Components of the Chart

Question 1

What is the HPI?

Answer 1

history of present illness/ chief complaint

Question 2

What are the subcategories of the HPI?

Answer 2

Location, radiation, onset, duration, course (improving, worsening), severity (1-10), quality (sharp), context (cause?), modifying factors (better/worse), associated symptoms (chest pain w shortness of breath)

Question 3

What are the associated symptoms with allergy/immunology?

Answer 3

rash, seasonal allergies, itching

Question 4

Which symptoms are associated with the cardiovascular system?

Answer 4

chest pain, palpitations, syncope (fainting)

Question 5

Which symptoms are constitutional (affecting multiple systems)?

Answer 5

fever, chills, anorexia, generalized weakness

Question 6

What is the HEENT system? Associated symptoms?

Answer 6

head, ear, eyes, nose and throat; ear ache, sore throat, rhinorrhia (nose flow)

Question 7

What are the components of an E&M level 1 chart?

Answer 7

1 HPI, 0 ROS, 0 PHM/SH/FHx, 1 PEx

Question 8

What are the components of a level 5 E&M chart?

Answer 8

4 HPI, 10 ROS, 2 PHM/SH/FHx, 8 PEx

Question 9

What are the components of a level 4 E&M chart?

Answer 9

4 HPI, 2 ROS, 1 PHM/SH/FHx, 5 PEx

Question 10

What are the components of a level 2 E&M chart?

Answer 10

1 HPI, 0 ROS, 1 PHM/SH/FHx, 2 PEx

Question 11

Which categories of the chart are subjective?

Answer 11

HPI, ROS, PHM/SH/FHx

Question 12

Which symptoms are associated with the eye?

Answer 12

photophobia (discomfort from light), blurred vision, diplopia (double vission)

Question 13

Which symptoms are associated with the endocrine system?

Answer 13

polyuria (excessive urine output)

Question 14

Which symptoms are associated with the GI tract?

Answer 14

abdominal pain, nausea, vomiting, hematochezia (red blood in stool)

Question 15

Which symptoms are associated with the genitourinary system?

Answer 15

vaginal bleeding, testicular pain, dysuria (difficult or painful peeing)

Question 16

Which symptoms are associated with the hematological/lymphatic system?

Answer 16

bruising

Question 17

Which symptoms are associated with the integumentary system?

Answer 17

rash, dryness

Question 18

Which symptoms are associated with the musculoskeletal system?

Answer 18

extremity pain, back pain and neck pain

Question 19

Which symptoms are associated with the neurological system?

Answer 19

headache, altered speech, altered mental status, dizziness

Question 20

Which symptoms are associated with the respiratory system?

Answer 20

cough, wheezing, shortness of breath

Question 21

What is ACS?

Answer 21

Acute coronary syndrome; a set of symptoms caused by insufficient O2 to the heart muscle –> muscle damage or death; can be symptoms of NSTEMI, STEMI, unstable angina; diagnosed with cardiac enzymes (troponins) and EKG/ECG

Question 22

What is an AAA?

Answer 22

Abdominal aortic aneurysm; enlargement of the aorta in the abdomen, increasing pressure on the vessel walls; risk of rupturing or separating (dissection)

Question 23

What is an aneurysm?

Answer 23

weak section of an artery wall; pressure from inside the artery causes the weakened area to bulge beyond the normal width of the vessel

Question 24

What is an AICD?

Answer 24

automatic implantable cardioverter-defibrillator; implanted in the chest wall that detects cardiac arrhythmias and able to perform cardioversion, defibrillation and pacing of the heart; capable of correcting most life-threatening arrhythmias

Question 25

What is angina?

Answer 25

chest pain caused by decreased blood flow to the heart

Question 26

Which are the objective parts of the chart?

Answer 26

unbiased finding; Physical exam (PEx), vital signs (VS), diagnostic test results (laboratory and radiological studies), and procedures

Question 27

What is SHx?

Answer 27

surgical or social history

Question 28

What is FHx?

Answer 28

family history

Question 29

When should surgical history be included in the HPI?

Answer 29

if it is related to the chief complaint; pt presents with chest pain, and they had a previous CABG

Question 30

What are some noteworthy things to include in the HPI?

Answer 30

vitals from EMS, recent ER, clinic, and/or patient admissions

Question 31

When should quotations be used?

Answer 31

when the pt specifically states something; esp non-medical terminology

Question 32

What is the beginner format for HPI?

Answer 32

[Age and gender] with history of [past medical history] presents to the emergency department complaining of [chief complaint] which began [onset]. The patient reports [secondary or associated symptoms]. Symptoms have improved with [modifying factors]and worsened with [modifying factors]. [Include other relevant aspects of the history]. Patient [reports or denies] history of similar symptoms [and include information about last time they had experienced similar symptoms if relevant].Denies [relevant symptoms].

Question 33

Which are common blood-thinners?

Answer 33

Plavix, Eliquis, Coumadin/Warfarin, Xarelto, and Pradaxa

Question 34

For which conditions may blood thinners be prescribed?

Answer 34

A-fib, stroke (CVA), and/or coronary artery disease (CAD)

Question 35

What are some medications for CHF?

Answer 35

Digoxin, Lasix/Furosemide

Question 36

What are some common medications for hypertension?

Answer 36

lisinopril, Norvasc, Hydralazine, Hydrochlorothiazide (HCTZ), clonidine

Question 37

What are some common medications for hyperlipidemia?

Answer 37

simvistatin, lovastatin, atorvastatin, rosuvastatin

Question 38

What is a mechanical fall?

Answer 38

caused by trip, slip, or loss of balance

Question 39

Which are some important things to document in pregnancies?

Answer 39

OB/GYN, prenatal care, and blood type of baby

Question 40

For RUQ pain, what are some important labs to include? (if available)

Answer 40

H&H, CBC, creatinine, BUN. LFTs

Question 41

For RUQ pain, what are other pertinent parts of the history?

Answer 41

prior abdominal surgeries, diverticulitis, IBS, and pancreatitis