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Course 3: HPI and ROS Flashcards

1
Q

What is an HPI?

A
  1. Story of symptoms and events that led to the pt’s ED visit.
  2. Contains only subjective information
  3. Information directly related to the chief complaint.
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2
Q

When complete story is unavailable…

A

“HPI is unobtainable due to pt’s non-verbal status”.

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3
Q

When story is limited…

A

Write exactly what you know (ex. “per EMS, this pt was found unresponsive 15 min ago.”)

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4
Q

Documentation order:

A
  1. HPI
  2. ROS
  3. PE
  4. Orders/results
  5. Diagnosis
  6. Disposition plan
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5
Q

“I took Tums and it didn’t help”

A

The symptoms were unchanged by Tums

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6
Q

“I have low back pain, but I always have that”

A

He notes chronic lower back pain, unchanged from baseline.

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7
Q

“It hurts when I touch it”

A

They symptoms are worsened by palpation of the area

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8
Q

“Nothing makes it better or worse”

A

The symptoms are unchanged by any position or activity.

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9
Q

“My sister has the same cold”

A

Positive sick contact with sister who has similar symptoms

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10
Q

“If I try to eat or drink anything, I throw it back up”

A

The vomiting is exacerbated by PO intake.

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11
Q

“It feels life a fizzing soda in the middle of my chest”

A

He describes the symptoms as “a fizzing soda” in his central chest

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12
Q

For previously similar symptoms document:

A
  1. Anything new or different about their symptoms today
  2. How long ago the similar symptoms occurred
  3. If they sought professional treatment at that time
  4. Any results or diagnosis from previous evaluations
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13
Q

HPI prior evaluation document:

A
  1. What symptoms prompted the prior evaluation?
  2. How long ago did the prior evaluation occur?
  3. Who did they see?
  4. What treatment did they receive? Did it help?
  5. What diagnosis was given?
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14
Q

Prior studies related to their complaint, document:

A
  1. Specific name of the test
  2. Date
  3. Specific results
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15
Q

4 most important elements for trauma HPI’s

A
  1. LOC
  2. Head injury
  3. Neck pain
  4. Back pain
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16
Q

What is the ROS?

A

A head-to-toe checklist of the pt’s body systems

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17
Q

Limited ROS…

A

“A complete ROS is unobtainable due to the pt’s condition.”

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18
Q

ROS 14 body systems:

A
  1. Constitutional
  2. Eyes
  3. ENT
  4. Cardiovascular
  5. Respiratory
  6. GI
  7. GU
  8. Musculoskeletal
  9. Integumentary/Skin
  10. Neurological
  11. Psychiatric
  12. Endocrine
  13. Hematologic/Lymph
  14. Immunologic
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19
Q

CP: red flag: worse with physical exertion

A

DDx:

MI

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20
Q

CP: red flag: worse with deep breaths

A

DDx:

PE

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21
Q

CP: red flag: radiation to the back

A

DDx:

Aortic Dissection

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22
Q

CP: red flag: recent trauma

A

DDx:

PTX

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23
Q

CP: red flag: SOB

A

DDx:

MI, PE, PTX

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24
Q

CP: red flag: diaphoresis, nausea, vomiting

A

DDx:

MI

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25
CP: red flag: pleuritic pain
DDx: | PE, PTX
26
CP: red flag: calf pain
DDx: | DVT causing PE
27
CP: minor DDx
Chest wall pain, costochondritis, pleural effusion, GERD
28
CP: red flags
1. worse with physical exertion 2. worse with deep breaths 3. radiation to the back 4. recent trauma 5. SOB 6. diaphoresis, nausea, vomiting 7. pleuritic pain 8. calf pain
29
SOB: red flag: productive cough
DDx: | PNA
30
SOB: red flag: orthopnea/ dyspnea on exertion
DDx: | CHF
31
SOB: red flag: bilateral leg swelling
DDx: | CHF
32
SOB: red flag: hemoptysis
DDx: | PE
33
SOB: red flag: unilateral leg swelling
DDx: | DVT causing a PE
34
SOB: red flag: wheezing
DDx: | Asthma
35
SOB: red flag: Hx of tobacco abuse
DDx: | COPD
36
SOB: red flag: CP
DDx: | MI, PE, PNA
37
SOB: red flags
1. Productive Cough 2. Orthopnea/ dyspnea on exertion 3. Bilateral leg swelling 4. Hemoptysis 5. Unilateral leg swelling 6. Wheezing 7. Hx of tobacco abuse 8. CP
38
Abd pain: red flag: RLG pain
DDx: | Appendicitis
39
Abd pain: red flag: RUQ pain
DDx: | Cholecystitis
40
Abd pain: red flag: LLQ pain
DDx: | Diverticulitis
41
Abd pain: red flag: LUQ pain
DDx: | Pancreatitis
42
Abd pain: red flag: fever
DDx: Appendicitis Cholecystitis Diverticulitis
43
Abd pain: red flag: Blood in vomit or stool
DDx: | GI bleed
44
Abd pain: red flag: Melena
DDx: | GI Bleed
45
Abd pain: red flag: dizziness
DDx: GI bleed AAA
46
Abd pain: red flags
1. RLQ pain 2. RUQ pain 3. LLQ pain 4. LUQ pain 5. Fever 6. Blood in vomit or stool 7. Melena 8. Dizziness
47
Female lower abd pain: red flag: suprapubic pain
DDx: | ovarian torsion
48
Female lower abd pain: red flag: pregnancy
DDx: | ectopic pregnancy
49
Female lower abd pain: red flags
1. Suprapubic pain | 2. Pregnancy
50
L-spine pain: red flag: weakness/numbness in lower extremities
DDx: | spinal cord injury
51
L-spine pain: red flag: numbness of the groin
DDx: | spinal cord injury or Cauda Equina
52
L-spine pain: red flag: loss of bowel or bladder control
DDx: | spinal cord injury or Cauda Equina
53
L-spine pain: red flag: Hx of IVDA
DDx: | spinal abscess
54
L-spine pain: red flag: fever
DDx: | spinal abscess
55
L-spine pain: red flag: abd pain
DDx: | AAA
56
L-spine pain: red flags
1. Weakness/ numbness in the lower extremities 2. Numbness of the groin 3. Loss of bowel or bladder control 4. Hx of IVDA 5. Fever 6. Abd pain
57
Dizziness/HA: red flag: weakness/numbness/tingling
DDx: CVA SAH
58
SAH
Subarachnoid Hemorrhage
59
Dizziness/HA: red flag: changes in speech or vision
DDx: CVA SAH
60
Dizziness/HA: red flag: difficulty with balance
DDx: | CVA SAH
61
Dizziness/HA: red flag: fever, neck pain
DDx: | Meningitis
62
Dizziness/ HA: red flag: AMS
DDx: Meningitis CVA SAH
63
Dizziness/ HA: red flag: thunderclap onset
DDx: Hemorrhagic CVA SAH
64
Dizziness/HA: red flag: syncope or seizure
DDx: | CVA, SAH
65
Dizziness/HA: red flags
1. Weakness/numbness/tingling 2. Changes in speech or vision 3. Difficulty with balance 4. Fever 5. Neck pain 6. AMS 7. Thunderclap onset 8. Syncope or Seizure
66
Syncope: red flag: tongue bite wound
DDx: | Sz
67
Syncope: red flag: numbness/weakness/tingling, changes in speech
DDx: | CVA
68
Syncope: red flag: CP
DDx: | MI
69
Syncope: red flag: SOB
DDx: | PE
70
Syncope: red flag: palpitations
DDx: | Arrhythmia
71
Syncope: red flags
1. Tongue bite wound 2. Numbness/Weakness/Tingling 3. Changes in speech or vision. 4. CP 5. SOB 6. palpitations
72
AMS: red flag: fever
DDx: | Sepsis
73
AMS: red flag: numbness/ weakness/ tingling, changes in speech or vision
DDx: | CVA
74
AMS: red flag: HA
DDx: | Hemorrhagic CVA
75
AMS: red flag: Hx of depression or drug abuse
DDx: | OD
76
AMS: red flag: Hx of DM
DDx: | Hypoglycemia
77
AMS: red flags
1. Fever 2. Numbness/ weakness/ tingling 3. Changes in speech or vision 4. HA 5. Hx of depression or drug abuse 6. Hx of DM
78
Trauma: red flag: LOC and unilateral numbness/ weakness/ tingling
DDx: Hemorrhagic CVA Subdural Hematoma
79
Trauma: red flag: bilateral numbness/ weakness/ tingling and neck or back pain
DDx: | spinal cord injury
80
Trauma: red flag: | SOB or CP
DDx: PTX Cardiac Contusion
81
Trauma: red flag: abd pain
DDx: | splenic or liver laceration
82
Trauma: red flags
1. LOC 2. Unilateral numbness/ weakness/ tingling 3. Bilateral numbness/ weakness/ tingling 4. neck or back pain 5. abd pain
83
RA
Rheumatoid Arthritis
84
CBP
Chronic Back Pain
85
Intermittent
Comes and goes
86
Waxing and waning
Always present but changing in intensity
87
Modifying factor
Something that makes the Sx better or worse
88
Exacerbate
To make worse

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