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ScribeAmerica: ER > Course 3: HPI & ROS > Flashcards

Course 3: HPI & ROS Flashcards

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1
Q

Subjective

A

Based on the patient’s feeling (ROS & HPI)

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2
Q

Objective

A

Factual information from provider (PE)

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3
Q

History of Present Illness (HPI)

A

The story of the patient’s chief complaint

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4
Q

Review of Systems (ROS)

A

Head-to-Toe checklist of the patient’s symptoms

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5
Q

Intermittent

A

Comes and goes

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6
Q

Waxing and Waning

A

always present but changing in intensity

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7
Q

Modifying factor

A

Something that makes a symptom better or worse

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8
Q

Exacerbate

A

To make worse

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9
Q

Onset

A
  • HPI

- when did the complaint begin?

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10
Q

Timing

A
  • HPI

- has it been constant, intermittent or waxing and waning?

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11
Q

Location

A
  • HPI

- where is the discomfort?

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12
Q

Quality

A
  • HPI

- Does it feel sharp, dull, aching, cramping, etc?

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13
Q

Severity

A
  • HPI

- How bad is it? Mild, mod, severe or 0-10

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14
Q

Modifying Factors

A
  • HPI

- what makes it better? What makes it worse?

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15
Q

Associated Sx

A
  • HPI

- Do any other symptoms accompany the complaint?

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16
Q

Context

A
  • HPI

- Is there anything else that is important?

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17
Q

What makes a complete HPI?

A

4 elements

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18
Q

Sentence 1 HPI

A

Age + Gender + CC+ Onset

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19
Q

Sentence 2 HPI

A

Quality+Severity+ Location +Radiation

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20
Q

Sentence 3 HPI

A

Associated Sx+ Pertinent Negatives

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21
Q

Sentence 4 HPI

A

Modifying Factors

  • what makes it better?
  • what makes it worse?
  • treatment tried (Meds, ice pack, etc.)
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22
Q

Sentence 5 HPI

A

Context

  • similar symptoms?
  • recent evaluations?
  • initiating factor that brought patient to ED
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23
Q

HPI Prior Evaluation

A

Important to document

  • what sx prompted prior eval?
  • how long ago did the prior eval occur?
  • what treatment did they receive? Did it help?
  • what diagnosis was given?
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24
Q

“I took Tums and it didn’t help”

A

the symptoms were unchanged by Tums

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25
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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26
Q

“It hurts when I touch it”

A

The symptoms are worsened by palpation of the area

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27
Q

“Nothing makes it better or worse”

A

The symptoms are unchanged by position or activity

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28
Q

“My sister has the same cold”

A

Positive sick contact with sister who has similar symptoms

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29
Q

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

A

The vomiting is exacerbated by P.O. intake

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30
Q

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

A

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

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31
Q

Trauma HPI: important symptoms to document

A

1) LOC
2) Head Injury
3) Neck Pain
4) Back Pain

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32
Q

MVA HPI

A

Additional questions help determine the severity of the accident as well as what tests the doctor will order

  • were you the driver or passenger?
  • were you wearing a seatbelt?
  • how fast were you moving?
  • what part of the car was hit?
  • did it hit a stationary object or a moving vehicle?
  • did the airbags deploy?
  • did you LOC?
  • did you hit your head?
  • did you sustain any injuries?
  • how much damage was done to your vehicle?
  • is the car drivable?
  • were you able to self-extricate?
  • were you able to ambulated on-scene?
  • did you require EMS treatment on scene?
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33
Q

Red Flag: Worse with physical Exertion

[Chest Pain]

A

MI

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34
Q

Red Flag: Worse with deep breathes

[Chest Pain]

A

PE

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35
Q

Red Flags: Radiation to the back

[Chest Pain]

A

Aortic Dissection

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36
Q

Red Flags: Recent trauma

[Chest Pain]

A

Pneumothorax (PTX)

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37
Q

Red Flags: SOB

[Chest Pain]

A

MI, PE, PTX

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38
Q

Red Flag: Diaphoresis, Nausea, Vomiting

[Chest Pain]

A

MI

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39
Q

Red Flag: Pleuritic Chest Pain

[Chest Pain]

A

PE, PTX

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40
Q

Red Flag: Calf Pain

[Chest Pain]

A

DVT (which can cause PE)

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41
Q

MI Risk Factors

A
  • CAD
  • HTN
  • HLD
  • DM
  • Smoking
  • FHx CAD <55y/o
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42
Q

PE Risk Factors

A
  • Hx DVT/PE
  • Known DVT
  • Recent surgery
  • Immobilization
  • A-Fib
  • Cancer
  • Pregnancy/Birth Control
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43
Q

Red Flag: Productive Cough

[SOB]

A

Pneumonia (PNA)

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44
Q

Red Flag:Orthopnea/DOE

[SOB]

A

Congestive Heart Failure (CHF)

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45
Q

Red Flag: Bilateral Leg Swelling

[SOB]

A

Congestive Heart Failure (CHF)

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46
Q

Red Flag: Hemoptysis

[SOB]

A

Pulmonary Embolism (PE)

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47
Q

Red Flag: Unilateral Leg Swelling

[SOB]

A

DVT causing a PE

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48
Q

Wheezing

[SOB]

A

Asthma

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49
Q

Hx of tobacco use

[SOB]

A

COPD

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50
Q

Red Flag: Chest Pain

[SOB]

A

MI, PE, PNA

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51
Q

Red Flag: RLQ Pain

[Abd Pain]

A

Appendicitis

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52
Q

Red Flag: RUQ Pain

[Abd Pain]

A

Cholecystitis

53
Q

Red Flag: LLQ Pain

[Abd Pain]

A

Diverticulitis

54
Q

Red Flag: LUQ Pain

[Abd Pain]

A

Pancreatitis

55
Q

Red Flag: Fever

[Abd Pain]

A

Appendicitis, Diverticulitis, Cholecystitis

56
Q

Red Flag: Blood In vomit or stool

[Abd Pain]

A

GI Bleed

57
Q

Red Flag: Melena

[Abd Pain]

A

GI Bleed

58
Q

Red Flag: Dizziness

[Abd Pain]

A

GI Bleed, AAA

59
Q

Red Flag: Suprapubic Pain

[Abd Pain in Females]

A

Ovarian Torsion

60
Q

Red Flags: Pregnancy

[Abd Pain in Females]

A

Ectopic Pregnancy

61
Q

Red Flag: weakness/numbness in LE

[Low Back Pain]

A

Spinal cord injury

62
Q

Red Flag: numbness of groin

[Low Back Pain]

A

Spinal cord injury or cauda equina

63
Q

Red Flag: Loss of bowel or bladder control

[Low Back Pain]

A

spinal cord injury or cauda equina

64
Q

Red Flag: Hx of IVDA

[Low Back Pain]

A

Spinal Abscess

65
Q

Red Flag: Fever

[Low Back Pain]

A

Spinal Abscess

66
Q

Red Flag: Abd Pain

[Low Back Pain]

A

AAA

67
Q

Red Flag:Weakness, Numbness, Tingling

[Dizziness/HA]

A

CVA, Subarachnoid hemorrhage (SAH)

68
Q

Red Flag: changes in speech or vision

[Dizziness/HA]

A

CVA, SAH

69
Q

Red Flag: Difficulty with Balance

[Dizziness/HA]

A

CVA, SAH

70
Q

Red Flag: Fever

[Dizziness/HA]

A

Meningitis

71
Q

Red Flag: Neck Pain

[Dizziness/HA]

A

Meningitis

72
Q

Red Flag: AMS

[Dizziness/HA]

A

Meningitis, CVA, SAH

73
Q

Red Flag: Worst HA of life/Thunderclap onset

[Dizziness/HA]

A

Hemorrhagic CVA, SAH

74
Q

Red Flag: Syncope or Seizure

[Dizziness/HA]

A

CVA, SAH

75
Q

Red Flag: tongue bite wound

[Syncope]

A

Seizure (Sz)

76
Q

Red Flag: Numbness/Tingling/Weakness

[Syncope]

A

CVA

77
Q

Red Flag: Changes in speech or vision

[Syncope]

A

CVA

78
Q

Red Flag: CP

[Syncope]

A

MI

79
Q

Red Flag: SOB

[Syncope]

A

PE

80
Q

Red Flags:Palpitations

[Syncope]

A

Arrhythmia

81
Q

CVA Risk Factors

A
  • HTN
  • HLD
  • DM
  • Smoking
  • FHx CVA
  • Hx TIA/CVA
  • AFIB
82
Q

Red Flag AMS: Fever

A

Sepsis

83
Q

Red Flag AMS: Numbness/Weakness/Tingling

A

CVA

84
Q

Red Flag AMS: Changes in speech or vision

A

CVA

85
Q

Red Flag AMS: HA

A

Hemorrhagic CVA

86
Q

Red Flag AMS: Depression or Drug Abuse

A

Drug OD

87
Q

Red Flag AMS: Diabetes

A

Hypoglycemia

88
Q

AMS Risk Factors

A
  • Dementia/Alzheimer’s
  • DM
  • Psychiatric History
  • Substance Abuse
89
Q

Red Flag Trauma: LOC

A

Hemorrhagic CVA or Subdural Hematoma

90
Q

Red Flag Trauma: Unilateral Numbness/Weakness/Tingling

A

Hemorrhagic CVA or Subdural Hematoma

91
Q

Red Flag Trauma: Bilateral Numbness/Weakness/Tingling

A

Spinal cord injury

92
Q

Red Flag Trauma:Neck Pain or Back Pain

A

Spinal Cord Injury

93
Q

Red Flag Trauma: SOB or CP

A

PTX or Cardiac Contusion

94
Q

Red Flag Trauma: Abd Pain

A

Liver or Spleen Laceration

95
Q

Trauma Risk Factors

A
  • Blood thinners (Coumadin/Warfarin, Aspirin, Plavix)

- Severe MOI

96
Q

A complete ROS requires…

A

-10/14 elements/body systems

OR

At least 2 elements with “all others symptoms negative except as marked” included

97
Q

ROS: Constitutional

A
  • fever
  • weight loss
  • sweats
98
Q

ROS: Eyes

A
  • changes in vision
  • eye pain
  • double vision
99
Q

ROS: ENT

A
  • earache
  • nosebleed
  • congestion
  • sore throat
100
Q

ROS: Cardiovascular

A
  • chest pain
  • palpitations
  • leg swelling
101
Q

ROS: Respiratory

A
  • SOB
  • Cough
  • Sputum
  • Wheezing
102
Q

ROS: GI

A
  • Abd pain
  • N/V/D
  • Black or bloody stool
103
Q

ROS: GU

A
  • dysuria
  • frequency
  • urgency
  • hematuria
104
Q

ROS: Musculoskeletal

A
  • joint pain

- muscle pain

105
Q

ROS: Integumentary

A
  • rash
  • itching
  • abrasion
  • laceration
106
Q

ROS: Neurological

A
  • HA
  • Syncope
  • Seizure
  • Numbness
  • Focal Weakness
107
Q

ROS: Psychiatric

A
  • depression

- anxiety

108
Q

ROS: Endocrine

A
  • polyuria

- polydipsia

109
Q

ROS: Hematologic/Lymph

A
  • bleeding gums
  • easy bruising
  • swollen lymph nodes
110
Q

ROS: Immunologic

A
  • HIV/AIDS

- splenectomy

111
Q

Describe the significance of an HPI

A

HPI is the story of the symptoms and events that led to the patient’s ED visit. Includes the CC and associated sx

112
Q

How is the HPI different from the ROS?

A

HPI is a story about the CC and assoc sx

ROS is a checklist of sx. It includes the CC, assoc sx and all other complaints the pt may have

113
Q

Name five elements of the HPI

A
  • onset
  • timing
  • location
  • quality
  • severity
  • modifying Factors
  • associated symptoms
  • context
114
Q

Name eight of the body systems includes in the ROS

A
  • constitutional
  • eyes
  • ENT
  • CV
  • Resp
  • GI
  • GU
  • MS
  • skin
  • neuro
  • psych
  • endocrine
  • heme/lymph
  • immunological
115
Q

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

A

NO

-symptoms documented in the HPI also need to be documented in ROS

116
Q

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

A

“HPI/ROS is limited by…”

117
Q

Identify the error in the HPI: “Patient states the CP has been intermittent since Thursday”

A

Don’t document days of the week in the HPI; instead count back the number of days and document numerically

118
Q

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

A

Because it is less likely that their symptoms are life threatening if they have survived similar symptoms in the past

119
Q

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

A

What symptoms prompted the evaluation?
How long ago did the prior evaluation occur?
Who did they see? (Name and specialty)
What treatment did they receive? Did it help?
What diagnosis was given?
Any prior test results?

120
Q

What should you focus on when writing an HPI?

A

Documenting the answers to every question asked by the doctor

121
Q

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

A

Chief complaint and onset

122
Q

True or False, in the ROS you should document “All other systems negative except as marked” for every patient.

A

False

123
Q

Why should you always pay special attention to the complaints of Chest Pain and SOB?

A

direct concern for MI

124
Q

Name three. Past surgical histories that indicate that the patient has a Hx of CAD?

A

Anigoplasty, CABG, Stents

125
Q

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

A

Cardiac catheterization: insertion of a catheter with injection of dye into the coronary artery used to Dx CAD

Cardiac stress test: measures heart’s ability to respond to physical distress to determine if there is adequate blood flow to your heart during increasing levels of activity (treadmill or chemical)

126
Q

What are the risk factors for an MI? (7)

A
  1. CAD
  2. HTN
  3. DM
  4. hyperlipidemia
  5. Smoking
  6. Smoking
  7. CAD <55 y/o
127
Q

What are the risk factors for a PE? (10)

A
  1. Known DVT
  2. PMHx of DVT or PE
  3. FHx of DVT or PE
  4. Recent surgery
  5. CA
  6. Afib
  7. Immobility
  8. Pregnancy
  9. BCP
  10. Smoking
128
Q

What are the risk factors for a CVA? (7)

A
  1. HTN
  2. HLD
  3. DM
  4. Hx TIA/CVA
  5. Smoking
  6. FHx CVA
  7. Afib
129
Q

What does MOI stand for in a trauma HPI?

A

Mechanism of Injury

ScribeAmerica: ER (9 decks)

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