Download Chapter_011 822KB Jan 14 2015 08:21:50 AM

Chapter 11
Focused History
and
Physical Examination
of the
Medical Patient
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 1
Case History
On arrival at a nursing home, you find an
alert, 65-year-old male complaining of chest
pain and shortness of breath that has been
present for 5 hours. The staff informs you that
this patient arrived today and they do not
have any information about him.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 2
Scope of History

History is key to assessment of the medical patient.



Points to areas of the body that require physical examination
Provides clues to preexisting conditions
Patients with no prior history of medical problems
need to have their condition explored to identify the
underlying problem.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 3
Scope of History

Patients with known history may
be aware of the probable cause
of their condition.


Examples
• Asthma
• Heart disease
• COPD
The extent of history and scope
of the physical exam will vary
among patients.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 4
Responsive Patients

Sequence for
responsive patients



Obtain the SAMPLE
history.
Perform a physical
examination focused on
chief complaint.
Obtain baseline vital
signs.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 5
Unresponsive Patients

Rapidly assess all body
regions.

Obtain baseline vital
signs.

Obtain SAMPLE history
from family or
bystanders.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 6
Chief Complaint

Expression of the patient’s
main problem in his own
words



“I feel terrible
chest pain.”
“I feel short of breath.”
“ I have a severe
pain in my abdomen.”
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 7
Assess History of Present
Illness

Expands on the chief
complaint

Systematic questions

O-P-Q-R-S-T approach
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 8
Assess SAMPLE History






Signs and symptoms
Allergies
Medications
Past medical history
Last oral intake
Events leading up to
incident
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 9
Symptoms — Questions About the
History of Present Illness






Onset
Provocation
Quality
Radiation
Severity
Time
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 10
Assess Complaints
Onset


Ask the patient to describe when the complaint first
occurred.
What was the patient’s activity at the time of onset?


Running, walking, sitting, driving, etc.
In which order did signs and symptoms appear?


“I have been short of breath for 2 hours.”
“I developed chest pain and nausea 30 minutes ago.”
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 11
Assess Complaints
Provocation

What makes the symptoms worse?

What makes the symptoms better?

Examples




“The pain increases when I walk.”
“My abdominal pain decreased after I took an antacid.”
“Lying flat makes my breathing worse.”
It is easier to breathe when I sit up.”
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 12
Assess Complaints
Quality

Description of symptoms in patient’s own words

Examples



“The chest pain feels like someone is sitting on my chest.”
“It feels like a sharp, stabbing pain in my lower abdomen.”
“It feels like a tearing sensation in my chest and back.”
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 13
Assess Complaints
Radiation

Pain may spread from one area to another.

Ask the patient whether the pain travels.

Examples



Heart attack pain may travel to the arms, neck or jaw
Spleen injuries may cause pain in the shoulder
Appendicitis may cause pain around the umbilicus (belly button).
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 14
Assess Complaints
Severity

Ask the patient to describe
severity of pain on a scale of 1 to
10.



10 being the worst
1 being the least
During reassessment, have the
patient rate the pain again.

This can show trends in relation to
treatment (e.g., oxygen).
Worst
10
9
8
7
6
5
4
3
2
1
Least
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 15
Assess Complaints
Time

Duration of significant
signs and symptoms

Examples


“I have had the pain for the past
2 hours.”
“My breathing has been getting
worse over the past hour.”
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 16
SAMPLE History
Allergies

Ask patients if they have any
allergies.


Examples
• Foods
• Medications
• Bee stings
Allergy history is critical to
identifying possible causes since
treatments may cause allergic
reaction.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 17
SAMPLE History
Medications

Medications may provide a clue to
the cause of the condition.

Medications may be the cause of the
condition.

Medications may alter vital signs and
may confuse assessment.

Drugs may lower blood pressure or
slow pulse rate.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 18
SAMPLE History
Past Medical History

May provide valuable clues to
the underlying condition

In adults, always ask about

High blood pressure
 Heart disease
 Diabetes
 Chronic obstructive pulmonary
disease (COPD)
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 19
SAMPLE History
Last Oral Intake

When did the patient last eat?

Particularly important for patients
with diabetes

When did the patient last drink?

Also note compliance (or lack of
compliance) in taking prescribed
medications.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 20
SAMPLE History
Events Leading to Present Illness

Ascertain the chronology of events leading to the call
for help.

Determine whether the patient has had any recent
trauma.

Example
• A patient found unresponsive may have experienced head
injury days or months before.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 21
Unresponsive Medical Patients
Unresponsive medical patients or patients
with altered mental status require a rapid
assessment similar to a rapid trauma
assessment to ensure trauma is not playing
an underlying role.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 22
Rapid Assessment

Head



DCAP-BTLS
Crepitation
Careful palpation to
avoid injury to brain
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 23
Rapid Assessment

Neck





DCAP-BTLS
Crepitation
Subcutaneous emphysema
Jugular venous distention
Tracheal shift
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 24
Rapid Assessment

Chest



DCAP-BTLS
Breath sounds
Paradoxical breathing
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 25
Rapid Assessment

Abdomen



DCAP-BTLS
Firm vs. soft
Distended
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 26
Rapid Assessment

Pelvis




DCAP-BTLS
Crepitation
Tenderness
Motion
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 27
Rapid Assessment

Lower Extremities


DCAP-BTLS
Distal pulse
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 28
Rapid Assessment

Lower Extremities


Sensation
Motor function
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 29
Rapid Assessment

Upper Extremities


DCAP-BTLS
Distal pulse
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 30
Rapid Assessment

Upper Extremities


Sensation
Motor function
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 31
Rapid Assessment

Back


DCAP-BTLS
Look for exit wounds with
penetrating trauma.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 32
Unresponsive Medical Patient

Rapid assessment

SAMPLE history

Baseline vital signs
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 33
SAMPLE History

Bystander

Family

Friends
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 34
Assess Baseline Vital Signs

Pulse

Respirations

Blood pressure

Temperature
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 35
Provide Emergency Medical
Care

Based on signs and
symptoms

In consultation with
medical direction
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 36
Respecting Privacy and
Autonomy


Be sensitive to a patient’s right to privacy during
questioning and physical examination.
Be sure to tell patient what you are going to do before
you do it.


Gather cooperation
Patient consent
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 37
Summary



History is a key aspect in the assessment of
medical patients.
Responsive patients require a focused
examination.
Unresponsive patients require a rapid
assessment.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 38