"Patient C/O diarrhea and vomiting. The problems began early this morning with multiple episodes of emesis during the night. He now feels dizzy and tired when standing. There has been no blood or mucous in the watery stool or vomit. No other family members are ill yet. He hasn't traveled outside of this area or changed his diet significantly."
Fortunately, our EMR has a separate section for ROS, so I don't have to deal with picking and choosing where to credit things, but for the sake of argument, I'll pretent this is all there is to the history. Here's how it could be broken down:
Patient C/O diarrhea and vomiting. - This is the CC (which can be shared with ROS and/or HPI). Since the CC can be shared, I'll count diarrhea as CC & ROS: GI, and the vomiting as HPI: Assoc. Signs/Sx
The problems began early this morning - HPI Duration
with multiple episodes of emesis during the night. HPI Contect and Timing (multi episodes = timing, during the night = context)
He now feels dizzy and tired when standing. This could be more HPI Assoc Signs or HPI context, but since I already have both of those, it would be better to credit this to ROS Constitutional
There has been no blood or mucous in the watery stool or vomit. Once again, this could be HPI Assoc. Signs, and HPI Quality (watery stool), but I already have 4 HPI counted. So instead, I'd count this under ROS. (I have to admit, though, I'm not 100% sure where I'd count it - probably under Heme/Immun/Lymph, but that might be a stretch.)
No other family members are ill yet. This could be HPI Context, but it could also be PFSH - Family, so that's what I'd count it under
He hasn't traveled outside of this area or changed his diet significantly.Once again, could be HPI Context or PFSH - Social. I'd count it as PFSH.
Just balance your criteria. You're either going to have less than 4 HPI, or more. If you've got an abundance of HPI like I did with that note, then count your 4 elements, and count everything else somewhere else. Count it in a way that produces the highest result. If you're barely going to hit 4 HPI, or it's clear that there's not going to be 4 HPI, I'd only count 1 HPI and put the rest elsewhere. Since all 3 areas of History have to meet or exceed a level for the overall Hx to meet that level, the whole history is only as good as the weakest category. Don't worry about getting more than 2 ROS if you can't get 4 HPI, or if there's no PFSH whatsoever. (Just as an example)
I also found this extremely useful in learning E/M - it really helped me to balance the history. http://trailblazerhealth.com/Publica...0reference.pdf
If you need any help with specific stuff in the book, let me know. I don't have that edition, but I learned on my own with the 2nd edition, and I know how frustrating it can be to not be sure if you're learning it correctly or not.
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