Day 3 Flashcards
(12 cards)
What is an HPI?
- the story of symptoms and events that led to the patient’s ED visit and should be at the beginning of every chart.
- only subjective information belongs in the HPI.
- the HPI should only contain information that is directly related to the chief complaint and important context for that patient, all other info goes in the ROS.
Details of the HPI
- always document the historian of the HPI
- document why some history is limited
- write what you know about the patient and how you know it.
Elements of an HPI
Onset: when did the complaint begin
Timing: Constant, intermittent, waxing or waning
Location: where is the discomfort
Quality: feel sharp, dull, aching, cramping, etc.
Severity: mild, moderate, severe or 1-10
Modifying Factors: what makes it better/ worse
Associated Sx: any other symptoms accompany the complaint
Context: anything else important
* A complete HPI requires the 4 elements
Formula for Writing an HPI
- Begin with pt age and sex
- State the complaint and onset
- Describe the quality, location, and timing
- Has anything improved or worsened it?
- List associated symptoms
- List pertinent negatives
- Describe any other important context specific to that pt
Trauma HPI
Focus on the exact Mechanism of Injury (MOI) and describe every possible detail about the circumstances and events causing the injury.
4 most important Sx to document for any trauma pt
LOC
Head injury
Neck pain
Back pain
ROS
- head to toe overview of the pt’s body systems
- simple list of positives and negatives
- complete list of ALL complaints
- includes Sx already listed in HPI and Sx unrelated to CC
14 Body Systems
- Constitutional
- Eyes
- Ear/Nose/Throat
- Cardiovascular
- Respiratory
- Gastrointestinal
- Genitourinary
- Musculoskeletal
- Integumentary/ Skin
- Neurological
- Psychiatric
- Endocrine
- Hematologic/ Lymph
- Immunologic
Major DDx for Chest Pain
*MI, PE, Aortic Dissection, PTX Red Flags: 1. worse with exertion> MI 2. Worse with deep breaths> PE 3. Radiation to the back> Aortic Dissection 4. Recent Trauma> PTX 5. SOB> MI,PE,PTX 6. Diaphoresis, N/V> MI 7. Pleuritic Pain>PE, PTX 8. Calf Pain>DVT causing a PE
Minor DDx for Chest Pain
*Chest wall pain, Costochondritis, Pleural Effusion, GERD
Associated Symptoms:
1. Pain with torso movement or palpation (chest wall pain, costochondritis)
2. Burning Pain (GERD)
MI Risk Factors
CAD HTN HLD DM Smoking FHx CAD<55 y/o
PE Risk Factors
Hx DVT/PE Known DVT Recent Surgery Immobilization A-Fib CA Pregnancy/ Birth Control