Day 3 Scribe America Training: HPI and ROS – Flashcards

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14
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How many body systems are there
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integumentary, psychological, neck, lymph, endocrine, GU, GI, cardiovascular, respiratory, eyes, ENT, musculoskeletal, neurological
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Name body systems
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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.
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G/P/A
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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
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What to learn from this PPT
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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.
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What is an HPI
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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"
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Other detail of HPI
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Onset, Timing, Location, Quality, severity, modifying factors, associated Sx, Context
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HPI Elements
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When did the complaint begin?
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Onset
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Has it been constant, intermittent, or waxing and waning?
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timing
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where is discomfort
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Location
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does it feel sharp, dull, aching, cramping
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quality
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how bad is it? mild, med, severe 0-10
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severity
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what makes it better? What makes it worse?
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mod factor
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Do any other symptoms accompany the complaint
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Associated Sx
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is there anything else thats important
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Context
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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
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Formula for writing an HPI
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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).
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Example of HPI
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-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.
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Tips for good HPI
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The symptoms were unchanged by Tums prior to arrival
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Pt says.."took tum and it didnt help"
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He notes chronic lower back pain, unchanged from baseline
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pt says"I have low back pain, but I always have that"
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The symptoms are worse with palpation of the area
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"It hurts when I touch it"
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The symptoms are unchanged by any position or activity
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Nothing makes it better or worse"
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Positive sick contact with sister who has similar symptoms
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My sister has the same cold"
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The vomiting is worsened by eating
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"If I try to eat anything, I throw it back up"
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He describes the symptoms as "a fizzing soda" in his central chest
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"it feels like a fizzing soda in the middle of my chest"
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-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
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HPI Do NOT
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-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
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HPI Do's
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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
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For patients who come with similar symptoms as the past
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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.
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Previous evaluation
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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.
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How to make Complete HPI
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ALWAYS followed up with an objective evaluation somewhere else in the chart; either the Physical Exam or Results section
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Every subjective complain is
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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
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Check your charting by
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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.
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Hint for HPI
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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
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HPI formula
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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.
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Ex good HPI
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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
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Trauma HPIs
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relevant to the CHIEF COMPLAINT
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HPI should only contain info...
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The ROS is a head to toe checklist of symptoms the patient does or does not have
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The HPI summarizes the STORY, CONTEXT and CHRONOLOGY that led to the patient's emergency room visit.
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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.
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ROS
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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.
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For major symtptoms
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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"
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When complete ROS unavailable
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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.
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All other systems as marked
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MI, PE, Dissection, PTX
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Major DDx for chest pain
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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)
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Red flags w/ Chest pain
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CHF, COPD, Asthma, PNA. Also consider MI or PE
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Major DDX w/ SOB and no CP
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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)
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Red flags for SOB w/ no CP
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Appendicitis, Cholecystitis, Diverticulitis, Pancreatitis, SBO, GI Bleed, AAA
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Major DDx for Abd pain
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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
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Red flags for Abd pain
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Appendicitis, Ovarian Torsion, Ectopic Pregnancy
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major ddx for female lower abd pain
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Pregnancy (Ectopic pregnancy), Fever (Appendicitis
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red flags for female lower abd pain
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Spinal cord injury, Cauda equina, Spinal abscess, AAA
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Major Ddx for Low back pain
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: 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)
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Red flags for low back pain
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Hemorrhagic CVA, Sub Arachnoid Hemorrhage (SAH), Ischemic CVA, Meningitis
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Major ddx for dizziness/headache
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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
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Red flags for dizziness/HA
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Seizure, CVA, MI, PE, Cardiac arrhythmia
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Major ddx for syncope
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Tongue bite wound → Sz Numbness/weakness/tingling, changes in speech or vision → CVA CP and/or SOB → MI and/or PE Palpitations → Arrhythmia
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Red flags for syncope
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Sepsis, CVA, Meningitis, Hypoglycemia, Drug overdose
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Major ddx for AMS
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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
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Red flag for AMS
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Hemorrhagic CVA, Subdural hematoma, Cervical/Thoracic/Lumbar spinal cord injury, PTX, Cardiac contusion, splenic laceration, liver laceration, compound fractur
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Major DDx for trauma
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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)
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Red flags for trauma
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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)
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Common PMHx
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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
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Common PSHx
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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
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Make sure you know from this PPT
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hest wall pain, Costochondritis, Pleural effusion, GERD
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minor ddx for chest pain
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bronchitis, URI
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minor ddx for SOB
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UTI, Gastroenteritis, Gastritis, Constipation
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minor ddx for abd pain
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Recent foreign travel, recent camping, bad food exposure, sick contacts, recent antibiotics, recent hospitalization
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Diarrhea risk factors
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ovarian cyst, UTI, STD
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minor ddx for female lower abd pain
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Dehydration, Benign Positional Vertigo (BPV), Migraine HA, Tension HA, Sinusitis,
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minor ddx for dizziness/HA
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UTI (if elderly), ETOH abuse, Narcotic abuse, Drug abuse
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minor ddx for AMS
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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?
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Questions for MVA
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LOC HA Neck pain Back Pain
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The four most important symptoms to document for any trauma patient are:
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