HPI Templates

AMS NOS

presenting with altered mental status, characterized as decreased responsiveness that was discovered today by a family member. Currently, the symptoms are persistent. The last known well time is unknown.
No recent head trauma, illicit drug use, medication changes.

There is associated generalized weakness with difficulty standing and walking.
The patient’s usual cognition is alert and oriented.
The patient’s usual ability to walk is walking without assistance.

Associated symptoms include:
Negative recent illness or fever
Negative nausea or vomiting
Negative headache
Negative focal numbness or weakness
Negative seizure activity

Social History: Patient denies any recent alcohol

Related: AMS NOS MDM

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Dizziness

___ with no known significant PMH p/w dizziness for one day described as ___lightheadedness/room spinning.

No ear pain or discharge. No recent sore throat or cough. No hearing loss. No ear ringing.
No morning headaches. No vision changes.
No melena or BRBPR. No other genitourinary bleeding.
They have had no sick contacts, fever, neck stiffness, rash, or seizure.
The patient has no recent history of head trauma and is not taking any anticoagulation.
Patient without chest pain. Denies any recent immobility, surgery, unilateral leg swelling, or prior PE. Patient without any prodromal symptoms of SOB and no h/o CHF.

Related: Dizziness MDM

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Headache

General Benign Primary Headache

___ year old patient with PMH ___ presents with headache for ___ hours that was non-thunderclap in origin.

This gradual headache that was non-maximal at onset is similar to headaches the patient has had in the past. The patient has no recent history of head trauma and is not taking any anticoagulation. They have had no sick contacts, fever, neck stiffness, rash, or seizure. Patient reports no eye pain and no change in pain when moving from light to dark environments. Additionally there have been no other household occupants with complaints of headache during this time.

Patient denies nausea/vomiting, chest pain, shortness of breath, or syncope.

Related: Headache MDM

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Psych

Suicidal
Patient complains of suicidal ideation.
They have been having thoughts of taking their own life for *** days.
Suicide Plan: None
Prior Suicide Attempts: None
Denies AH, VH, HI.
Denies any ingestions and denies any other medical complaints.

They have felt otherwise in their normal state of health
They deny fever, nausea, vomiting.
Denies acute headache, new cold/heat intolerance, hematochezia/melena, chest pain, shortness of breath.

Related: Psych MDMs

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Syncope

Symptoms ARE related to position change.
No melena or BRBPR. No new genitourinary bleeding.
They have had no sick contacts, fever, neck stiffness, rash, or seizure.
The patient has no recent history of head trauma and is not taking any anticoagulation.
Patient without chest pain. Denies any recent immobility, surgery, unilateral leg swelling, or prior PE. Patient without any prodromal symptoms of SOB and no h/o CHF.

Related: Syncope MDM

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Tox

Time of ingestion: Suspected ___
Currently denies AH, VH, SI, HI.
Psychiatric history includes: ___
Complaining of ___

Was previously in normal state of health with no other medical complaints.
Denies loss of consciousness, confusion, seizure, or memory impairment.
Denies vomiting, numbness/weakness, fever.
Denies SOB, chest pain.

Related: Toxic Ingestions MDM