Course 3: HPI & ROS Flashcards
1
Q
Onset
A
When did the complaint begin?
2
Q
Timing
A
Has it been constant, intermittent, or waxing and waning?
3
Q
Location
A
Where is the discomfort?
4
Q
Quality
A
Does it feel sharp, dull, aching, cramping…?
5
Q
Severity
A
How bad is it? Mild, moderate, sever, or 0-10.
6
Q
Modifying Factors
A
What makes it better? What makes it worse?
7
Q
Associated Sx
A
Do any other symptoms accompany the complaint?
8
Q
Context
A
Is there anything else that’s important?
9
Q
HPI formula: Sentence One
A
Complaint + Onset
10
Q
HPI formula: Sentence Two
A
Quality, Severity, Location, Radiation
11
Q
HPI formula: Sentence Three
A
Associated Sx, Pertinent Negatives
12
Q
HPI formula: Sentence Four
A
Modifying Factors (What makes it worse/better? Treatments tried?)
13
Q
HPI formula: Sentence Five
A
Context (Similar symptoms? Recent Evaluations? Initiating factor that brought patient to ED)
14
Q
“I took Tums and it didn’t help”
A
The symptoms were unchanged by Tums
15
Q
“I have low back pain but I always have that”
A
He notes chronic lower back pain, unchanged from baseline
16
Q
“It hurts when I touch it”
A
The symptoms are worsened by palpation of the area
17
Q
“Nothing makes it better or worse”
A
The symptoms are unchanged by any position or activity
18
Q
“My sister has the same cold”
A
Positive sick contact with sister who has similar symptoms
19
Q
“If I try to eat or drink anything, I throw it back up”
A
The vomiting is exacerbated by PO intake
20
Q
“It feels like a fizzing soda in the middle of my chest”
A
He describes the symptoms as “a fizzing soda” in his central chest
21
Q
Trauma HPI Template: Second Sentence
A
What caused the incident?
22
Q
Chest Pain: Worse with physical exertion
A
Myocardial Infarction (MI)
23
Q
Chest Pain: Worse with deep breaths
A
Pulmonary Embolism (PE)
24
Q
Chest Pain: Radiation to the back
A
Aortic Dissection
25
Chest Pain: Recent trauma
Pneumothorax (PTX)
26
Chest Pain: Shortness of breath
MI, PE, PTX
27
Chest Pain: Diaphoresis, Nausea, Vomiting
Myocardial Infarction (MI)
28
Chest Pain: Pleuritic pain
PE, PTX
29
Chest Pain: Calf Pain
Deep Vein Thrombosis (DVT) causing PE
30
Chest Pain: Minor DDx (4)
Chest wall pain, Costochondritis, Pleural effusion, GERD
31
Chest Pain: Pain with torso movement or palpation
Chest wall pain, Costochondritis
32
Chest Pain: Burning pain
GERD
33
MI Risk Factors (6)
CAD, HTN, HLD, DM, Smoking, FHx CAD
34
PE Risk Factors (8)
Hx DVT/PE, DVT, Recent Surgery, Immobilization, A-FIB, CA, Pregnancy, Birth Control Pills
35
Shortness of Breath (w/o chest pain): Productive cough
Pneumonia (PNA)
36
Shortness of Breath (w/o chest pain): Orthopnea / Dyspnea on Exertion
Congestive Heart Failure (CHF)
37
Shortness of Breath (w/o chest pain): Bilateral leg swelling
Congestive Heart Failure (CHF)
38
Shortness of Breath (w/o chest pain): Hemoptysis
Pulmonary Embolism (PE)
39
Shortness of Breath (w/o chest pain): Unilateral leg swelling
DVT causing a PE
40
Shortness of Breath (w/o chest pain): Wheezing
Asthma
41
Shortness of Breath (w/o chest pain): Hx of tobacco abuse
COPD
42
Shortness of Breath (w/o chest pain): Chest Pain
MI, PE, PNA
43
Shortness of Breath (w/o chest pain): Minor DDx (2)
Bronchitis, URI
44
Shortness of Breath (w/o chest pain): Cough, Sputum, Nasal congestion, Sore throat
Bronchitis, URI
45
Abdominal Pain: RLQ Pain
Appendicitis
46
Abdominal Pain: RUQ Pain
Cholecystitis
47
Abdominal Pain: LLQ Pain
Diverticulitis
48
Abdominal Pain: LUQ Pain
Pancreatitis
49
Abdominal Pain: Fever
Appendicitis, Cholecystitis, Diverticulitis
50
Abdominal Pain: Blood in vomit or stool
GI Bleed
51
Abdominal Pain: Melena
GI Bleed
52
Abdominal Pain: Dizziness
GI Bleed, Abdominal Aortic Aneurysm
53
Abdominal Pain: Minor DDx (4)
UTI, Gastroenteritis, Gastritis, Constipation
54
Abdominal Pain: Dysuria
UTI
55
Abdominal Pain: Nausea/Vomiting, Diarrhea
Gastroenteritis, Gastritis
56
Abdominal Pain: Constipation
Constipation
57
Female Lower Abdominal Pain: Suprapubic Pain
Ovarian Torsion
58
Female Lower Abdominal Pain: Pregnancy
Ectopic Pregnancy
59
Female Lower Abdominal Pain: Fever, RLQ Pain
Appendicitis
60
Female Lower Abdominal Pain: Minor DDx
Ovarian Cyst, UTI, STD
61
Female Lower Abdominal Pain: N/V, Vaginal Spotting, Vaginal Discharge, Flank Pain, Dysuria
Ovarian Cyst, STD, UTI
62
Diarrhea Risk Factors (6)
Recent foreign travel, recent camping, bad food exposure, sick contacts, recent Abx, recent hospitalization
63
Female Abdominal Pain Risk Factors (3)
Possibility of Pregnancy, Unprotected Sex, History of STD
64
Low Back Pain: Weakness/Numbness in lower extremities
Spinal Cord injury
65
Low Back Pain: Numbness of the groin
Spinal cord injury or Cauda Equina
66
Low Back Pain: Loss of bowel or bladder control
Spinal cord injury or Cauda Equina
67
Low Back Pain: History of IVDA (intravenous drug abuse)
Spinal Abscess
68
Low Back Pain: Fever
Spinal Abscess
69
Low Back Pain: Abdominal Pain
Abdominal Aortic Aneurysm (AAA)
70
Low Back Pain: Minor DDx (3)
Musculoskeletal back pain, Back Strain, Sciatica
71
Low Back Pain: Radiating pain down the backs of the legs
Sciatica
72
Back Pain Risk Factors (3)
Recent trauma, Hx of IVDA, Spinal hardware
73
Dizziness/Headache: Weakness/Numbness/Tingling
Cerebral Vascular Accident (CVA), Subarachnoid Hemorrhage (SAH)
74
Dizziness/Headache: Changes in speech or vision
Cerebral Vascular Accident (CVA), Subarachnoid Hemorrhage (SAH)
75
Dizziness/Headache: Difficulty with balance
CVA, SAH
76
Dizziness/Headache: Fever
Meningitis
77
Dizziness/Headache: Neck Pain
Meningitis
78
Dizziness/Headache: Altered Mental Status
Meningitis, CVA, SAH
79
Dizziness/Headache: Worst headache of life / Thunderclap unset
Hemorrhagic CVA, SAH
80
Dizziness/Headache: Syncope or Seizure
CVA, SAH
81
Dizziness/Headache: Minor DDx (5)
Dehydration, Benign Positional Vertigo (BPV), Migraine HA, Tension HA, Sinusitis
82
Dizziness/Headache Minor DDx Associated Sx (4)
Nasal congestion, runny nose, nausea, vomiting
83
Syncope: Tongue bit wound
Seizure (Sz)
84
Syncope: Numbness/Weakness/Tingling
CVA
85
Syncope: Changes in speech or vision
CVA
86
Syncope: CP
MI
87
Syncope: SOB
PE
88
Syncope: Palpitations
Arrhythmia
89
Syncope: Minor DDx (2)
Vasovagal syncope, dehydration
90
Syncope: Minor DDx Associated Sx (4)
feeling "about to pass out" (near-syncope), sweating, dizziness, lightheadedness
91
CVA Risk Factors (7)
HTN, HLD, DM, Smoking, FHx CVA, Hx TIA/CVA, AFIB
92
Trauma: LOC
Hemorrhagic CVA, Subdural Hematoma
93
Trauma: Unilateral Numbness/Weakness/Tingling
Hemorrhagic CVA, Subdural Hematoma
94
Trauma, Bilateral Numbness/Weakness/Tingling
Spinal cord injury
95
Trauma: Neck pain or back pain
Spinal cord injury
96
Trauma: SOB or CP
PTX, Cardiac Contusion
97
Trauma: Abdominal Pain
Splenic or Liver Laceration
98
Trauma: Minor DDx (5)
Closed Head Injury (CHI), simple Fx, dislocation, strain/sprain, lac (laceration)
99
Trauma Risk Factors (2)
Blood thinners (Coumadin/Warfarin, Plavix, Aspirin), Severe MOI
100
Subjective
Based on the patient's feeling (HPI, ROS)
101
Objective
Factual information from provider (PE)
102
History of Present Illness
The story of the patient's CC
103
Review of Systems
Head-to-toe checklist of pt Sx
104
Intermittent
Comes and goes
105
Waxing and waning
Always present but changing in intensity
106
Modifying factor
Something that makes a symptom better or worse
107
Exacerbate
To make worse
108
Based of the pt feeling (HPI, ROS)
Subjective
109
Factual information from provider (PE)
Objective
110
The story of the pt CC
History of Present Illness
111
Head to toe checklist of pt Sx
Review of Systems
112
Comes and goes
Intermittent
113
Always present but changing in intensity
Waxing and waning
114
Something that makes a symptom better or worse
Modifying factor
115
To make worse
Exacerbate
116
PTX
Pneumothorax
117
SDH
Subdural Hematoma
118
CVA
Cerebrovascular Accident
119
SAH
Subarachnoid Hemorrhage
120
Sz
Seizure
121
AAA
Abdominal Aortic Aneurysm
122
PNA
Pneumonia
123
CHF
Congestive Heart Failure
124
Intermittent
comes and goes
125
waxing and waning
always present but changing in intensity
126
Modifying factor
something that makes a symptom better or worse
127
exacerbate
to make worse
128
Example ED Chart
129
ED Chart Flow
1. **Day 0:** HPI & ROS
2. **Day 1:** Past Hx
3. **Day 4:** Phyical Exam (PE)
4. **Day 5:** ED Course
5. **Day 6:** Dx & Dispositoin
132
how does the HPI determine the pc's entire ER visit?
1. each subjective complaint is ALWAYS followed up with objective evaluation somewhere in the chart
1. **"2X Checking Your Chart"—»** to ensure your chart is complete, check to see pc subjective CC from the HPI followed up with objective measures thoughout the rest of the chart
133
HPI: Content
134
HPI: Elements
1. How many elements are there for the HPI?
2. What are they?
3. how many elements are needed for a complete HPI?
135
What is an HPI?
1. History of Present Illness is the story of symptoms and events that led to the patient’s ED visit—»summary of pc reason for visit
2. only **SUBJECTIVE** information in HPI
* Main components = **cheif complaint (CC)** and **important context** for the pc
3. HPI = a story
1. accurate chronology—»try to listen for what finally made the pc come into the ER
4. Document the *historian...*
1. most often the pc, but for pediatric pc's or pc's that cant speak—»DOCUMENT WHO IS PROVIDING INFORMATION
136
What do you do if a complete Hx is unavailable?
1. critical to document WHY Hx is limited—»
* i.e. "HPI is unobtainable due to the patient's nonverbal status"
2. if HPI is limited, ONLY document what EXACTLY you know about pc—»
* i.e. "Per EMS, this patient was found unresponsive 15 min ago"
137
Writing a basic HPI
1. 2. 3. 4. 5. 6. 7.
1. age/sex of pc
2. complaint and onset
3. timing, severity, qualiy, and location
4. anything improved/worsened symptoms?
5. associated symptoms
6. pertinent negatives
7. any other important contet specific to the pc
138
HPI Formula
* Sentance 1:
* Sentance 2:
* Sentance 3:
* Sentance 4:
* Sentance 5:
139
re-wording what pt says
140
HPI Do's & Dont's
141
HPI Phrasing
142
HPI: Trauma
1. what is main focus of trauma HPI?
2. what are the 4 most important symptoms to document for any trauma pt?
1. key for trauma HPI is to focus on the exact **Mechanism of Injury (MOI)**—»every detail about circumstances and events to cause injury
2. 4 most important symptoms to document are
1. **LOC (**loss of consciousness**)**
2. **head injury**
3. **neck pain**
4. **back pain**
143
Trauma HPI Template
## Footnote
Sentance 1:
Sentance 2:
Sentance 3:
Sentance 4:
Sentance 5:
Sentance 6:
145
Major Complaints: **CHEST PAIN**
1. Red flags and associated DDx?
2. Other DDx —» Associated symptoms?
1. chest wall pain
2. costochondritis
3. pleural effusion
4. GERD
2. Associated symptoms:
- pain w/torso movement or palpation = chest wall pain, Costochondritis
- burning pain = GERD
148
Major Complaint: SHORTNESS OF BREATH (w/out chest pain)
1. Red flags and associated DDx?
2. Other DDx —» Associated symptoms?
1. Bronchitis
2. URI
3. Risk factors of back pain?
2. Associated symptoms:
- cough
- sputum
- nasal congestion
- Sore throat
149
Major Complaint: ABDOMINAL PAIN
1. Red flags and associated DDx?
2. Other DDx —» Associated symptoms?
- UTI
- Gastroenteritis
- Gastritis
- Constipation
2. Associated symptoms:
- dysuria
- N/V
- diarrhea
- constipation
150
How to do the HPI for a patient seeking treatment for a symptom they've experienced previously?
1. Document...
1. anything new/different about symptoms that day
2. how long ago the similar symptoms occured?
3. did they seek professional treatment at the time?
4. any result/diagnosis from previous evals?
151
FEMALE LOWER ABDOMINAL PAIN
1. Red flags?
2. Other DDx —» Associated symptoms?
1. Ovarian cyst
2. UTI
3. STD
3. Risk factors?
2. Associated symptoms:
- N/V, vaginal spotting, vaginal discharge, Dysuria, Flank pain
3. possibility of pregnancy, unprotected sex, history of STD
152
_LOWER BACK PAIN_
1. Red flags and associated DDx?
2. Other DDx —» Associated symptoms?
1. Musculoskeletal back pain
2. Back Strain
3. Sciatica
1. associated symtoms: Radiating pain down the backs of the legs (**sciatica)**
2. Back Pain Risk Factors:
1. recent trauma
2. hx of IVDA
3. spinal heardware
153
_DIZZINESS/HEADACHE_
1. Red flags and associated DDx?
2. Other DDx —» Associated symptoms?
1. Dehydration
2. Begnign Positional Vertigo (BPV)
3. Migraine HA
4. Tension HA
5. sinusitis
3. Risk factors of back pain?
1. Red flags and associated DDx?
2. Other DDx —» Associated symptoms?
1. Associated Symptoms = Nasal conjestion, runny nose, N/V
154
HPI: Prior Evaluations
1. when pc is evaluated by another healthcare provider, its important to document...
1. why symptoms promted the prior eval?
2. how long ago was this prior eval?
3. who they saw? (name and specialty)
4. what treatment did they recieve? was it helpful?
5. what was diagnosis, if any?
2. if pc had prior tests completed...
1. specify type of test (CT, XR, etc.)
2. date
3. specific results
155
_SYNCOPE_
1. Red flags and associated DDx?
2. Other DDx —» Associated symptoms?
1. Vasovagul syncope
2. dehydration
2. Associated symptoms:
- *near-syncope:* "feeling about to pass out"
- sweating
- dizziness
- lightheadedness
156
_ALTERED MENTAL STATUS_ (AMS)
1. Red flags and associated DDx?
2. Other DDx?
3. AMS risk factors?
1. Other DDx:
* UTI (if elderly)
* ETOH abuse
* Narcotics abuse
* Drug abuse
2. **AMS** Risk Factors:
1. dementia/Alzheimer's
2. DM
3. psychiatric history
4. Substance abuse
157
_TRAUMA_
1. Red flags and associated DDx?
2. Other DDx —» Associated symptoms?
3. Risk factors of Trauma?
1. **Other DDx —» Associated symptoms?**
1. Closed Head Injury (CHI)
2. simple fracture
3. dislocation
4. strain/sprain
5. laceration
2. **Risk factors of Trauma?**
1. Blood thinners (Coumadin/Warfarin, Plavix, Aspirin)
2. Severe Mechanism of Injury
158
ROS Content
1. depending on physician, "**All other systems negative except as marked"** used to communicate that the pt did not have any complaints orther than those that were documented
2. like HPI, include statement like "**A complete ROS is unobtainable due to the patient's condition"**
3. For major symptoms such as Chest Pain or Shortness of Breath —» **never** just mention “Positive Chest Pain” or Positive Shortness of Breath” in the ROS w**ithout providing further explanation in the HPI.**
160
14 body systems and examples of symptoms
161
Example ROS (Based on example HPI)
168
MVA HPI
1. what are the 14 questions the doctor will ask?
1. Were you the driver or the passenger?
2. Were you wearing a seatbelt?
3. How fast were you moving?
4. What part of the car was hit?
5. Did it hit a stationary object or another moving vehicle?
6. Did the airbags deploy?
7. Did you lose consciousness?
8. Did you hit your head?
9. Did you sustain any injuries?
10. How much damage was done to your vehicle?
11. Is the car drivable?
12. Were you able to get out of the vehicle (self-extricate)?
13. Were you able to ambulate (walk) on scene?
14. Did you require EMS treatment on scene?
170
MI Risk Factors
(1)–(6)?
1. CAD
2. HTN
3. HLD
4. DM
5. Smoking
6. FHx of CAD \<55 y/o
171
PE Risk Factors
(1)–(7)?
1. Hx of DVT/PE
2. known DVT
3. recent surgery
4. immobilization
5. A-fib
6. Cancer
7. Pregnancy/Birth Control
174
Diarrhea Risk Factors (1-6?)
1. recent foreign travel
2. recent camping
3. bad food exposure
4. sick contacts
5. recent antibiotics
6. recent hospitalization
178
False
179
180
181
182
G: 4
P: 1
A: 2
183
**TRUE**
184
YES —» [6]
185
YES —» **[****5]**
186
1. hematochezia
2. hemoptysis
3. carotid endarterectomy
4. myalgia
187
188
Name 7 CVA risk factors
1. HTN
2. HLD
3. DM
4. Smoking
5. FHx CVA
6. Hx TIA/CVA
7. AFib
193
Body Systems of ROS
1. What are the 14?
2. how many are required for a complete ROS?
1. 14 Body Systems:
1. constitutional
2. eyes
3. ear/nose/throat
4. cardiovascular
5. respiratory
6. gastrointestinal
7. genitourinary
8. musculoskeletal
9. integumentary/skin
10. neurological
11. psychiatric
12. endocrine
13. hematologic/lymph
14. immunologic
2. complete ROS only requires **2 elements** (instead of 10) if "**All other systems negative except as marked"** is included
196
In your own words, describe the significance of an HPI.
* The HPI is the story of the symptoms and events that led to the patient’s ED visit.
* It includes the CC and the associated sx
197
How is the HPI different from the ROS?
* **HPI** focuses is a story about the chief complaint and its associated symptoms.
* **ROS** is a checklist of symptoms. It includes the chief complaint, associated symptoms, and all other complaints the pt may have.
198
Name five “elements” of the HPI.
1. Onset,
2. timing,
3. location,
4. quality,
5. severity,
6. modifying factors,
7. associated symptoms,
8. context
199
Name 10 of the body systems included in the ROS.
1. Constitutional
2. eyes
3. ENT
4. CV
5. Resp
6. GI
7. GU
8. MS
9. skin
10. neuro
11. psych
12. endocrine
13. heme/lymph
14. immunological
200
Can the symptoms listed in the ROS ever contradict the symptoms described in the HPI?
Why or why not?
**_NO._**—»Symptoms that are documented in the HPI also need to be documented in the ROS.
201
What do you need to remember to document in the HPI and ROS for any patient that is unconscious or incapable of providing information?
“HPI/ROS limited by…”
202
Identify the error in this sentence from an example HPI:
“Patient states the CP has been intermittent since Thursday.”
* We do not document days of the week in the HPI.
* Instead, we would count back the number of days and document this numerically
203
Why is it important to remember to document if the patient has had similar symptoms in the past?
Because it is less likely that their current symptoms are life threatening if they have survived similar symptoms in the past.
204
Name one detail that is important to document if the patient has been evaluated in the past for a similar complaint.
1. What symptoms prompted the prior evaluation?
2. How long ago did the prior evaluation occur?
3. Who did they see? (Name and specialty)
4. What treatment did they receive? Did it help?
5. What diagnosis was given?
6. Any prior test results?
205
What should you focus on when writing an HPI (choose one).
a) Capturing everything that is said by the patient
b) Documenting the answers to every question asked by the doctor
**b) Documenting the answers to every question asked by the doctor**
206
Which is the first item in the formula for writing an HPI?
a) Pertinent negatives
b) Timing, quality, and location
c) Chief complaint and onset
d) Associated symptoms
**c) Chief complaint and onset**
207
What does MOI stand for in a Trauma HPI?
**Mechanism of Injury**
208
*True or False:* In the ROS, you should document “All other systems negative except as marked” for every patient.
**FALSE**
209
Based on your knowledge from Day 2, why should you always pay special attention to the complaints of Chest Pain and SOB?
Direct concern for MI
210
Name _three_ past surgical histories that indicate that the patient has a history of CAD.
1. CABG
2. Angioplasty
3. Stents
211
What is the difference between a...
1. _cardiac catheterization_
2. _cardiac stress test_
A. **Cardiac catheterization:** insertion of a catheter with injection of dye into the coronary artery, used to diagnose CAD.
B. **Cardiac stress test:** measures the heart's ability to respond to physical stress to determine if there is adequate blood flow to your heart during increasing levels of activity.
* There are two different types of stress tests...
* _Exercise (treadmill) stress test_
* _Nuclear stress test_ —» for patients with a medical problem (e.g. arthritis) that prevents you from exercising.
* They use a medication to stresses the heart (mimicking exercise)
