Flashcards in History of Present Illness (HPI) Deck (22):
What are the two components of patient assessment?
Of the two components of patient assessment, which is most important?
What are the categories of patient history?
Chief complaint (CC)
History of present illness (HPI)
Past medical history (PMI)
Review of systems (ROS)
What are the subcategories of past medical history?
Childhood history (immunizations)
Adult history (Illness, trauma, hospitalizations)
There are several components of obtaining a patient's history. How is this achieved?
Ask in systematic order (Ask questions in same order every time!)
Ask open-ended questions
Problem-focused (Be flexible when patient is in acute distress)
How can you describe "Chief complaint (CC)?"
Subjective complaint (I.e., pain, discomfort)
Answer to "What bring's you in today?"
Should be recorded in patients own words
Should summarize in one or two lines
What is a symptom?
A sign of existence; usually unwanted medical result (I.e., pain, discomfort, or dysfunction)
What is the "History of present illness?"
Further exploration of the chief complaint
What type of questions do you ask when getting a history of present illness?
When did it first start? / Was it previously diagnosed?
Where is is located?
Can you describe the quality of the pain? I.e, sharp, dull / Does the pain stay the same or get worse?
How long does it last?
Does anything make it better? / Have you tried any medications?
Does anything make it worse? / Does anything trigger it?
Are there associated symptoms? I.e., nausea
How frequent does it happen?
What is the mnemonic for collecting a history of present illness?
O - Onset
P - Provocation/Palliation (What brings it on? / What makes it better?)
Q - Quality
R - Region/Radiation
S - Severity
T - Time
AS - Associated symptoms
PN - Pertinent negatives (Element patient denied is present; I.e., breathing rapidly, but doesn't complain about chest pain)
Onset of illness can be gradual or sudden. What question could you ask a patient to determine onset of illness?
What were you doing when the symptoms began?
What questions could you ask a patient to determine provocation/palliation of illness?
What provokes or exacerbates the symptoms?
Does anything palliate (make better) the symptoms?
What question could you ask a patient to determine the quality of the illness?
What does the pain feel like?
When recording the quality of the illness, have the patient describe the quality of the pain. What might you want to do when collecting this history?
Quote patients description in clinical report
What questions could you ask a patient to determine the region/radiation of the illness?
Where is the symptom located?
Does it radiate?
Is there tenderness or pain when palpated?
What is referred pain?
Pain or discomfort located at a site distant to the involved organ
(The organ and area are innervated by same nerve, causing referred pain)
What questions could you ask a patient to determine the severity of the illness?
How severe is the pain?
On a scale from 1-10, how would you rate your pain?
What questions could you ask a patient to determine the time(frame) of the illness?
When did the symptoms begin?
Are the symptoms constant or intermittent?
How long does it last?
How long has it affected you?
How frequently is it occurring? / When did previous episodes occur? / How is it the same or different?
What question could you ask a patient to determine any associated symptoms of the illness?
What other symptoms commonly accompany the chief complaint?
I.e., shortness of breath, nausea, sweating
What questions could you ask yourself to determine any pertinent negatives of the illness?
Are any likely associated symptoms absent? I.e., no aura accompanying partial seizures/migraine
What is it called when a patient provides a poor history?