Day 3: HPI Flashcards
What is an HPI?
The History of Present Illness is the story of symptoms and events that led to the patient’s ED visit.
Where is the HPI always located?
The HPI is the beginning of every chart summarizing the reason for the visit.
What kind of information belongs in the HPI?
Only subjective information.
The HPI should only include information directly related to the ____.
Chief complaint and important context for that patient. All other information belongs in a different section of the chart.
It is always important to document who the _____ is for the HPI. Why?
Historian
Most often the patient is the historian; however for pediatric patients or patients incapable of speaking, always remember to document who is providing the information.
What should you do when a complete history is not available?
In this case, it is important to document why the history is limited.
For example, “HPI is unobtainable due to patient’s nonverbal status.”
In the event that the history is limited, remember to only write exactly what _____.
You know about the patient, specifically how you know it.
For example, “Per EMS, this patient was found unresponsive 15 mins ago.”
The entire Emergency Department visit is based on ____.
The patient’s story.
Every subjective complaint is ALWAYS followed up with an objective evaluation somewhere else in the chart; either the Physical Exam or Results section. One way to “check” your chart for completeness is to find the subjective complaints in the HPI and follow them through the rest of your chart.
Elements of the HPI
Onset
Timing – (constant, intermittent, waxing/waning)
Location – (where is the discomfort)
Quality – (sharp, dull, aching, cramping…?)
Severity – How bad is it? (Mild, mod, severe, 0-10)
Modifying factors – (what makes better/worse?)
Associated Sx – Do any other symptoms accompany the complaint?
Context – (anything else important)
The formula for writing the HPI
- Age/sex pt
- Chief complaint/onset
- Quality, location, timing
- Modifying factors – what makes it better or worse?
- Associated Sx
- List pertinent negs
- Other important context related to the CC
Example of a detailed HPI
30 y/o female presents to the ED complaining of abdominal pain that began abruptly 2 hours ago. The patient describes the pain as sharp, moderate in severity, located in her left flank that radiates into her lower back. She notes associated nausea, vomiting (2 episodes PTA that consisted of stomach contents), lower back pain, and hematuria, but denies any fevers, urinary retention, loss of appetite, or diarrhea. Pain is worse with movement and after vomiting. She states she took a Percocet prior to arrival with mild relief of her pain.
The patient has a history of kidney stones in the past requiring lithotripsy and states that her symptoms are similar to past episodes. She was recently seen at Dr. Smith’s (Urology) office earlier today for the same complaint and was referred to the ED for further evaluation and management. The patient completed a POC urine in the office that was positive for blood. She was referred to the ED for a CT A/P to rule out kidney stones. She denies any recent injury or history of chronic back pain.
Another example of a detailed HPI – Single Complaint
Jane Doe is a 35 year old female presenting to the ED with abdominal pain for the last two days. She describes the pain as intermittent, cramping, and burning, located in her RUQ. The pain was worse after a breakfast of ham and eggs this morning and unchanged by Pepto Bismol this afternoon. She notes nausea and a subjective fever but denies any diarrhea, dysuria, back pain, CP, or SOB. Otherwise, she has been in her normal state of health and denies any history of cholelithiasis.
Trauma HPI: 4 things
LOC
Head injury
Back Pain
Neck Pain
Trauma HPI Template
- Sentence One: Complaint + Onset
- Sentence Two: What caused the incident?
- How did they land?
- What surface did they land on? (Concrete, carpet, wood floors, grass, etc…)
- Sentence Three: What injuries did they sustain?
- Location, Quality, Severity, Radiation
- Sentence Four: Modifying Factors
- What makes it better?
- What makes it worse?
- Treatment tried? (Medication, Ice Pack, etc…)
- Sentence Five: Associated Symptoms, Pertinent Negatives
- Loss of consciousness?
- Head injury?
- Neck or back pain?
- Numbness, Weakness, Tingling
- Sentence Six: Context
- Similar symptoms? Previous injuries?
- Initiating factor that brought the patient to ED
Example of a Trauma HPI
18 y/o male presents to ED via EMS s/p fall that occurred 30 minutes PTA. The patient states he was playing soccer when he tripped on his shoelaces, fell onto the left side of his body, and landed on the hard dirt ground. The pt denies hitting his head or LOC. He complains of moderate throbbing left shoulder pain. His pain radiates into his left clavicle and has been constant since the fall. Movement of the left arm exacerbates his pain, however, he can still raise and lower his left arm. Remaining still provides relief. The patient states that on the scene, EMS applied an ice pack and gave him Motrin, which also mildly relieved his pain. He notes mild associated swelling to his left shoulder with surrounding abrasions. He denies any numbness, weakness, tingling, headaches, lacerations, or dizziness. The patient denies previous left shoulder injuries or dislocations.
HPI for MVA (Motor Vehicle Accident)
- Were you 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 another moving vehicle?
- Did the airbags deploy?
- Did you lose consciousness?
- 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 get out of the vehicle (self-extricate)?
- Were you able to ambulate (walk) on scene?
- Did you require EMS treatment on scene?
ROS is a checklist of Sx the pt ____ or ______ have.
does or does not
If a complete ROS is unable to be obtained write:
A complete ROS is unobtainable due to the pt’s condition
ROS: The 14 body systems
Constitutional – (Fever, Weight loss, Sweats)
Eyes – Change in vision, Eye pain, Double vision
ENT (Ears, Nose, Throat) – Earache, Nosebleed, Congestion, Sore throat
CV (Cardiovascular) – Chest pain, Palpitations, Leg swelling
Respiratory – SOB, Cough, Sputum, Wheezing
GI (Gastrointestinal) – Abdominal pain, N/V/D, Black or bloody stools
GU (Genitourinary) – Dysuria, Frequency, Urgency, Hematuria
MS (Musculoskeletal) – Joint pain, Muscle pain
Integumentary (Skin) – Rash, Itching, Abrasion, Laceration
Neurological – Heachache, Syncope, Seizure, Numbness, Focal weakness
Psychiatric – Depression, Anxiety
Endocrine – Polyuria, Polydipsia
Hematologic/Lymph – Bleeding gums, easy bruising, swollen lymph nodes
Immunologic – HIV/AIDS, Splenectomy
Complete ROS requires ____ elements
10
Example of a complete ROS
CP Major DDx vs. Minor DDx
Major DDx: MI, PE, Aortic Dissection, PTX
Minor DDx: Chest wall pain, Costochondritis, Pleural effusion, GERD
CP, SOB: MI Risk factors
CAD, HTN, HLD, DM, Smoking, FHx CAD <55 yo
CP, SOB: PE Risk factors
Hx DVT/PE, known DVT, Recent surgery, Immobilization, A-fib, Cancer, Pregnancy/birth control pill
SOB: Major DDx vs. Minor DDx
Major DDx: CHF, COPD, Asthma, PNA. (also consider MI or PE)
Minor DDx: Bronchitis, URI
Abdominal Pain: Major DDx vs. Minor DDx
Major DDx: Appy, Cholecystitis, Diverticulitis, Pancreatitis, SBO, GI bleed, AAA
Minor DDx: UTI, Gastroenteritis, Gastritis, Constipation
Diarrhea Risk Factors
Recent foreign travel, Recent camping, Bad food exposure, Sick contacts, Recent antibiotics, Recent hospitalization
Female lower abdomen pain Major DDx vs. Minor DDx
Major DDx: Appendicitis, Ovarian torsion, Ectopic pregnancy
Minor DDx: Ovarian cyst, UTI, STD
Ovarian Cyst – a fluid-filled sac that develops on an ovary.
Female abdominal pain risk factors:
Possible pregnancy, Unprotected sex, History of STD
Low back pain: Major DDx vs. Minor DDx
Major DDx: Spinal cord injury, Cauda equina, Spinal abscess, AAA
Minor DDx: Musculoskeletal back pain, Back strain, Sciatica
Back pain risk factors:
Recent trauma, Hx of IVDA, Spinal hardware
IVDA – Intravenous Drug Abuse
Dizziness/HA Major DDx vs. Minor DDx
Major DDx: Hemorrhagic CVA, Sub Arachnoid Hemorrhage (SAH), Ischemic CVA, Meningitis
Minor DDx: Dehydration, Benign Positional Vertigo (BPV) Migraine HA, Tension HA, Sinusitis
CVA Risk factors:
HTN, HLD, DM, Smoking, FHx CVA, Hx TIA/CVA, Afib
Syncope Major/Minor DDx
Major DDx: Sz, CVA, MI, PE, Cardiac arrhythmias
Minor DDx: Vasovagal syncope, Dehydration
AMS Major/Minor DDx
Major DDx: Sepsis, CVA, Meningitis, Hypoglycemia, Drug overdose
Minor DDx: UTI (if elderly), EtOH abuse, Narcotic Abuse, Drug abuse
AMS Risk factors
Dementia/Alzheimers, DM, Psychiatric Hx, Substance abuse
Trauma Major/Minor DDx
Major DDx: Hemorrhagic CVA, Subdural hematoma, Cervical/Thoracic/Lumbar spinal cord injury, PTX, Cardiac contusion, Splenic laceration, Liver laceration, Compound fracture
Minor DDx: Closed head injury, Simple fracture, Dislocation, Strain/sprain, Laceration
Trauma Risk factors
Blood thinners (Coumadin/Warfarin, Plavix, ASA), Severe Mechanism of Injury
Review Common PMHx
General: HTN, HLD, CA, DM
Cardiac: MI, CAD, Angina, CHF, AFib
Pulmonary: PE, PNA, COPD, Asthma
Abdominal: GERD, AAA, Pancreatitis, Hepatitis, Diverticulitis
GU: Kidney Stones, UTI, Renal Insufficiency/Failure
Neuro: CVA, TIA, Epilepsy/Sz, Migraines, Dementia, Alzheimer’s
Psych: Depression, Anxiety, Bipolar, Schizophrenia
Others: DVT, MRSA, RA, CBP
Review Common PSHx
ENT: Tonsillectomy, Adenoidectomy, PE Tubes
Cardiac: CABG, Coronary Stents, Pacemaker, AICD, Catheterization, Angioplasty, Valve replacement
Abdominal: Appendectomy, Cholecystectomy, Herniorrhaphy, Gastric Bypass, Colectomy, Colostomy
GU: Hysterectomy, C-section, Oophorectomy, Salpingo-Oophorectomy, Tubal Ligation, TURP
Ortho: AKA/BKA, Hip Arthroplasty
Neuro: Carotid Endarterectomy, Craniotomy, VP shunt
Others: Mastectomy, PICC Line
Nephrectomy: Kidney removal
G/P/A convention:
G: Total number of times pt has been pregnant
P: Number of live births
A: Number of miscarriages or elective abortions
