HPI
the history of present illness - the story of symptoms and events that led to ED visit. Beginning of every chart, summarizing reason for visit. Contains SUBJECTIVE information only. Information related directly to the chief complaint and important context
onset, timing, location, quality, severity, modifying factors, associated Sx, and context
HPI elements (8 total)
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? mild, mod, severe or 0-10
Modifying factors
what makes it better? What makes it worse
Associated Sx
does any other symptoms accompany this complaint?
Context
is there anything else important?
Formula order
1) begin with the age and sex of patient 2) state the complain and onset 3) describe the timing, quality, severity, and location 4) has anything improved or worsened it? 5) list associated symptoms 6) list pertinent negative; 7) describe any other importa
The mechanism of injury (MOI)
for trauma HPI focus on what?
LOC, head injury, neck pain, or back pain
4 most important symptoms to document for trauma HPI
MI
chest pain + worse with physical exertion
PE
chest pain + worse with deep breaths
Aortic dissection
chest pain + radiation to back
PTX
chest pain + recent trauma
MI, PE, PTX
chest pain + SOB
MI
chest pain + diaphoresis, nausea, vomiting
DVT
chest pain + calf pain
PNA
SOB + productive cough
CHF
SOB + orthopnea/dyspnea on exertion
CHF
SOB + bilateral leg swelling
PE
SOB + hemoptysis
DVT causing a PE
SOB + unilateral leg swelling
asthma
SOB + wheezing
COPD
SOB + Hx of tobacco use
MI, PE, PNA
SOB + chest pain
Appendicitis
Abd. Pain + RLQ pain
Cholecystitis
Abd. Pain + RUQ pain
diverticulitis
abd. Pain + LLQ pain
pancreatitis
Abd. Pain + LUQ pain
Appendicitis, cholecystitis, diverticulitis
Abd. Pain + fever
GI bleed
Abd. Pain + blood in vomit or stool
GI bleed
Abd. Pain + melena
GI bleed, AAA
Abd. Pain + dizziness
Ovarian torsion
female lower abdominal pain + suprapubic pain
Ectopic pregnancy
female lower abdominal pain + pregnancy
appendicitis
female lower abdominal pain + fever / RLQ pain
Spinal cord injury
low back pain + weakness/numbness in lower extremities
Spinal cord injury or caudal equina
low back pain + numbness in groin
Spinal cord injury or caudal equina
low back pain + loss of bowel or bladder control
Spinal abscess
low back pain + history of IVDA
Spinal abscess
low back pain + fever
AAA
low back pain + abdominal pain
CVA or SAH
dizziness/headache + weakness/numbness/tingling
CVA or subarachnoid hemorrhage
dizziness/headache + changes in speech or vision
CVA or SAH
dizziness/headache + difficulty with balance
meningitis
dizziness/headache + fever
meningitis
dizziness/headache + neck pain
Meningitis, CVA, SAH
altered mental status + dizziness/headache
Hemorrhagic CVA, SAH
dizziness/headache + worst headache of life/thunderclap onset
CVA, SAH
dizziness/headache + syncope or seizure
seizure
syncope + tongue bite wound
Cerebral vascular accident (CVA)
syncope + numbness/weakness/tingling
CVA
syncope + changes in speech or vision
MI
syncope + chest pain
PE
syncope + SOB
Arrhythmia
syncope + palpitations
sepsis
AMS + fever
CVA
AMS + numbness/weakness/tingling
CVA
AMS + changes in speech or vision
Hemorrhagic CVA
AMS + headache
Drug overdose
AMS + Hx or depression of drug abuse
hypoglycemia
AMS + Hx of diabetes
Hemorrhagic CVA, subdural hematoma
trauma + loss of consciousness (LOS)
Hemorrhagic CVA, subdural hematoma
trauma + unilateral numbness/weakness/tingling
Spinal cord injury
trauma + bilateral numbness/weakness/tingling
Spinal cord injury
trauma + neck pain or back pain
PTX, cardiac contusion
trauma + SOB or CP
Splenic or liver laceration
trauma + abdominal pain
Review of systems (ROS)
a head-to-toe checklist of the patient's body systems; list of positive and negatives. Never contradicts the HPI
Constitutional
fever, weight loss, sweats
eyes
changes in vision, eye pain, double vision
ear/nose/throat
earache, nosebleed, congestion, sore throat
cardiovascular
chest pain, palpitation, leg swelling
Respiratory
SOB, cough, sputum, wheezing
gastrointestinal
abdominal pain, N/V/D, black or bloody stools
Genitourinary
dysuria, frequency, urgency, hematuria
Musculoskeletal
joint pain, muscle pain
integumentary/skin
rash, itching, abrasion, laceration
Neurological
headache, syncope, seizure, numbness, focal weakness
psychiatric
depression, anxiety
endocrine
polyuria, polydipsia
Hematologic/lymph
bleeding gums, easy bruising, swollen lymph nodes
Immunological
HIV/AIDS, splenectomy