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Scribing > HPI and ROS > Flashcards

HPI and ROS Flashcards

1
Q

What is an HPI

A

The story of symptoms and events that led to the pt’s ED visit

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2
Q

What do you write if a complete history isn’t available?

A

“HPI is unobtainable/limited due to the pt’s non-verbal status”

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3
Q

HPI Elements (8)

A 
Onset - When did Sx begin
Timing - Constant/intermittent/waxing and waning
Location - Where
Quality - Sharp/dull/aching/cramping
Severity - Mild/mod/severe/0-10
Modifying Factors - What better/worse? What tried?
Assoc. Sx - Other Sx
Context - Anything else important
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4
Q

How many HPI elements needed?

A

At least 4

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5
Q

Detailed HPI Formula

A

1: Complaint & Onset
2: Timing, Location, Quality, Severity
3: Assoc. Sx, Pertinent (-)
4: Modifying Factors, Tx tried
5: Context (similar experience? What new/different?)

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6
Q

MOI

A

Mechanism of Injury: Detailed explanation of trauma

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7
Q

Important Sx for Trauma Pts

A

LOC, head/neck/back injury

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8
Q

MVA HPI Biggies

A
  1. Driver or passenger
  2. Seat belt?
  3. Type of collision
  4. Airbags deploy?
  5. Were you able to get out/ambulate?
  6. Did you require EMS treatment?
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9
Q

ROS

A

Head to toe checklist of Sx the pt does or does not have

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10
Q

Body Systems (14)

A

Constitutional, Eyes, Ears/Nose/Throat, Cardiovascular, Respiratory, Gastrointestinal, Genitourinary, Musculoskeletal, Integumentrary, Neurological, Psychiatric, Endocrine, Hematologic/Lymph, Immunologic

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11
Q

How many ROS systems needed?

A

10

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12
Q

Minimum of ROS systems needed?

A

2 with “All other systems negative except as marked” noted

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13
Q

CP DDx: Worse with physical exertion

A

MI

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14
Q

CP DDx: Worse with deep breaths

A

PE

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15
Q

CP DDx: Radiation to back

A

Aortic Disse tion

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16
Q

CP DDx: Recent Trauma

A

PTX

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17
Q

CP DDx: Shortness of Breath

A

MI, PE, PTX

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18
Q

CP DDx: Diaphoresis, N/V

A

MI

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19
Q

CP DDx: Pleuritic Pain

A

PE, PTX

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20
Q

CP DDx: Calf Pain

A

DVT causing PE

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21
Q

SOB w/o CP DDx: Productive Cough

A

PNA

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22
Q

SOB w/o CP DDx: Orthopnea/Dyspnea on Exertion

A

CHF

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23
Q

SOB w/o CP DDx: Bilateral Leg Swelling

A

CHF

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24
Q

SOB w/o CP DDx: Hemoptysis

A

PE

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25
Q

SOB w/o CP DDx: Unilateral Leg Swelling

A

DVT causing PE

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26
Q

SOB w/o CP DDx: Wheezing

A

Asthma

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27
Q

SOB w/o CP DDx: Hx of Tobacco Abuse

A

COPD

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28
Q

Abd Pain: RLQ Pain

A

Appendicitis

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29
Q

Abd Pain: RUQ Pain

A

Cholecystitis

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30
Q

Abd Pain: LLQ Pain

A

Divericulitis

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31
Q

Abd Pain: LUQ Pain

A

Pancreatitis

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32
Q

Abd Pain: Fever

A

Appendicitis, Cholecystitis, Diverticulitis

33
Q

Abd Pain: Blood in Vomit/Stool

A

GI Bleed

34
Q

Abd Pain: Memena

A

GI Bleed

35
Q

Abd Pain: Dizziness

A

GI Bleed, AAA

36
Q

Female Lower Abd Pain: Suprapubic Pain

A

Ovarian Torsion

37
Q

Female Lower Abd Pain: Pregancy

A

Ectopic Pregnancy

38
Q

Female Lower Abd Pain: Fever, RLQ Pain

A

Appencicitis

39
Q

Low Back Pain: Weakness/Numbness in Lower Extremities

A

Spinal Cord Injury

40
Q

Low Back Pain: Numbness in Groin

A

Spinal Cord Injury, Cauda Equina

41
Q

Low Back Pain: Loss of Bowel/Bladder Control

A

Spinal Cord Injury, Cauda Equina

42
Q

Low Back Pain: History of IVDA

A

Spinal Abscess

43
Q

Low Back Pain: Fever

A

Spinal Abscess

44
Q

Low Back Pain: Abd Pain

A

AAA

45
Q

Dizziness/HA: Weakness/Numbness/Tingling

A

CVA, SAH

46
Q

Dizziness/HA: Changes in Speech or Vision

A

CVA, SAH

47
Q

Dizziness/HA: Difficulty with Balance

A

CVA, SAH

48
Q

Dizziness/HA: Fever

A

Meningitis

49
Q

Dizziness/HA: Neck Pain

A

Meningitis

50
Q

Dizziness/HA: AMS

A

Meningitis, CVA, SAH

51
Q

Dizziness/HA: Worst HA of Life/Thunderclap Onset

A

Hemorrhagic CVA, SAH

52
Q

Dizziness/HA: Syncope or Seizure

A

CVA, SAH

53
Q

Syncope: Tongue Bite Wound

A

SZ

54
Q

Syncope: Numbness/Tingling/Weakness

A

CVA

55
Q

Syncope: Changes in Speech/Vision

A

CVA

56
Q

Syncope: CP

A

MI

57
Q

Syncope: SOB

A

PE

58
Q

Syncope: Palpitations

A

Arrhythmia

59
Q

AMS: Fever

A

Sepsis

60
Q

AMS: Numbness/Weakness/Tingling

A

CVA

61
Q

AMS: Changes in Speech/Vision

A

CVA

62
Q

AMS: HA

A

Hemorrhagic CVA

63
Q

AMS: Hx of Depression or Drug Abuse

A

Drug Overdose

64
Q

AMS: Hx of Diabetes

A

Hypoglycemia

65
Q

Trauma: LOC

A

Hemorrhagic CVA, Subdural Hematoma

66
Q

Trauma: Unilateral Numbness/Weakness/Tingling

A

Hemorrhagic CVA, Subdural Hematoma

67
Q

Trauma: Bilateral Numbness/Weakness/Tingling

A

Spinal Cord Injury

68
Q

Trauma: Neck/Back Pain

A

Spinal Cord Injury

69
Q

Trauma: SOB or CP

A

PTX, Cardiac Contusion

70
Q

Trauma: Abd Pain

A

Splenic or Liver Laceration

71
Q

CP Minor DDx

A

Chest wall pain, Costochondritis, Pleural effusion, GERD

72
Q

SOB Minor DDx

A

Bronchitis, URI

73
Q

Abd Pain Minor DDx

A

UTI, Gastroenteritis, Gastritis, Constipation

74
Q

Female Lower Abd Pain Minor DDx

A

Ovarian Cyst, UTI, STD

75
Q

Low Back Pain Minor DDx

A

Musculoskeletal back pain, Back Strain, Sciatica

76
Q

Dizziness/Headache Minor DDx

A

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

77
Q

Syncope Minor DDx

A

Vasovagal syncope, dehydration

78
Q

AMS Minor DDx

A

UTI (elderly), EtOH Abuse, Narcotic Abuse, Drug Abuse

79
Q

Trauma Minor DDx

A

Closed head injury, simple fracture, dislocation, strain/sprain, laceration

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