Doctor Adrian Levi Magbojos Charting Guidelines.

HPI
1. PRIMARY SYMPTOM Pain Symptoms (SOCRATES)
a. Frequency a. Site
b. Onset b. Onset
c. Relieving factor c. Character
d. Duration d. Radiation
e. Precipitating factors e. Association
f. Associated symptoms f. Time course
g. Previous episodes g. Exacerbating/relieving factors
h. Progression h. Severity
2. Associated symptoms: List all
3. Differentials with Pertinent negatives
4. Interim history: Progression, Frequency, Timing of symptoms, relieving and aggravating factors,
5. Medical Consults if any
6. Medications taken if any: Generic stock dose, dosing, frequency, duration (Co-amoxiclav 1 g/tab, 1tab Q12
for 7 days)
7. Reason for consult

General Survey Conscious, coherent, not in cardiorespiratory distress

Skin Skin is brown moist with good skin turgor
HEENT (Inspection, Normocephalic, Pink palpebral Conjunctiva, anicteric sclera, No Nasal nor aural
Palpation) discharge, no tonsillopharyngeal congestion, Neck is supple with no CLAD and no JVD
Chest/Lungs No mass or lesions, Symmetrical chest expansion, no retractions, no chest lagging,
(Insp, Palp, Perc, vesicular breath sounds.
Ausc)
Heart (Ausc) Adynamic Precordium, PMI at 5th ICS Left Midclavicular line, Normal Rate, Regular
Rhythm, distinct S1 and S2, No murmurs
Abdomen (Insp, Aus, Globular, no mass or lesions, normoactive bowel sounds, soft, non-tender, tympanitic,
Palp, Perc) no CVA tenderness, Negative Murphy sign.
Extremities No gross deformities, full and equal pulses, capillary refill time <2 secs, No edema.
Other exams

Neuro PE
I Not assessed
II PERRLA
III, IV, VI EOM- Normal ROM
V clenches teeth symmetrically, intact facial sensation
VII Symmetrical facie
VIII Intact Audition
IX, X Uvula in midline, (+) gag reflex
XI Shrugs both shoulders symmetrically
XII Tongue protrudes in midline, no fasc.
Sample Charting
Assessment
Primary diagnosis then from most significant to least
significant diagnosis
CAP-LR
Metabolic Syndrome
(Hypertension stage II controlled
DM Type 2 controlled
Obese II)
Plan
Diagnostics
Priority: Labs that are relevant to the diagnosis
Then Labs that are needed but may be delayed.
When writing Ancillary tests, do it in LIV format
Location, Imaging modality, View (what type of view
or special views)
eg. Chest Xray PAL, HBT UTZ, Lumbosacral MRI,
Cranial CT scan with contrast, 2D Echo with doppler
studies, Arterial, Venous, AV duplex scan etc.
Special Lab work up: ask your resident
Routine lab work up: FBS, LP, BUA, CBC with pc, UA,
Na, K, Ca, , BUN, Crea, SGPT SGOT
Drugs (standard format): Generic name, stock dose,
dosing, frequency, duration. DO NOT USE, BID, TID,
QID,
Eg. Co-amoxiclav 1 g/tab, 1tab q12 for 7 days
Cefuroxime 500 mg/tab 1 tab q 12 for 7 days
Celecoxib 200 mg/ tab, 1 tab q12 for 5 days
Paracetamol + tramadol 325+37.5mg/tab, 1 tab q8
PRN for pain for 5 days
Paracetamol + Orphenadrine 650+50 mg/tab, 1 tab
q8PRN for pain for 5 days
Omeprazole 40 mg/cap, 1 cap OD 30 minutes before
breakfast for 2 weeks (dyspepsia, 4 weeks for GERD)
Losartan 50/100 mg/tab, 1 tab OD, q12
Irbesartan 150/300 mg/tab, 1 tab OD
Amlodipine 5/10 mg/tab, 1 tab OD
Atorvastatin 20/40 mg/tab, 1 tab ODHS
Non-Pharmacologic management
Specific:
UTI: Increase Oral fluid intake, proper perineal
hygiene, avoid delays in voiding,
Cough: Increase Oral fluid intake, proper cough
etiquette, airborne or droplet precaution, allergen
avoidance,
CAP: Increase Oral fluid intake, proper cough
etiquette, droplet precaution, advised pneumococcal
and influenza vaccines.
Allergy: proper cough etiquette, identify potential
allergens. allergen avoidance, hypoallergenic diet,
PTB: proper cough etiquette, airborne precaution,
encourage screening of household members.
Hypertension: LSLF diet, Strict compliance with
medications, Daily BP monitoring and record,
adequate rest and sleep,
MSD: Proper body mechanics, avoid prolonged
sitting/ standing (or any potential risk factor),
adequate rest and sleep, warm compress affected
area for 15 minutes 3x a day or as needed.
DM: DM diet, Increase Oral fluid intake, Strict
compliance with medications, Proper foot gear, Daily
footcare before bedtime
Dyspepsia: Avoid spicy, acidic, fatty, and caffeinated
food and beverages, small frequent meals, avoid
skipping of meals.
Urethritis: Sexual Abstinence during treatment,
encourage sexual partner screening,
Smoker: Smoking cessation advised,
General:
Fluid intake: Increase Oral fluid intake except on CKD,
CHF patients. Limit fluid intake to 1L/ day instead.
Activity: Moderate intensity physical activity 30
mins/day 5x per week as tolerated.
Referrals:
Refer to Internal Medicine for further evaluation and
co-management (always state the reason)
Refer to Ophthalmology for official fundoscopy (all
DM and Hypertensive patients) annual fundoscopy for
old patients who had screening last year.
Refer to HACT (all urethritis and other STI’s)
Refer to Nutrition Clinic for a diet plan
Diet: Low Salt, Low Fat Diet
TC: 1539, CHO: 923, CHON: 231, Fat: 385 (all Obese,
DM and Hypertensive patients)
Preventive:
Female, 21 years old and above or 3 years from
coitarche: PAP smear and HPV screening every 3 years
Female, 40 years old and above - Screening annual
Mammography
Males, 50 years old and above, Do DRE
Follow up after
3 days for those in pain, infectious, started on
antibiotics,
1 week for other chronic diseases
Advised.