Attributes of HPI to ROS Flashcards
History of Present Illness (HPI) includes:
- Opening sentence
- Attributes for CC (Chronology, Location, etc.)
- Relevant ROS (positive & negative responses)
- Relevant Past Medical History (PMH)
- Relevant Social/Spiritual/Sexual/Family Hx
What information is included in the Opening sentence for the HPI?
Age, Race, Gender, Chief Complaint
Attributes for Chief Complaint
- Chronology
- Location & Radiation
- Quality
- Quantity/Severity
- Aggravating/Alleviating
- Any Additional Concurrent Symptom(s)
- Setting
What is included in Chronology
Chronology (aka Timing) of symptom development
- Onset
- Duration
- Periodicity
What is included in Location & Radiation
Anatomical location
What is included in Quality
Description (eg. dull, sharp, etc.)
What is included in Quantity/Severity
- Pain Scale (1-10)
- How bad is it?
- How does it affect daily activities
What is included in Aggravating/Alleviating
- What makes it worse (exacerbating)
- What makes it better (remitting)
- Self Treatment?
What is included in Setting
Environmental factors
Emotional factors
Personal factors
Past Medical History (PMH) includes…
General Health:
- Childhood illnesses (date, type, outcome, complications)
- Adult illness, accidents, injuries, hospitalizations not already listed
- Immunizations (eg. DPT, MMR, Polio)
- Screening Tests (eg. CBC or H&H, UA, pap smear, mammogram)
Attributes of Past Surgical History includes…
- Date of surgery
- Type of surgery
- Reason
- Outcome
- Transfusions
- Complications
Family members to include in Family Hx
- Parents
- Siblings
- Spouse
- Children
Attributes to include for each relative in FHx
- Age
- Health status/Cause of death
Diseases to include in Family Hx
Asthma, TB, HTN, Heart Disease, DM, Stroke, Seizure disorders, Mental illness or Addiction issues, Cancer, Bleeding disorders, Arthritis
Attributes of Social History includes…
- Birthplace
- Education
- Employment
- Religion/spirituality
- Relationship status
- Living accommodations
- Hobbies
- Exercise & Diet
Attributes of Medications
- Current medication names with dose
- Frequency
- Duration of use
- Reason for taking
- How compliant with taking medication or write none if not taking anything
Attributes of Allergies
- Name of medication/substance-
- Description of reaction
Tobacco, Alcohol, Drugs
- Current and Past Usage / Never Used
- If addiction Hx give summary of overdose/treatment/rehab
What is included in ROS: General
- Recent weight change
- Weakness
- Fatigue
- Fever/chills
- Night sweats
What is included in ROS: Skin
- Changes in hair, skin or nails
- Rashes
- Sores
- Pruritis
- Change in size or color of moles
What is included in ROS: Head
New or uncharacteristic Headache, Trauma
-If yes: Location, Nausea/Vomiting, Frequency, Visual changes
What is included in ROS: Eyes:
- General state of vision (use of corrective lenses
- Date of last eye examination & results of exam)
- Excessive tearing
- Diplopia or blurred vision
- Acute vision loss (glaucoma, cataracts)
What is included in ROS: Ears
- Change in hearing
- Earache
- Vertigo
- Tinnitus
- Discharge
What is included in ROS: Nose/Sinuses
- Rhinorrhea
- Epistaxis
- Nasal congestion
- Discharge or sneezing
What is included in ROS: Oral cavity/Throat/Neck
- Last dental exam
- Bleeding gums
- Sore throat
- Hoarseness
- Swollen glands
What is included in ROS: Breasts
- Self-exam practice
- Lumps/masses
- Pain
- Nipple discharge or changes in skin
What is included in ROS: Cardiac
- HTN
- Murmurs
- Chest pain or angina
- Dyspnea on exertion (DOE)
- Orthopnea
- Paroxysmal nocturnal dyspnea
- Palpitations
- Last ECG
What is included in ROS: Respiratory
- Cough
- Sputum (if “yes” - quantity/color)
- Hemoptysis
- Wheezing
- Shortness of breath (SOB)
- TB or exposure to TB
- COPD or emphysema
- Asthma
- Pneumonia
- Bronchitis
- Last CXR
What is included in ROS: GI
- Appetite,
- Nausea
- Vomiting
- Dysphagia
- Indigestion
- Bowel habits (frequency, stool color & consistency)
- Diarrhea
- Constipation
- Bleeding (hemorrhoids, hematemesis, melena, hematechezia)
- Abdominal pain
- Jaundice
- Hepatitis
- Date/results of any GI studies
What is included in ROS: Urinary
- Frequency
- Polyuria
- Hesitancy
- Urgency
- Dysuria
- Hematuria
- Nocturia
- Stones
- Incontinence
- UTI
What is included in ROS: Genital (Male)
- Hernias
- Penile lesions or discharge
- Testicular pain or masses
What is included in ROS: Genital (Female GYN)
- Menarche
- Frequency & duration of menses
- LMP
- Vaginal pruritis
- Discharge or lesions
- Pregnancies & complications
- Miscarriages/terminations
- BCM
- Menopausal symptoms
What is included in ROS: Genital (General)
STI hx & treatments
- Interest (change in libido or satisfaction with sex)
- Problems (safety in relationship, hx assault, # lifetime partners, length of relationships, issues w/gender of partners or types of intercourse)
What is included in ROS: Vascular
- Claudication
- Leg edema
- Varicose veins
- Thromboses/emboli
What is included in ROS: Musculoskeletal
- Muscle weakness or pain
- Joint stiffness
- Range of motion
- Instability
- Erythema
- Edema
- Arthritis
- Gout
What is included in ROS: Neurologic
- Fainting or blackouts
- Seizures
- Weakness or paralysis
- Numbness
- Tingling
- Tremors
What is included in ROS: Hematologic
- Anemia
- Easy bruising or bleeding
- Past transfusions (if YES reason for transfusion & any transfusion reactions)
What is included in ROS: Endocrine
- Thyroid trouble
- DM
- Heat or cold intolerance
- Excessive sweating
- Increased thirst (polydipsia)
- Hunger (polyphagia)
- Urination (polyuria)
What is included in ROS: Psychiatric
- Change in mood or memory
- Anxiety
- Tension
- Depression; if positive depression - inquire about suicidal ideation or attempts (Are you thinking about killing yourself or putting yourself in a dangerous situation in the hope that you are killed? If there were no ramifications – would you kill yourself? Do you have a plan to kill yourself?)
