Download GENERAL APPROACH TO THE PATIENT

GENERAL APPROACH TO
THE PATIENT
• Case history
• Patient Compliance
• pertinent physical examination
The medical interview should
accomplish three important
functions
• to collect information
• to respond appropriately to the patient's
emotional state
• to educate the patient and beneficially
influence patient behavior
Patient Compliance
• For many illnesses, treatment depends on
fundamental behavioral changes
• alterations in diet
• Exercise
• Smoking
• drinking
COMMON SYMPTOMS
• PAIN
• Pain is the most common symptom causing
patients to seek medical attention.
Information about the nature, location,
timing, severity, and radiation of pain is
crucial for proper treatment; the same is true
for aggravating or alleviating factors.
Recommended clinical approach
to pain management
• Ask about pain regularly. Assess pain
systematically (quality, description,
location, intensity or severity, aggravating
and ameliorating factors, cognitive
responses). Ask about goals for pain
control, management preferences
• Believe the patient and family in their
reports of pain and what relieves it.
• Choose pain control options appropriate for
the patient, family, and setting. Consider
drug type, dosage, route, contraindications,
side effects. Consider nonpharmacologic
adjunctive measures.
• Deliver interventions in a timely, logical,
coordinated manner.
• Empower patients and their families. Enable
patients to control their course to the
greatest extent possible.
• Follow up to reassess persistence of pain,
changes in pain pattern, development of
new pain.
Drug Therapy
• The proper treatment of any patient's pain
depends upon a careful diagnosis of its
cause, selection of appropriate and costeffective treatment, and ongoing evaluation
of treatment results
Drugs for Mild to Moderate Pain
• aspirin, acetaminophen
• ibuprofen or naproxen in the 200 mg
dosage formulation.
• For moderate pain, salicylates, NSAIDs, or
acetaminophen in higher doses often
suffice; if not, the clinician can prescribe
drugs such as codeine or oxycodone.
Drugs for Moderate to Severe
Pain:
• Opioids
• Opioids can be classified as full opioid
agonists, partial agonists, or mixed agonistantagonists
• Full agonists include morphine,
hydromorphone, codeine, oxycodone,
methadone, levorphanol, and fentany
Contraindications to Opioids
• In patients with acute abdominal pain
• Patients with hypothyroidism, adrenal
insufficiency, hypopituitarism, acute
intermittent porphyria, reduced blood
volume, and severe debility are particularly
apt to suffer adverse effects from opioid
analgesics
Adverse Effects of Opioids
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Respiratory Depression
Central Nervous System Effects
Gastrointestinal Side Effects
Urinary Retention
Pruritus
Hypersensitivity
Allergic Response
Respiratory Depression
• Respiratory depression is commonly feared
as a hazard of parenteral morphine
administration. Morphine acts to depress the
respiratory center in the brainstem. The
respiratory rate decreases gradually; abrupt
cessation of breathing does not occur.
Severe respiratory depression is uncommon,
occurring in 0.05–0.9% of treated patients
Central Nervous System Effects
• Central nervous system effects include
euphoria, mental clouding, and sedation.
Antidepressants, antihistamines,
phenothiazines, sedative-hypnotics, and
alcohol can potentiate these effects.
Gastrointestinal Side Effects
• Gastrointestinal side effects are chiefly
decreased bowel motility and constipation
and nausea and vomiting. Because
constipation is an inevitable side effect of
opioid administration, the physician should
attempt to prevent it by prescribing dietary
fiber and regularly scheduled doses of a
laxative
Urinary Retention
• Urinary retention sometimes occurs because
morphine inhibits parasympathetic outflow
from the spinal cord, causing bladder
spasm. It is more common following spinal
(epidural) than parenteral or oral
administration and more often a problem in
older men with benign prostatic hyperplasia
Pruritus
• Pruritus occurs commonly when morphine
is administered via the epidural or
intrathecal routes, less frequently with
intravenous or intramuscular administration,
and uncommonly following oral dosing
Hypersensitivity
• Enhanced sensitivity to the opioid drugs
occurs in patients with hepatic impairment;
biliary spasm may cause severe biliary
colic.
Allergic Response
• Allergic manifestations also occur, but
rarely
FEVER & HYPERTHERMIA
• The average normal oral body temperature is 36.7
°C (range 36–37.4 °C)
• The normal rectal or vaginal temperature is 0.5 °C
higher than the oral temperature, and the normal
axillary temperature is correspondingly lower.
Rectal temperature is more reliable than oral
temperature, particularly in the case of patients
who are mouth-breathers or who are tachypneic.
• The normal diurnal temperature variation may be
as much as 1 °C, being lowest in the early
morning and highest in the late afternoon
• Fever is a regulated rise to a new "set point" of
body temperature. When proper stimuli act on
appropriate monocyte-macrophages, these cells
elaborate one of several pyrogenic cytokines,
which causes elevation of the set point through
effects in the hypothalamus. These cytokines
include interleukin-1 (IL-1), tumor necrosis factor
(TNF), interferon-gamma, and interleukin-6 (IL6). The elevation in temperature may result from
either increased heat production (eg, shivering) or
decreased heat loss (eg, peripheral
vasoconstriction). Body temperature in
interleukin-1-induced fever seldom exceeds 41.1
°C unless there is structural damage in the
hypothalamus.
Important Causes of Fever &
Hyperthermia
• Infections:Bacterial, viral, rickettsial, fungal,
parasitic.
• Autoimmune Diseases
• Central Nervous System Disease
• Malignant Neoplastic Disease
• Hematologic Disease:Lymphomas, leukemias,
hemolytic anemias.
• Cardiovascular Disease:Myocardial infarction,
thrombophlebitis, pulmonary embolism
• Gastrointestinal Disease:Inflammatory bowel
disease, liver abscess, alcoholic hepatitis,
granulomatous hepatitis.
• Endocrine Disease:Hyperthyroidism,
pheochromocytoma may raise temperature
because of altered thermoregulation.
• Diseases Due to Chemical Agents: Drug reactions
(including serum sickness), neuroleptic malignant
syndrome, malignant hyperthermia of anesthesia,
serotonergic syndrome
• Factitious fever
Treatment
• Temperature over 41 °C is a medical
emergency
• Measures for Removal of Heat:Alcohol
sponges, cold sponges, ice bags, ice-water
enemas, and ice baths will lower body
temperature and provide physical comfort
for patients who complain of feeling hot
Antipyretic Drugs
• In most instances, antipyretic therapy by
itself is not needed except for reasons of
comfort or in patients with marginal
hemodynamic status. Aspirin or
acetaminophen, 325–650 mg every 4 hours,
is quite effective in reducing fever
Fluid Replacement
• Oral or parenteral fluids must be
administered to compensate for increased
insensible fluid and electrolyte losses as
well as those from perspiration
• Antibiotic Therapy
Dyspnea
• Dyspnea is the subjective experience of
difficulty in breathing and may be
characterized by patients as tightness,
shortness of breath, or a feeling of
suffocation
• Treatment of dyspnea is usually first
directed at the underlying cause
Nausea & Vomiting
• Nausea and vomiting are common and
distressing symptoms
• Vomiting may be due to stimulation of
peripheral afferent nerves
Constipation
• Given the frequent use of opioids, poor
dietary intake, and physical inactivity
DIAGNOSIS OF SKIN
DISORDERS
• Morphology
• History
• Physical Physical
Examination
Examination
Morphologic categorization of
skin lesions and diseases.
• Pigmented – Freckle, lentigo, seborrheic keratosis,
nevus, blue nevus, halo nevus, dysplastic nevus,
melanoma
• Scaly - Psoriasis, dermatitis (atopic, stasis,
seborrheic, chronic allergic contact or irritant
contact), xerosis (dry skin), lichen
simplexchronicus, tinea, tinea versicolor,
secondary syphilis, pityriasis rosea, discoid lupus
erythematosus, exfoliative dermatitis
Vesicular
• Herpes simplex, varicella, herpes zoster,
dyshidrosis (vesicular dermatitis of palms
and soles), vesicular tinea, dermatophytid,
dermatitis herpetiformis, miliaria, scabies,
photosensitivity
Weepy or encrusted
• Impetigo, acute contact allergic dermatitis,
any vesicular dermatitis
Pustular
• Acne vulgaris, acne rosacea, folliculitis,
candidiasis, miliaria, any vesicular
dermatitis
Figurate (-shaped) erythema
• Urticaria, erythema multiforme, erythema
migrans, cellulitis, erysipelas, erysipeloid,
arthropod bites
Bullous
• Impetigo, blistering dactylitis, pemphigus,
pemphigoid, porphyria cutanea tarda, drug
eruptions, erythema multiforme,
toxic epidermal necrolysis
Papular
• Hyperkeratotic: warts, corns, seborrheic
keratosPurple-violet: lichen planus, drug
eruptions, Kaposi's sarcoma Flesh-colored,
umbilicated: molluscum contagiosum
Pearly: basal cell carcinoma, intradermal
nevi Small, red, inflammatory: acne,
miliaria, candidiasis, scabies,folliculitis
Pruritus
• Xerosis, scabies, pediculosis, bites,
systemic causes,anogenital pruritus
Nodular, cystic
• Erythema nodosum, furuncle, cystic acne,
follicular (epidermal)inclusion cyst
Photodermatitis
(photodistributed rashes)
• Drug, polymorphic light eruption, lupus
erythematosus
Morbilliform
• Drug, viral infection, secondary syphilis
Erosive
• Any vesicular dermatitis, impetigo, aphthae,
lichen planus, erythema multiforme
Ulcerated
• Decubiti, herpes simplex, skin cancers,
parasitic infections, syphilis (chancre),
chancroid, vasculitis, stasis, arterial disease
Respiratory system
• PHYSIOLOGY OF RESPIRATION
The medulla (located in the brain stem just above
the spinal cord) is the respiratory center. It is
stimulated by the increased concentration of
carbon dioxide and increased hydrogen ions.The
lungs and circulation act together to bring gases to
body tissues for gas exchange. Movement of
oxygen into the lungs (inspiration) and removing
carbon dioxide (exhalation) is called ventilation.
Respiration occurs in the alveoli capillary system
where there is an actual exchange of gases
between the air and blood.
Normal respiratory
functioning-Depends on four
essential factors
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The integrity of the airway system
Properly functioning alveolar system
Properly functioning cardiovascular system
Muscle movements which provide the force for
ventilation
• The diaphragm and the intercostal muscles are
responsible for normal breathing.
SYMPTOMS OF ACUTE
HYPOXIA
• Dyspnea
• Elevated blood pressure with a small pulse
pressure
• Increased respiratory and pulse rates
• Paleness
• Cyanosis
• Anxiety and restlessness
SYMPTOMS OF CHRONIC
HYPOXIA
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Altered thought processes
Headaches
Chest pain
Enlarged heart
Polycythemia -clubbed fingers - secondary to
polycythemia
Anorexia
Constipation
Decreased urinary output
Weakness of extremity muscles
FACTORS AFFECTING RESPIRATORY
FUNCTIONING
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HEALTH -Persons with renal or cardiac problems often have respiratory
problems related to fluid overload.
DEVELOPMENT- Scoliosis- Obesity and pregnancy
NARCOTICS AND ANALGESICS
Versed and Valium can cause respiratory arrest particularly if given IV push at
too fast a rate.
LIFE-STYLE
Smoking decreases lung ciliary action, decreases production of surfactant,
and increases blood pressure due to nicotine absorption.
Smoking is measured in pack-years. To calculate, take how many packs a
day the person smokes, times the number of years the person has smoked.
ENVIRONMENT
Smoke, and irritating fumes (butane, paint thinner, glue) can lead to upper
respiratory irritation such as laryngitis.
PSYCHOLOGIC HEALTH
Stress can lead to excessive sighing or hyperventilation.
Anxiety has be linked to bronchospasm and bronchial asthma.
Hyperventilation
• SUDDEN anxiety or "panic attacks" can be
accompanied by hyperventilation.
• Common symptoms of anxiety attacks with
hyperventilation include: nervousness,
palpitations, increased respiratory rate, numbness,
and tingling around mouth, tip of nose, and finger
tips.
• Continued hyperventilation will result in
respiratory alkalosis, nausea, lightheadedness,
fainting, and cramping of the hands.
ASSESSING RESPIRATORY
FUNCTIONING
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INSPECTION
PALPATION
PERCUSSION
AUSCULTATION
INSPECTION
• The anterior-posterior diameter should be less
than the transverse diameter
• Movement of the chest should be symmetrical
• Skin should be warm and dry
• No cyanosis or pallor
• Respiratory rate 16 to 24 per min for adult
• Flaring nostrils, intercostal retractions,
tachypena, or bradypnea needs evaluation.
PALPATION
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Trachea equidistant from each clavicle
Vocal fremitus - bilateral equal mild fremitus
Increased fremitus is seen with pneumonia.
Decreased or absent fremitus is noted in
COPD.
• The presence or absence of crepitations,
masses, edema, or tenderness should be noted
PERCUSSION
• Resonance is heard over the normal lung
• Emphysematous lungs have loud low, booming
sound (hyperresonance).
• Dull sound over liver is normal. Dullness over the
lung field occurs when fluid or solid tissue
replaces normal lung tissue and requires
investigation.
• Dullness over the lung field is indicative of the
following conditions: pneumonia, hemothorax,
and lung tumors
AUSCULTATION
• The client should breath through his open
mouth slowly.
• If abnormal sound is heard, have the client
cough and listen again.
• Location, change in breath sounds after
coughing, and heard of inspiration or
expiration should be noted
Adventitious Breath Sounds
• Crackles (Rales)
• Crackling sounds caused by air passing
through moisture in the alveoli or
bronchioles
• Heard in Bronchitis, Pneumonia,
Pulmonary edema, CHF, Interstitial
fibrosis
• Rattles (Rhonchi)
• Coarse rattling/bubbling sounds from
fluid or obstructions in large airways.
Sounds tend to change with coughing
• Heard in Chronic bronchitis, Tumors,
Pneumonia and COPD
• Squeaks or Wheezes
• Squeaky, musical sounds associated with
air squeezing through narrowed airways
• Bronchospasm (asthma) Edema, Tumors,
RSV
• Rubs (Pleural friction rubs)
• Rough, grating, scratching sounds caused
by inflamed surfaces of the pleura
rubbing together. Usually associated with
pain on deep inspirations.
• Pleurisy, TB, Pneumonia, and Lung
Cancer
PROBLEMS ASSOCIATED WITH THE
UPPER RESPIRATORY TRACT
• Epistaxis -Most caused by injury
• Irritation, dryness, Inhalation of drugs High blood pressure
and blood clotting abnormalities
• Most nosebleeds occur in the front part of the nasal septum
• In most cases, nasal bleeding can be controlled easily by
tilting the head forward and using a firm 15 minute
nose pinch (include the soft bulb of the nose)
• If the patient is currently taking anticoagulants be sure to
notify the MD.
• It is important not to pick, rub, or blow after bleeding has
stopped.
• Avoid hot liquids. Aspirin and smoking can also promote
bleeding.
Allergic Rhinitis
• Inflammation and irritation of the nasal mucosa in
response to allergic stimuli: pollen, dust, dander, fungus,
molds, foods, grasses
• Symptoms: clear nasal discharge, itchy nose, sneezing,
watery and itchy eyes.
• The nasal mucosa may appear pale, engorged, and
bluish grey in client with allergic rhinitis.
• To exam-tilt the clients head back and use a pen-light.
• Evaluation will involve physical exam of the nasopharanax
for signs of pale edematous mucosa and nasal polyps,
which are a frequent complication of allergic rhinitis.
• May involve allergy testing with conventional skin testing,
or blood testing.
• Sinus x-rays may be performed to rule out sinus infection.
Upper Respiratory Infections or Colds
• The "common cold" is the most common infectious upper respiratory
illness (URI).
• Viral infection transmitted by inhalation or self-innoculation
• Frequent hand washing prevents spread
• Usually lasts 3-7 days
• Symptoms are congestion, runny nose with clear to white mucous,
sneezing, watery eyes, sore throat and dry cough.
• Dark yellow or green nasal drainage could indicate a bacterial
infection such as sinusitis.
• Treatment - Good nutrition, vitamins, plenty of fluids, and rest.
Decongestants and antihistamines, and cough suppressants can
help with the symptoms
• Persistent symptoms, high fevers, chills, dark colored nasal
drainage, productive cough, shortness of breath, or chest pains on
coughing could indicate a more serious infection
Sinusitis or Sinus Infection
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Viral or bacterial infection of the sinuses
Pt with allergic rhinitis have greater incidence of Sinusitis.
Common symptoms of sinusitis
runny nose, posterior nasal drip, yellowish or greenish
nasal discharge, dull facial pain or headache in the area
of the sinuses is common. Cough can develop
secondarily post-nasal drip .
Sinus headaches frequently become worse with position
changes
Evaluation
History and physical examination
Palpation will increase pain.
X-rays - Sinus Series
Culture and Sensitivity
Sinusitis or Sinus Infection-Treatment
• Decongestants, Antihistamines - when allergies
are involved.
• Antibiotics when fever, colored nasal discharge, or
x-ray findings of sinusitis are present .
• Antibiotic therapy is often necessary for 3-4
weeks duration to reduce the likelihood of
recurrence.
• Patients will be encouraged to rest, and drink
plenty of fluids.
• A cool steam vaporizer at the bedside can help
liquefy secretions and promote drainage
Tonsillitis and Pharyngitis
• Inflammation of the pharynx and/or tonsils from a viral or
bacterial infection
• Often coexist and are treated in the same manner
• Majority of cases are viral -But a culture needs done to
rule out strep throat
• antibiotics will have no effect on viral pharyngitis
• Symptoms of viral pharyngitis
• Red painful throat, hoarse voice, but usually no great
difficulty with swallowing, and no difficulty opening
the mouth
• Treatment of viral pharyngitis
• Rest, fluids, Tylenol, anesthetic lozenges and gargling
with warm saline