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Scribe america > Course 3: HPI & ROS > Flashcards

Course 3: HPI & ROS Flashcards

1
Q

Onset

A

When did the complaint begin?

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2
Q

Timing

A

Has it been constant, intermittent, or waxing and waning?

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3
Q

Location

A

Where is the discomfort?

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4
Q

Quality

A

Does it feel sharp, dull, aching, cramping…?

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5
Q

Severity

A

How bad is it? Mild, moderate, sever, or 0-10.

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6
Q

Modifying Factors

A

What makes it better? What makes it worse?

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7
Q

Associated Sx

A

Do any other symptoms accompany the complaint?

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8
Q

Context

A

Is there anything else that’s important?

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9
Q

HPI formula: Sentence One

A

Complaint + Onset

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10
Q

HPI formula: Sentence Two

A

Quality, Severity, Location, Radiation

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11
Q

HPI formula: Sentence Three

A

Associated Sx, Pertinent Negatives

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12
Q

HPI formula: Sentence Four

A

Modifying Factors (What makes it worse/better? Treatments tried?)

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13
Q

HPI formula: Sentence Five

A

Context (Similar symptoms? Recent Evaluations? Initiating factor that brought patient to ED)

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14
Q

“I took Tums and it didn’t help”

A

The symptoms were unchanged by Tums

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15
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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16
Q

“It hurts when I touch it”

A

The symptoms are worsened by palpation of the area

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17
Q

“Nothing makes it better or worse”

A

The symptoms are unchanged by any position or activity

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18
Q

“My sister has the same cold”

A

Positive sick contact with sister who has similar symptoms

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19
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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20
Q

“It feels like 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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21
Q

Trauma HPI Template: Second Sentence

A

What caused the incident?

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22
Q

Chest Pain: Worse with physical exertion

A

Myocardial Infarction (MI)

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23
Q

Chest Pain: Worse with deep breaths

A

Pulmonary Embolism (PE)

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24
Q

Chest Pain: Radiation to the back

A

Aortic Dissection

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25
Q

Chest Pain: Recent trauma

A

Pneumothorax (PTX)

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26
Q

Chest Pain: Shortness of breath

A

MI, PE, PTX

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27
Q

Chest Pain: Diaphoresis, Nausea, Vomiting

A

Myocardial Infarction (MI)

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28
Q

Chest Pain: Pleuritic pain

A

PE, PTX

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29
Q

Chest Pain: Calf Pain

A

Deep Vein Thrombosis (DVT) causing PE

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30
Q

Chest Pain: Minor DDx (4)

A

Chest wall pain, Costochondritis, Pleural effusion, GERD

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31
Q

Chest Pain: Pain with torso movement or palpation

A

Chest wall pain, Costochondritis

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32
Q

Chest Pain: Burning pain

A

GERD

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33
Q

MI Risk Factors (6)

A

CAD, HTN, HLD, DM, Smoking, FHx CAD

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34
Q

PE Risk Factors (8)

A

Hx DVT/PE, DVT, Recent Surgery, Immobilization, A-FIB, CA, Pregnancy, Birth Control Pills

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35
Q

Shortness of Breath (w/o chest pain): Productive cough

A

Pneumonia (PNA)

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36
Q

Shortness of Breath (w/o chest pain): Orthopnea / Dyspnea on Exertion

A

Congestive Heart Failure (CHF)

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37
Q

Shortness of Breath (w/o chest pain): Bilateral leg swelling

A

Congestive Heart Failure (CHF)

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38
Q

Shortness of Breath (w/o chest pain): Hemoptysis

A

Pulmonary Embolism (PE)

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39
Q

Shortness of Breath (w/o chest pain): Unilateral leg swelling

A

DVT causing a PE

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40
Q

Shortness of Breath (w/o chest pain): Wheezing

A

Asthma

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41
Q

Shortness of Breath (w/o chest pain): Hx of tobacco abuse

A

COPD

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42
Q

Shortness of Breath (w/o chest pain): Chest Pain

A

MI, PE, PNA

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43
Q

Shortness of Breath (w/o chest pain): Minor DDx (2)

A

Bronchitis, URI

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44
Q

Shortness of Breath (w/o chest pain): Cough, Sputum, Nasal congestion, Sore throat

A

Bronchitis, URI

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45
Q

Abdominal Pain: RLQ Pain

A

Appendicitis

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46
Q

Abdominal Pain: RUQ Pain

A

Cholecystitis

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47
Q

Abdominal Pain: LLQ Pain

A

Diverticulitis

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48
Q

Abdominal Pain: LUQ Pain

A

Pancreatitis

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49
Q

Abdominal Pain: Fever

A

Appendicitis, Cholecystitis, Diverticulitis

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50
Q

Abdominal Pain: Blood in vomit or stool

A

GI Bleed

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51
Q

Abdominal Pain: Melena

A

GI Bleed

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52
Q

Abdominal Pain: Dizziness

A

GI Bleed, Abdominal Aortic Aneurysm

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53
Q

Abdominal Pain: Minor DDx (4)

A

UTI, Gastroenteritis, Gastritis, Constipation

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54
Q

Abdominal Pain: Dysuria

A

UTI

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55
Q

Abdominal Pain: Nausea/Vomiting, Diarrhea

A

Gastroenteritis, Gastritis

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56
Q

Abdominal Pain: Constipation

A

Constipation

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57
Q

Female Lower Abdominal Pain: Suprapubic Pain

A

Ovarian Torsion

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58
Q

Female Lower Abdominal Pain: Pregnancy

A

Ectopic Pregnancy

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59
Q

Female Lower Abdominal Pain: Fever, RLQ Pain

A

Appendicitis

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60
Q

Female Lower Abdominal Pain: Minor DDx

A

Ovarian Cyst, UTI, STD

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61
Q

Female Lower Abdominal Pain: N/V, Vaginal Spotting, Vaginal Discharge, Flank Pain, Dysuria

A

Ovarian Cyst, STD, UTI

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62
Q

Diarrhea Risk Factors (6)

A

Recent foreign travel, recent camping, bad food exposure, sick contacts, recent Abx, recent hospitalization

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63
Q

Female Abdominal Pain Risk Factors (3)

A

Possibility of Pregnancy, Unprotected Sex, History of STD

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64
Q

Low Back Pain: Weakness/Numbness in lower extremities

A

Spinal Cord injury

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65
Q

Low Back Pain: Numbness of the groin

A

Spinal cord injury or Cauda Equina

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66
Q

Low Back Pain: Loss of bowel or bladder control

A

Spinal cord injury or Cauda Equina

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67
Q

Low Back Pain: History of IVDA (intravenous drug abuse)

A

Spinal Abscess

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68
Q

Low Back Pain: Fever

A

Spinal Abscess

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69
Q

Low Back Pain: Abdominal Pain

A

Abdominal Aortic Aneurysm (AAA)

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70
Q

Low Back Pain: Minor DDx (3)

A

Musculoskeletal back pain, Back Strain, Sciatica

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71
Q

Low Back Pain: Radiating pain down the backs of the legs

A

Sciatica

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72
Q

Back Pain Risk Factors (3)

A

Recent trauma, Hx of IVDA, Spinal hardware

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73
Q

Dizziness/Headache: Weakness/Numbness/Tingling

A

Cerebral Vascular Accident (CVA), Subarachnoid Hemorrhage (SAH)

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74
Q

Dizziness/Headache: Changes in speech or vision

A

Cerebral Vascular Accident (CVA), Subarachnoid Hemorrhage (SAH)

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75
Q

Dizziness/Headache: Difficulty with balance

A

CVA, SAH

76
Q

Dizziness/Headache: Fever

A

Meningitis

77
Q

Dizziness/Headache: Neck Pain

A

Meningitis

78
Q

Dizziness/Headache: Altered Mental Status

A

Meningitis, CVA, SAH

79
Q

Dizziness/Headache: Worst headache of life / Thunderclap unset

A

Hemorrhagic CVA, SAH

80
Q

Dizziness/Headache: Syncope or Seizure

A

CVA, SAH

81
Q

Dizziness/Headache: Minor DDx (5)

A

Dehydration, Benign Positional Vertigo (BPV), Migraine HA, Tension HA, Sinusitis

82
Q

Dizziness/Headache Minor DDx Associated Sx (4)

A

Nasal congestion, runny nose, nausea, vomiting

83
Q

Syncope: Tongue bit wound

A

Seizure (Sz)

84
Q

Syncope: Numbness/Weakness/Tingling

A

CVA

85
Q

Syncope: Changes in speech or vision

A

CVA

86
Q

Syncope: CP

A

MI

87
Q

Syncope: SOB

A

PE

88
Q

Syncope: Palpitations

A

Arrhythmia

89
Q

Syncope: Minor DDx (2)

A

Vasovagal syncope, dehydration

90
Q

Syncope: Minor DDx Associated Sx (4)

A

feeling “about to pass out” (near-syncope), sweating, dizziness, lightheadedness

91
Q

CVA Risk Factors (7)

A

HTN, HLD, DM, Smoking, FHx CVA, Hx TIA/CVA, AFIB

92
Q

Trauma: LOC

A

Hemorrhagic CVA, Subdural Hematoma

93
Q

Trauma: Unilateral Numbness/Weakness/Tingling

A

Hemorrhagic CVA, Subdural Hematoma

94
Q

Trauma, Bilateral Numbness/Weakness/Tingling

A

Spinal cord injury

95
Q

Trauma: Neck pain or back pain

A

Spinal cord injury

96
Q

Trauma: SOB or CP

A

PTX, Cardiac Contusion

97
Q

Trauma: Abdominal Pain

A

Splenic or Liver Laceration

98
Q

Trauma: Minor DDx (5)

A

Closed Head Injury (CHI), simple Fx, dislocation, strain/sprain, lac (laceration)

99
Q

Trauma Risk Factors (2)

A

Blood thinners (Coumadin/Warfarin, Plavix, Aspirin), Severe MOI

100
Q

Subjective

A

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

101
Q

Objective

A

Factual information from provider (PE)

102
Q

History of Present Illness

A

The story of the patient’s CC

103
Q

Review of Systems

A

Head-to-toe checklist of pt Sx

104
Q

Intermittent

A

Comes and goes

105
Q

Waxing and waning

A

Always present but changing in intensity

106
Q

Modifying factor

A

Something that makes a symptom better or worse

107
Q

Exacerbate

A

To make worse

108
Q

Based of the pt feeling (HPI, ROS)

A

Subjective

109
Q

Factual information from provider (PE)

A

Objective

110
Q

The story of the pt CC

A

History of Present Illness

111
Q

Head to toe checklist of pt Sx

A

Review of Systems

112
Q

Comes and goes

A

Intermittent

113
Q

Always present but changing in intensity

A

Waxing and waning

114
Q

Something that makes a symptom better or worse

A

Modifying factor

115
Q

To make worse

A

Exacerbate

116
Q

PTX

A

Pneumothorax

117
Q

SDH

A

Subdural Hematoma

118
Q

CVA

A

Cerebrovascular Accident

119
Q

SAH

A

Subarachnoid Hemorrhage

120
Q

Sz

A

Seizure

121
Q

AAA

A

Abdominal Aortic Aneurysm

122
Q

PNA

A

Pneumonia

123
Q

CHF

A

Congestive Heart Failure

124
Q

Intermittent

A

comes and goes

125
Q

waxing and waning

A

always present but changing in intensity

126
Q

Modifying factor

A

something that makes a symptom better or worse

127
Q

exacerbate

A

to make worse

128
Q

Example ED Chart

A
129
Q

ED Chart Flow

A
  1. Day 0: HPI & ROS
  2. Day 1: Past Hx
  3. Day 4: Phyical Exam (PE)
  4. Day 5: ED Course
  5. Day 6: Dx & Dispositoin
132
Q

how does the HPI determine the pc’s entire ER visit?

A
  1. each subjective complaint is ALWAYS followed up with objective evaluation somewhere in the chart
    1. “2X Checking Your Chart”—» to ensure your chart is complete, check to see pc subjective CC from the HPI followed up with objective measures thoughout the rest of the chart
133
Q

HPI: Content

A
134
Q

HPI: Elements

  1. How many elements are there for the HPI?
  2. What are they?
  3. how many elements are needed for a complete HPI?
A
135
Q

What is an HPI?

A
  1. History of Present Illness is the story of symptoms and events that led to the patient’s ED visit—»summary of pc reason for visit
  2. only SUBJECTIVE information in HPI
    • Main components = cheif complaint (CC) and important context ​for the pc
  3. HPI = a story
    1. accurate chronology—»try to listen for what finally made the pc come into the ER
  4. Document the historian…
    1. most often the pc, but for pediatric pc’s or pc’s that cant speak—»DOCUMENT WHO IS PROVIDING INFORMATION
136
Q

What do you do if a complete Hx is unavailable?

A
  1. critical to document WHY Hx is limited—»
    • i.e. “HPI is unobtainable due to the patient’s nonverbal status”
  2. if HPI is limited, ONLY document what EXACTLY you know about pc—»
    • i.e. “Per EMS, this patient was found unresponsive 15 min ago”
137
Q

Writing a basic HPI

            1. 7.
A
  1. age/sex of pc
  2. complaint and onset
  3. timing, severity, qualiy, and location
  4. anything improved/worsened symptoms?
  5. associated symptoms
  6. pertinent negatives
  7. any other important contet specific to the pc
138
Q

HPI Formula

  • Sentance 1:
  • Sentance 2:
  • Sentance 3:
  • Sentance 4:
  • Sentance 5:
A
139
Q

re-wording what pt says

A
140
Q

HPI Do’s & Dont’s

A
141
Q

HPI Phrasing

A
142
Q

HPI: Trauma

  1. what is main focus of trauma HPI?
  2. what are the 4 most important symptoms to document for any trauma pt?
A
  1. key for trauma HPI is to focus on the exact Mechanism of Injury (MOI)—»every detail about circumstances and events to cause injury
  2. 4 most important symptoms to document are
    1. LOC (loss of consciousness)
    2. head injury
    3. neck pain
    4. back pain
143
Q

Trauma HPI Template

Sentance 1:

Sentance 2:

Sentance 3:

Sentance 4:

Sentance 5:

Sentance 6:

A
145
Q

Major Complaints: CHEST PAIN

  1. Red flags and associated DDx?
  2. Other DDx —» Associated symptoms?
    1. chest wall pain
    2. costochondritis
    3. pleural effusion
    4. GERD
A
  1. Associated symptoms:
    - pain w/torso movement or palpation = chest wall pain, Costochondritis
    - burning pain = GERD
148
Q

Major Complaint: SHORTNESS OF BREATH (w/out chest pain)

  1. Red flags and associated DDx?
  2. Other DDx —» Associated symptoms?
    1. Bronchitis
    2. URI
  3. Risk factors of back pain?
A
  1. Associated symptoms:
    - cough
    - sputum
    - nasal congestion
    - Sore throat
149
Q

Major Complaint: ABDOMINAL PAIN

  1. Red flags and associated DDx?
  2. Other DDx —» Associated symptoms?
  • UTI
  • Gastroenteritis
  • Gastritis
  • Constipation
A
  1. Associated symptoms:
    - dysuria
    - N/V
    - diarrhea
    - constipation
150
Q

How to do the HPI for a patient seeking treatment for a symptom they’ve experienced previously?

A
  1. Document…
    1. anything new/different about symptoms that day
    2. how long ago the similar symptoms occured?
    3. did they seek professional treatment at the time?
    4. any result/diagnosis from previous evals?
151
Q

FEMALE LOWER ABDOMINAL PAIN

  1. Red flags?
  2. Other DDx —» Associated symptoms?
    1. Ovarian cyst
    2. UTI
    3. STD
  3. Risk factors?
A
  1. Associated symptoms:
    - N/V, vaginal spotting, vaginal discharge, Dysuria, Flank pain
  2. possibility of pregnancy, unprotected sex, history of STD
152
Q

LOWER BACK PAIN

  1. Red flags and associated DDx?
  2. Other DDx —» Associated symptoms?
    1. Musculoskeletal back pain
    2. Back Strain
    3. Sciatica
A
  1. associated symtoms: Radiating pain down the backs of the legs (sciatica)
  2. Back Pain Risk Factors:
    1. recent trauma
    2. hx of IVDA
    3. spinal heardware
153
Q

DIZZINESS/HEADACHE

  1. Red flags and associated DDx?
  2. Other DDx —» Associated symptoms?
    1. Dehydration
    2. Begnign Positional Vertigo (BPV)
    3. Migraine HA
    4. Tension HA
    5. sinusitis
  3. Risk factors of back pain?
A
  1. Red flags and associated DDx?
  2. Other DDx —» Associated symptoms?
    1. Associated Symptoms = Nasal conjestion, runny nose, N/V
154
Q

HPI: Prior Evaluations

A
  1. when pc is evaluated by another healthcare provider, its important to document…
    1. why symptoms promted the prior eval?
    2. how long ago was this prior eval?
    3. who they saw? (name and specialty)
    4. what treatment did they recieve? was it helpful?
    5. what was diagnosis, if any?
  2. if pc had prior tests completed…
    1. specify type of test (CT, XR, etc.)
    2. date
    3. specific results
155
Q

SYNCOPE

  1. Red flags and associated DDx?
  2. Other DDx —» Associated symptoms?
    1. Vasovagul syncope
    2. dehydration
A
  1. Associated symptoms:
    - near-syncope: “feeling about to pass out”
    - sweating
    - dizziness
    - lightheadedness
156
Q

ALTERED MENTAL STATUS (AMS)

  1. Red flags and associated DDx?
  2. Other DDx?
  3. AMS risk factors?
A
  1. Other DDx:
    • UTI (if elderly)
    • ETOH abuse
    • Narcotics abuse
    • Drug abuse
  2. AMS Risk Factors:
    1. dementia/Alzheimer’s
    2. DM
    3. psychiatric history
    4. Substance abuse
157
Q

TRAUMA

  1. Red flags and associated DDx?
  2. Other DDx —» Associated symptoms?
  3. Risk factors of Trauma?
A
  1. Other DDx —» Associated symptoms?
    1. Closed Head Injury (CHI)
    2. simple fracture
    3. dislocation
    4. strain/sprain
    5. laceration
  2. Risk factors of Trauma?
    1. Blood thinners (Coumadin/Warfarin, Plavix, Aspirin)
    2. Severe Mechanism of Injury
158
Q

ROS Content

A
  1. depending on physician, “All other systems negative except as marked” used to communicate that the pt did not have any complaints orther than those that were documented
  2. like HPI, include statement like “A complete ROS is unobtainable due to the patient’s condition”
  3. For major symptoms such as Chest Pain or Shortness of Breath —» never just mention “Positive Chest Pain” or Positive Shortness of Breath” in the ROS without providing further explanation in the HPI.
160
Q

14 body systems and examples of symptoms

A
161
Q

Example ROS (Based on example HPI)

A
168
Q

MVA HPI

  1. what are the 14 questions the doctor will ask?
A
  1. Were you the driver or the passenger?
  2. Were you wearing a seatbelt?
  3. How fast were you moving?
  4. What part of the car was hit?
  5. Did it hit a stationary object or another moving vehicle?
  6. Did the airbags deploy?
  7. Did you lose consciousness?
  8. Did you hit your head?
  9. Did you sustain any injuries?
  10. How much damage was done to your vehicle?
  11. Is the car drivable?
  12. Were you able to get out of the vehicle (self-extricate)?
  13. Were you able to ambulate (walk) on scene?
  14. Did you require EMS treatment on scene?
170
Q

MI Risk Factors

(1)–(6)?

A
  1. CAD
  2. HTN
  3. HLD
  4. DM
  5. Smoking
  6. FHx of CAD <55 y/o
171
Q

PE Risk Factors

(1)–(7)?

A
  1. Hx of DVT/PE
  2. known DVT
  3. recent surgery
  4. immobilization
  5. A-fib
  6. Cancer
  7. Pregnancy/Birth Control
174
Q

Diarrhea Risk Factors (1-6?)

A
  1. recent foreign travel
  2. recent camping
  3. bad food exposure
  4. sick contacts
  5. recent antibiotics
  6. recent hospitalization
178
Q
A

False

179
Q
A
180
Q
A
181
Q
A
182
Q
A

G: 4

P: 1

A: 2

183
Q
A

TRUE

184
Q
A

YES —» [6]

185
Q
A

YES —» [5]

186
Q
A
  1. hematochezia
  2. hemoptysis
  3. carotid endarterectomy
  4. myalgia
187
Q
A
188
Q

Name 7 CVA risk factors

A
  1. HTN
  2. HLD
  3. DM
  4. Smoking
  5. FHx CVA
  6. Hx TIA/CVA
  7. AFib
193
Q

Body Systems of ROS

  1. What are the 14?
  2. how many are required for a complete ROS?
A
  1. 14 Body Systems:
    1. constitutional
    2. eyes
    3. ear/nose/throat
    4. cardiovascular
    5. respiratory
    6. gastrointestinal
    7. genitourinary
    8. musculoskeletal
    9. integumentary/skin
    10. neurological
    11. psychiatric
    12. endocrine
    13. hematologic/lymph
    14. immunologic
  2. complete ROS only requires 2 elements (instead of 10) if “All other systems negative except as marked” is included
196
Q

In your own words, describe the significance of an HPI.

A
  • The HPI is the story of the symptoms and events that led to the patient’s ED visit.
  • It includes the CC and the associated sx
197
Q

How is the HPI different from the ROS?

A
  • HPI focuses is a story about the chief complaint and its associated symptoms.
  • ROS is a checklist of symptoms. It includes the chief complaint, associated symptoms, and all other complaints the pt may have.
198
Q

Name five “elements” of the HPI.

A
  1. Onset,
  2. timing,
  3. location,
  4. quality,
  5. severity,
  6. modifying factors,
  7. associated symptoms,
  8. context
199
Q

Name 10 of the body systems included in the ROS.

A
  1. Constitutional
  2. eyes
  3. ENT
  4. CV
  5. Resp
  6. GI
  7. GU
  8. MS
  9. skin
  10. neuro
  11. psych
  12. endocrine
  13. heme/lymph
  14. immunological
200
Q

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

Why or why not?

A

NO.—»Symptoms that are documented in the HPI also need to be documented in the ROS.

201
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 limited by…”

202
Q

Identify the error in this sentence from an example HPI:

“Patient states the CP has been intermittent since Thursday.”

A
  • We do not document days of the week in the HPI.
  • Instead, we would count back the number of days and document this numerically
203
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 current symptoms are life threatening if they have survived similar symptoms in the past.

204
Q

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

A
  1. What symptoms prompted the prior evaluation?
  2. How long ago did the prior evaluation occur?
  3. Who did they see? (Name and specialty)
  4. What treatment did they receive? Did it help?
  5. What diagnosis was given?
  6. Any prior test results?
205
Q

What should you focus on when writing an HPI (choose one).

a) Capturing everything that is said by the patient
b) Documenting the answers to every question asked by the doctor

A

b) Documenting the answers to every question asked by the doctor

206
Q

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

a) Pertinent negatives
b) Timing, quality, and location
c) Chief complaint and onset
d) Associated symptoms

A

c) Chief complaint and onset

207
Q

What does MOI stand for in a Trauma HPI?

A

Mechanism of Injury

208
Q

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

A

FALSE

209
Q

Based on your knowledge from Day 2, why should you always pay special attention to the complaints of Chest Pain and SOB?

A

Direct concern for MI

210
Q

Name three past surgical histories that indicate that the patient has a history of CAD.

A
  1. CABG
  2. Angioplasty
  3. Stents
211
Q

What is the difference between a…

  1. cardiac catheterization
  2. cardiac stress test
A

A. Cardiac catheterization: insertion of a catheter with injection of dye into the coronary artery, used to diagnose CAD.

B. Cardiac stress test: measures the heart’s ability to respond to physical stress to determine if there is adequate blood flow to your heart during increasing levels of activity.

  • There are two different types of stress tests…
    • Exercise (treadmill) stress test
    • Nuclear stress test —» for patients with a medical problem (e.g. arthritis) that prevents you from exercising.
      • They use a medication to stresses the heart (mimicking exercise)

Scribe america (8 decks)

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