Components of the Chart Flashcards
What is the HPI?
history of present illness/ chief complaint
What are the subcategories of the HPI?
Location, radiation, onset, duration, course (improving, worsening), severity (1-10), quality (sharp), context (cause?), modifying factors (better/worse), associated symptoms (chest pain w shortness of breath)
What are the associated symptoms with allergy/immunology?
rash, seasonal allergies, itching
Which symptoms are associated with the cardiovascular system?
chest pain, palpitations, syncope (fainting)
Which symptoms are constitutional (affecting multiple systems)?
fever, chills, anorexia, generalized weakness
What is the HEENT system? Associated symptoms?
head, ear, eyes, nose and throat; ear ache, sore throat, rhinorrhia (nose flow)
What are the components of an E&M level 1 chart?
1 HPI, 0 ROS, 0 PHM/SH/FHx, 1 PEx
What are the components of a level 5 E&M chart?
4 HPI, 10 ROS, 2 PHM/SH/FHx, 8 PEx
What are the components of a level 4 E&M chart?
4 HPI, 2 ROS, 1 PHM/SH/FHx, 5 PEx
What are the components of a level 2 E&M chart?
1 HPI, 0 ROS, 1 PHM/SH/FHx, 2 PEx
Which categories of the chart are subjective?
HPI, ROS, PHM/SH/FHx
Which symptoms are associated with the eye?
photophobia (discomfort from light), blurred vision, diplopia (double vission)
Which symptoms are associated with the endocrine system?
polyuria (excessive urine output)
Which symptoms are associated with the GI tract?
abdominal pain, nausea, vomiting, hematochezia (red blood in stool)
Which symptoms are associated with the genitourinary system?
vaginal bleeding, testicular pain, dysuria (difficult or painful peeing)
Which symptoms are associated with the hematological/lymphatic system?
bruising
Which symptoms are associated with the integumentary system?
rash, dryness
Which symptoms are associated with the musculoskeletal system?
extremity pain, back pain and neck pain
Which symptoms are associated with the neurological system?
headache, altered speech, altered mental status, dizziness
Which symptoms are associated with the respiratory system?
cough, wheezing, shortness of breath
What is ACS?
Acute coronary syndrome; a set of symptoms caused by insufficient O2 to the heart muscle –> muscle damage or death; can be symptoms of NSTEMI, STEMI, unstable angina; diagnosed with cardiac enzymes (troponins) and EKG/ECG
What is an AAA?
Abdominal aortic aneurysm; enlargement of the aorta in the abdomen, increasing pressure on the vessel walls; risk of rupturing or separating (dissection)
What is an aneurysm?
weak section of an artery wall; pressure from inside the artery causes the weakened area to bulge beyond the normal width of the vessel
What is an AICD?
automatic implantable cardioverter-defibrillator; implanted in the chest wall that detects cardiac arrhythmias and able to perform cardioversion, defibrillation and pacing of the heart; capable of correcting most life-threatening arrhythmias
What is angina?
chest pain caused by decreased blood flow to the heart
Which are the objective parts of the chart?
unbiased finding; Physical exam (PEx), vital signs (VS), diagnostic test results (laboratory and radiological studies), and procedures
What is SHx?
surgical or social history
What is FHx?
family history
When should surgical history be included in the HPI?
if it is related to the chief complaint; pt presents with chest pain, and they had a previous CABG
What are some noteworthy things to include in the HPI?
vitals from EMS, recent ER, clinic, and/or patient admissions
When should quotations be used?
when the pt specifically states something; esp non-medical terminology
What is the beginner format for HPI?
[Age and gender] with history of [past medical history] presents to the emergency department complaining of
[chief complaint] which began [onset]. The patient reports [secondary or associated symptoms]. Symptoms have
improved with [modifying factors]and worsened with [modifying factors]. [Include other relevant aspects of the
history]. Patient [reports or denies] history of similar symptoms [and include information about last time they had
experienced similar symptoms if relevant].Denies [relevant symptoms].
Which are common blood-thinners?
Plavix, Eliquis, Coumadin/Warfarin, Xarelto, and Pradaxa
For which conditions may blood thinners be prescribed?
A-fib, stroke (CVA), and/or coronary artery disease (CAD)
What are some medications for CHF?
Digoxin, Lasix/Furosemide
What are some common medications for hypertension?
lisinopril, Norvasc, Hydralazine, Hydrochlorothiazide (HCTZ), clonidine
What are some common medications for hyperlipidemia?
simvistatin, lovastatin, atorvastatin, rosuvastatin
What is a mechanical fall?
caused by trip, slip, or loss of balance
Which are some important things to document in pregnancies?
OB/GYN, prenatal care, and blood type of baby
For RUQ pain, what are some important labs to include? (if available)
H&H, CBC, creatinine, BUN. LFTs
For RUQ pain, what are other pertinent parts of the history?
prior abdominal surgeries, diverticulitis, IBS, and pancreatitis
