Chapter 4 for 12 Lead Training - ACS Assessment: History and Exam -

1. Chapter 4 for 12 Lead Training- ACS Assessment: History and Exam- Ontario Base Hospital Group Education Subcommittee 2008 TIME IS MUSCLE

2. ACS Assessment: History and Exam REVIEWERS/CONTRIBUTORS Neil Freckleton, AEMCA, ACP Hamilton Base Hospital Jim Scott, AEMCA, PCP Sault Area Hospital Ed Ouston, AEMCA, ACP Ottawa Base Hospital Laura McCleary, AEMCA, ACP SOCPC Tim Dodd, AEMCA, ACP Hamilton Base Hospital Dr. Rick Verbeek, Medical Director SOCPC AUTHOR Greg Soto, BEd, BA, ACP Niagara Base Hospital 2008 Ontario Base Hospital Group

3. Chapter 4 Objectives • Explain why getting a good medical history is so important in the AMI patient • List key elements to OPQRST & SAMPLE mnemonics for clinical investigation of possible ischemic problem

4. Importance of Clinical Presentation • No diagnostic test for acute myocardial infarction is perfect. • All medical literature related to ACS recognition suggest that the clinical presentation of the patient is of great importance. Clinical presentation consists of: • Incident history • Chief complaints • PMHX • Risk factors • Vital signs • Assessment findings

5. Getting a Good History • It is HOW we ask the questions • Mnemonics (OPQRST) are memory aids • Should not be asked literally to a patient

6. Investigating the C/C • O – Onset • P – Provoke • Q – Quality • R – Radiation • S – Severity • T – Time

7. O – Onset P – Provoke Q – Quality R – Radiation S – Severity T – Time Actual time this episode started Open-ended questions Try to get an actual time, i.e., 10:30 a.m. Very important for cardiac patients What to Ask

8. Onset “When did this episode of chest pressure start?” “When did this asthma attack start?” “When did the accident occur?”

9. Onset • Avoid using closed or leading questions... “Did the pain start last night or this morning?”

10. O – Onset P – Provoke Q – Quality R – Radiation S – Severity T – Time What makes it better or worse? Note the position of the patient What they were doing when it happened? What to Ask

11. Rule # 1 of Questioning While investigating a chief complaint, the only words you may use are the words the patient told you

12. Rule # 1 If the patient tells you: “I’m having a tightness in my chest.” You would reply: “When did this tightness start, Jack?” Rather than: “When did the pain start, Jack?”

13. Provoke “Jack, does anything you do make the tightness worse?” (Inspiration/Palpation/Movement/Position) “Does anything you do make the tightness less?” (Inspiration/Palpation/Movement/Position) “Jack, what were you doing when this tightness first started?”

14. O – Onset P – Provoke Q – Quality R – Radiation S – Severity T – Time What does pain feel like? Avoid closed and leading questions Let the patient have as many choices as they like to describe their “pain” What to Ask

15. Quality “Jack, what does this “pain” feel like?” “What would I have to do to you to make that kind of “pain?”

16. Closed or Leading Questions “Is the pain sharp or dull?” “Does the pain kinda feel like a belt around your chest?”

17. O – Onset P – Provoke Q – Quality R – Radiation S – Severity T – Time Do they have any problems or pain anywhere else? Watch for nonverbal clues Where is the pain? Pain may not “go” anywhere What to Ask

18. Radiation Instead of: “Does it hurt in the center or side of your chest?” Try: “Where does it hurt?” or “Can you draw a circle around it?”

19. O – Onset P – Provoke Q – Quality R – Radiation S – Severity T – Time Scale of 1–10 Make sure you find out what the worst pain was. Answers of >10 mean it hurts really BAD! What to Ask

20. Severity “On a scale of 1–10 with 10 being the worst pain you’ve ever had, and 1 being barely any pain at all, how would you rate your pain right now?” “What was the worst pain you have ever felt?”

21. O – Onset P – Provoke Q – Quality R – Radiation S – Severity T – Time The duration of the problem How long the current episode has been going on? If prolonged duration, was there a recent sudden severity increase? What to Ask

22. Time “How long has this recent episode of chest pressure lasted, Jack?” “How long did Jack’s seizure last?”

23. Tag-ons • Tag-ons are extra questions tacked on to the end of an ordinarily good question “Do you have diabetes, hypertension, or cardiac disease?” “Are you nauseated?” “Are you short of breath?” “Are you having chest pain?” “Is it sharp or dull?”

24. Tag-ons The best way to avoid a tag-on is to ask one question at a time and wait for the answer

25. SAMPLE History • S–Signs/symptoms • A– Allergies • M–Medications • P– Past History • L– Last meal • E– Events

26. Allergies “Jack, are you allergic to any medications?” “Jill, are you allergic to anything?” “Do you have any allergies, Jill?”

27. Medications “Do you take any doctor-prescribed medicines every day?”

28. Past Medical History • Ask one question at a time • Allow the patient time to answer • Explore what is pertinent

29. Last Oral Intake • Very important in diabetic emergencies • Important information for patient who may have to have surgery • Need to know when they ate last (time) and approximate amount

30. Events Leading up to C/C • What were they doing when the episode started? • Mechanism of injury? • Useful for neuro exam in head injuries • Pain at rest or on exertion?

31. Physical Exam • Head to toe • Look for JVD • Assess lung and heart sounds • Palpate the chest wall • Palpate the abdomen • Palpate radial pulses at the same time

32. Physical Exam (cont.) • Blood pressure in each arm • Positional changes for the patient • Apical versus radial pulses • Full auscultated blood pressure • Look for peripheral edema

33. The 12 Lead ECG • Best “early” confirming diagnostic test • Should be performed on any patient with a “pulse and problem” between nose and naval that is suspicious for cardiac • Should be acquired and triaged in less than 10 minutes arrival on scene

34. QUESTIONS?

35. START QUIT Well Done! Education Subcommittee