Course #3 Flashcards
(24 cards)
What is a CC?
The main reason for the patients visit
Onset
When the symptoms started
Timing
When the symptoms occur: constant, intermittent, occasional…
Quality
Description of how the symptoms feel: sharp, shooting, burning, cramping, “feels like an elephant on my chest”…
Location
Where the symptoms are located: RLQ abdominal pain, epigastric abdominal pain, HA behind R eye
Severity
How bad is the pain on a 0-10 scale or mild, moderate, or severe scale
Associated symptoms vs. pertinent negatives
AS: symptoms that are related to the CC that the patient has
PN: symptoms that are related to the CC that the patient denies having
Example: patient ahas associated symptoms of cough and wheezing but denies any chest pain or fever
Modifying factors
Does anything change the patients symptoms to be better or worse?
Example: patients pain was improved with Ibuprofen and exacerbated with movement
Context
Anything else important to understanding the CC such as a mechanism of injury (MOI), risk factors, similar symptoms, prior tests
What should be included in the first sentence of the HPI?
Age, sex, CC, and onset
How should you write “to touch”
Palpate, palpation
How should you write “to worsen”
Exacerbate or aggravate
What is a caveat statement?
Describes why we are limited in information usually when a patient is AMS/unresponsive
What is the following element: “10/10 pain”
Severity
What is the following element: “sharp”
Quality
What are the 8 HPI elements in order?
Onset, timing, location, quality, severity, associated symptoms and pertinent negatives, modifying factors, and context
What is the following element: “pain is worse with exertion”
Modifying factor
What is the following element: “the pain is constant”
Timing
What is the following element: “it hurts right here on my right side”
Location
What is the following element: “ I think it started about 2 hours ago”
Onset
What is the following element: “I am also having some nausea and I think intermittent fevers”
Associated symptoms
What is the following element: I had a stress test dknie last year and it was normal. My cardiologist is Dr. Singh”
Context
List 3 differences between the HPI and ROS
- HPI is a paragraph and the ROS is a list
- The HPI only includes info pertinent to the CC while the ROS includes all symptoms discussed heat to toe
- The HPI includes relevant context while the ROS is only +/-
List 2 similarities between the HPI and the ROS
- They are both subjunctive
- They include information coming from the patient
