If you only have 5 minutes… PHYSICAL ASSESSMENT PEARLS

1. If you only have 5 minutes…PHYSICAL ASSESSMENT PEARLS Barb Bancroft, RN, MSN, PNP

2. 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 possible • Pick and choose the parts of the present and past history that are relevant to their current problem

3. 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 lisinopril was prescribed for hypertension, or has the patient had the cough for 6 years from asthma and hay fever

4. What is the patient telling you in his/her own words? • “I’ve had a terrible cough for 3 weeks…” • “I can’t catch my breath…” • “I am having awful pain in my chest…” • “My head feels like it’s going to explode…” • “My ankle is swollen…” • “I’ve got this shooting pain down the back of my leg…” • “My cat bit me and my hand is swollen…”

5. To characterize the “chief complaint” start with the PQRST mnemonic • P—Precise location? Where? • Pinpoint the location? Show me… • Precipitate the problem? What were you doing when it started? • Palliate the problem? Did anything help?

6. 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 bat…”Nurse: “duh…no wonder it hurts…”

7. 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: “uh-oh…” • Why “uh-oh?...more in a minute

8. To characterize the “chief complaint” start with the PQRST mnemonic • Quality of the pain? Help them out with this one…is it deep, burning, lancinating (shooting), cramping, crushing, vice-like, sharp, dull, explosive… • Quantitiy of the (blood, vomit, sputum)? Is it a teaspoon (size of your first thumb joint)? Is it a cup? Quart?

9. 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 intermittent production of purulent sputum in large quantities, as much as a quart/day

10. 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? Embryologic origins of pain

11. 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

12. Referred pain – another example • The ureters, kidney stones and the scrotum • Does a woman have a scrotum?

13. To characterize the “chief complaint” start with the PQRST mnemonic • S—what is the Severity of the pain? • Adults? 1 to 10 with 1 being the least painful and 10 being the most painful • Peds? Smiley to “frowney” faces

14. To characterize the “chief complaint” start with the PQRST mnemonic • T—what is the Time frame 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 pathophysiologic mechanisms which in turn imply specific diagnoses

15. 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 caused by a catastrophic infection, cancer, or other illness

16. 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 with symptoms? • Bed at 11? Woke up at 5, perfectly fine, to go to the bathroom? Woke up again at 7 with symptoms?

17. The A’s…Associated 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 your fatigue? • My mom passed away…my husband is in Iraq…my boyfriend dumped me…all my kids have the flu”, everybody in my family has diabetes…” • Nausea, vomiting, weight loss, blurred vision, cough…”worst headache I have every had…”

18. Chief complaint… “Severe chest pain for 25 minutes”—first thought? Is this an 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, think…what structures are located in the chest and how should I go about considering this specific patient with chest pain?

19. Evaluation of chest pain… • Cardiac—Acute coronary syndrome (MI, angina), pericarditis, aortic dissection, MVP • Pulmonary—pulmonary embolism, pleuritis, pneumothorax, pneumonia • GI—esophageal spasms, GERD, esophagitis, gall bladder

20. Evaluation of chest pain… • Musculoskeletal—costochondritis, muscle strain, rib fracture (falls, or trauma, cough, cancer) • Neurologic—herpes zoster (“band-like” pain may precede vesicular eruption) • Psychological—panic disorder, depression • Subphrenic causes—usually subdiaphragmatic

21. So, use the PQRST + AA • Start with the P’s…Pinpoint the pain, what is the precise location? • LEVINE sign…fist 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/GERD

22. 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 you just have a fight with your boss? Did the pain start during sex? • Digression: Can you have a heart attack during sex?

23. ONLY IF YOU’RE HAVING SEX WITH SOMEONE YOU SHOULDN’T BE HAVING IT WITH!!! • Usually NOT if it’s your same old, same old partner…

24. First question for any male (from 20 to 120 years old) with chest pain…(whether it’s during sex or not) • When was your last dose of an erectile dysfunction drug? • Sildenafil (Viagra)(24) • Tadalafil (Cialis)(36-48) • Vardenafil (Levitra)(24)

25. Remember… • The combination of an ED drug with a nitrate can be deadly • Tell the whole truth, nuttin’ but the truth!!

26. Back to the P’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?

27. Quality or Quantity • What is the Quality of the pain? Throbbing, burning, shooting, squeezing, crushing?

28. Radiate/Referred • Where does it Radiate? Front, back, side, down arm, up to the jaw? • Is it Referred pain?

29. Severity • What is the severity of the pain… • On a scale from 1-10, with 1 being the least and 10 being “outta control”—where do you rank pain on this scale? • Angina 5 or 6 • MI—9 or 10 or greater

30. 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? • What’s unique about the time of day and an acute coronary syndrome?

31. PQRST • Any additional symptoms? • Sweating? Nausea? Fatigue? • Dizziness? Light-headedness • Dyspnea (cardiac or respiratory)?? BNP test (B-type natriuretic peptide—under 100 pg/mL rules out cardiac failure; greater than 500 pg/ rules in CHF) • The feeling of impending doom…

32. What is the age of the patient? Sex? • 38 y.o. female with chest pain? • Quick questions to rule OUT a myocardial infarction in a young woman…what 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

33. How does coronary heart disease present in women? • The studies on heart disease were all done in VA hospitals • Hello? • Sexual bias? White men, 176 pounds, 45 years old

34. 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 of ischemia, such as vasospastic and microvascular angina, and syndromes of nonischemic chest pain such as mitral valve prolapse, panic attacks, esophageal spasms

35. The evaluation of chest pain in women • Heart attack warning signs for women—instead of crushing pain in the chest (40% DON’T have crushing 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

36. What about a… • 38 y.o. male with chest pain? Family history? Illicit drugs? • 68 y.o. female with classic chest pain? Most likely an ACS due to age…onset of menopause? • 58 y.o. diabetic male with sweating, nausea, hypotension and the feeling of impending doom? Assume heart attack until proven otherwise…silent ischemia due to vagal neuropathy

37. Medical History? How much time do you have? What is relevant to current episode? • Allergies • Drug list—prescription, 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)

38. ALARM SIGNS • 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

39. How about a quick review of vital signs? • Weight is a vital sign in the elderly • Unexplained weight loss • Consider? • Depression, hyperthyroidism, $, GI, tremor, oral problems, swallowing, dementia, low salt/low fat diets, infection, cancer • Weight loss and drugs

40. Weight gain • Weight gain and drugs (antidepressants, antipsychotics) • Weight gain and heart failure

41. Kids and growth • Asian children? African-American children? Latino children? • Weight and growth parameters • Premies? • Breast fed babies gain weight more slowly

42. 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 growth retardation • Do kids have growing pains at night?

43. Vertical growth and Iron • Iron is essential for vertical growth • Iron deficiency anemias in kids • Consider celiac disease

44. Temperature patterns in the elderly • Loss of diurnal variation • May not rise as rapidly with infections or as high • A rise of greater than 3 degrees Fahrenheit within 2 hours—consider sepsis • Patients on neuroleptic drugs (dopamine blockers)—c/o “cold”

45. Temperature patterns in the elderly • Difficulty maintaining internal temperatures with extremes of ambient temperature • “You’re not dead until you’re warm and dead.” • The thyroid gland – myxedema coma (end-stage hypothyroidism) • ALARM SIGN: hypothermia in a septic patient

46. 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 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

47. Drug fever—greater than 102ºF (39º C) • Antibiotics may cause a drug fever after 5 days of administration • Drug allergy—look 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

48. Drug fever • Penicillin • Cephalosporins • Amphotericin B • Tagamet • Anticholinergics • Neuroleptic fever

49. 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 blockers such as verapamil/diltiazem • Bradycardia and a fever?

50. 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 you’ll be off by 4 beats and with only a 10-second pulse you’ll be off by at least 6 beats