In your own words, describe the significance of an HPI
The HPI is the story of he symptoms and events that led to the pts ED visit. It included the CC and the associated sx
Name the five "elements" of the HPI
onset, timing, location, quality, severity, modifying factors, associated symptoms, context
Name eight of the body systems included in the ROS
Constitutional, eyes, ent, cv, resp, gi, gu, ms, skin, neuro, psych, endocrine, heme/lymph, immunological
Can the symptoms in the ROS ever contradict the symptoms described in the HPI?
No. Symptoms that are documented in the HPI should also be documented in the ROS
What do you need to remember to document in the HPI and ROS for any patient that is unconscious or incapable of providing information?
HPI/ROS limited by...
Why is it important to remember to document if the patient has had similar symptoms in the past?
Because it is less likely that their current symptoms or life-threatening if they have survive similar symptoms in the past
Name one detail that is important to document the patient has been evaluated in the past for similar complaints
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 is given? Any prior test results?
What should you focus on writing and HPI
Documenting the answers to every question asked by the doctor
Which is the first item in the formula for writing HPI
Chief complaint and onset
What does MOI stand for in a trauma HPI
Mechanism of injury
In the our ROS, you should document "All other systems negative except as mark" For every patient
False
Based on your knowledge from day to, why should you always pay special attention to the complaints of chest pain and SOB
Direct concern for MI
Name three past surgical histories to indicate that the patient has a history of CAD
Angioplasty, CABG, stents
What is the difference between a cardiac stress test and a cardiac catheterization
Cardiac Catheterization- Insertion of a catheter with Ejection Of dye to the coronary artery, use the Dina CAD. Stress test-Measures the hearts ability to respond to physical stress to determine if there is adequate blood flow to your heart during increasing levels of activity. There are two different types of stress test:Exercise(treadmill), Nuclear stress test is for patients with a medical problem that prevents you from exercising.
What are the risk factors for an MI
CAD, HTN, DM, dyslipidemia, smoking, FHx of CAD <55y/o
What are the risk factors for a PE
Known DVT, PMHx of DVT or PE, FHx of DVT or PE, recent surgery, CA, Afib, immobility, pregnancy, BCP, smoking
What are the risk factors for a CVA
HTN, HLD, DM, hx TIA/CVA, Smoking, FHx CVA, Afib
The patients entire ED visit is based on their answers the questions asked during interview
True
Accurate chronology is not imported an HPI
False