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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