPD skin test
4. Therapeutic trial
of empiric antibiotics
5. Consider
ventilation/perfusion
scan if no response
to antimicrobial
agents within 24
hours
Therapeutic:
 1. IV hydration
2. Empiric broad spectrum antibiotics
a) Vancomycin because of concern for resistant
pneumococci and MRSA
b) Azithromycin for atypical organisms
c) Duration of course and nature of antibiotics will await
evaluation of response to therapy and results of
diagnostic tests

2. Right hilar mass

The mass could be a tumor or a hilar node from a chronic infection
such as tuberculosis. Given the intensive exposure to tobacco and
asbestos and the history consistent with chronic bronchitis, it is
possible that there is a bronchogenic carcinoma that partially
obstructs a bronchus, impairing clearance of secretions and causing
pneumonia. In favor of a neoplasm is the weight loss, anemia, and
exposure history. There are no findings against this. Thus, for the
lung mass I favor bronchogenic carcinoma (70% chance),
tuberculosis (10% chance), other granulomatous disease (10%
chance), or lung abscess (10% chance).

Plan
Diagnostic:
1. CT scan of the chest
2. Sputum cytology
3. May need bronchoscopy for tissue diagnosis

Therapeutic:
Will be based on the specific etiology

3. Chronic cough
Chronic cough in a 118-pack-year smoker with purulent sputum that
clears with antibiotics suggests chronic bronchitis. The barrel chest,
hyper-resonance, and flattened diaphragm also suggest emphysema.
Thus, the patient likely has mixed picture (typical of COPD with
both bronchitis and emphysema).

Plan
Diagnostic:
1. PFTs to confirm diagnosis, assess extent of disease and
predict response to bronchodilators.
2. ABG when acute illness resolves to assess prognosis and
potential therapeutic response to continuing oxygen
therapy.

Therapeutic:
Will depend on the results of diagnostic tests.

4. Weight loss
Weight loss with cachexia
13
The plan is based on the assessment. The diagnostic component should include and wasting is indicative
the tests that will differentiate among the major items in the differential
of a chronic process.
diagnosis. The therapeutic component should include non-specific elements that
should be done regardless of the specific cause (e.g. blood pressure support for a Consider neoplasm or
hypotensive patient) as well as specific measures addressed to the most likely infection. With a right
etiologies. hilar mass, a strong
history of exposures,
bronchogenic carcinoma
is most likely (80%
chance). Other
neoplasms are much less
 likely (10% chance). Also consider tuberculosis (10% chance),
17
but apices are normal, and TB usually does not present as a Follow the AMA Manual of Style
citation format.
mass.

Plan
Diagnostic:
Proposed Pathogenesis of this Patient’s
1. Cytology
`
Illness
2. Bronchoscopy
3. Sputum for AFB

Therapeutic:Chronic tobacco use Asbestos exposure

Pending test results
5. Anemia
Cachexia
Diagnostic and therapeutic plan as above.

6. Skin Lesion
Chronic
As above.cough COPD Bronchogenic CA Weight loss
Barrel chest
Diagnoses 14 ( hilar mass)
Flat diaphragm Anemia
1. Right lower lobe pneumonia, possibly secondary to 2
Breath
or 3. sounds
2. COPD
3. Probable lung cancer with weight loss, anemia
4. Endobronchial
Skin lesion, probable seborrheic keratosis. lesion
5. History of gout, on medication
6. History of depression
7. Allergy to tetracycline

Partial obstruction

Proposed Pathogenesis15

Inability to clear
Micro-aspiration of micro-aspiration
oral flora

Discussion16
References17 Acute pyogenic Cough Hemoptysis
pneumonia Fever
14
This is your diagnostic impression at this point in time (admission or whenever you leukocytosis
did the H & P and may have some initial labs). This is not a paragraph, but a list that
includes all of the patient’s problems and diagnoses. It should not be a differential
diagnosis of one problem since you have already done this in your assessment. If you
are not sure of a diagnosis, commit yourself to the most likely and those very few you
still want to rule out. Try to consolidate problems you have considered in your
assessment into unifying diagnoses if possible.
Consolidation
15
Create a diagram that ties together as many as possible of the patient’s main
symptoms, physical findings, and labs with your understanding of the disease
processes involved and their pathogeneses. See attached example.

16 Shunt
Elaborate on an aspect of the leading problem, and review either pathophysiology,
Symptoms
etiology, andorsigns
prognosis, therapy.are
Be underlined.
sure to bring the discussion back to your patient.
Do not write more than one or two pages.

Tachypnea