HPI Templates

Asthma

Known h/o asthma for years.
+ worsening SOB for ___.
This presentation feels similar to prior asthma exacerbations.
Has attempted ___ at home.

No h/o heart failure and no orthopnea or new leg swelling.
No chest pain.
No fever or recent hospitalization. No sick contacts.
No smoking or COPD history. No recent choking or aspiration events. Denies any recent immobility, surgery, unilateral leg swelling, or prior PE.

Related: Asthma Exacerbation MDM

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Chest Pain

Location: Central chest
Duration: Intermittent for 1 day
Quality: Pressure-like
Severity: Moderate
Timing: Constant; intermittently worsens
Modifying factors: None, appears to have no overt relationship to exertion, food intake, or other
Associated signs and symptoms: Denies palpitations, diaphoresis, radiation of pain to arm, tearing to back. Denies F/N/V/D. Denies shortness of breath and cough.
Context: Brought in by car. Has history of same.
Denies any recent surgery, unilateral leg swelling, or prior PE/DVT.
Patient has felt otherwise well at home.
Family: No primary relatives with MI at similar or younger age.

Related: Chest Pain MDM

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Heart Failure

patient presents to the emergency department with worsening shortness of breath for last week.
Patient has worsening orthopnea and lower extremity swelling.
This presentation is consistent with prior heart failure exacerbations.
Denies chest pain at this time. Denies palpitations, diaphoresis.
No recent sick contacts. Denies fever, N/V/D.
Denies any recent immobility, surgery, unilateral leg swelling, or prior PE.

Related: Heart Failure MDM