HPI Templates

Ankle Sprain

an injury of the ___ ankle which occurred [just prior to arrival].
The mechanism of injury was [twisting after tripping].
Patient [was] able to ambulate since the event.

Pain is rated as ___ out of 10.
Pain quality is characterized as [aching] in nature. Symptoms are worse with touching or moving, and better with rest.
There was no head impact or other injury.
Patient denies numbness or weakness.
No recent fever. No h/o gout. No STD hx or recent genitourinary complaints.

Related: Foot and Ankle Problems MDM

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Assault

(With punches to head)
presenting after an assault that occurred [just prior to arrival].
Patient complains of pain in the ___
Patient states that the injury occurred at ___
Pain is described as moderate in nature and worse with movement.
Patient states that they ___ know the assailant.

Physical Violence Context:
Patient was punched.
Patient was not kicked.
Patient was not choked.
Patient was not bitten.

Sexual Violence Context:
Patient states there was not anal or genital penetration.

Associated symptoms:
Endorses head trauma.
Denies loss of consciousness.

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Exam:

General: well developed patient in [moderate] distress.
Head: [no head trauma].
Eyes: [PERL, EOMI, no entrapment].
ENT: [oropharynx normal, no dental injury, no septal hematoma].
Neck: [NEXUS negative, normal inspection].
Back: [no vertebral tenderness, normal inspection].
Cardiovascular: regular rate and rhythm; no rubs, murmur, gallops.
Respiratory: [chest non tender, no crepitus, clear to auscultation bilaterally, normal respiratory effort].
Abdominal exam: [soft non-tender, no peritoneal signs, normal inspection, no seat belt sign].
Neurological: [alert and oriented, Glascow Coma Scale 15].
Skin: [warm, well perfused, no rashes, normal capillary refill].
Psych: normal.
Extremities: [no evidence of trauma, normal range of motion, no tenderness, normal distal pulses].
Genitourinary: [no injuries noted].

Related: Trauma (MVA, other) MDM

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Hand Injury

presenting with an injury to the ___ hand that occurred ___ hours prior to arrival.
Patient states that the injury occurred at ___ when they ____.
Pain is described as moderate in nature and worse with movement.
Associated symptoms:
Negative for loss of feeling to hand and fingers in affected extremity.

Related: Hand and Finger Problems MDM

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Joint Pain/Arthropathy

presents with ___ days of pain to ___

Pt with no recent history of trauma to the affected joint.
No fever/N/V/D. Denies any overlying redness to the affected joint. No history of STDs or genital discharge. No new sexual partners with unprotected sex.
No h/o gout and no recent increase in alcohol or meat intake. No changes to vision and no dysuria. No facial rash, no personal or family history of autoimmune conditions.
No immunosuppresive history.
Otherwise well with no other medical complaints.

Related: Joint Pain/Arthropathy MDM

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Low Back Pain

Location: Lower back
Duration: Weeks, worsening over past few days
Quality: Aching
Severity: Moderate
Timing: Constant; worsens with movement
Modifying factors: Relieved with rest
Associated signs and symptoms:
Context:
Other: Denies sudden onset or other unexplained changes in bladder or bowel control (retention or incontinence). Denies sudden onset or otherwise unexplained lower extremity weakness. Denies saddle numbness, hypoesthesia, or anesthesia.

Patient not currently on anti-coagulation and without recent blunt back trauma.
Denies unexplained weight loss, night sweats. No history of malignancy, tuberculosis, immunosuppression. Denies IVDU
No known history of aortic pathology.
Denies h/o urinary tract stones. Denies dysuria
Denies F/N/V/D.

Related: Low Back Pain MDM

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MVC

Patient was the ___ in an automobile which was involved in an accident.
The patient denies rollover or other severe mechanism, or steering wheel damage.
The patient was ___ wearing a seatbelt, did not ___ require extrication, and was not ___ ejected.
The patient did not ___ experience loss of consciousness, and denies numbness, paralysis, or weakness. The patient did not experience symptoms preceding the accident.

The patient denies chest pain, shortness of breath, abdominal pain, and extremity pain or deformity.

Related: Trauma (MVA, other) MDM