HPI and ROS Flashcards
describe the elements of the HPI
onset - when complaint began
timing - has it been constant, intermittent, or waxing/waning?
location - where is the discomfort
quality - does it feel sharp, dull, aching, cramping..?
severity - how bad is it? mild, moderate, severe, or 1-10
modifying fx - what makes it better? what makes it worse?
associated sx - do any other sx accompany the complaint?
context - is there anything else that’s important? risk factors, similar sx in the past, prior testing, PMHx, PSHx, SHx, FHx relevant
describe the significance of an HPI
provides a story of why the pt came in and determines the basis for the rest of the visit
imagine a pt w/ a CC of a headache. name 5 elements of the HPI and provide an applicable example of each element
onset (began 12hr ago), timing (constant, intermittent), location (head, temporal, frontal), quality (dull, sharp, burning), severity (mild, moderate, severe, 1-10), modifying fx (improves ibuprofen, exacerbated by movement), associated sx (n/v, fatigue), context (PMHx stroke, head injury)
true or false: the pt’s entire ED visit is based on their answers to the questions asked during the interview
true
true or false: accurate chronology is not important in an HPI
false
what is the main difference between an HPI and an ROS
the HPI is the story about the visit and includes history, focuses on the CC; ROS is the review of systems and documents the presence and absence of all sx reviewed by the physician
true or false: the sx listed in the ROS can contradict the sx discussed in the HPI
false
how would you document the GPA for a pt who is currently pregnant, has been pregnant 4 times in the past, and has one child at home?
G5 P1 A3
list 5 body systems found in the ROS and provide 2 sx for each system
constitutional - fever, chills, distraught
cardio - chest pain, palpitations
resp - cough, SOB, wheezing
neuro - headache, seizures, numbness
skin - rashes, itching, redness
psych - anxiety, depression, hallucinations
read the paragraph and determine the elements and pertinent negatives for the HPI:
A 36 y/o female w/ a hx of asthma present to the ED w/ intermittent, gradually worsening wheezing that started 4 days ago. The pt says feels like she cannot take a full breath similar to her previous asthma exacerbtations, but the albuterol inhalers prescribed by her pulmonologist (Dr. Aranibar) have not provided relief. She reports dyspnea and a mild dry cough since last night, but no fever, chest pain, leg pain, leg swelling, or recent travel. The pt was unable to walk to her bathroom this afternoon secondary to her dyspnea, prompting the 911 call. When paramedics arrived to the pt’s home, 30 min ago, tight expiratory wheezes in all fields were appreciated and the pt’s spO2 was 90% on RA. The pt received a DuoNeb breathing treatment and Solumedrol 125 mg en route to the ED, w/ mild sx relief.
A. CC B. onset C. timing D. location E. quality F. severity G. modifying fx H. associated sx. I. pertinent negatives J. context
A. CC: wheezing
B. onset: 4 days ago
C. timing: intermittent
D. location: not stated and often not reviewed with wheezing or SOB
E. quality: “cannot take a full breath”
F. severity: not stated, but the SpO2 reported by paramedics allows us to understand the objective severity
G. modifying factors: mild relief with DuoNeb breathing treatment and Solumedrol 125mg, no relief with prescribed albuterol inhaler
H. associated sx: dyspnea, mild dry cough
I. pertinent negatives: denies leg pain, fever, chest pain, leg swelling, or recent travel
J. context: Hx of asthma, episode similar to asthma
