How to write the Identifying Sentence and HPI

LPCC 101.

1. Identifying Sentence. Begin with an identifying sentence. Choose
carefully which pieces of the PMH to include -- a laundry list of diagnoses is not
necessary. Include only what is pertinent (see below for a discussion of what
pertinent means). If the patient doesnt have any significant past medical
history, simply write otherwise healthy. This sentence concludes with the chief
complaint: why the patient is seeing you today. Your differential diagnosis begins
immediately!

2. HPI. There are 2 steps to the HPI. It is okay to break these up into 2
paragraphs, or keep as one large paragraph.

First Paragraph. After the identifying sentence, next describe the chronologic
sequence of events that lead up to the patient seeing you. What is the
description of the symptom(s) (use PQRST for describing pain)? When did the
symptoms begin? What did the patient do about it? Did they see another
physician, or try a remedy of some kind? Then what happened? Why are they
here today? This paragraph can and should be written in prose.

Second Paragraph. The second paragraph is dedicated to the pertinent
positives and negatives. These are the ROS questions that are pertinent to the
HPI. What is pertinent? It is pertinent if it relates to the differential diagnosis. So,
you have to know what your differential is, to know what questions to ask and
include here. It is okay to write this up as a series of short, even fragmented
sentences (patient endorses x, y, z. Denies a, b, c. Has d intermittently).


HPI write up example for an ACUTE complaint:

ID: 22 yr white female generally in good health with hx of migraine headaches
presents with worsening headaches over past 6 weeks.
HPI: Pt has hx of intermittent experience of migraine HA since age 16, worse
around menstrual cycle. No apparent food triggers. Sleep has been less
in the last two months due to juggling work, school and 2 year old child as
a single mother (lives with parents); averages 4 hours sleep per day.
Headaches begin with very brief aura of visual flashes then pulsating sharp
pain localized behind right eye. This is followed by waves of nausea, no
vomiting. Bright lights and noise aggravates pain. Previously has tried
abortive therapy with sumatriptan, but not helpful. Recently patient has
tried, Advil, Caffeine, Tylenol PM but with only temporary relief. Headache
now nearly every day with worsening later in the day and most severe on
her menses. Her chief concern is loss of work (may lose current job due
to increased absenteeism) and poorer school performance. Her mother
also has long history of migraine headaches and is currently on Topamax.
She denies any neurologic deficits such as numbness, weakness, or vision
loss. No neck pain or back pain. No rhinorrhea, lacrimentation.

Example HPI write up for multiple CHRONIC illnesses visit:

ID: AB is a 70 yr old female here today for follow up on her diabetes, htn, and
hld.
1. HTN: pt checks her BP at home 1-2 times per week, and states that it
typically runs in the 120-130s/70-80s. Reports taking her medication
daily. Denies cp, sob, vision changes, or headache.
2. HLD: on a statin. denies RUQ pain or myalgias. Tries to follow a low-fat/low-
cholesterol diet but states she ate out quite a bit this past month.
3. DM: checks her BS twice per day, readings brought in for review. Fasting BS
runs from low 100s to as high as 147, typically in the 120s. Post-
prandial BS runs from 120 - 150s mostly, has 2 readings of > 200. Has
met with diabetes educator since last visit to work on dietary changes.
Struggled some this past month due to eating out frequently. Last eye
exam was 1 yr ago. Denies polyuria, polydipsia, wt change,
numbness/tingling. No calf pain with walking. Nonsmoker.

**Please note that with chronic diseases, the work up has typically already been
done so there isnt a differential diagnosis. Note that in this example, all pertinent
ROS questions (aimed at assessing disease progression, comorbidities of
disease, or medication side effects, rathen than refining the differential diagnosis)
are at the end of each problem instead of in a separate paragraph. It would also
be acceptable to lump these together in a separate paragraph.**