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?