course 3 Flashcards
Subjective
Based on the Patient’s feeling(HPI, ROS)
Objective
Factual information from provider (PE)
History of present illness
The story of the patient’s chief complaint.
Review of systems
head to toe list of patient’s symptoms .
intermittent
comes and goes
Waxing and waning
always present but changing with intensity
modifying factors
something that makes a symptom better or worse.
Exacerbate
to make worst .
Element
description
onset
when did the complaint begin
timing
has it been constant, intermittent, waxing or waning.
location
where is the discomfort
quality
Does it feel sharp, dull, aching, cramping….?
severity
How bad is it? Mild, mod, severe or 0-10
modifying factors
What makes it better? What makes it worse?
Associated Sx
Do any other symptoms accompany the complaint?
context
Is there anything else that’s important?
A complete HPI requires atleast..
4 complete elements
Outline for HPI
- complaint + onset
- Timing, quality, severity
- What makes it better or worse
- Associated symptoms
- Pertinent negatives
- Context
I took tums and it didn’t help
the symptoms were unchanged by tums
I have low back pain, but always have that
He notes chronic back pain, unchanged from baseline
It hurts when I touch it
The symptoms worsen with palpations in the area
Nothing makes it better or worse
the symptoms are unchanged by any position or activity
My sister has the same cold
positive sick contact with sister who has similar symptoms.
If I try to eat or drink anything, I throw it back up
The vomiting exacerbated by PO
it feels like a fizzing soda in the middle of my chest
He describes the Sx as a “fizzing soda” in his central chest.
don’t s of HPI
Use days of week, use got, start sentences the same, write self diagnoses, include Hx that is no relevant.
Key to writing a trauma HPI
focusing on the MOI
Four most important Sx to document for any trauma pt.
LOC, Head injury, Neck pain, back pain
A complete ROS requires..
At least ten elements. If cannot make a complete ROS, state and explain why. When all other systems are negative only require 2
Constitutional .
Fever, weight loss, swets
Eyes
change in vision, eye pain, double vision.
Ear/nose/throat
Ear ache, Nose bleed, Congestion, Sore throat
cardiovascular
Chest pain, Palpitations, Leg swelling
respiratory
SOB, Cough, Sputum, Wheezing
gastrointestinal
Abdominal pain, N/V/D, Black or bloody stools
Genitourinary
Dysuria, Frequency, Urgency, Hematuria
Musculoskeletal
Joint pain, Muscle pain
integumentary/skin
Rash, Itching, Abrasion, Laceration
neurological
Headache, Syncope, Seizure, Numbness, Focal weakness
psychiatric
Depression, Anxiety
endocrine
Polyuria, polydipsia
hematologic/lymph
Bleeding gums, easy bruising, swollen lymph nodes
immunologic
HIV/AIDS, Splenectomy
worse with physical exertion-cp
MI
worse with deep breaths -cp
PE
radiation to the back -cp
aortic dissection
recent trauma- cp
PTX
SOB -cp
MI, PE, PTX
Diaphoresis, Nausea, vomiting -cp
MI
Pleuritic pain -cp
PE, PTX
Calf pain -cp
DVT` causing PE
Minor DDx of Cp
chest wall pain, costochondritis, Pleural effusion, GERD
Associated Sx - Cp with minor DDX
pain with torso movement or palpation(chest wall, costo-), burning (GERD)
MI risk factors
CAD, HTN, HLD, dM, Smoking, FHx CAD <55 y/o
PE risk factors
Hx DVT/PE, known DVT, recent surgery, mobilization, A-fib, cancer, pregnancy/BCP
Hx of tobacco abuse -SOB
COPD
Chest ain-SOB
MI, PE, PNA
minor DDx of SOB
Bronchitis, URI
Associated Sx of Bronchitis, URI
cough, sputum, Nasal congestion, Sore throat.
Mi risk factors
CAD, HTN, HLD, DM, Smoking, FHx CAD < 55 y/o
PE Risk factors
Hx DVT/PE, Known DVT, Recent surgery, Immobilization, A-Fib, Cancer, Pregnancy/Birth Control
Abd pain -RLQ
appendicitis
RUQ pain
cholecystitis
LLQ pain
diverticulitis
LUQ pain
Pancreatitis
Fever - Abd pain
appendicitis, cholecystitis, diverticulitis
Blood in vomit or stool
GI bleed
Melena
GI bleed
Dizziness - Abd pain
GI bleed, AAA - (anemia, low blood volume)
Minor DDx of Abd pain
gastroenteritis, gastritis, constipation
Associated Sx with Gastroenteritis, gastritis, constipation
Dysuria, Nausea/Vomiting, Diarrhea, Constipation
Diarrhea risk factors
Recent foreign travel, recent camping, bad food exposure, sick contacts, recent antibiotics, recent hospitalization
Suprapubic pain
ovarian torsion
pregnancy - with lower abd pain
ectopic pregnancy
Fever, RLQ pain for femail
appendicitis
minor DDx for female Lower abd pain
Ovarian Cyst, UTI, STD
Associated Sx with female lower abd pain
Nausea/Vomiting, Vaginal Spotting, Vaginal Discharge, Dysuria, Flank pain
Female Abd pain risk factors
Possibility of Pregnancy, Unprotected Sex, History of STD
Weakness/numbness in lower extremities
spinal cord injury
numbness of the groin
spinal cord injury or cauda equina
loss of bowel or bladder control
spinal cord injury or cauda equina
History of IVDA - w/ lower back pain.
Spinal abscess
Fever - with lower back pain
spinal abscess
Abdominal Pain- with lower back pain
Abdominal Aortic Aneurysm (AAA)
Minor DDx of Low back pain
Musculoskeletal back pain, Back Strain, Sciatica
Associated Sx of Low back pain
Radiating pain down the backs of the legs (sciatica)
Back pain risk factors
Recent trauma, hx of IVDA, spinal hardware
Weakness/numbness/tingling W/ Dizziness HA
CVA
Changes in speech or vision
w/ Diz/HA
CVA, SAH
difficulty with balance w/ Diz HA
CVA, SAH
fever W/ Diz/HA
Meningitis
neck pain w/ Diz/HA
Meningitis
AMS w/ Diz/HA
meningitis, CVA, SAH
Worst headache of life/ thunderclap onset
Hemorrhagic CVA, SAH
syncope or seizure w/ Diz/HA
CVA, SAH
Minor DDx of Dizziness and HA
Dehydration, Benign Positional Vertigo (BPV), Migraine HA, Tension HA, Sinusitis,
Associated Sx Minor DDx for Dizziness/HA
Nasal congestion, runny nose, nausea, vomiting
CVA risk factors
HTN, HLD, DM, Smoking, FHx CVA, Hx TIA/CVA, AFib
tongue bit wound
Sz
SAH
Subarachnoid Hemorrhage
Numbness/weakness/Tingling with syncope
CVA
Changes in speech or vision w/ syncope
CVA
chest pain w/ syncope
MI
SOB w/ syncope
PE
Palpitations w/ syncope
Arrhythmia
Minor DDx of Syncope
Vasovagal syncope, dehydration
Associated Sx with with vasovagal syncope, dehydration
Associated Symptoms: Feeling “about to pass out” (near-syncope), sweating, dizziness, lightheadedness
Associated Sx with with vasovagal syncope, dehydration
Associated Symptoms: Feeling “about to pass out” (near-syncope), sweating, dizziness, lightheadedness
Fever with AMS
Sepsis
Numbness/Weakness/Tingling w/ AMS
CVA
HA w/ AMS
Hemorrhagic CVA
Hx of depression or drug abuse w/ AMS
Drug overdose
Hx of DM w/ AMS
hypoglycmia
Minor DDx of AMS
UTI (Elderly), ETOH abuse, Narcotic abuse, drug abuse
AMS risk factors
Dementia/Alzheimers, DM, Psychiatric history, Substance abuse
LOC w/ Trauma
Hemorrhagic CVA, Subdural Hematoma
Unilateral numbness/weakness/tingling w/ trauma
Hemorrhagic CVA, Subdural Hematoma
Bilateral Numbness/weakness/tingling w/ trauma
spinal cord injury
Neck pain or back pain w/ trauma
spinal cord injury
SOB or CP w/ Trauma
PTX, cardiac contusion
Abd Pain w/ trauma
Splenic or Liver Laceration
Minor DDx W/ trauma
Closed Head Injury, simple fracture, dislocation, strain/sprain, laceration
Trauma risk factors
Blood thinners (Coumadin/Warfarin, Plavix, Aspirin), Severe Mechanism of Injury
General PMHx
• HTN, HLD, CA, DM (IDDM/NIDDM)
Cardiovascular PMHx
• MI, CAD, Angina, CHF, AFIB
Pulmonary PMHx
• PE, PNA, COPD, Asthma
GI PMHx
• GERD, AAA, Pancreatitis, Hepatitis, Diverticulitis
Genitourinary PMHx
• Kidney stones, UTI, Renal insufficiency/failure
Neurological PMHx
• CVA, TIA, Epilepsy/Seizure, Migraines, Dementia, Alzheimer’s
Psychological PMHx
• Depression, Anxiety, Bipolar, Schizophrenia
Other PMHx
• DVT, MRSA, RA (Rheumatoid Arthritis), CBP (Chronic Back Pain)
ENT PSHx
• Tonsillectomy, Adenoidectomy, PE tubes
Cardiac PSHx
• CABG, Coronary Stents, Pacemaker, AICD, Catheterization, Angioplasty, Valve replacement
Abd PSHx
• Appendectomy, Cholecystectomy, Herniorrhaphy, Gastric Bypass, Colectomy, Colostomy, Nephrectomy
GU PSHx
• Hysterectomy, C-section, Oophorectomy, Salpingo- oophorectomy, Tubal ligation, TURP
Ortho PSHx
• AKA/BKA, Hip Arthroplasty, Spinal fusion
Neuro PSHx
Carotid endarterectomy, craniotomy, VP shunt
Other PSHx
• Mastectomy, PICC line
