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50 Cards in this Set
- Front
- Back
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What is HPI?
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History of Present Illness = story of symptoms and events leading to the patient's ED visit; summarizes the reason for the visit.
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What kind of information belongs in the HPI.
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Subjective
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HPI records what?
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Subjective complaints that give rise to the entire patient workup.
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HPI should only include what?
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-- The Chief Complaint and Important Context
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For HPIs, the patient is the what? For pediatric patients what should you do?
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Historian; Document who is providing the information e.g. "Per the mother"
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What do you do when a complete history is not available?
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Document why it's not. And specifically how you know it.
e.g. "HPI is limited due to patient's non-verbal status" or "AMS" |
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A complete HPI contains what elements
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Onset, Timing, Location, Quality, Severity, Modifying factors, Associated Symptoms, Context
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Explain the HPI elements:
Onset, Timing, Location, quality, Severity, Modifying factors, Context |
onset - when did the complaint begin?
timing - has it been constant, intermittent, or waxing and waning? Location - Where is the discomfort? Quality - Does it feel sharp, dull, aching, cramping? Severity - How bad is it? Mod factors - what makes it better? What makes it worse? Assoc symptoms - Do any other symptoms accompany the complaint? Context - Is there anything else that's important? |
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Writing an HPI includes what 6 things.
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1. Age and sex of pt
2. State complaint and onset 3. Describe quality, location, and timing 4. Has anything improved or worsened it? 5. List assoc. symptoms 6. List pertinent negatives. |
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What does the HPI focus on?
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The moment a pt realized they needed to go to the ER; inc context, events, and symptoms.
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HPI vs. ROS
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HPI = info directly relevant to the chief complaint; summarizes the context and events leading to ER visit
ROS = contains all patient complaints, both from HPI and otherwise. |
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What is the ROS?
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Head-to-toe overview of the pt's body systems.
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ROS is phrased in the form of?
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Positives and Negatives
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ROS is a complete list of ?
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All the patient's complaints.
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ROS includes ?
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symptoms already placed in the HPI; symptoms not relevant to the chief complaint
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It is very impt that the listed ROS symptoms do not ....?
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Contradict any of the symptoms discussed in the HPI.
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To communicate that the pt did not mention any complaints other than those documented, document what?
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"All other systems negative except as marked"
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When a complete history is not available, it is impt to document what?
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Complete ROS unobtainable due to pt's condition.
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ROS' 14 Body systems
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1.Constitutional
2. Eyes 3. Ear Nose Throat 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7.Genitourinary 8. Musculoskeletal 9. Integumentary/Skin 10. Neurological 11. Psychiatric 12. Endocrine 13. Hematologic/Lymph 14. Immunologic |
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Examples of Constitutional
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Fever, Weight loss, Sweats
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Eyes
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Change in vision, Eye pain, double vision
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Ear/Nose/Throat
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Ear ache, Nose bleed, Congestion, Sore throat
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Cardiovascular
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Chest pain, Palpitations, Leg swelling
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Respiratory
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SOB, Cough, Sputum, Wheezing
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Gastrointestinal
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Abdominal pain, N/V/D, Black or Bloody stools
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Genitourinary
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Dysuria, Frequency, Urgency, Hematuria
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Musculoskeletal
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Joint pain, Muscle pain
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Integumentary/Skin
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Rash, itching, Abrasion, Laceration
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Neurological
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Headache, Syncope, Seizure, Numbness, Focal weakness
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Psychiatric
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Depression, Anxiety
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Endocrine
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Polyuria, polydipsia
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Hematologic/Lymph
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Bleeding gums, easy bruising, swollen lymph nodes
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Immunologic
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HIV/AIDS, Splenectomy
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Common PMHx: General
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HTN, Hyperlipidemia/Dyslipidemia, CA, DM
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Common PMHx: Cardiac
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MI, CAD, Angina, CHF, AFIB
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Common PMHx: Pulmonary
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PE, PNA, COPD, Asthma
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Common PMHx: Abdominal
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GERD, AAA, Pancreatitis, Hepatitis, Diverticulitis
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Common PMHx: GU
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Kidney stones, UTI, Renal insufficiency/failure
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Common PMHx: Psych
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CVA, TIA, Epilepsy/Sz, Migraines, Dementia, Alzheimer's
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Common PMHx:Psych
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Depression, Anxiety, Bipolar, Schizophrenia
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Common PMHx: Other
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DVT, MRSA, RA (Rheumotoid Arthritis), CBP (Chronic Back Pain)
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Common PSHx: ENT
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Tonsillectomy, Adenoidectomy, Myringotomy
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Common PSHx: Cardiac
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CABG, Coronary Stents, Pacemaker, AICD, Catherterization, Angioplasy, Valve replacement
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Common PSHx: Abdominal
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Appendectomy, Cholecystectomy, Herniorrhaphy, Gastric Bypass, Colectomy, Colostomy
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Common PSHx: GU
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Hysterectomy, C-section, Oophorectomy, Salpingo-oophorectomy, Tubal ligation, TURP
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Common PSHx: Ortho
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AKA/BKA, Hip Arthroplasty
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Common PSHx: Neuro
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Carotid Endarterectomy, Craniotomy, AV Shunt
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Common PSHx: Other
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Ex Lap, Mastectomy, PICC line
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G: P: A:
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G - # of times the patient has been pregnant // P - # of lives births that pt has had // A - # of total abortions (miscarriages or elective)
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General/Constitutional: Normal & Abnormal
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Normal = NAD
Abnormal = Mild/Moderate/Severe Distress Cachectic/Emaciated/Malnourished Somnolent |
