Initial commit

skills/clinical-reports/assets/history_physical_template.md

@@ -0,0 +1,305 @@
+# History and Physical Examination (H&P) Template
+
+**Patient Name:** [Last, First]  
+**Medical Record Number:** [MRN]  
+**Date of Birth:** [MM/DD/YYYY]  
+**Age:** [years]  
+**Sex:** [M/F]
+
+**Date of Admission/Encounter:** [MM/DD/YYYY]  
+**Time:** [HH:MM]  
+**Location:** [Hospital floor, Clinic, ED]  
+**Admitting Service:** [Medicine, Surgery, etc.]  
+**Attending Physician:** [Name]
+
+---
+
+## Chief Complaint (CC)
+
+"[Patient's stated reason for seeking care, in quotes]"
+
+---
+
+## History of Present Illness (HPI)
+
+[Patient Name] is a [age]-year-old [sex] with a history of [relevant PMHx] who presents with [chief complaint].
+
+[Use OPQRST format for symptoms, provide chronological narrative]
+
+**Onset:** [When did symptoms start? Sudden vs gradual onset?]  
+**Location:** [Where? Does it radiate?]  
+**Duration:** [How long?]  
+**Character:** [Quality - sharp, dull, pressure, etc.]  
+**Aggravating factors:** [What makes it worse?]  
+**Relieving factors:** [What makes it better?]  
+**Timing:** [Constant or intermittent? Pattern?]  
+**Severity:** [0-10 scale for pain, functional impact]  
+**Associated symptoms:** [Other symptoms?]
+
+**Prior evaluations and treatments:**  
+**Why presenting now:**
+
+---
+
+## Past Medical History (PMH)
+
+1. [Condition] - diagnosed [year], [current status]
+2. [Condition] - diagnosed [year], [treatment]
+3. [Additional conditions]
+
+[ ] No known medical problems
+
+---
+
+## Past Surgical History (PSH)
+
+1. [Procedure] ([year]) - [indication, complications if any]
+2. [Procedure] ([year])
+
+[ ] No prior surgeries
+
+---
+
+## Medications
+
+| Medication | Dose | Route | Frequency | Indication |
+|------------|------|-------|-----------|------------|
+| [Drug name] | [mg] | [PO/IV/etc] | [BID/etc] | [Why prescribed] |
+
+[ ] No current medications
+
+---
+
+## Allergies
+
+| Allergen | Reaction |
+|----------|----------|
+| [Drug/Food/Environmental] | [Type of reaction] |
+
+[ ] No known drug allergies (NKDA)
+
+---
+
+## Family History (FH)
+
+- **Father:** [Age/deceased at age X], [medical conditions]
+- **Mother:** [Age/deceased at age X], [medical conditions]
+- **Siblings:** [Number], [relevant conditions]
+- **Children:** [Number], [relevant conditions]
+
+[Note hereditary conditions relevant to patient's presentation]
+
+[ ] Non-contributory
+
+---
+
+## Social History (SH)
+
+**Tobacco:** [Current/former/never], [pack-years if applicable]  
+**Alcohol:** [Frequency and amount, CAGE questions if indicated]  
+**Illicit drugs:** [Current/former/never, type, route]  
+**Occupation:** [Current or former occupation]  
+**Living situation:** [Lives alone/with family, housing type]  
+**Marital status:** [Single/married/divorced/widowed]  
+**Sexual history:** [If relevant]  
+**Exercise:** [Type and frequency]  
+**Diet:** [General diet description]  
+**Functional status:** [ADL independence, baseline activity level]
+
+---
+
+## Review of Systems (ROS)
+
+[Systematic review - check relevant systems]
+
+**Constitutional:** [ ] Fever [ ] Chills [ ] Night sweats [ ] Weight loss [ ] Weight gain [ ] Fatigue  
+**Eyes:** [ ] Vision changes [ ] Eye pain [ ] Discharge  
+**ENT:** [ ] Hearing loss [ ] Tinnitus [ ] Sinus problems [ ] Sore throat  
+**Cardiovascular:** [ ] Chest pain [ ] Palpitations [ ] Edema [ ] Orthopnea [ ] PND [ ] Claudication  
+**Respiratory:** [ ] Dyspnea [ ] Cough [ ] Wheezing [ ] Hemoptysis  
+**Gastrointestinal:** [ ] Nausea [ ] Vomiting [ ] Diarrhea [ ] Constipation [ ] Abdominal pain [ ] Melena [ ] Hematochezia  
+**Genitourinary:** [ ] Dysuria [ ] Frequency [ ] Urgency [ ] Hematuria [ ] Incontinence  
+**Musculoskeletal:** [ ] Joint pain [ ] Swelling [ ] Stiffness [ ] Back pain [ ] Weakness  
+**Skin:** [ ] Rash [ ] Lesions [ ] Itching [ ] Changes in moles  
+**Neurological:** [ ] Headache [ ] Dizziness [ ] Syncope [ ] Seizures [ ] Weakness [ ] Numbness [ ] Tingling  
+**Psychiatric:** [ ] Depression [ ] Anxiety [ ] Sleep disturbance  
+**Endocrine:** [ ] Heat/cold intolerance [ ] Polyuria [ ] Polydipsia [ ] Polyphagia  
+**Hematologic/Lymphatic:** [ ] Easy bruising [ ] Bleeding [ ] Lymph node swelling  
+**Allergic/Immunologic:** [ ] Seasonal allergies [ ] Frequent infections
+
+**All other systems reviewed and negative** [ ]
+
+---
+
+## Physical Examination
+
+**Vital Signs:**
+- Temperature: _____ °F (oral/axillary/tympanic)
+- Blood Pressure: _____/_____ mmHg ([right arm, sitting])
+- Heart Rate: _____ bpm (regular/irregular)
+- Respiratory Rate: _____ breaths/min
+- Oxygen Saturation: _____% on [room air / O2 at ___ L/min]
+- Height: _____ cm / inches
+- Weight: _____ kg / lbs
+- BMI: _____ kg/m²
+- Pain Score: ___/10
+
+**General:**  
+[Overall appearance, apparent vs stated age, nutritional status, distress level]
+
+**HEENT:**
+- Head: [Normocephalic, atraumatic, scalp lesions]
+- Eyes: [PERRLA, EOMI, conjunctiva, sclera, fundoscopy if done]
+- Ears: [TMs, canals, hearing]
+- Nose: [Nares, septum, discharge, sinus tenderness]
+- Throat: [Oropharynx, tonsils, dentition, mucosa]
+
+**Neck:**  
+[Supple/stiff, lymphadenopathy, thyroid, JVP, carotid bruits]
+
+**Cardiovascular:**
+- Inspection: [PMI, precordial movement]
+- Palpation: [PMI location, thrills, lifts]
+- Auscultation: [Rate, rhythm, S1/S2, murmurs/rubs/gallops, location and radiation]
+- Peripheral pulses: [Radial, femoral, DP, PT - rate quality bilaterally]
+- Extremities: [Edema, cyanosis, clubbing]
+
+**Pulmonary:**
+- Inspection: [Respiratory effort, use of accessory muscles, chest wall deformities]
+- Palpation: [Tactile fremitus, chest expansion]
+- Percussion: [Resonance, dullness]
+- Auscultation: [Breath sounds, adventitious sounds - location and quality]
+
+**Abdomen:**
+- Inspection: [Contour, scars, distention, visible peristalsis]
+- Auscultation: [Bowel sounds - present, hyperactive, hypoactive, absent]
+- Percussion: [Tympany, dullness, liver span, spleen]
+- Palpation: [Soft/firm, tenderness, masses, organomegaly, rebound, guarding, Murphy's sign]
+
+**Musculoskeletal:**
+- Inspection: [Deformities, swelling, erythema]
+- Palpation: [Tenderness, warmth]
+- Range of motion: [Active and passive, limitations]
+- Strength: [5-point scale by major muscle groups]
+- Gait: [Normal, antalgic, ataxic, spastic]
+
+**Skin:**  
+[Color, temperature, moisture, turgor, lesions, rashes, wounds]
+
+**Neurological:**
+- Mental Status: [Alert, oriented x3 (person, place, time), speech, memory]
+- Cranial Nerves: [II-XII - document abnormalities]
+- Motor: [Strength 5-point scale, tone, bulk, fasciculations]
+- Sensory: [Light touch, pinprick, proprioception, vibration]
+- Reflexes: [Deep tendon reflexes 0-4+ scale, Babinski]
+- Coordination: [Finger-to-nose, heel-to-shin, rapid alternating movements]
+- Gait: [Already documented above or describe here]
+
+**Psychiatric:**  
+[Mood, affect, thought process, thought content, judgment, insight]
+
+**Genitourinary:** (if applicable)  
+[Defer/document findings if examined]
+
+**Rectal:** (if applicable)  
+[Defer/document findings if examined]
+
+---
+
+## Laboratory and Imaging Results
+
+[Include relevant results available at time of H&P]
+
+**Labs ([Date]):**
+
+| Test | Result | Reference Range | Flag |
+|------|--------|----------------|------|
+| WBC | [Value] | [Range] | [H/L/-] |
+| Hemoglobin | [Value] | [Range] | [H/L/-] |
+| [Additional labs] | | | |
+
+**Imaging ([Study], [Date]):**  
+[Key findings]
+
+**ECG ([Date]):**  
+[Rate, rhythm, intervals, axis, ST-T changes, other findings]
+
+**Other Studies:**
+
+---
+
+## Assessment and Plan
+
+**Assessment:**
+
+[Patient summary statement in one sentence]
+
+**Problem List:**
+
+**1. [Primary Problem/Diagnosis] ([ICD-10 code])**
+
+**Assessment:** [Brief description of problem, severity, stability]
+
+**Plan:**
+- **Diagnostics:** [Labs, imaging, consultations needed]
+- **Therapeutics:** [Medications, procedures, interventions]
+  - [Medication]: [dose, route, frequency] for [indication]
+- **Monitoring:** [What to monitor, how often]
+- **Follow-up:** [When and with whom]
+- **Disposition:** [Admit to floor/ICU, discharge, observation]
+
+**2. [Secondary Problem] ([ICD-10 code])**
+
+**Assessment:** [Description]
+
+**Plan:**
+- [Diagnostics]
+- [Therapeutics]
+- [Monitoring]
+
+**3. [Additional Problems]**
+[Continue for all active problems]
+
+**Code Status:** [Full code / DNR / DNI / Other]
+
+**Prophylaxis:**
+- DVT prophylaxis: [Pharmacologic and/or mechanical]
+- GI prophylaxis: [If indicated]
+- Aspiration precautions: [If indicated]
+
+**Disposition:** [Admit to service, location (floor/ICU), level of care]
+
+---
+
+## Signature
+
+**Physician:** [Name, credentials]  
+**Level:** [Intern, Resident, Attending]  
+**Date/Time:** [MM/DD/YYYY at HH:MM]  
+**Signature:** ____________________
+
+**Co-signature (if applicable):**  
+**Attending:** [Name, credentials]  
+**Date/Time:** [MM/DD/YYYY at HH:MM]  
+**Signature:** ____________________
+
+---
+
+## Template Completion Checklist
+
+- [ ] Chief complaint documented
+- [ ] HPI comprehensive (≥4 HPI elements for billing)
+- [ ] PMH reviewed
+- [ ] Medications reconciled
+- [ ] Allergies documented
+- [ ] ROS performed (≥10 systems for comprehensive)
+- [ ] Complete physical exam documented (≥8 systems for comprehensive)
+- [ ] Labs/imaging reviewed
+- [ ] Assessment and plan for each problem
+- [ ] Code status documented
+- [ ] Prophylaxis addressed
+- [ ] Disposition clear
+- [ ] Completed within 24 hours of admission (TJC requirement)
+- [ ] Signed and dated
+
+