Day 3

Question 1

What is an HPI?

Answer 1

• the story of symptoms and events that led to the patient’s ED visit and should be at the beginning of every chart.
• only subjective information belongs in the HPI.
• the HPI should only contain information that is directly related to the chief complaint and important context for that patient, all other info goes in the ROS.

Question 2

Details of the HPI

Answer 2

• always document the historian of the HPI
• document why some history is limited
• write what you know about the patient and how you know it.

Question 3

Elements of an HPI

Answer 3

Onset: when did the complaint begin
Timing: Constant, intermittent, waxing or waning
Location: where is the discomfort
Quality: feel sharp, dull, aching, cramping, etc.
Severity: mild, moderate, severe or 1-10
Modifying Factors: what makes it better/ worse
Associated Sx: any other symptoms accompany the complaint
Context: anything else important
* A complete HPI requires the 4 elements

Question 4

Formula for Writing an HPI

Answer 4

1. Begin with pt age and sex
2. State the complaint and onset
3. Describe the quality, location, and timing
4. Has anything improved or worsened it?
5. List associated symptoms
6. List pertinent negatives
7. Describe any other important context specific to that pt

Question 5

Trauma HPI

Answer 5

Focus on the exact Mechanism of Injury (MOI) and describe every possible detail about the circumstances and events causing the injury.

Question 6

4 most important Sx to document for any trauma pt

Answer 6

LOC
Head injury
Neck pain
Back pain

Question 7

ROS

Answer 7

• head to toe overview of the pt’s body systems
• simple list of positives and negatives
• complete list of ALL complaints
• includes Sx already listed in HPI and Sx unrelated to CC

Question 8

14 Body Systems

Answer 8

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

Question 9

Major DDx for Chest Pain

Answer 9

*MI, PE, Aortic Dissection, PTX
Red Flags:
1. worse with exertion> MI
2. Worse with deep breaths> PE
3. Radiation to the back> Aortic Dissection
4. Recent Trauma> PTX
5. SOB> MI,PE,PTX
6. Diaphoresis, N/V> MI
7. Pleuritic Pain>PE, PTX
8. Calf Pain>DVT causing a PE

Question 10

Minor DDx for Chest Pain

Answer 10

*Chest wall pain, Costochondritis, Pleural Effusion, GERD
Associated Symptoms:
1. Pain with torso movement or palpation (chest wall pain, costochondritis)
2. Burning Pain (GERD)

Question 11

MI Risk Factors

Answer 11

CAD
HTN
HLD 
DM
Smoking
FHx CAD<55 y/o

Question 12

PE Risk Factors

Answer 12

Hx DVT/PE
Known DVT
Recent Surgery
Immobilization
A-Fib
CA
Pregnancy/ Birth Control