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

Course 3: HPI & ROS Flashcards

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
“I have low back pain but I always have that”
He notes chronic lower back pain, unchanged from baseline
26
“It hurts when I touch it”
The symptoms are worsened by palpation of the area
27
“Nothing makes it better or worse”
The symptoms are unchanged by position or activity
28
“My sister has the same cold”
Positive sick contact with sister who has similar symptoms
29
“If I try to eat or drink anything, I throw it back up”
The vomiting is exacerbated by P.O. intake
30
“It feels like a fizzing soda in the middle of my chest”
He described the symptoms as “a fizzing soda” in his central chest
31
Trauma HPI: important symptoms to document
1) LOC 2) Head Injury 3) Neck Pain 4) Back Pain
32
MVA HPI
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?
33
Red Flag: Worse with physical Exertion [Chest Pain]
MI
34
Red Flag: Worse with deep breathes [Chest Pain]
PE
35
Red Flags: Radiation to the back [Chest Pain]
Aortic Dissection
36
Red Flags: Recent trauma [Chest Pain]
Pneumothorax (PTX)
37
Red Flags: SOB [Chest Pain]
MI, PE, PTX
38
Red Flag: Diaphoresis, Nausea, Vomiting [Chest Pain]
MI
39
Red Flag: Pleuritic Chest Pain [Chest Pain]
PE, PTX
40
Red Flag: Calf Pain [Chest Pain]
DVT (which can cause PE)
41
MI Risk Factors
- CAD - HTN - HLD - DM - Smoking - FHx CAD <55y/o
42
PE Risk Factors
- Hx DVT/PE - Known DVT - Recent surgery - Immobilization - A-Fib - Cancer - Pregnancy/Birth Control
43
Red Flag: Productive Cough [SOB]
Pneumonia (PNA)
44
Red Flag:Orthopnea/DOE [SOB]
Congestive Heart Failure (CHF)
45
Red Flag: Bilateral Leg Swelling [SOB]
Congestive Heart Failure (CHF)
46
Red Flag: Hemoptysis [SOB]
Pulmonary Embolism (PE)
47
Red Flag: Unilateral Leg Swelling [SOB]
DVT causing a PE
48
Wheezing [SOB]
Asthma
49
Hx of tobacco use [SOB]
COPD
50
Red Flag: Chest Pain [SOB]
MI, PE, PNA
51
Red Flag: RLQ Pain [Abd Pain]
Appendicitis
52
Red Flag: RUQ Pain [Abd Pain]
Cholecystitis
53
Red Flag: LLQ Pain [Abd Pain]
Diverticulitis
54
Red Flag: LUQ Pain [Abd Pain]
Pancreatitis
55
Red Flag: Fever [Abd Pain]
Appendicitis, Diverticulitis, Cholecystitis
56
Red Flag: Blood In vomit or stool [Abd Pain]
GI Bleed
57
Red Flag: Melena [Abd Pain]
GI Bleed
58
Red Flag: Dizziness [Abd Pain]
GI Bleed, AAA
59
Red Flag: Suprapubic Pain [Abd Pain in Females]
Ovarian Torsion
60
Red Flags: Pregnancy [Abd Pain in Females]
Ectopic Pregnancy
61
Red Flag: weakness/numbness in LE [Low Back Pain]
Spinal cord injury
62
Red Flag: numbness of groin [Low Back Pain]
Spinal cord injury or cauda equina
63
Red Flag: Loss of bowel or bladder control [Low Back Pain]
spinal cord injury or cauda equina
64
Red Flag: Hx of IVDA [Low Back Pain]
Spinal Abscess
65
Red Flag: Fever [Low Back Pain]
Spinal Abscess
66
Red Flag: Abd Pain [Low Back Pain]
AAA
67
Red Flag:Weakness, Numbness, Tingling [Dizziness/HA]
CVA, Subarachnoid hemorrhage (SAH)
68
Red Flag: changes in speech or vision [Dizziness/HA]
CVA, SAH
69
Red Flag: Difficulty with Balance [Dizziness/HA]
CVA, SAH
70
Red Flag: Fever [Dizziness/HA]
Meningitis
71
Red Flag: Neck Pain [Dizziness/HA]
Meningitis
72
Red Flag: AMS [Dizziness/HA]
Meningitis, CVA, SAH
73
Red Flag: Worst HA of life/Thunderclap onset [Dizziness/HA]
Hemorrhagic CVA, SAH
74
Red Flag: Syncope or Seizure [Dizziness/HA]
CVA, SAH
75
Red Flag: tongue bite wound [Syncope]
Seizure (Sz)
76
Red Flag: Numbness/Tingling/Weakness [Syncope]
CVA
77
Red Flag: Changes in speech or vision [Syncope]
CVA
78
Red Flag: CP [Syncope]
MI
79
Red Flag: SOB [Syncope]
PE
80
Red Flags:Palpitations [Syncope]
Arrhythmia
81
CVA Risk Factors
- HTN - HLD - DM - Smoking - FHx CVA - Hx TIA/CVA - AFIB
82
Red Flag AMS: Fever
Sepsis
83
Red Flag AMS: Numbness/Weakness/Tingling
CVA
84
Red Flag AMS: Changes in speech or vision
CVA
85
Red Flag AMS: HA
Hemorrhagic CVA
86
Red Flag AMS: Depression or Drug Abuse
Drug OD
87
Red Flag AMS: Diabetes
Hypoglycemia
88
AMS Risk Factors
- Dementia/Alzheimer’s - DM - Psychiatric History - Substance Abuse
89
Red Flag Trauma: LOC
Hemorrhagic CVA or Subdural Hematoma
90
Red Flag Trauma: Unilateral Numbness/Weakness/Tingling
Hemorrhagic CVA or Subdural Hematoma
91
Red Flag Trauma: Bilateral Numbness/Weakness/Tingling
Spinal cord injury
92
Red Flag Trauma:Neck Pain or Back Pain
Spinal Cord Injury
93
Red Flag Trauma: SOB or CP
PTX or Cardiac Contusion
94
Red Flag Trauma: Abd Pain
Liver or Spleen Laceration
95
Trauma Risk Factors
- Blood thinners (Coumadin/Warfarin, Aspirin, Plavix) | - Severe MOI
96
A complete ROS requires...
-10/14 elements/body systems OR At least 2 elements with “all others symptoms negative except as marked” included
97
ROS: Constitutional
- fever - weight loss - sweats
98
ROS: Eyes
- changes in vision - eye pain - double vision
99
ROS: ENT
- earache - nosebleed - congestion - sore throat
100
ROS: Cardiovascular
- chest pain - palpitations - leg swelling
101
ROS: Respiratory
- SOB - Cough - Sputum - Wheezing
102
ROS: GI
- Abd pain - N/V/D - Black or bloody stool
103
ROS: GU
- dysuria - frequency - urgency - hematuria
104
ROS: Musculoskeletal
- joint pain | - muscle pain
105
ROS: Integumentary
- rash - itching - abrasion - laceration
106
ROS: Neurological
- HA - Syncope - Seizure - Numbness - Focal Weakness
107
ROS: Psychiatric
- depression | - anxiety
108
ROS: Endocrine
- polyuria | - polydipsia
109
ROS: Hematologic/Lymph
- bleeding gums - easy bruising - swollen lymph nodes
110
ROS: Immunologic
- HIV/AIDS | - splenectomy
111
Describe the significance of an HPI
HPI is the story of the symptoms and events that led to the patient’s ED visit. Includes the CC and associated sx
112
How is the HPI different from the ROS?
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
Name five elements of the HPI
- onset - timing - location - quality - severity - modifying Factors - associated symptoms - context
114
Name eight of the body systems includes in the ROS
- constitutional - eyes - ENT - CV - Resp - GI - GU - MS - skin - neuro - psych - endocrine - heme/lymph - immunological
115
Can the symptoms listed in the ROS ever contradict the symptoms described in the HPI?
NO | -symptoms documented in the HPI also need to be documented in ROS
116
What do you need to remember to document in the HPI and ROS for any patient that is unconscious or incapable of providing information?
“HPI/ROS is limited by...”
117
Identify the error in the HPI: “Patient states the CP has been intermittent since Thursday”
Don’t document days of the week in the HPI; instead count back the number of days and document numerically
118
Why is it important to remember to document if the patient has had similar symptoms in the past?
Because it is less likely that their symptoms are life threatening if they have survived similar symptoms in the past
119
Name one detail that is important to document if the patient has been evaluated in the past for a similar complaint.
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
What should you focus on when writing an HPI?
Documenting the answers to every question asked by the doctor
121
Which is the first item in the formula for writing an HPI?
Chief complaint and onset
122
True or False, in the ROS you should document “All other systems negative except as marked” for every patient.
False
123
Why should you always pay special attention to the complaints of Chest Pain and SOB?
direct concern for MI
124
Name three. Past surgical histories that indicate that the patient has a Hx of CAD?
Anigoplasty, CABG, Stents
125
What is the difference between a cardiac stress test and a cardiac catheterization?
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
What are the risk factors for an MI? (7)
1. CAD 2. HTN 3. DM 4. hyperlipidemia 5. Smoking 6. Smoking 7. CAD <55 y/o
127
What are the risk factors for a PE? (10)
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
What are the risk factors for a CVA? (7)
1. HTN 2. HLD 3. DM 4. Hx TIA/CVA 5. Smoking 6. FHx CVA 7. Afib
129
What does MOI stand for in a trauma HPI?
Mechanism of Injury

ScribeAmerica: ER (9 decks)

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