Course 3 History of present Illness

Question 1

How is the HPI different from the ROS?

Answer 1

The ROS includes all other information the pt has. It is rated in a positive and negative form.

Question 2

Name five elements of the HPI

Answer 2

Onset, timing, location, quality, severity, modifying factors, associated sx, context.

Question 3

Name eight elements of the body systems included in the ROS

Answer 3

Constitutional, eyes, ears/nose/throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, integumentary/skin, neurological, psychiatric, endocrine, hematologic/lymph, immunologic

Question 4

Can the symptoms listed in the ROS ever contradict the systems described in the HPI?

Answer 4

No because they are both subjective coming from the pt’s POV

Question 5

What do you need to remember to document in the HPI and ROS for any patient that is unconscious or incapable of providing information?

Answer 5

Document why the history is limited. “HPI unobtainable due to the pt’s non-verbal status”.

Question 6

Why is it important to remember to document if the pt has had similar symptoms in the past?

Answer 6

It is likely that their current symptoms are related. It is also less likely that their current symptoms are life threatening if they have survived the same symptoms in the past.

Question 7

Name one detail that is important to document if the pt has been evaluated in the past for a similar complaint.

Answer 7

Anything new or different about the sx today, how long ago their similar Sx occurred, if they sought professional treatment at the time, any result or dx form previous evaluations.

Question 8

What should you focus on when writing an HPI

Answer 8

Documenting the answers to every question asked by the doctor.

Question 9

Which is the first item in the formula for writing an HPI

a) pertinent negatives
b) timing, quality, and location
c) chief complaint and onset
d) associated symptoms

Answer 9

C)

Question 10

Often complex HPI’s do not follow the HPI formula; how should you organize the events in a complex HPI

Answer 10

chronological ordder

Question 11

What does MOI stand for in a Trauma HPI

Answer 11

Mechanism of Injury

Question 12

True or false: in the ROS you should document “All other systems negative except as mark” for every pt.

Answer 12

False

Question 13

Based on your knowledge from Day 2, why should you always pay special attention to the complaints of Chest Pain and SOB

Answer 13

These are Sx of cardiac problems. edit

Question 14

Name three past surgical histories that indicate that the pt has a history of CAD

Answer 14

coronary artery bypass graft, coronary stents, angioplasty

Question 15

What is the difference between cardiac stress test and a cardiac catheterization?

Answer 15

Cardiac catheterization is used to diagnose CAD, stress test and cardiac catherization assess the severity of CAD

there is no difference?

Question 16

What are the risk factors for an MI?

Answer 16

CAD, HTN, HLD, DM, Smoker, FHx of CAD

Question 17

What are the risk factors for a PE?

Answer 17

Known DVT, PMHx of DVT or PE, FHx, recent surgery, Cancer, A-Fib, Immobility, Pregnancy, BCP, Smoking

Question 18

What are the risk factors for a CVA

Answer 18

HTN, HLD, DM, hx TIA/CVA, smoking, Fx CVA, AFIB

Question 19

Describe the the significance of an HPI

Answer 19

Is the story of symptoms and events that led to the pt’s ED visit. includes information directly related to the chief complaint and important context for that pt.