DOCSLIB.ORG

The Patient History for Example…

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
The Patient History for Example… 3/28/2017 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 possible • 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 lisinopril was prescribed for hypertension, or has the patient had the cough for 16 years 1 3/28/2017 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…” WATCH the patient as you are taking the history • Body language • Facial expressions 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? 2 3/28/2017 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… • Quantity of the (blood, vomit, sputum)? • Estimated volumes: Teaspoon = size of your first thumb joint; 1 “Dixie” cup = 75 mL; 1 coffee cup = 225 mL; 1 cola can = 350 mL; 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 Referred pain • Embryologic origins • The diaphragm starts in the neck and is supplied by cervical cord segments C3,4 (The phrenic nerve)—to supply your gills • Shared afferents with the shoulder/neck area of skin • Gills close up—diaphragm moves to the area between the thorax and abdomen; pulls the phrenic nerve with it • Anything that causes diaphragmatic irritation can refer the pain to the shoulder 3 3/28/2017 What causes diaphragmatic irritation? • Above the diaphragm (pneumonia, cardiac) and below the diaphragm (spleen, liver, gall bladder, ectopic pregnancy) • Lower lobe pneumonia • Fever (greater than 37.8), tachypnea (greater than 22) in the geriatric patient, confusion, and shoulder pain = pneumonia in the elderly 10 The fancy dermatome chart from textbooks • Area of skin supplied by a posterior (sensory) spinal cord segment— • Shared afferents with visceral organs • dermatomes T1‐T4—shared with myocardium, pericardium, aorta, pulmonary artery, esophagus…maximal intensity of pain is retrosternal/precordial area, up neck and down arm MY dermatome chart… • C3,4 (shoulder* and referred pain) • T4 (nipple) • T10 (umbilicus) • L1 (bikini underwear) • L2 (thigh) • L3,4 (knees) • S1,2 (back of the leg)‐‐ sciatica • S3‐5 (perineum)(anal wink) 4 3/28/2017 Herpes simplex –Sacral 3,4, &5 • Herpes “genitalia” • Enters via mucous membranes below the belt – lives in sacral nerve dorsal roots (S3‐S5) • “Hey nurse, can I get hairpiece from a toelet seat?” Sensory innervation to the face— cranial nerve V (trigeminal)—V1, 2, 3 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 • BODY LANGUAGE 5 3/28/2017 Pain severity in patients with Shingles (Herpes Zoster, Hell’s Fire) • The research scale used is from 1‐100 instead of 1 – 10 • Patients with reported scores greater than 40 are considered to have severe pain 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. • Did the nausea and vomiting precede the abdominal pain or did the abdominal pain come first followed by nausea and vomiting? If N & V first, consider gastroenteritis; if pain then N & V, it could be acute appendicitis in patients over age 13 with abdominal pain Time or Temporal sequence • Did the pain last for an hour, 15 minutes, 5 minutes, or less than 5 minutes? Or off and on for 5 years? • Acute appendicitis usually presents within 24 hours of the abdominal pain • Symptoms persisting for years are unlikely to be caused by a catastrophic infection, cancer, or other illness 6 3/28/2017 Temporal sequence and an ischemic stroke • Patients may wake up with a “stroke in progress…” • You have a 3 to 4.5 hour “window” to give tissue plasminogen activator (alteplase) in patients having an ischemic stroke • You need to know WHEN the stroke symptoms started? • “When did you last see your husband as normal?” • 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? The AAA’s…Associated symptoms , Absent symptoms or events or ALARM symptoms‐‐ • What else can you tell me about your problem? • Asking and CHARTING associated signs and symptoms as well as ABSENT signs and symptoms ALARM SIGNS • Headache every morning when awakening vs. headache every afternoon when the kids get home from school • Chronic cough with hemoptysis and weight loss • Chest pain with nausea and diaphoresis • GERD with unexplained weight loss 7 3/28/2017 Chief complaint… “Severe chest pain for 25 minutes”— first thought? Is this an acute coronary syndrome? • FIRST ACTION: Any patient with a suspected acute coronary syndrome should chew 160‐325 mg of ASA; • this one simple therapy is associated with a 35‐day mortality reduction exceeding 20% • 13% of patients in the Emergency Department with acute chest pain are having an acute coronary syndrome • Only 1.5% seen in the primary care setting are having an ACS • Now, think…what structures are located in the chest and how should I go about considering this specific patient with chest pain? Evaluation of chest pain…first thoughts • Cardiac—Acute coronary syndrome (MI, angina), pericarditis, aortic dissection, MVP • Pulmonary—pulmonary embolism, pleuritis, pneumothorax, pneumonia • GI—esophageal spasms, GERD, esophagitis, gall bladder 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 • *Musculoskeletal conditions account for 29% ‐36% of patients presenting to primary care facilities with the chief complaint of chest pain‐‐also associated with high anxiety rates (54%‐93%) 8 3/28/2017 Is it ACS? The following features help narrow the DX • HIGH LIKELIHOOD • Chest pain radiating to one or both arms • Chest pain associated with exertion, N, V, diaphoresis • Chest pain described as pressure or as “worse than previous angina or similar to previous MI” • (Cayley WE, Clinician Reviews, September 2014) Is it ACS? The following features help narrow the DX • LOW LIKELIHOOD • Stabbing, pleuritic, or positional chest pain • Pain in an inframammary location • Pain NOT associated with exertion • Pain IS reproducible with palpation* (*The most helpful sign or symptom in evaluating a patient with chest pain is chest wall tenderness on palpation, which largely rules out ACS in low‐ prevalence settings) • Cayley WE, Clinician Reviews, September 2014) So, use the PQRST + AA • Start with the P’s…Pinpoint the pain, what is the precise location? WATCH THE PATIENT • LEVINE sign…clenched 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 9 3/28/2017 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? Only if… • 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… • (Only 1% of all ACSs are during sex; 75% are when husbands are having an extramarital affair) 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) • Avanafil (Stendra)(24) 10 3/28/2017 Remember… • The combination of an ED drug with a nitrate can be deadly • Tell the whole truth, nuttin’ but the truth!! • “Two hours ago, but don’t tell my wife…” 31 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? (5‐minute lag time with cardiac ischemic pain) • 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?
Load more

Recommended publications
  • 1 IPC II Œ Quick Review Œ Abdominal Examination
    IPC II – Quick Review – Abdominal Examination Abdominal Examination Goals and Objectives: 1. Review normal abdominal examination a. Inspection, auscultation, percussion and palpations techniques I. Inspection Surface characteristics: Skin, Venous return, Lesions/scars, Tautness/ Striae, Contour, Location of umbilicus, Symmetry, Surface motion - Motion with respiration, Peristaltic waves, Pulsations Causes of distention: (The 9 F’s) Fat, Fluid, Feces, Fetus, Flatus, Fibroid, Full bladder, False pregnancy, Fatal tumor Types of distention: –Generalized –Below umbilicus –Above umbilicus –Asymmetric II. Palpation a. Used to assess the organs, detect muscle spasm, fluid, and tenderness b. Begin with Light Palpation of all 4 quadrants to detect muscular resistance (indicating peritoneal irritation) and areas of tenderness. Palpate the area that the patient complains of pain in-last. c. Progress to Moderate Palpation over all 4 quadrants to elicit tenderness that was not present with Light Palpation d. Use Deep Palpation to thoroughly delineate abdominal organs and to detect less obvious masses e. If a mass can no longer be detected when the patient lifts his/her head from the table (i.e., contracting the abdominal muscles), it is in the abdominal cavity, and not the abdominal wall f. Palpate the umbilical ring, and around the umbilicus for potential hernias III. Percussion a. Used to detect the size and density of the abdominal organs, fluid (ascites), air (gastric distention), or fluid-filled/solid masses b. Percuss all 4 quadrants for a sense of tympany or dullness 1. Tympany is heard over regions of air, i.e., stomach and intestines 2. Dullness is heard over organs and solid masses c.
    [Show full text]
  • Uncommon Differential Diagnosis of Acute Right-Sided Abdominal Pain – Case Report
    CASE REPORT SURGERY // RADIOLOGY Uncommon Differential Diagnosis of Acute Right-sided Abdominal Pain – Case Report Cédric Kwizera1, Benedikt Wagner2, Johannes B. Wagner3, Călin Molnar1 1 Department of Surgery, Emergency County Hospital, Târgu Mureș, Romania 2 Student, Faculty of General Medicine, University of Medicine, Pharmacy, Science and Technology, Târgu Mureș, Romania 3 Department of General, Abdominal and Endovascular Surgery, District Hospital Landsberg am Lech, Germany CORRESPONDENCE ABSTRACT Cédric Kwizera The appendix is a worm-like, blind-ending tube, with its base on the caecum and its tip in Str. Gheorghe Marinescu nr. 50 multiple locations. Against all odds, it plays a key role in the digestive immune system and 540136 Târgu Mureș, Romania appendectomy should therefore be cautiously considered and indicated. We report the case Tel: +40 729 937 393 of a 45-year-old male with a known history of Fragile-X syndrome who presented to the emer- E-mail: [email protected] gency department with intense abdominal pain and was suspected of acute appendicitis, after a positive Dieulafoy’s triad was confirmed. The laparoscopic exploration showed no signs of ARTICLE HISTORY inflammation of the appendix; nonetheless, its removal was carried out. Rising inflammatory laboratory parameters led to a focused identification of a pleural empyema due to a tooth inlay Received: February 22, 2019 aspiration. Our objective is to emphasize the importance of a thorough anamnesis, even in Accepted: March 27, 2019 cases of mentally impaired patients, as well as to highlight a rare differential diagnosis for ap- pendicitis. Acute appendicitis is an emergency condition that requires a thorough assessment and appropriate therapy.
    [Show full text]
  • ACUTE APPENDICITIS Anatomy
    ACUTE APPENDICITIS Anatomy • Embryologically, the appendix is a continuation of the cecum, first delineated during the fifth month of gestation • The appendix averages 10 cm in length (range 2‐20 cm). • The wall of the appendix consists of both an inner circular and an outer longitudinal layer of muscle. The longitudinal layer is a continuation of the taeniae coli. • The appendix is lined by colonic epithelium • Few submucosal lymphoid follicles are noted at birth. These follicles enlarge, peak between age 12 and 20 years, then decrease. Anatomy Anatomy • Blood supply from the appendicular artery, a branch of the ileocolic artery. This artery courses through the mesoappendix posterior to the terminal ileum. • An accessory appendicular artery can branch from the posterior cecal artery. • The appendix runs into a serosal sheet of the peritoneum called the mesoappendix Anatomy Anatomy • While the appendiceal base is in a constant location, the position of the tip of the appendix varies widely. • 65% of patients, the tip is located in a retrocecal position • 30%, it is located at the brim or in the true pelvis • 5%, it is extraperitoneal, situated behind the cecum, ascending colon, or distal ileum. Anatomy ETIOLOGY Appendicitis results from obstruction of the lumen of the appendix. o lymphoid hyperplasia (60%) o fecalith or fecal stasis (35%) o foreign body (4%) o tumors (1%) • Rarely non‐obstructive; vasculitis, Yersinia Obstructive causes Fecaliths form when calcium salts and fecal debris become layered around a nidus of inspissated fecal material located within the appendix. Lymphoid hyperplasia is associated with various inflammatory and infectious disorders including Crohn disease, gastroenteritis, amebiasis, respiratory infections, measles, and mononucleosis.
    [Show full text]
  • Robert Dachs, MD, FAAFP 8
    Board Review Express® February 19-22, 2020 Houston, TX geor Day 3 Friday, February 21 7:00 – 8:00 am Breakfast Provided 8:00 – 8:30 am Acute CVA & TIA – Robert Dachs, MD, FAAFP 8:30 – 9:00 am Adult Pulmonary Disease – Dana King, MD, MS, FAAFP 9:00 – 9:30 am The Surgical Abdomen – Robert Dachs, MD, FAAFP 9:30 – 10:00 am Asthma: Pediatric and Adult – Dana King, MD, MS, FAAFP 10:00 – 10:15 am Q&A 10:15 – 10:30 am Break 10:30 – 11:15 am Selected Issues in Women’s Health – David Weismiller, MD, ScM, FAAFP 11:15 – 11:45 am Musculoskeletal Medicine – Joseph Garry, MD, FACSM, FAAFP 11:45 am – 12:30 pm COPD, Lung Cancer, OSA, Sarcoidosis – Dana King, MD, MS, FAAFP 12:30 – 12:45 pm Q&A 12:45 – 1:45 pm Lunch Provided 1:45 – 2:15 pm Behavioral Medicine I: Major Depression – Stanley Oakley, MD, DLFAPA 2:15 – 2:45 pm Fracture Care in Family Medicine – Joseph Garry, MD, FACSM, FAAFP 2:45 – 3:15 pm Behavioral Medicine II: Bipolar & Anxiety Disorders – Stanley Oakley, MD, DLFAPA 3:15 – 3:30 pm Q&A 3:30 – 3:45 pm Break 3:45 – 4:15 pm Sports Medicine – Joseph Garry, MD, FACSM, FAAFP 4:15 – 4:45 pm Behavioral Medicine III: ADHD, Autism, & OCD– Stanley Oakley, MD, DLFAPA 4:45 – 5:15 pm Pediatric Orthopedics – Joseph Garry, MD, FACSM, FAAFP 5:15 – 5:30 pm Q&A Acute CVA and TIA Robert Dachs, MD, FAAFP Clinical Associate Professor Ellis Hospital Family Medicine Residency Program Albany Medical College, Albany, New York Disclosure Statement It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation.
    [Show full text]
  • Acute Abdominal Pain Handout.Pptx
    9/9/15 Evaluation and Management of Acute Abdominal Pain in Primary Care Joanna Guenther, PhD, RN, FNP-BC, CNE Objectives ! Discuss the symptoms of acute abdominal pain in relationship to the patient’s history and clinical presentation. ! Review the etiology of acute abdominal pain in relationship to anatomic location and the patient’s age. ! Review diagnostic testing to evaluate acute abdominal pain and discuss appropriate treatment plans. Epidemiology ! Abdominal Pain (AP) is a common reason for patients to seek primary care. ! Acute AP is defined in terms of symptoms lasting <1 wk. ! Admission rates for patients with acute AP range from 20-40% (and even higher in the elderly population). ! The diagnosis is undetermined in at least 50% of patients at the time of discharge. ! Initial diagnosis is accurate in only 50-65% of cases. 1 9/9/15 Abdominal Pain ! Differential very broad –"Work-up based on symptoms, medical history, physical exam, lab, and location (RUQ, RLQ, LUQ, LLQ, Epigastric, Flank) –"Determine which patients can be safely observed or treated symptomatically and which require further investigation and/or referral Rx Travel Hx Social Hx Duration Intensity Location HISTORY Onset Relieving & Triggers & aggravating associated factors symptoms Med Hx Surg Hx Family Hx Mechanisms of Pain Transmission Parietal Visceral Referred 2 9/9/15 Parietal Pain ! Caused by stimuli to nociceptors in parietal peritoneum/abdominal wall ! Sharp, discrete pain which is worsened by coughing, moving, sudden jolts - Patient lies still, scared to move Visceral Pain Caused by irritation of pain receptors in abdomen by mechanical and chemical stimuli –" Mechanical: distention, contraction, compression, torsion –" Chemical: serotonin, bradykinin, prostaglandins released in response to inflammation or ischemia ! Autonomic symptoms frequently present (N&V, sweating, pallor) ! Dull, colicky pain that is poorly localized ! Patient is restless, can’t get comfortable Referred Pain ! Pain is felt at a site away from the pathological organ.
    [Show full text]
  • GIS-K-25 ACUTE APPENDICITIS Appendiceal Mass / Abscess
    GIS-K-25 ACUTE APPENDICITIS Appendiceal Mass / Abscess Syahbuddin Harahap Division of Digestive Surgery Department of Surgery Faculty of Medicine University of North Sumatera Adam Malik Hospital INTRODUCTION The appendix is : -Wormlike extension of the cecum (vermiform appendix). -Length is 8-10 cm (ranging from 2-20 cm). -Fifth month of gestation -Several lymphoid follicles. Etiology: Obstruction of the lumen appendix followed by infection Catarrhal appendicitis. -lymphoid hyperplasia (60% children) -Gastro enteritis -Virus -Acute respiratory infection -Mononucleosis Obstructive appendicitis -fecalith 35% adults. -foreign body / parasites (4%) - tumors (1%) Pathophysiology Wangensteen proposed 1. Closed loop obstruction 2. Increase in luminal pressure. 3. Exceeds capillary pressure causes mucosal ischemia 4. Luminal bacterial overgrowth and translocation bacteria across the appendiceal wall result : -Inflammation -Edema -Necrosis perforation occur about 48 hours . If the body successfully walls off the perforation Appendiceal Mass If the perforation is not successfully walled off Diffuse peritonitis will develop. Problem: Appendicitis can mimic several abdominal conditions. Laboratory test Imaging investigation Statistics report 1 of 5 cases is misdiagnosed Normal appendix is found in 15-40% Emergency appendectomy.(Negative Appendectomy) Differential diagnosis of acute appendicitis Surgical Urological • • Acute Intestinalobstruction Right ureteric colic • • Intussusception Right pyelonephritis • • Acute cholecystitis Urinary tract
    [Show full text]
  • Abdominal Emergencies
    Prehospital: Emergency Care Eleventh Edition Chapter 23 Abdominal, Hematologic, Gynecologic, Genitourinary, and Renal Emergencies Slides in this presentation contain hyperlinks. JAWS users should be able to get a list of links by using INSERT+F7 Copyright © 2018, 2014, 2010 Pearson Education, Inc. All Rights Reserved Setting the Stage • Overview of Lesson Topics – Acute Abdomen – Hematologic Emergencies – Gynecologic Emergencies – Genitourinary/Renal Emergencies Copyright © 2018, 2014, 2010 Pearson Education, Inc. All Rights Reserved Case Study Introduction 67-year-old Mary Hill began experiencing intermittent, abdominal pain and cramping around her umbilical area several hours ago, but the pain has since become more intense and steady, and more localized toward the right lower quadrant. She feels nauseated, and as if she might be developing a fever. Copyright © 2018, 2014, 2010 Pearson Education, Inc. All Rights Reserved Case Study • How concerning is the patient's chief complaint? Explain your answer. • What questions should you ask this patient? • What are the steps of physical examination for this patient? Copyright © 2018, 2014, 2010 Pearson Education, Inc. All Rights Reserved Introduction • Abdominopelvic pain has many causes, and can be caused by serious underlying conditions. • Care includes managing life threats, making the patient comfortable, and transport. • Hematologic disorders are disorders of the blood and its components. • Gynecologic emergencies can present with abdominopelvic pain and vaginal bleeding. • Some gynecologic emergencies can be life-threatening. • Renal disease is common, and E M T s commonly encounter patients undergoing dialysis. Copyright © 2018, 2014, 2010 Pearson Education, Inc. All Rights Reserved Acute Abdomen • Abdominal Structures and Functions – The abdominal cavity extends from the diaphragm to the pelvis.
    [Show full text]
  • L'appendicite Acuta Questa «Sconosciuta»
    L’appendicite acuta questa «sconosciuta» Monica Ortenzi XIX congresso SICE, Ancona, 30 Settembre-1 Ottobre 2019 1522 Mc Burney’s Berengario Da Carpi, first description point 1561 Gabriele Falloppio and the «worm» 1570 Caspar Bauhin and a new theory of its purpose The mysterious appendix De Souza SC et al. Journal of Coloproctology, 2015, 35.4: 212-216 Mestivier Lawson Mc Burney Ott Acute appendicitis Double purse string and his point Transvaginal route 1735 1812 1886 1902 1759 1880 1889 1908 Aymand Parkinson Fitz Sir Treves The perforated A new name Appendectomy First appendectomy appendix in English and antisepsis The technique before the disease 90–100 patients/100 000 inhabitants per year in developed countries Geographical differences: lifetime risks for appendicitis of 16% in South Korea, 9-0% in the USA, and 1-8% in Africa More common the second or third decade of life “……Since Dr Fitz described appendicitis in 1886 the incidence has climbed, declined, and then plateaued in Western countries, whereas newly industrialized countries appear to be in the first stage of this sequence….” The most common abdominal emergency worldwilde…. Ferris M, et al. Annals of Surgery, 2017, 266(2):237-241 Female 2500 Male 2000 1500 1000 500 1 2 3 4 5 6 7 8 9 10 11 12 Ceresoli M, et al. World J Gastrointest Surg. 2016;8(10):693–699. …….yet the least understood “..It seems surprising and somewhat ironic that the diagnosis of acute appendicitis, one of“ the most common made by anatomic pathologists, remains poorly defined, subject to misconceptions, and prone to variable terminology….” Bhangu A, et al.
    [Show full text]
  • Physical Assessment 2017
    Disclosures • None related to this topic Physical Assessment Kenneth Wysocki PhD, FNP-BC, FAANP Objectives • Identify history components to establish differential diagnosis and management plan • Demonstrate advanced physical exam skills that support differential diagnosis and management plan Complete physical or focused exam? • Identify and demonstrate physical assessment components in the Medicare Advantage Program assessment visit Complete physical Focused exam • New patient • Concern, issue/problem, injury, work/DOT? • Pre surgery • History of Present Illness – OLDCARTS • Work/DOT • Onset • Location (radiation) • Welcome to Medicare • Duration • Medicare Advantage Program • Character • Aggravating factors • Relieving factors • Timing • Severity Problem Solving Chief complaint and demographics Clinical Reasoning: Differential Diagnosis Identify possible diagnoses STOP. THINK. What’s related to CC? Match possible diagnoses with - Anatomy findings that support (rule in) or - Systems/Physiology eliminate (rule out) diagnoses - Predisposing conditions Begin differential diagnosis thinking Determine top 3 most likely diagnostic hypotheses/ Guides assessments assessments - Subjective - Objective Sorting the results Subjective CC – HPI OLDCARTS • 70-75% (or more) of the diagnosis is in the history Pertinent ROS • Reasons for assessment • Problem focus • Medication reconciliation • Treatment revaluation • Complete physical • Active listening • History of present illness (HPI) • Review of systems (ROS) • Past medial history / Family history
    [Show full text]
  • Robert Dachs, MD, FAAFP 8:30 – 9:00 Am Common ENT Problems
    Board Review Express® February 6-9, 2020 Virtual Course geor Day 2 Friday, February 7 8:00 – 8:30 am Emergency Medicine I – Robert Dachs, MD, FAAFP 8:30 – 9:00 am Common ENT Problems – Teresa Holt, MD 9:00 – 9:30 am Emergency Medicine II – Robert Dachs, MD, FAAFP 9:30 – 10:00 am Challenging Issues in Hematology – Teresa Holt, MD 10:00 – 10:15 am Q&A 10:15 – 10:30 am Break 10:30 – 11:00 am Common Neurological Disorders – Teresa Holt, MD 11:00 – 11:30 am Peripheral Vascular Disease – Robert Dachs, MD, FAAFP 11:30 am – 12:00 pm The Major Arthritides – Benjamin Gilmer, MD, MS 12:00 – 12:15 pm Q&A 12:15 – 1:15 pm Break 1:15 – 1:45 pm Acute CVA & TIA – Robert Dachs, MD, FAAFP 1:45 – 2:15 pm Urologic Problems – Benjamin Gilmer, MD, MS 2:15 – 2:45 pm Maternity Care I – David Weismiller, MD, ScM, FAAFP 2:45 – 3:15 pm Endocrine Diseases – Benjamin Gilmer, MD, MS 3:15 – 3:30 pm Q&A 3:30 – 3:45 pm Break 3:45 – 4:15 pm Maternity Care II – David Weismiller, MD, ScM, FAAFP 4:15 – 4:45 pm The Surgical Abdomen – Robert Dachs, MD, FAAFP 4:45 – 5:30 pm Selected Issues in Women’s Health – David Weismiller, MD, ScM, FAAFP 5:30 – 5:45 pm Q&A Emergency Medicine: Part 1 Robert Dachs, MD, FAAFP Clinical Associate Professor Ellis Hospital Family Medicine Residency Program Albany Medical College, Albany, New York Disclosure Statement It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation.
    [Show full text]
  • Significant Causes of Pediatric Abdominal Pain Abdominal Distress Is Suspicious for Different Conditions at Different Ages
    Significant Causes of Pediatric Abdominal Pain Abdominal distress is suspicious for different conditions at different ages. The authors provide an age-based guide to major concerns in the differential diagnosis and a review of three painful illnesses that may present in children of any age: appendicitis, gastroenteritis, and constipation. By Alex Yeats, MD, and Jon D. Mason, MD major challenge that frequently con- a familial predisposition and a higher prevalence in fronts emergency physicians is accu- first-born males. rately diagnosing and treating children History and physical. In the first few weeks of with abdominal complaints. Although life, the infant will be asymptomatic and will appear Amost presentations are non-life-threatening, certain healthy. Subsequently, the caregiver will observe disease states have a high potential for morbidity vomiting after feeding, usually within 30 minutes of and mortality if unrecognized or not identified in each meal. After vomiting, the patient will frequently a timely manner. want to eat again. As the condition worsens, it causes Many factors contribute to the difficulty of this projectile nonbilious vomiting, which may be fre- process, most notably the variability of disease pre- quent or strenuous enough to produce the “coffee sentations and the inability of young children to ver- ground” appearance or streaks of blood that indicate balize their complaints or give an accurate history. Mallory-Weiss tears. Furthermore, abdominal pain may be the only pre- The physical examination findings depend on the senting complaint in some conditions that are rooted duration of symptoms. Early in the course, the patient in distant anatomic locations, including pharyngitis, may look well or, if vomiting has been severe, may pneumonia, urinary tract infections, diabetic keto- show signs of dehydration and weight loss.
    [Show full text]
  • Recurrent Fever in Childhood: What Must Be Considered?
    9/5/2015 Recurrent Fever in Childhood: What Must Be Considered? Wendy L. Wright, MS, APRN, BC, FAANP, FAAN Adult / Family Nurse Practitioner Owner - Wright & Associates Family Healthcare Amherst, New Hampshire Owner – Wright & Associates Family Healthcare Concord, New Hampshire Owner – Partners in Healthcare Education, LLC Disclosures • Speaker Bureau: Sanofi-Pasteur, Merck, Takeda, Boehringer • Consultant: Sanofi-Pasteur, Takeda, Pfizer Wright, 2015 2 Objectives • Upon completion of this lecture, the participant will be able to: – Discuss various causes of fever of recurrent fever or fever of unknown origin in children – Identify the most common tests to identify etiology of pediatric recurrent fevers – Discuss treatment options for children with recurrent fevers Wright, 2015 3 1 9/5/2015 Starting With the Basics No Single Accepted Definition of Fever • What is a fever? – Rectal temperature above 100.4ºF (38ºC) – Oral temperature above 100ºF (37.8ºC) – Axillary (armpit) temperature above 99ºF (37.2ºC) – Ear (tympanic membrane) temperature above 100.4ºF (38ºC) in rectal mode or 99.5ºF (37.5ºC) in oral mode – Forehead (temporal artery) temperature above 100.4ºF (38ºC) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3287087/ accessed 08-01-2015 No Consensus: Recurrent Fevers in Children • Recurrent fevers are defined as: – Three or more febrile episodes – Over a six-month period – Occurring at least seven days apart – No causative medical illness http://www.aafp.org/afp/2003/0215/p863.html accessed 08-01-2015 2 9/5/2015 Approach to Child with
    [Show full text]