HPI/ROS, Red Flags/DDx Flashcards
Elements of HPI
- Onset
- Timing
- Location
- Quality
- Severity
- Modifying factors
- Associated Sx
- Context
A complete ROS requires…
10 elements OR 2 elements if “all other systems negative except as marked” is included
What to document if HPI/ROS is unobtainable
“A complete HPI/ROS is unobtainable due to the patient’s condition”
CP: worse w/ physical exertion
MI
CP: worse w/ deep breaths
PE
CP: radiation to the back
Aortic dissection
CP: recent trauma
PTX
CP: SOB
MI, PE, PTX
CP: diaphoresis, nausea, vomiting
MI
CP: calf pain
DVT causing PE
CP: pleuritic pain
PE, PTX
SOB w/o CP: productive cough
PNA
SOB w/o CP: orthopnea/DOE
CHF
SOB w/o CP: bilateral leg swelling
CHF
SOB w/o CP: hemoptysis
PE
SOB w/o CP: unilateral leg swelling
DVT causing a PE
SOB w/o CP: wheezing
Asthma
SOB w/o CP: Hx of tobacco abuse
COPD
MI risk factors
- CAD
- HTN
- HLD
- DM
- Smoking
- FHx CAD < 55 y/o
- Recent cocaine use
PE risk factors
- Hx DVT/PE
- Known DVT
- Recent surgery
- Immobilization
- A-Fib
- CA
- Pregnancy/birth control
ABD pain: RLQ pain
Appendicitis
ABD pain: RUQ pain
Cholecystitis
ABD pain: LLQ pain
Diverticulitis
ABD pain: LUQ pain
Pancreatitis
ABD pain: fever
Appendicitis, cholecystitis, diverticulitis