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Scribe > Course 3: HPI and ROS > Flashcards

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
Q

CP: red flag: pleuritic pain

A

DDx:

PE, PTX

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26
Q

CP: red flag: calf pain

A

DDx:

DVT causing PE

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27
Q

CP: minor DDx

A

Chest wall pain, costochondritis, pleural effusion, GERD

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28
Q

CP: red flags

A
  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
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29
Q

SOB: red flag: productive cough

A

DDx:

PNA

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30
Q

SOB: red flag: orthopnea/ dyspnea on exertion

A

DDx:

CHF

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31
Q

SOB: red flag: bilateral leg swelling

A

DDx:

CHF

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32
Q

SOB: red flag: hemoptysis

A

DDx:

PE

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33
Q

SOB: red flag: unilateral leg swelling

A

DDx:

DVT causing a PE

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34
Q

SOB: red flag: wheezing

A

DDx:

Asthma

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35
Q

SOB: red flag: Hx of tobacco abuse

A

DDx:

COPD

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36
Q

SOB: red flag: CP

A

DDx:

MI, PE, PNA

37
Q

SOB: red flags

A
  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
Q

Abd pain: red flag: RLG pain

A

DDx:

Appendicitis

39
Q

Abd pain: red flag: RUQ pain

A

DDx:

Cholecystitis

40
Q

Abd pain: red flag: LLQ pain

A

DDx:

Diverticulitis

41
Q

Abd pain: red flag: LUQ pain

A

DDx:

Pancreatitis

42
Q

Abd pain: red flag: fever

A

DDx:
Appendicitis
Cholecystitis
Diverticulitis

43
Q

Abd pain: red flag: Blood in vomit or stool

A

DDx:

GI bleed

44
Q

Abd pain: red flag: Melena

A

DDx:

GI Bleed

45
Q

Abd pain: red flag: dizziness

A

DDx:
GI bleed
AAA

46
Q

Abd pain: red flags

A
  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
Q

Female lower abd pain: red flag: suprapubic pain

A

DDx:

ovarian torsion

48
Q

Female lower abd pain: red flag: pregnancy

A

DDx:

ectopic pregnancy

49
Q

Female lower abd pain: red flags

A
  1. Suprapubic pain

2. Pregnancy

50
Q

L-spine pain: red flag: weakness/numbness in lower extremities

A

DDx:

spinal cord injury

51
Q

L-spine pain: red flag: numbness of the groin

A

DDx:

spinal cord injury or Cauda Equina

52
Q

L-spine pain: red flag: loss of bowel or bladder control

A

DDx:

spinal cord injury or Cauda Equina

53
Q

L-spine pain: red flag: Hx of IVDA

A

DDx:

spinal abscess

54
Q

L-spine pain: red flag: fever

A

DDx:

spinal abscess

55
Q

L-spine pain: red flag: abd pain

A

DDx:

AAA

56
Q

L-spine pain: red flags

A
  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
Q

Dizziness/HA: red flag: weakness/numbness/tingling

A

DDx:
CVA
SAH

58
Q

SAH

A

Subarachnoid Hemorrhage

59
Q

Dizziness/HA: red flag: changes in speech or vision

A

DDx:
CVA
SAH

60
Q

Dizziness/HA: red flag: difficulty with balance

A

DDx:

CVA SAH

61
Q

Dizziness/HA: red flag: fever, neck pain

A

DDx:

Meningitis

62
Q

Dizziness/ HA: red flag: AMS

A

DDx:
Meningitis
CVA
SAH

63
Q

Dizziness/ HA: red flag: thunderclap onset

A

DDx:
Hemorrhagic CVA
SAH

64
Q

Dizziness/HA: red flag: syncope or seizure

A

DDx:

CVA, SAH

65
Q

Dizziness/HA: red flags

A
  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
Q

Syncope: red flag: tongue bite wound

A

DDx:

Sz

67
Q

Syncope: red flag: numbness/weakness/tingling, changes in speech

A

DDx:

CVA

68
Q

Syncope: red flag: CP

A

DDx:

MI

69
Q

Syncope: red flag: SOB

A

DDx:

PE

70
Q

Syncope: red flag: palpitations

A

DDx:

Arrhythmia

71
Q

Syncope: red flags

A
  1. Tongue bite wound
  2. Numbness/Weakness/Tingling
  3. Changes in speech or vision.
  4. CP
  5. SOB
  6. palpitations
72
Q

AMS: red flag: fever

A

DDx:

Sepsis

73
Q

AMS: red flag: numbness/ weakness/ tingling, changes in speech or vision

A

DDx:

CVA

74
Q

AMS: red flag: HA

A

DDx:

Hemorrhagic CVA

75
Q

AMS: red flag: Hx of depression or drug abuse

A

DDx:

OD

76
Q

AMS: red flag: Hx of DM

A

DDx:

Hypoglycemia

77
Q

AMS: red flags

A
  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
Q

Trauma: red flag: LOC and unilateral numbness/ weakness/ tingling

A

DDx:
Hemorrhagic CVA
Subdural Hematoma

79
Q

Trauma: red flag: bilateral numbness/ weakness/ tingling and neck or back pain

A

DDx:

spinal cord injury

80
Q

Trauma: red flag:

SOB or CP

A

DDx:
PTX
Cardiac Contusion

81
Q

Trauma: red flag: abd pain

A

DDx:

splenic or liver laceration

82
Q

Trauma: red flags

A
  1. LOC
  2. Unilateral numbness/ weakness/ tingling
  3. Bilateral numbness/ weakness/ tingling
  4. neck or back pain
  5. abd pain
83
Q

RA

A

Rheumatoid Arthritis

84
Q

CBP

A

Chronic Back Pain

85
Q

Intermittent

A

Comes and goes

86
Q

Waxing and waning

A

Always present but changing in intensity

87
Q

Modifying factor

A

Something that makes the Sx better or worse

88
Q

Exacerbate

A

To make worse

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