1、If you only have 5 minutes PHYSICAL ASSESSMENT PEARLS,Barb Bancroft, RN, MSN, PNP,The patient history,The most important part of any patient assessment is the patient history Components of the history are numerous, but remember, since you ONLY have FIVE minutes, a detailed 2-hour history is not poss
2、ible Pick and choose the parts of the present and past history that are relevant to their current problem,For example,Someone with new onset muscle aches and pains on a statin drug vs. someone who starts a statin drug but has had muscle aches and pains for 15 years New onset cough since the drug lis
3、inopril was prescribed for hypertension, or has the patient had the cough for 6 years from asthma and hay fever,What is the patient telling you in his/her own words?,“Ive had a terrible cough for 3 weeks” “I cant catch my breath” “I am having awful pain in my chest” “My head feels like its going to
4、explode” “My ankle is swollen” “Ive got this shooting pain down the back of my leg” “My cat bit me and my hand is swollen”,To characterize the “chief complaint” start with the PQRST mnemonic,PPrecise location? Where?Pinpoint the location? Show mePrecipitate the problem? What were you doing when it s
5、tarted?Palliate the problem? Did anything help?,History,Patient: “My shoulder hurts” Nurse: “Show me where it hurts, point to where it hurts” Patient pointing to the shoulder joint: ”It hurts right here” Nurse: “Do you know what caused your shoulder to hurt?” Patient: “ George hit me with a baseball
6、 bat” Nurse: “duhno wonder it hurts”,History,Patient rubbing the area of the shoulder next to the neck: “My shoulder hurts” Nurse: “Do you know what caused your shoulder to hurt?” Patient: “It started hurting when I smashed into the car in front of me and I slammed into the steering wheel” Nurse: “u
7、h-oh” Why “uh-oh?.more in a minute,To characterize the “chief complaint” start with the PQRST mnemonic,Quality of the pain?Help them out with this oneis it deep, burning, lancinating (shooting), cramping, crushing, vice-like, sharp, dull, explosive Quantitiy of the (blood, vomit, sputum)? Is it a te
8、aspoon (size of your first thumb joint)? Is it a cup? Quart?,Q is for quantity,CC”spitting up gunk from my lungs”chronic bronchitis (daily production of a tablespoon or more of sputum every day for at least 2 months in 2 successive years vs. bronchiectasis, a chronic, advanced inflammation with inte
9、rmittent production of purulent sputum in large quantities, as much as a quart/day,To characterize the “chief complaint” start with the PQRST mnemonic,Radiate? Where does it go? Up the jaw? Down the arm? One side of the head? To the back? Down the back of the leg? To the groin? Referred pain? Embryo
10、logic origins of pain,Referred pain,Embryologic origins The diaphragm (C3,4) The phrenic nerve Shared afferents with the shoulder What causes diaphragmatic irritation? Above and below the diaphragm,Referred pain another example,The ureters, kidney stones and the scrotum Does a woman have a scrotum?,
11、To characterize the “chief complaint” start with the PQRST mnemonic,Swhat is the Severity of the pain?Adults? 1 to 10 with 1 being the least painful and 10 being the most painfulPeds? Smiley to “frowney” faces,To characterize the “chief complaint” start with the PQRST mnemonic,Twhat is the Time fram
12、e or Temporal sequence? Clarify which symptom came first and the order in which others follow. Temporal relationships between associated symptoms are also most helpful. The simultaneous occurrence of equally intense symptoms or the development of symptoms while others regress suggest pathophysiologi
13、c mechanisms which in turn imply specific diagnoses,Time or Temporal sequence,Did the pain last for an hour, 15 minutes, 5 minutes, or less than 5 minutes? Did the pain start before you vomited? After you vomited? Did the vomiting stop the pain? Symptoms persisting for years are unlikely to be cause
14、d by a catastrophic infection, cancer, or other illness,Temporal sequence and an ischemic stroke,Patients may wake up with a “stroke in progress” You have a 4.5 hour “window” to give tissue plasminogen activator (alteplase) You need to know WHEN the stroke symptoms started? Bed at 11? Woke up at 7 w
15、ith symptoms? Bed at 11? Woke up at 5, perfectly fine, to go to the bathroom? Woke up again at 7 with symptoms?,The AsAssociated symptoms , Absent symptoms or events or ALARM symptoms,What else can you tell me about your problem? Has anything happened in your life that you think might be related to
16、your fatigue?My mom passed awaymy husband is in Iraqmy boyfriend dumped meall my kids have the flu”, everybody in my family has diabetes” Nausea, vomiting, weight loss, blurred vision, cough”worst headache I have every had”,Chief complaint “Severe chest pain for 25 minutes”first thought? Is this an
17、acute coronary syndrome?,FIRST THINGS FIRST: Any patient with a suspected acute coronary syndrome should chew 160-325 mg of ASA; one simple therapy is associated with a 35-day mortality reduction exceeding 20%) Now, thinkwhat structures are located in the chest and how should I go about considering
18、this specific patient with chest pain?,Evaluation of chest pain,CardiacAcute coronary syndrome (MI, angina), pericarditis, aortic dissection, MVP Pulmonarypulmonary embolism, pleuritis, pneumothorax, pneumonia GIesophageal spasms, GERD, esophagitis, gall bladder,Evaluation of chest pain,Musculoskele
19、talcostochondritis, muscle strain, rib fracture (falls, or trauma, cough, cancer) Neurologicherpes zoster (“band-like” pain may precede vesicular eruption) Psychologicalpanic disorder, depression Subphrenic causesusually subdiaphragmatic,So, use the PQRST + AA,Start with the PsPinpoint the pain, wha
20、t is the precise location? LEVINE signfist held over sternum is pretty classic for angina or an MI Swooping the hand from the back, under the axillary region and to the front may indicate a neuropathy Moving the fingers up and down from the bottom of the sternum to the top may indicate heartburn/GER
21、D,What precipitated the pain?,Exertion? What were you doing when the chest pain started? How long did it take before the chest pain started? Shoveling snow? Raking leaves? Usually a 5-minute delay (Lag time) for cardiac pain. Did the pain start as soon as you picked up the shovel or the rake? Did yo
22、u just have a fight with your boss? Did the pain start during sex? Digression: Can you have a heart attack during sex?,ONLY IF YOURE HAVING SEX WITH SOMEONE YOU SHOULDNT BE HAVING IT WITH!Usually NOT if its your same old, same old partner,First question for any male (from 20 to 120 years old) with c
23、hest pain(whether its during sex or not),When was your last dose of an erectile dysfunction drug?Sildenafil (Viagra)(24) Tadalafil (Cialis)(36-48) Vardenafil (Levitra)(24),Remember,The combination of an ED drug with a nitrate can be deadly Tell the whole truth, nuttin but the truth!,25,Back to the P
24、s,What palliates the pain? Stopping the activity? How long did it take before the chest pain stopped when you ceased the activity? Did you put a little white pill under your tongue? If so, how many and how long did it take for the pain to stop? Did you take an antacid?,Quality or Quantity,What is th
25、e Quality of the pain? Throbbing, burning, shooting, squeezing, crushing?,Radiate/Referred,Where does it Radiate? Front, back, side, down arm, up to the jaw? Is it Referred pain?,Severity,What is the severity of the painOn a scale from 1-10, with 1 being the least and 10 being “outta control”where d
26、o you rank pain on this scale?Angina 5 or 6 MI9 or 10 or greater,Timing or Temporal sequence,Temporal sequence; Timing When did it start? How long did it last? How often do you experience this type of pain? Whats unique about the time of day and an acute coronary syndrome?,PQRST,Any additional sympt
27、oms? Sweating? Nausea? Fatigue? Dizziness? Light-headedness Dyspnea (cardiac or respiratory)? BNP test (B-type natriuretic peptideunder 100 pg/mL rules out cardiac failure; greater than 500 pg/ rules in CHF) The feeling of impending doom,What is the age of the patient? Sex?,38 y.o. female with chest
28、 pain? Quick questions to rule OUT a myocardial infarction in a young womanwhat is her risk of having an MI at age 32? Family history Diabetes Birth control pills? Obesity? Surgical menopause? Autoimmune disease? SLE, RA, vasculitis Methamphetamine, cocaine, other drugs,How does coronary heart disea
29、se present in women?,The studies on heart disease were all done in VA hospitals Hello? Sexual bias? White men, 176 pounds, 45 years old,How does coronary heart disease present in women?,Atypical pain is more common in women than men, because of the higher prevalence among women of less common causes
30、 of ischemia, such as vasospastic and microvascular angina, and syndromes of nonischemic chest pain such as mitral valve prolapse, panic attacks, esophageal spasms,The evaluation of chest pain in women,Heart attack warning signs for womeninstead of crushing pain in the chest (40% DONT have crushing
31、chest pain), they may have: Fatigue or extreme tiredness SOB N & V, cold sweats Flushing, dizziness Jaw pain, abdominal pain, elbow pain Flu-like symptoms Symptoms that last for hours or days or even a month before the myocardial infarction,What about a,38 y.o. male with chest pain? Family history?
32、Illicit drugs? 68 y.o. female with classic chest pain? Most likely an ACS due to ageonset of menopause? 58 y.o. diabetic male with sweating, nausea, hypotension and the feeling of impending doom? Assume heart attack until proven otherwisesilent ischemia due to vagal neuropathy,Medical History? How m
33、uch time do you have? What is relevant to current episode?,Allergies Drug listprescription, OTC, illegal Prior surgeries or illnesses (but only if related to this episode) Family history Social history (if an STD is relevant) Smoking and drinking Dietary history (weight loss or weight gain),ALARM SI
34、GNS,Headache in the early morning vs. headache in the late afternoon when the kids get home from school Cough with hemoptysis and weight loss Chest pain with nausea and diaphoresis GERD with unexplained weight loss,How about a quick review of vital signs?,Weight is a vital sign in the elderly Unexpl
35、ained weight loss Consider? Depression, hyperthyroidism, $, GI, tremor, oral problems, swallowing, dementia, low salt/low fat diets, infection, cancer Weight loss and drugs,Weight gain,Weight gain and drugs (antidepressants, antipsychotics) Weight gain and heart failure,Kids and growth,Asian childre
36、n? African-American children? Latino children? Weight and growth parameters Premies? Breast fed babies gain weight more slowly,Kids and growth,Growth occurs in a step-wise pattern Vertical growth occurs during sleep when GH is released during the late stages of SWS Tonsillitis, adenoiditis and growt
37、h retardation Do kids have growing pains at night?,Vertical growth and Iron,Iron is essential for vertical growth Iron deficiency anemias in kids Consider celiac disease,Temperature patterns in the elderly,Loss of diurnal variation May not rise as rapidly with infections or as high A rise of greater
38、 than 3 degrees Fahrenheit within 2 hoursconsider sepsis Patients on neuroleptic drugs (dopamine blockers)c/o “cold”,Temperature patterns in the elderly,Difficulty maintaining internal temperatures with extremes of ambient temperature “Youre not dead until youre warm and dead.” The thyroid gland myx
39、edema coma (end-stage hypothyroidism) ALARM SIGN: hypothermia in a septic patient,Other temperature facts,Once antibiotics have been started, the finding of an unusually prolonged fever (longer than 72 hours) indicates: either that the diagnosis of infection was incorrect (the patient instead has a
40、connective tissue disorder or cancer) or that the patient has one of several complications such as resistant organisms, superinfection, drug fever, or an abscess requiring surgical drainage,Drug fevergreater than 102F (39 C),Antibiotics may cause a drug fever after 5 days of administration Drug alle
41、rgylook for a macular rash; Check the WBC and differential (increased eosinophils) If the child has been on AB for 4-5 days and the fever goes back up, check for “bands” on the WBC for re-infection with bacteria,Drug fever,Penicillin Cephalosporins Amphotericin B Tagamet Anticholinergics Neuroleptic
42、 fever,Heart rate,Unexplained tachycardia (greater than 100)consider hyperthyroidism, dehydration, atrial fibrillation, autonomic neuropathy with the loss of the vagus nerve in diabetics (results in silent ischemia) Bradycardia (less than 55)hypothyroidism, dig, beta blockers, calcium channel blocke
43、rs such as verapamil/diltiazem Bradycardia and a fever?,Heart rate, pulses,Important to take a pulse for at least 30 seconds for patient with an arrhythmia, but a full minute is more accurate With a 15-second pulse youll be off by 4 beats and with only a 10-second pulse youll be off by at least 6 be
44、ats,Heart rate in kids,Very labile in kids; more sensitive to the effects of illness, exercise, and emotions 1-2 years (120) 4-8 years (100) 10-12 years (75) Check radial with femoral (more valuable in older infants and toddlers; in infants a PDA may shunt blood to the lower extremities, bypassing a
45、 severe coarctation (MF),Heart rate,Beta-2 agonists for bronchodilation in asthmatics may cause tachycardia even tho they are beta-2 specific Tremor and saturation of B-2 receptor sites,Respirations,Fever and tachypnea in the older adultconsider an acute pulmonary syndrome-pulmonary embolism or pneu
46、monia,Rapid, deep breathing (acidosis)KUSMAL mnemonic,Ketones (DKA?) Uremia Salicylates Metabolic (consider thyroid) Alcohol Lactic acidosisCHF, sepsis,Blood pressure,What is ideal? 120/80 May be slightly higher in the elderly to avoid hypotension, fainting, and a broken hip (especially in diabetics
47、 on hypoglycemic meds) Keeping the blood pressure BELOW 140/90 prevents strokes, MIs, renal failure and DAT Lying down, sitting, and standing if possible,Blood pressure meds and physical assessment pearls,Beta blockers (“olols, alols, ilols”)cold feet, hair loss, decreased heart rate (10-15%), exerc
48、ise intolerance Thiazide diureticselectrolyte imbalances (especially sodium and potassium), confusion, blood sugar may rise,BP medications and physical assessment pearls,ACE inhibitors (“prils”)dry, hacking cough, hypoglycemia, hyperkalemia (muscle aches and pains), angioedema “Does my voice sound f
49、unny to you?” Calcium channel blockers (“dipines”)peripheral edema, headaches Calcium channel blockers (verapamil)-constipation,In the geriatric patientalways consider medications as a possible source of their chief complaint,Muscle aches and pains? Statins? ED drugs? Constipation? Burning in esophagus? Bisphosphonates? Did a pill “stick”? Confusion? Lots of drugs,“Nurse, I have the worst headache, can you give me something for pain?,P Q R S T Associated symptoms Absent signs and symptoms ALARM symptoms,
