question

14

answer

How many body systems are there

question

integumentary, psychological, neck, lymph, endocrine, GU, GI, cardiovascular, respiratory, eyes, ENT, musculoskeletal, neurological

answer

Name body systems

question

Gravida- how many times woman has been pregnant Para-How many viable children were born Abortion- number of elective/miscarriage abortion If twins then P will be greater than G.

answer

G/P/A

question

Understand the importance of the History of Present Illness Learn the basic elements of writing an HPI Analyze an example HPI to understand each component Learn how to write an HPI like a physician Read example HPI's Learn the difference between the HPI and ROS Review major Chief Complaints from Day 2 Review Common Past Medical and Surgical history

answer

What to learn from this PPT

question

The History of Present Illness is the story of symptoms and events that led to the patient's ED visit. Only SUBJECTIVE information belongs in the HPI. The HPI is the beginning of every chart summarizing the reason for the visit. 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.

answer

What is an HPI

question

It is always important to document who the historian is for the HPI. 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. Sometimes a complete history is not available. In this case it is important to document why the history is limited. For example, "HPI is limited due to the patient's non-verbal status". In the event that the history is limited remember to only write exactly what you know about the patient, and specifically how you know it. For example, "Per EMS, this patient was found unresponsive 15 min ago"

answer

Other detail of HPI

question

Onset, Timing, Location, Quality, severity, modifying factors, associated Sx, Context

answer

HPI Elements

question

When did the complaint begin?

answer

Onset

question

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

answer

timing

question

where is discomfort

answer

Location

question

does it feel sharp, dull, aching, cramping

answer

quality

question

how bad is it? mild, med, severe 0-10

answer

severity

question

what makes it better? What makes it worse?

answer

mod factor

question

Do any other symptoms accompany the complaint

answer

Associated Sx

question

is there anything else thats important

answer

Context

question

1) Begin with the age and sex of the patient - 43 year old male 2) State the complaint and onset - complains of chest pain since yesterday 3) Describe the quality, location, and timing - described as a constant pressure in the central chest 4) Has anything improved or worsened it? - worse when walking up stairs 5) List associated symptoms - SOB and nausea 6) List pertinent negatives - No vomiting, sweating, or leg swelling

answer

Formula for writing an HPI

question

43 year old male complains of chest pain(CC) since yesterday(onset). The chest pain is described as a constant(timing) pressure(quality) in the central chest(location). It is worse when walking up stairs(exacerbating factor). He notes SOB and nausea(assoc sx), but denies vomiting, sweating, or leg swelling(pert neg). Sx described as similar to prior MI(context specific to patient).

answer

Example of HPI

question

-The more closely you can stick to the formula, the better your HPI will be. -Try to remember the pt's answers as a general story, rather than focusing on remembering the individual facts. -Group all related information together; finish describing all the details of one complaint before moving on to the next -Try to word your HPI as a doctor would speak; translate things that the patient says into phrasing that sounds more like a doctor. When in doubt, you may always document direct patient quotes.

answer

Tips for good HPI

question

The symptoms were unchanged by Tums prior to arrival

answer

Pt says.."took tum and it didnt help"

question

He notes chronic lower back pain, unchanged from baseline

answer

pt says"I have low back pain, but I always have that"

question

The symptoms are worse with palpation of the area

answer

"It hurts when I touch it"

question

The symptoms are unchanged by any position or activity

answer

Nothing makes it better or worse"

question

Positive sick contact with sister who has similar symptoms

answer

My sister has the same cold"

question

The vomiting is worsened by eating

answer

"If I try to eat anything, I throw it back up"

question

He describes the symptoms as "a fizzing soda" in his central chest

answer

"it feels like a fizzing soda in the middle of my chest"

question

-Document days of the week, e.g. "it started Monday" -Use the words "got" "got better" or "got worse" -Start every sentence the same eg "Pt states" -Document self diagnoses in the HPI, e.g. "I have the flu" -Include PMHx, PSHx, or SHx that is not relevant to the chief complaint

answer

HPI Do NOT

question

-Count the number of days since the symptoms started, or write a date -Use phrasing like "the symptoms worsened" or "the symptoms improved" -Vary the beginning of your sentences and avoid repetition -Describe the specific symptoms affecting the patient -Document only medical histories, surgeries, or social habits that directly relate to the patient's chief complaint

answer

HPI Do's

question

For these patients, remember to document... Anything new or different about their symptoms today How long ago the similar symptoms occurred If they sought treatment at that time Any result or diagnosis from previous evaluations If the patient has experienced similar symptoms in the past, it is very likely that their current symptoms are related. It also makes it less likely that their current symptoms are life threatening, if they have survived the same symptoms in the past

answer

For patients who come with similar symptoms as the past

question

Anytime a patient has been evaluated by another healthcare provider for a similar complaint, it is important to document... What symptoms prompted the prior evaluation? How long ago did the prior evaluation occur? Who did they see? (Name and specialty) What treatment did they receive? Did it help? What diagnosis was given? If the patient has had any prior testing for the same complaint, it is important to document what testing they had, when, and what the results showed. Documenting the prior testing may save us from repeating the same study for their current visit.

answer

Previous evaluation

question

When writing an HPI, your goal is to capture the answer to every question the doctor asks the patient. You don't have to write everything the patient says, but always write the answer to the doctor's specific questions. Each question is asked to help the doctor raise or lower their suspicion for a particular disease; to help them decide what tests to order. If your chart is missing the answer to a question, there is no record that the doctor ever asked it. Since the orders are based on the patient's answers to the doctor's questions, your chart may be missing the doctor's rationale for choosing to order a particular study, or choosing not to order it.

answer

How to make Complete HPI

question

ALWAYS followed up with an objective evaluation somewhere else in the chart; either the Physical Exam or Results section

answer

Every subjective complain is

question

to count the number of subjective complaints in the HPI, then follow them through the rest of your chart: they should be repeated accurately as positives in the ROS, then addressed with some type of objective information in the PE or Results

answer

Check your charting by

question

A hint is to listen closely for the precipitating event that finally made the patient choose to come to the ED. There is some point in every patient's day when they realize they need to go to the ED. The HPI focuses on this moment and what lead up to it.

answer

Hint for HPI

question

1) Chief complaint and onset 2) Timing, quality, and location 3) What makes it better or worse 4) Associated symptoms 5) Pertinent negatives 6) Overall context

answer

HPI formula

question

John Doe is an 85 year old male with a PMHx of CAD, hypothyroidism, and A-Fib (on Coumadin) presenting to the ED for new sudden onset of slurred speech, facial droop, and problems with balance. The patient was recently admitted several months ago for a TIA (per son) with symptoms of disorientation and confusion. He did not have weakness or speech symptoms at that time. Since then the patient has been in his normal state of health and went to bed at his mental baseline last night. When his wife woke him from sleep this morning around 7:30 am, she noticed the right side of his face to be drooping, along with slurred speech and difficulty with his balance. Over the last 40 minutes the symptoms have improved. The wife and son provide that the patient's speech is currently at baseline, and his facial droop has significantly improved. The patient specifically denies any headache, dizziness/lightheadedness, chest pain, SOB, neck pain, or focal weakness in his arms or legs. The patient has had a non-productive cough for the last several days, but otherwise denies any new or different symptoms.

answer

Ex good HPI

question

For some patients, there is an actual injury that prompted their ED visit. These patients require very specific HPI's. The key to writing a trauma HPI is focusing on the exact Mechanism of Injury (MOI). Describe every possible detail about the circumstances and events causing the injury. The four most important symptoms to document for any trauma patient are: LOC HA Neck pain Back Pain

answer

Trauma HPIs

question

relevant to the CHIEF COMPLAINT

answer

HPI should only contain info...

question

The ROS is a head to toe checklist of symptoms the patient does or does not have

answer

The HPI summarizes the STORY, CONTEXT and CHRONOLOGY that led to the patient's emergency room visit.

question

The Review of Systems is the head-to-toe overview of the patient's body-systems. It is phrased in the form of simple list of POSITIVES and NEGATIVES The ROS is a complete list of all of the patient's complaints. It includes symptoms already mentioned in the HPI, as well as symptoms that are not relevant to the chief complaint. It is very important that the listed ROS symptoms do not contradict any of the symptoms discussed in the HPI.

answer

ROS

question

For major symptoms such as Chest Pain or Shortness of Breath you should never just mention "Positive Chest Pain" or Positive Shortness of Breath" in the ROS without providing further explanation in the HPI.

answer

For major symtptoms

question

When a complete ROS is unable to be obtained (for example, the patient is unconscious) it is important to document that the ROS is also limited: "Complete ROS unobtainable due to patient's condition"

answer

When complete ROS unavailable

question

For some physicians, it is important to document "All other systems negative except as marked" to communicate that the patient did not mention any complaints other than those documented. Some physicians may ask you not to document this.

answer

All other systems as marked

question

MI, PE, Dissection, PTX

answer

Major DDx for chest pain

question

worse with exertion(MI), worse with deep breaths(PE), radiation to the back(dissection), trauma(PTX), SOB(MI,PE,PTX), Diaphoresis(MI), Pleuritic pain(PE,PTX), Calf pain(DVT->PE)

answer

Red flags w/ Chest pain

question

CHF, COPD, Asthma, PNA. Also consider MI or PE

answer

Major DDX w/ SOB and no CP

question

Productive cough or Fever (PNA), Orthopnea/DOE (CHF), Bilateral Leg swelling (CHF), Unilateral leg swelling (DVT → PE), Hemoptysis (PE), Wheezing (Asthma), Hx tobacco abuse (COPD), Chest Pain (MI, PE, PNA)

answer

Red flags for SOB w/ no CP

question

Appendicitis, Cholecystitis, Diverticulitis, Pancreatitis, SBO, GI Bleed, AAA

answer

Major DDx for Abd pain

question

RLQ pain (Appy), RUQ pain (Cholecysitis), LLQ pain (Diverticulitis), Fever (Appy, Cholecystitis, Diverticulitis), Blood in vomit/stool (GI Bleed), Melena (GI Bleed), Dizziness (GI Bleed

answer

Red flags for Abd pain

question

Appendicitis, Ovarian Torsion, Ectopic Pregnancy

answer

major ddx for female lower abd pain

question

Pregnancy (Ectopic pregnancy), Fever (Appendicitis

answer

red flags for female lower abd pain

question

Spinal cord injury, Cauda equina, Spinal abscess, AAA

answer

Major Ddx for Low back pain

question

: Weakness or Numbness in lower extremities (spinal cord injury or cauda equina), numbness of the groin (cauda equina, spinal cord injury), loss of bowel or bladder control (cauda equina, spinal cord injury), Fever (spinal abscess), abdominal pain (AAA)

answer

Red flags for low back pain

question

Hemorrhagic CVA, Sub Arachnoid Hemorrhage (SAH), Ischemic CVA, Meningitis

answer

Major ddx for dizziness/headache

question

Numbness/weakness/tingling, changes in speech or vision → CVA, SAH Difficulty with balance → CVA, SAH Fever or Neck Pain → Meningitis AMS → Meningitis, CVA, SAH Worst headache of life/Thunderclap onset → Hemorrhagic CVA, SAH Syncope or seizure → CVA, SAH

answer

Red flags for dizziness/HA

question

Seizure, CVA, MI, PE, Cardiac arrhythmia

answer

Major ddx for syncope

question

Tongue bite wound → Sz Numbness/weakness/tingling, changes in speech or vision → CVA CP and/or SOB → MI and/or PE Palpitations → Arrhythmia

answer

Red flags for syncope

question

Sepsis, CVA, Meningitis, Hypoglycemia, Drug overdose

answer

Major ddx for AMS

question

Fever → Sepsis Headache → Hemorrhagic CVA Numbness/weakness/tingling, changes in speech or vision → CVA Hx of depression or drug abuse → Drug overdose Hx DM → Hypoglycemia

answer

Red flag for AMS

question

Hemorrhagic CVA, Subdural hematoma, Cervical/Thoracic/Lumbar spinal cord injury, PTX, Cardiac contusion, splenic laceration, liver laceration, compound fractur

answer

Major DDx for trauma

question

Loss of consciousness (Hemorrhagic CVA, Subdural hematoma) Changes in speech or vision (Hemorrhagic CVA, Subdural hematoma) Unilateral numbness/weakness/tingling (Hemorrhagic CVA, Subdural hematoma) Bilateral numbness/weakness/tingling (spinal injury) Neck pain or Back Pain (spinal injury) SOB or Chest pain (PTX, Cardiac contusion) Abdominal pain (Splenic or liver laceration)

answer

Red flags for trauma

question

General: HTN, HLD, CA, DM (IDDM/NIDDM) 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/Seizure, Migraines, Dementia, Alzheimer's Psych: Depression, Anxiety, Bipolar, Schizophrenia Other: DVT, MRSA, RA (Rheumatoid Arthritis), CBP (Chronic Back Pain)

answer

Common PMHx

question

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 Other: Mastectomy, PICC line

answer

Common PSHx

question

Know the elements of an HPI Write a basic HPI Accurately document an ROS Begin to associate major complaints with specific differential diagnoses Demonstrate retention of common PMHx and PSHx Document G, P, and A for OB patients

answer

Make sure you know from this PPT

question

hest wall pain, Costochondritis, Pleural effusion, GERD

answer

minor ddx for chest pain

question

bronchitis, URI

answer

minor ddx for SOB

question

UTI, Gastroenteritis, Gastritis, Constipation

answer

minor ddx for abd pain

question

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

answer

Diarrhea risk factors

question

ovarian cyst, UTI, STD

answer

minor ddx for female lower abd pain

question

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

answer

minor ddx for dizziness/HA

question

UTI (if elderly), ETOH abuse, Narcotic abuse, Drug abuse

answer

minor ddx for AMS

question

Were you the driver or the passenger? Were you wearing a seat belt? 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 the 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?

answer

Questions for MVA

question

LOC HA Neck pain Back Pain

answer

The four most important symptoms to document for any trauma patient are:

Day 3 Scribe America Training: HPI and ROS – Flashcards

Unlock all answers in this set

Haven't found what you were looking for?

Search for samples, answers to your questions and flashcards