Huppert’s Notes: Pathophysiology and Clinical Pearls for Internal Medicine >Practical Skills for Learners

Laura A. Huppert, Timothy G. Dyster, (Lead Contributing Editor)+

TABLE A1.1Aspects of an Admission Note for Internal Medicine (“H&P”)

1. Chief complaint (or chief concern)

2. History of present illness (HPI)
3. Past medical history (PMH)
4. Past surgical history (PSH)
5. Medications
6. Allergies
7. Family history (FHx)
8. Social history (SoHx; information about the person as an individual and their unique life story) and health-related behaviors (HRB; behaviors that change risk profiles for pathology)
9. Physical exam (PE)
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11. Problem representation (a description of the patient’s presentation that highlights the defining features of a case, helping the clinician to summarize their thoughts and create a differential diagnosis).
12. Assessment &Plan (A&P; a plan by problem for the patient’s diagnostic and therapeutic work-up)

Date of download: 12/29/22 from AccessMedicine: accessmedicine.mhmedical.com, Copyright © McGraw Hill. All rights reserved.