Course #3 Flashcards
What is a CC?
The main reason for the patients visit
Onset
When the symptoms started
Timing
When the symptoms occur: constant, intermittent, occasional…
Quality
Description of how the symptoms feel: sharp, shooting, burning, cramping, “feels like an elephant on my chest”…
Location
Where the symptoms are located: RLQ abdominal pain, epigastric abdominal pain, HA behind R eye
Severity
How bad is the pain on a 0-10 scale or mild, moderate, or severe scale
Associated symptoms vs. pertinent negatives
AS: symptoms that are related to the CC that the patient has
PN: symptoms that are related to the CC that the patient denies having
Example: patient ahas associated symptoms of cough and wheezing but denies any chest pain or fever
Modifying factors
Does anything change the patients symptoms to be better or worse?
Example: patients pain was improved with Ibuprofen and exacerbated with movement
Context
Anything else important to understanding the CC such as a mechanism of injury (MOI), risk factors, similar symptoms, prior tests
What should be included in the first sentence of the HPI?
Age, sex, CC, and onset
How should you write “to touch”
Palpate, palpation
How should you write “to worsen”
Exacerbate or aggravate
What is a caveat statement?
Describes why we are limited in information usually when a patient is AMS/unresponsive
What is the following element: “10/10 pain”
Severity
What is the following element: “sharp”
Quality
