1. Driver or passenger 2. Seat belt? 3. Type of collision 4. Airbags deploy? 5. Were you able to get out/ambulate? 6. Did you require EMS treatment?

HPI and ROS Flashcards by Ashlee Smalley

What is an HPI

The story of symptoms and events that led to the pt’s ED visit

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What do you write if a complete history isn’t available?

“HPI is unobtainable/limited due to the pt’s non-verbal status”

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HPI Elements (8)

Onset - When did Sx begin
Timing - Constant/intermittent/waxing and waning
Location - Where
Quality - Sharp/dull/aching/cramping
Severity - Mild/mod/severe/0-10
Modifying Factors - What better/worse? What tried?
Assoc. Sx - Other Sx
Context - Anything else important

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How many HPI elements needed?

At least 4

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Detailed HPI Formula

1: Complaint & Onset
2: Timing, Location, Quality, Severity
3: Assoc. Sx, Pertinent (-)
4: Modifying Factors, Tx tried
5: Context (similar experience? What new/different?)

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MOI

Mechanism of Injury: Detailed explanation of trauma

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Important Sx for Trauma Pts

LOC, head/neck/back injury

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MVA HPI Biggies

Driver or passenger
Seat belt?
Type of collision
Airbags deploy?
Were you able to get out/ambulate?
Did you require EMS treatment?

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ROS

Head to toe checklist of Sx the pt does or does not have

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Body Systems (14)

Constitutional, Eyes, Ears/Nose/Throat, Cardiovascular, Respiratory, Gastrointestinal, Genitourinary, Musculoskeletal, Integumentrary, Neurological, Psychiatric, Endocrine, Hematologic/Lymph, Immunologic

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How many ROS systems needed?

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Minimum of ROS systems needed?

2 with “All other systems negative except as marked” noted

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CP DDx: Worse with physical exertion

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CP DDx: Worse with deep breaths

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CP DDx: Radiation to back

Aortic Disse tion

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CP DDx: Recent Trauma

PTX

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CP DDx: Shortness of Breath

MI, PE, PTX

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CP DDx: Diaphoresis, N/V

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CP DDx: Pleuritic Pain

PE, PTX

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CP DDx: Calf Pain

DVT causing PE

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SOB w/o CP DDx: Productive Cough

PNA

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SOB w/o CP DDx: Orthopnea/Dyspnea on Exertion

CHF

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SOB w/o CP DDx: Bilateral Leg Swelling

CHF

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SOB w/o CP DDx: Hemoptysis

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SOB w/o CP DDx: Unilateral Leg Swelling

DVT causing PE

SOB w/o CP DDx: Wheezing

Asthma

SOB w/o CP DDx: Hx of Tobacco Abuse

COPD

Abd Pain: RLQ Pain

Appendicitis

Abd Pain: RUQ Pain

Cholecystitis

Abd Pain: LLQ Pain

Divericulitis

Abd Pain: LUQ Pain

Pancreatitis

Abd Pain: Fever

Appendicitis, Cholecystitis, Diverticulitis

Abd Pain: Blood in Vomit/Stool

GI Bleed

Abd Pain: Memena

GI Bleed

Abd Pain: Dizziness

GI Bleed, AAA

Female Lower Abd Pain: Suprapubic Pain

Ovarian Torsion

Female Lower Abd Pain: Pregancy

Ectopic Pregnancy

Female Lower Abd Pain: Fever, RLQ Pain

Appencicitis

Low Back Pain: Weakness/Numbness in Lower Extremities

Spinal Cord Injury

Low Back Pain: Numbness in Groin

Spinal Cord Injury, Cauda Equina

Low Back Pain: Loss of Bowel/Bladder Control

Spinal Cord Injury, Cauda Equina

Low Back Pain: History of IVDA

Spinal Abscess

Low Back Pain: Fever

Spinal Abscess

Low Back Pain: Abd Pain

AAA

Dizziness/HA: Weakness/Numbness/Tingling

CVA, SAH

Dizziness/HA: Changes in Speech or Vision

CVA, SAH

Dizziness/HA: Difficulty with Balance

CVA, SAH

Dizziness/HA: Fever

Meningitis

Dizziness/HA: Neck Pain

Meningitis

Dizziness/HA: AMS

Meningitis, CVA, SAH

Dizziness/HA: Worst HA of Life/Thunderclap Onset

Hemorrhagic CVA, SAH

Dizziness/HA: Syncope or Seizure

CVA, SAH

Syncope: Tongue Bite Wound

Syncope: Numbness/Tingling/Weakness

CVA

Syncope: Changes in Speech/Vision

CVA

Syncope: CP

Syncope: SOB

Syncope: Palpitations

Arrhythmia

AMS: Fever

Sepsis

AMS: Numbness/Weakness/Tingling

CVA

AMS: Changes in Speech/Vision

CVA

AMS: HA

Hemorrhagic CVA

AMS: Hx of Depression or Drug Abuse

Drug Overdose

AMS: Hx of Diabetes

Hypoglycemia

Trauma: LOC

Hemorrhagic CVA, Subdural Hematoma

Trauma: Unilateral Numbness/Weakness/Tingling

Hemorrhagic CVA, Subdural Hematoma

Trauma: Bilateral Numbness/Weakness/Tingling

Spinal Cord Injury

Trauma: Neck/Back Pain

Spinal Cord Injury

Trauma: SOB or CP

PTX, Cardiac Contusion

Trauma: Abd Pain

Splenic or Liver Laceration

CP Minor DDx

Chest wall pain, Costochondritis, Pleural effusion, GERD

SOB Minor DDx

Bronchitis, URI

Abd Pain Minor DDx

UTI, Gastroenteritis, Gastritis, Constipation

Female Lower Abd Pain Minor DDx

Ovarian Cyst, UTI, STD

Low Back Pain Minor DDx

Musculoskeletal back pain, Back Strain, Sciatica

Dizziness/Headache Minor DDx

Dehydration, Benign Positional Vertigo (BPV), Migraine HA, Tension HA, Sinusitis

Syncope Minor DDx

Vasovagal syncope, dehydration

AMS Minor DDx

UTI (elderly), EtOH Abuse, Narcotic Abuse, Drug Abuse

Trauma Minor DDx

Closed head injury, simple fracture, dislocation, strain/sprain, laceration

HPI and ROS Flashcards

(79 cards)