Attributes of HPI to ROS

Question 1

History of Present Illness (HPI) includes:

Answer 1

• Opening sentence
• Attributes for CC (Chronology, Location, etc.)
• Relevant ROS (positive & negative responses)
• Relevant Past Medical History (PMH)
• Relevant Social/Spiritual/Sexual/Family Hx

Question 2

What information is included in the Opening sentence for the HPI?

Answer 2

Age, Race, Gender, Chief Complaint

Question 3

Attributes for Chief Complaint

Answer 3

• Chronology
• Location & Radiation
• Quality
• Quantity/Severity
• Aggravating/Alleviating
• Any Additional Concurrent Symptom(s)
• Setting

Question 4

What is included in Chronology

Answer 4

Chronology (aka Timing) of symptom development

• Onset
• Duration
• Periodicity

Question 5

What is included in Location & Radiation

Answer 5

Anatomical location

Question 6

What is included in Quality

Answer 6

Description (eg. dull, sharp, etc.)

Question 7

What is included in Quantity/Severity

Answer 7

• Pain Scale (1-10)
• How bad is it?
• How does it affect daily activities

Question 8

What is included in Aggravating/Alleviating

Answer 8

• What makes it worse (exacerbating)
• What makes it better (remitting)
• Self Treatment?

Question 9

What is included in Setting

Answer 9

Environmental factors
Emotional factors
Personal factors

Question 10

Past Medical History (PMH) includes…

Answer 10

General Health:

• Childhood illnesses (date, type, outcome, complications)
• Adult illness, accidents, injuries, hospitalizations not already listed
• Immunizations (eg. DPT, MMR, Polio)
• Screening Tests (eg. CBC or H&H, UA, pap smear, mammogram)

Question 11

Attributes of Past Surgical History includes…

Answer 11

• Date of surgery
• Type of surgery
• Reason
• Outcome
• Transfusions
• Complications

Question 12

Family members to include in Family Hx

Answer 12

• Parents
• Siblings
• Spouse
• Children

Question 13

Attributes to include for each relative in FHx

Answer 13

• Age

- Health status/Cause of death

Question 14

Diseases to include in Family Hx

Answer 14

Asthma, TB, HTN, Heart Disease, DM, Stroke, Seizure disorders, Mental illness or Addiction issues, Cancer, Bleeding disorders, Arthritis

Question 15

Attributes of Social History includes…

Answer 15

• Birthplace
• Education
• Employment
• Religion/spirituality
• Relationship status
• Living accommodations
• Hobbies
• Exercise & Diet

Question 16

Attributes of Medications

Answer 16

• Current medication names with dose
• Frequency
• Duration of use
• Reason for taking
• How compliant with taking medication or write none if not taking anything

Question 17

Attributes of Allergies

Answer 17

• Name of medication/substance-

- Description of reaction

Question 18

Tobacco, Alcohol, Drugs

Answer 18

• Current and Past Usage / Never Used

- If addiction Hx give summary of overdose/treatment/rehab

Question 19

What is included in ROS: General

Answer 19

• Recent weight change
• Weakness
• Fatigue
• Fever/chills
• Night sweats

Question 20

What is included in ROS: Skin

Answer 20

• Changes in hair, skin or nails
• Rashes
• Sores
• Pruritis
• Change in size or color of moles

Question 21

What is included in ROS: Head

Answer 21

New or uncharacteristic Headache, Trauma

-If yes: Location, Nausea/Vomiting, Frequency, Visual changes

Question 22

What is included in ROS: Eyes:

Answer 22

• General state of vision (use of corrective lenses
• Date of last eye examination & results of exam)
• Excessive tearing
• Diplopia or blurred vision
• Acute vision loss (glaucoma, cataracts)

Question 23

What is included in ROS: Ears

Answer 23

• Change in hearing
• Earache
• Vertigo
• Tinnitus
• Discharge

Question 24

What is included in ROS: Nose/Sinuses

Answer 24

• Rhinorrhea
• Epistaxis
• Nasal congestion
• Discharge or sneezing

Question 25

What is included in ROS: Oral cavity/Throat/Neck

Answer 25

- Last dental exam - Bleeding gums - Sore throat - Hoarseness - Swollen glands

Question 26

What is included in ROS: Breasts

Answer 26

- Self-exam practice - Lumps/masses - Pain - Nipple discharge or changes in skin

Question 27

What is included in ROS: Cardiac

Answer 27

- HTN - Murmurs - Chest pain or angina - Dyspnea on exertion (DOE) - Orthopnea - Paroxysmal nocturnal dyspnea - Palpitations - Last ECG

Question 28

What is included in ROS: Respiratory

Answer 28

- Cough - Sputum (if “yes” - quantity/color) - Hemoptysis - Wheezing - Shortness of breath (SOB) - TB or exposure to TB - COPD or emphysema - Asthma - Pneumonia - Bronchitis - Last CXR

Question 29

What is included in ROS: GI

Answer 29

- Appetite, - Nausea - Vomiting - Dysphagia - Indigestion - Bowel habits (frequency, stool color & consistency) - Diarrhea - Constipation - Bleeding (hemorrhoids, hematemesis, melena, hematechezia) - Abdominal pain - Jaundice - Hepatitis - Date/results of any GI studies

Question 30

What is included in ROS: Urinary

Answer 30

- Frequency - Polyuria - Hesitancy - Urgency - Dysuria - Hematuria - Nocturia - Stones - Incontinence - UTI

Question 31

What is included in ROS: Genital (Male)

Answer 31

- Hernias - Penile lesions or discharge - Testicular pain or masses

Question 32

What is included in ROS: Genital (Female GYN)

Answer 32

- Menarche - Frequency & duration of menses - LMP - Vaginal pruritis - Discharge or lesions - Pregnancies & complications - Miscarriages/terminations - BCM - Menopausal symptoms

Question 33

What is included in ROS: Genital (General)

Answer 33

STI hx & treatments - Interest (change in libido or satisfaction with sex) - Problems (safety in relationship, hx assault, # lifetime partners, length of relationships, issues w/gender of partners or types of intercourse)

Question 34

What is included in ROS: Vascular

Answer 34

- Claudication - Leg edema - Varicose veins - Thromboses/emboli

Question 35

What is included in ROS: Musculoskeletal

Answer 35

- Muscle weakness or pain - Joint stiffness - Range of motion - Instability - Erythema - Edema - Arthritis - Gout

Question 36

What is included in ROS: Neurologic

Answer 36

- Fainting or blackouts - Seizures - Weakness or paralysis - Numbness - Tingling - Tremors

Question 37

What is included in ROS: Hematologic

Answer 37

- Anemia - Easy bruising or bleeding - Past transfusions (if YES reason for transfusion & any transfusion reactions)

Question 38

What is included in ROS: Endocrine

Answer 38

- Thyroid trouble - DM - Heat or cold intolerance - Excessive sweating - Increased thirst (polydipsia) - Hunger (polyphagia) - Urination (polyuria)

Question 39

What is included in ROS: Psychiatric

Answer 39

- Change in mood or memory - Anxiety - Tension - Depression; if positive depression - inquire about suicidal ideation or attempts (Are you thinking about killing yourself or putting yourself in a dangerous situation in the hope that you are killed? If there were no ramifications – would you kill yourself? Do you have a plan to kill yourself?)