Course 3: HPI & ROS Flashcards
Subjective
Based on the patient’s feeling (ROS & HPI)
Objective
Factual information from provider (PE)
History of Present Illness (HPI)
The story of the patient’s chief complaint
Review of Systems (ROS)
Head-to-Toe checklist of the patient’s symptoms
Intermittent
Comes and goes
Waxing and Waning
always present but changing in intensity
Modifying factor
Something that makes a symptom better or worse
Exacerbate
To make worse
Onset
- HPI
- when did the complaint begin?
Timing
- HPI
- has it been constant, intermittent or waxing and waning?
Location
- HPI
- where is the discomfort?
Quality
- HPI
- Does it feel sharp, dull, aching, cramping, etc?
Severity
- HPI
- How bad is it? Mild, mod, severe or 0-10
Modifying Factors
- HPI
- what makes it better? What makes it worse?
Associated Sx
- HPI
- Do any other symptoms accompany the complaint?
Context
- HPI
- Is there anything else that is important?
What makes a complete HPI?
4 elements
Sentence 1 HPI
Age + Gender + CC+ Onset
Sentence 2 HPI
Quality+Severity+ Location +Radiation
Sentence 3 HPI
Associated Sx+ Pertinent Negatives
Sentence 4 HPI
Modifying Factors
- what makes it better?
- what makes it worse?
- treatment tried (Meds, ice pack, etc.)
Sentence 5 HPI
Context
- similar symptoms?
- recent evaluations?
- initiating factor that brought patient to ED
HPI Prior Evaluation
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?
“I took Tums and it didn’t help”
the symptoms were unchanged by Tums
“I have low back pain but I always have that”
He notes chronic lower back pain, unchanged from baseline
“It hurts when I touch it”
The symptoms are worsened by palpation of the area
“Nothing makes it better or worse”
The symptoms are unchanged by position or activity
“My sister has the same cold”
Positive sick contact with sister who has similar symptoms
“If I try to eat or drink anything, I throw it back up”
The vomiting is exacerbated by P.O. intake
“It feels like a fizzing soda in the middle of my chest”
He described the symptoms as “a fizzing soda” in his central chest
Trauma HPI: important symptoms to document
1) LOC
2) Head Injury
3) Neck Pain
4) Back Pain
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?
Red Flag: Worse with physical Exertion
[Chest Pain]
MI
Red Flag: Worse with deep breathes
[Chest Pain]
PE
Red Flags: Radiation to the back
[Chest Pain]
Aortic Dissection
Red Flags: Recent trauma
[Chest Pain]
Pneumothorax (PTX)
Red Flags: SOB
[Chest Pain]
MI, PE, PTX
Red Flag: Diaphoresis, Nausea, Vomiting
[Chest Pain]
MI
Red Flag: Pleuritic Chest Pain
[Chest Pain]
PE, PTX
Red Flag: Calf Pain
[Chest Pain]
DVT (which can cause PE)
MI Risk Factors
- CAD
- HTN
- HLD
- DM
- Smoking
- FHx CAD <55y/o
PE Risk Factors
- Hx DVT/PE
- Known DVT
- Recent surgery
- Immobilization
- A-Fib
- Cancer
- Pregnancy/Birth Control
Red Flag: Productive Cough
[SOB]
Pneumonia (PNA)
Red Flag:Orthopnea/DOE
[SOB]
Congestive Heart Failure (CHF)
Red Flag: Bilateral Leg Swelling
[SOB]
Congestive Heart Failure (CHF)
Red Flag: Hemoptysis
[SOB]
Pulmonary Embolism (PE)
Red Flag: Unilateral Leg Swelling
[SOB]
DVT causing a PE
Wheezing
[SOB]
Asthma
Hx of tobacco use
[SOB]
COPD
Red Flag: Chest Pain
[SOB]
MI, PE, PNA
Red Flag: RLQ Pain
[Abd Pain]
Appendicitis
Red Flag: RUQ Pain
[Abd Pain]
Cholecystitis
Red Flag: LLQ Pain
[Abd Pain]
Diverticulitis
Red Flag: LUQ Pain
[Abd Pain]
Pancreatitis
Red Flag: Fever
[Abd Pain]
Appendicitis, Diverticulitis, Cholecystitis
Red Flag: Blood In vomit or stool
[Abd Pain]
GI Bleed
Red Flag: Melena
[Abd Pain]
GI Bleed
Red Flag: Dizziness
[Abd Pain]
GI Bleed, AAA
Red Flag: Suprapubic Pain
[Abd Pain in Females]
Ovarian Torsion
Red Flags: Pregnancy
[Abd Pain in Females]
Ectopic Pregnancy
Red Flag: weakness/numbness in LE
[Low Back Pain]
Spinal cord injury
Red Flag: numbness of groin
[Low Back Pain]
Spinal cord injury or cauda equina
Red Flag: Loss of bowel or bladder control
[Low Back Pain]
spinal cord injury or cauda equina
Red Flag: Hx of IVDA
[Low Back Pain]
Spinal Abscess
Red Flag: Fever
[Low Back Pain]
Spinal Abscess
Red Flag: Abd Pain
[Low Back Pain]
AAA
Red Flag:Weakness, Numbness, Tingling
[Dizziness/HA]
CVA, Subarachnoid hemorrhage (SAH)
Red Flag: changes in speech or vision
[Dizziness/HA]
CVA, SAH
Red Flag: Difficulty with Balance
[Dizziness/HA]
CVA, SAH
Red Flag: Fever
[Dizziness/HA]
Meningitis
Red Flag: Neck Pain
[Dizziness/HA]
Meningitis
Red Flag: AMS
[Dizziness/HA]
Meningitis, CVA, SAH
Red Flag: Worst HA of life/Thunderclap onset
[Dizziness/HA]
Hemorrhagic CVA, SAH
Red Flag: Syncope or Seizure
[Dizziness/HA]
CVA, SAH
Red Flag: tongue bite wound
[Syncope]
Seizure (Sz)
Red Flag: Numbness/Tingling/Weakness
[Syncope]
CVA
Red Flag: Changes in speech or vision
[Syncope]
CVA
Red Flag: CP
[Syncope]
MI
Red Flag: SOB
[Syncope]
PE
Red Flags:Palpitations
[Syncope]
Arrhythmia
CVA Risk Factors
- HTN
- HLD
- DM
- Smoking
- FHx CVA
- Hx TIA/CVA
- AFIB
Red Flag AMS: Fever
Sepsis
Red Flag AMS: Numbness/Weakness/Tingling
CVA
Red Flag AMS: Changes in speech or vision
CVA
Red Flag AMS: HA
Hemorrhagic CVA
Red Flag AMS: Depression or Drug Abuse
Drug OD
Red Flag AMS: Diabetes
Hypoglycemia
AMS Risk Factors
- Dementia/Alzheimer’s
- DM
- Psychiatric History
- Substance Abuse
Red Flag Trauma: LOC
Hemorrhagic CVA or Subdural Hematoma
Red Flag Trauma: Unilateral Numbness/Weakness/Tingling
Hemorrhagic CVA or Subdural Hematoma
Red Flag Trauma: Bilateral Numbness/Weakness/Tingling
Spinal cord injury
Red Flag Trauma:Neck Pain or Back Pain
Spinal Cord Injury
Red Flag Trauma: SOB or CP
PTX or Cardiac Contusion
Red Flag Trauma: Abd Pain
Liver or Spleen Laceration
Trauma Risk Factors
- Blood thinners (Coumadin/Warfarin, Aspirin, Plavix)
- Severe MOI
A complete ROS requires…
-10/14 elements/body systems
OR
At least 2 elements with “all others symptoms negative except as marked” included
ROS: Constitutional
- fever
- weight loss
- sweats
ROS: Eyes
- changes in vision
- eye pain
- double vision
ROS: ENT
- earache
- nosebleed
- congestion
- sore throat
ROS: Cardiovascular
- chest pain
- palpitations
- leg swelling
ROS: Respiratory
- SOB
- Cough
- Sputum
- Wheezing
ROS: GI
- Abd pain
- N/V/D
- Black or bloody stool
ROS: GU
- dysuria
- frequency
- urgency
- hematuria
ROS: Musculoskeletal
- joint pain
- muscle pain
ROS: Integumentary
- rash
- itching
- abrasion
- laceration
ROS: Neurological
- HA
- Syncope
- Seizure
- Numbness
- Focal Weakness
ROS: Psychiatric
- depression
- anxiety
ROS: Endocrine
- polyuria
- polydipsia
ROS: Hematologic/Lymph
- bleeding gums
- easy bruising
- swollen lymph nodes
ROS: Immunologic
- HIV/AIDS
- splenectomy
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
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
Name five elements of the HPI
- onset
- timing
- location
- quality
- severity
- modifying Factors
- associated symptoms
- context
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
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
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…”
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
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
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?
What should you focus on when writing an HPI?
Documenting the answers to every question asked by the doctor
Which is the first item in the formula for writing an HPI?
Chief complaint and onset
True or False, in the ROS you should document “All other systems negative except as marked” for every patient.
False
Why should you always pay special attention to the complaints of Chest Pain and SOB?
direct concern for MI
Name three. Past surgical histories that indicate that the patient has a Hx of CAD?
Anigoplasty, CABG, Stents
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)
What are the risk factors for an MI? (7)
- CAD
- HTN
- DM
- hyperlipidemia
- Smoking
- Smoking
- CAD <55 y/o
What are the risk factors for a PE? (10)
- Known DVT
- PMHx of DVT or PE
- FHx of DVT or PE
- Recent surgery
- CA
- Afib
- Immobility
- Pregnancy
- BCP
- Smoking
What are the risk factors for a CVA? (7)
- HTN
- HLD
- DM
- Hx TIA/CVA
- Smoking
- FHx CVA
- Afib
What does MOI stand for in a trauma HPI?
Mechanism of Injury
