DOCSLIB.ORG

CARDIOVASCULAR EXAM/HISTORY Study Hub OSCE Sessions Dr Alison Cheung Structure

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
CARDIOVASCULAR EXAM/HISTORY Study Hub OSCE Sessions Dr Alison Cheung Structure CARDIOVASCULAR EXAM/HISTORY Study Hub OSCE Sessions Dr Alison Cheung Structure ■ Cardiovascular examination ■ OSCE tips ■ Cardiovascular history ■ Communication skills CARDIOVASCULAR EXAM Cardio exam - Introduction ■ WIPP – Wash hands – Introduce yourself (Name and position) – Identity: Confirm the patient’s name and DOB – Permission: – State that you would like to perform an exam – Explain what the exam will involve – Exposure, chaperone – Ask if they have any questions and if they are ok to begin – Position: Position patient 45’ in bed, ask if the patient has any pain IPPA - Inspection, Palpation, Percussion, Auscultation Cardio exam - Inspection ■ Bedside inspection ■ Closer inspection of the – Oxygen, fluids, medication, ECG, patient cardiac monitor, GTN spray – Hands – Nails – Wrist ■ General inspection of the patient – Arm – General appearance - well or unwell, in pain, distressed, cyanotic, breathless, fluid overloaded Cardio exam – Hand + Nails ■ Perfusion: – temperature – peripheral cyanosis – cap refill (>2 seconds in hypoperfusion) ■ Nails: – Clubbing (IE, cyanotic congenital heart disease) – Splinter hemorrhages (IE) – Koilonychia (iron deficiency anaemia) ■ Dorsum of hand: – Extensor tendon xanthomata (hyperlipidaemia) ■ Palm: – Osler’s nodes (IE, rheumatic fever) – Janeway lesions (IE, rheumatic fever) Cardio exam - Arms ■ Inspection: – Bruising (anticoagulation) – scar (radial artery harvest for CABG) ■ Radial pulse – rate (N =60-100bpm) – rhythm (regular, regularly irregular or irregularly irregular) – volume (normal, thready, bounding) – radio-radial delay (assess over 10 secs; aortic coarctation, aortic dissection, embolism, cervical rib) – offer to test radio-femoral delay (aortic coarctation, aortic dissection) ■ Collapsing pulse – Shoulder hurt? – Occlude radial pulse + feel for brachial pulse, raise arm above head – If brachial pulse disappear after raising hand = collapsing pulse (Aortic regurgitation) ■ Mention you would now measure the BP (measure in both arms if radio-radial delay) Cardio exam – Closer inspection of patient – Face ■ Malar flush (mitral stenosis) – Eyes ■ Corneal arcus and xanthelasma (hypercholesterolaemia) ■ Conjunctival pallor (anaemia) – Mouth ■ Central cyanosis (lung disease, cardiac shunt, hypoxia) ■ Poor dentition (risk of IE) ■ Tongue cracked? (hydration) Cardio exam - Neck ■ Inspection – De Musset’s sign – Head bobbing to heartbeat = severe aortic regurgitation ■ JVP (Jugular venous pressure) – Head turned slightly to the side – Seen up to 3 cm above sternal angle, between the two SCM heads ■ You shouldn’t see it - >3cm = heart failure, fluid overload, pulmonary HTN – Push RUQ – temporary increase of JVP (hepatojugular reflux) ■ Carotid pulse – Auscultate for bruits ■ Use bell – “breathe in and hold your breath” ■ Palpate radial pulse at the same time – Palpate: character and volume ■ 1 side @ a time! Cardio exam - Chest ■ Inspection – Scars (median <CABG>, infraclavicular <pacemaker>) – Visible heave (left or right ventricular hypertrophy) – Deformities – pectus exacavatum / carinatum ■ Palpate – Apex beat ■ Position (5th IC space, mid clavicular line; whole hand then 1 finger) ■ Displaced = ventricular hypertrophy – Left parasternal heave ■ Place the base of your right hand over the patient’s left parasternal edge ■ Forceful movement at the heel of hand ■ Right ventricular hypertrophy – Thrills (palpable murmur) ■ Place the base of your fingers on patient’s at all four heart valve positions ■ = turbulent blood flow ■ AS thrill most common (pulmonary area) – pulmonary HTN Cardio exam – Auscultation of chest ■ Auscultate – Listen over all 4 heart valves and simultaneously palpate the radial pulse – If you hear a murmur - where is it the loudest, timing, character, volume and radiation ■ Mitral valve - palpate apex beat, then auscultate ■ To confirm MM – roll patient to left, listen to left axilla with bell ■ Tricuspid valve ■ Pulmonary valve ■ Aortic valve ■ Listen over carotid artery and get the patient to hold their breath (aortic stenosis – § Pulmonary oedema carotid bruits) – Auscultate lungs ?fine ■ Ask the patient to lean forward and breath crepitations out (aortic regurgitation) – HI + HII + 0 is normal ■ Peripheral oedema – Extra sounds: S3, S4, clicks, snapping – Palpate tibia / medial – Murmurs = RILE (right on inspiration, left on malleolus for 10 seconds expiration) ?pitting Cardio exam - End and to complete ■ Thank patient ■ Offer to help patient get dressed ■ Does the patient have any questions? ■ Summarise findings and suggest differential diagnosis and/or further investigations – Bedside: Respiratory exam, Peripheral vascular exam, other baseline observations (Sats, Temperature) ECG, ABG – Bloods: FBCs, U&Es, LFTs, Troponin, BNP, Clotting profile – Imaging: CXR, ECHO *Only mention those investigations that are relevant OSCE TIPS OSCE tips ■ Approach with confidence – know what you’re looking for ■ Explain what you are doing to patients ■ Running commentary “I’ll be explaining my findings to the examiner as I go along” ■ If stuck – “I’ll take a moment to gather my thoughts” ■ Practice Practice Practice CARDIOVASCULAR HISTORY Cardiovascular history - Introduction ■ Name, role ■ Confirm patient’s name and DOB ■ Why you’re speaking to them ■ Confidentiality ■ Consent Cardio history – Presenting complaint ■ Pain – SOCRATES ■ Syncope – before, during, after ■ Site, onset, character, radiation, associated – Aortic stenosis – SOB + chest pain symptoms, timing (constant/intermittent), + syncope exacerbating and relieving factors, severity – Arrythmia (random +/- palpitations) (0-10) – Postural hypotension (after ■ Radiate to left arm and neck/jaw (ACS) standing quickly) ■ Crushing central chest pain, nausea, sweaty/clammy (myocardial infarction) ■ Relieved when lean forward (pericarditis) ■ SOB ■ Radiates to the back (aortic dissection) – Onset, exacerbating factors, ■ Last for few mins +/- brought on by normal vs current exercise exertion and relieved by rest (angina) tolerance ■ Palpitations – More pillows? Paroxysmal – Regular / irregular (tap out rhythm); fast/slow? nocturnal dyspnea (HF) – Associated – nausea, LOC, – Cough? Sputum (colour, blood, sweating/clamminess, SOB amount)? Wheeze? – Episodic? How does it feel like? What brings it – Leg swelling (HF) on? Cardiovascular history Other differentials for chest pain: ■ Respiratory – Pleuritic chest pain – PE ■ Gastrointestinal – Epigastric pain – Acid reflux / heartburn ■ MSK cause – Tenderness on specific point on palpation – costochondritis / rib # ■ Psychological cause – Anxiety Cardiovascular history ■ History of presenting complaint – Previous episode? – Systems review: Head to toe – Red flag symptoms: Fever, clammy/sweaty, chest pain ■ Past medical/surgical history – Diabetes, hypertension, high cholesterol – Been to the hospital for anything? See the GP regularly for anything? ■ Drug history (+OTC and herbal) and allergies (what happens?) ■ Family history ■ Heart problems / lung problems – Sudden death, diabetes, hypertension ■ Social history – Living circumstances, Job, Impact on life, Smoking (do you smoke? Have you ever smoked? How many/day? How long have you smoked?) Recreational drugs, Alcohol (how much per week?), diet ■ ICE - ideas, concerns, expectations ■ End – thanks, questions, safety net Summary of history - example ■ Today I’ve spoken to Mrs Smith, who is a 64 year old lady presenting with sudden onset chest pain. ■ She described it as a central crushing pain, radiating to her neck and left arm, associating with clamminess, SOB and nausea. She has no vomiting, no fever or LOC. ■ She has had this pain before, which is usually brought on by exertion and relieved by rest, lasting a few minutes. ■ Her past medical history includes T2 diabetes and hypertension. She takes metformin and amlodipine regularly and has no drug allergies. ■ She is an ex smoker, stopped 3 years ago. She does not drink alcohol or use recreational drugs. ■ In summary this is a 64 year old lady with sudden onset central chest pain. ■ My top differentials include myocardial infarction and unstable angina. ■ I would like to perform a cardio-respiratory examination, obtain baseline observations (temperature, saturations, HR), perform an ECG and get some blood tests including FBC, troponin, U&Es. ■ I would like a senior review. COMMUNICATION SKILLS Communication skills ■ Start with open questions, let the patient talk ■ Active listening, empathy ■ Chunk and check, summarise back ■ Signpost ■ Go with patients’ agenda ■ Thought parking ■ Form differentials in your head as you go along ■ Structure structure structure ■ ICE ICE ICE – early! FEEDBACK? THANK YOU!.
Load more

Recommended publications
  • Patient/ Family History
    Patient/ Family Mankato History Location: Mankato Fairmont New Prague Springfield St. James Waseca PATIENT PROVIDED INFORMATION The information you provide us will greatly help us to provide the highest quality and comprehensive care for you. Date Gender Male Female Date of birth (Month/Day/Year) A. PAST MEDICAL HISTORY 1. Have you ever traveled or lived outside of the United States or Canada? Do not know No Yes 2. Have you ever received a blood transfusion? Do not know No Yes (If yes, check all that apply.) Before 1980 1980-1990 After 1990 3. Have you received the following immunizations and/or had the disease? Pneumococcal (For pneumonia) Do not know No Yes Mumps Do not know No Yes Hepatitis B Do not know No Yes Rubella Do not know No Yes Hepatitis A Do not know No Yes Polio Do not know No Yes Measles Do not know No Yes Varicella (For chicken pox) Do not know No Yes 4. Indicate whether you have ever had a medical problem or surgery related to each of the following. Check all that apply. Medical Problem Surgery/Year Medical Problem Surgery/Year Eyes Lungs Ears Esophagus (Food or swallowing pipe) Nose Stomach (Ulcer) Sinuses Bowel (Small or large intestine, rectum) Tonsils Appendix Thyroid or parathyroid gland Lymph nodes Heart problems: Spleen Heart attack Liver Heart valves Gallbladder Abnormal heart rhythm Pancreas Narrowed coronary arteries Hernia Other Kidneys Arteries (Head, arms, legs, aorta, etc.) Bladder Veins or blood clots in the veins Bones ©2014 Mayo Foundation for Medical Education and Research Page 1 of 4 1081MR rev10/14 (Label) Patient Name DOB Unit No.
    [Show full text]
  • GUIDELINES for WRITING SOAP NOTES and HISTORY and PHYSICALS
    GUIDELINES FOR WRITING SOAP NOTES and HISTORY AND PHYSICALS by Lois E. Brenneman, M.S.N, C.S., A.N.P, F.N.P. © 2001 NPCEU Inc. all rights reserved NPCEU INC. PO Box 246 Glen Gardner, NJ 08826 908-537-9767 - FAX 908-537-6409 www.npceu.com Copyright © 2001 NPCEU Inc. All rights reserved No part of this book may be reproduced in any manner whatever, including information storage, or retrieval, in whole or in part (except for brief quotations in critical articles or reviews), without written permission of the publisher: NPCEU, Inc. PO Box 246, Glen Gardner, NJ 08826 908-527-9767, Fax 908-527-6409. Bulk Purchase Discounts. For discounts on orders of 20 copies or more, please fax the number above or write the address above. Please state if you are a non-profit organization and the number of copies you are interested in purchasing. 2 GUIDELINES FOR WRITING SOAP NOTES and HISTORY AND PHYSICALS Lois E. Brenneman, M.S.N., C.S., A.N.P., F.N.P. Written documentation for clinical management of patients within health care settings usually include one or more of the following components. - Problem Statement (Chief Complaint) - Subjective (History) - Objective (Physical Exam/Diagnostics) - Assessment (Diagnoses) - Plan (Orders) - Rationale (Clinical Decision Making) Expertise and quality in clinical write-ups is somewhat of an art-form which develops over time as the student/practitioner gains practice and professional experience. In general, students are encouraged to review patient charts, reading as many H/Ps, progress notes and consult reports, as possible. In so doing, one gains insight into a variety of writing styles and methods of conveying clinical information.
    [Show full text]
  • Medical History and Physical Examination Worksheet
    U.S. Department of State OMB No. 1405-0113 EXPIRATION DATE: xx/xx/xxxx MEDICAL HISTORY AND PHYSICAL EXAMINATION WORKSHEET ESTIMATED BURDEN: 35 minutes For use with DS-2053 (See Page 2 - Back of Form) Name (Last, First, MI) Exam Date (mm-dd-yyyy) Birth Date (mm-dd-yyyy) Passport Number Alien (Case) Number 1. Past Medical History (indicate conditions requiring medication or other treatment after resettlement and give details in Remarks) NOTE: The following history has been reported, has not been verified by a physician, and should not be deemed medically definitive. No Yes No Yes General Ever caused SERIOUS injury to others, caused MAJOR Illness or injury requiring hospitalization (including psychiatric) property damage or had trouble with the law because of Cardiology medical condition, mental disorder, or influence of alcohol or drugs Angina pectoris Hypertension (high blood pressure) Obstetrics and Sexually Transmitted Diseases Pregnancy Fundal height cm Cardiac arrhythmia Last menstrual period Date (mm-dd-yyyy) Congenital heart disease Sexually transmitted diseases, specify Pulmonology History of tobacco use Current useYes No Endocrinology and Hematology Asthma Diabetes mellitus Chronic obstructive pulmonary disease (emphysema) Thyroid disease History of tuberculosis (TB) disease History of malaria Treated Yes No Other Current TB symptoms Yes No Malignancy, specify Neurology and Psychiatry Chronic renal disease History of stroke, with current impairment Chronic hepatitis or other chronic liver disease Seizure disorder Hansen's Disease
    [Show full text]
  • Guidelines and Discussion of the History and Physical Examination
    GUIDELINES AND DISCUSSION OF THE HISTORY AND PHYSICAL EXAMINATION U.S. Department of Health and Human Services Centers for Disease Control and Prevention National Center for Emerging and Zoonotic Infectious Diseases Division of Global Migration and Quarantine April 16, 2012 Over 600,000 refugees have resettled in the United States over the past decade, with a steady increase in numbers since 2006 [1]. Refugees arrive from around the globe and settle throughout the United States. Depending on their country of origin, refugees are at increased risk for many diseases, both infectious and noninfectious, not commonly seen in the native US-born population. Conditions such as tuberculosis and sexually transmitted infections are particularly important to recognize early, given their potential public health consequences. The initial history and physical (H&P) examination is a critically important first step in the assessment of newly arrived refugees. A thoughtful H&P can both assist in identifying disease and help refugees develop a sense of trust in our medical system and in the care being provided (e.g., in many cultures a clinical encounter is viewed as useless if a physical examination is not performed during the visit). Given the complexity of the domestic medical screening visit, it is vital that clinicians set aside an adequate amount of time, create a trusting environment, and provide competent interpretation services to facilitate compassionate and culturally appropriate history acquisition and performance of the physical examination. Performing a History The first step in the examination of a newly arrived refugee is to obtain a detailed history, including any current symptoms, past medical problems, medications, allergies, social/family history, and a mental health assessment.
    [Show full text]
  • The Oral Presentation Nersi Nikakhtar, M.D
    Guidelines for the Oral Presentation Nersi Nikakhtar, M.D. University of Minnesota Medical School !1 Table of Contents The Oral Presentation: An Introduction ..................................3 Why Worry About the Oral Presentation? ...............................4 Presenting the New Patient .....................................................5 The Opening Statement ......................................................5 History of Present Illness ....................................................5 Past Medical History ...........................................................6 Medications/Allergies ..........................................................7 Social and Family History ...................................................7 Review of Systems ..............................................................7 Vitals .....................................................................................8 Physical Exam .....................................................................8 Labs and Studies .................................................................8 Summary Statement ............................................................8 Assessment and Plan ..........................................................9 The Follow Up (or Daily) Presentation: What's Different? ...................................................................11 The Outpatient (Known Patient) Presentation: What's Different? ...................................................................12 !2 The Oral Presentation: An Introduction The
    [Show full text]
  • Medical Terminology Information Sheet
    Medical Terminology Information Sheet: Medical Chart Organization: • Demographics and insurance • Flow sheets • Physician Orders Medical History Terms: • Visit notes • CC Chief Complaint of Patient • Laboratory results • HPI History of Present Illness • Radiology results • ROS Review of Systems • Consultant notes • PMHx Past Medical History • Other communications • PSHx Past Surgical History • SHx & FHx Social & Family History Types of Patient Encounter Notes: • Medications and medication allergies • History and Physical • NKDA = no known drug allergies o PE Physical Exam o Lab Laboratory Studies Physical Examination Terms: o Radiology • PE= Physical Exam y x-rays • (+) = present y CT and MRI scans • (-) = Ф = negative or absent y ultrasounds • nl = normal o Assessment- Dx (diagnosis) or • wnl = within normal limits DDx (differential diagnosis) if diagnosis is unclear o R/O = rule out (if diagnosis is Laboratory Terminology: unclear) • CBC = complete blood count o Plan- Further tests, • Chem 7 (or Chem 8, 14, 20) = consultations, treatment, chemistry panels of 7,8,14,or 20 recommendations chemistry tests • The “SOAP” Note • BMP = basic Metabolic Panel o S = Subjective (what the • CMP = complete Metabolic Panel patient tells you) • LFTs = liver function tests o O = Objective (info from PE, • ABG = arterial blood gas labs, radiology) • UA = urine analysis o A = Assessment (Dx and DDx) • HbA1C= diabetes blood test o P = Plan (treatment, further tests, etc.) • Discharge Summary o Narrative in format o Summarizes the events of a hospital stay
    [Show full text]
  • Patient Assessment – Medical
    National Registry of Emergency Medical Technicians® Emergency Medical Technician Psychomotor Examination PATIENT ASSESSMENT/MANAGEMENT – MEDICAL Candidate: Examiner: Date: Signature: Scenario # Possible Points Actual Time Started: __________ Points Awarded Takes or verbalizes appropriate body substance isolation precautions 1 SCENE SIZE-UP Determines the scene/situation is safe 1 Determines the mechanism of injury/nature of illness 1 Determines the number of patients 1 Requests additional EMS assistance if necessary 1 Considers stabilization of the spine 1 PRIMARY SURVEY/RESUSCITATION Verbalizes the general impression of the patient 1 Determines responsiveness/level of consciousness (AVPU) 1 Determines chief complaint/apparent life-threats 1 Assesses airway and breathing 3 -Assessment (1 point) -Assures adequate ventilation (1 point) -Initiates appropriate oxygen therapy (1 point) Assesses circulation -Assesses/controls major bleeding (1 point) -Checks pulse (1 point) 3 -Assesses skin [either skin color, temperature or condition] (1 point) Identifies patient priority and makes treatment/transport decision 1 HISTORY TAKING History of the present illness -Onset (1 point) -Quality (1 point) -Severity (1 point) 8 -Provocation (1 point) -Radiation (1 point) -Time (1 point) -Clarifying questions of associated signs and symptoms related to OPQRST (2 points) Past medical history -Allergies (1 point) -Past pertinent history (1 point) -Events leading to present illness (1 point) 5 -Medications (1 point) -Last oral intake (1 point) SECONDARY ASSESSMENT
    [Show full text]
  • OPQRST-AAA One Tool That Some Clinicians Find Helpful Is Using the Mnemonic OPQRST-AAA to Elicit the Details of a Pain Complaint
    #1 Take a history related to diarrhea Diarrhea is subjective and can be defined as an increase in the volume, frequency or fluidity of stool relative to normal conditions. First introduce yourself to the patient and start: Personal and Social History: name, age, gender, occupation – Use as your own (Single, living with parents. No tobacco use). Present complaint: “ What brought you here”? 1-When these complaints started? It started early in the morning. 2-How many times do you go to the toilet today? 6 times. 3-How many times did you use to go to the toilet before this problem? Once daily. 4-Can you describe your stool: a. Is it watery, or bulky? Yes, watery. b.What color? Light yellow. c. Is there any blood or mucous in stool? No. d.Does it have foul smell? A little bit. 5-Do you have any additional symptoms - any nausea or vomiting? I vomited twice. 6-Do you have fever? No 7- Is there any pain on passing stools? No, but I have abdominal discomfort. 8-Can you describe what do you mean by abdominal discomfort? Is it located in certain part of the abdomen? When it comes I urgently go to the toilet. It is all around, I can’t specify any location. 9-Recent dietary history, consumption of meats (cooked, uncooked) eggs, seafood, or unusual foods? I ate fast food last night in the restaurant. 10-Anyone around you have the same symptoms? No 11-Does anything make it better or worse? I did not recognize anything specific.
    [Show full text]
  • Guide to History Taking and Examination
    MBBS Year 4 GUIDE TO HISTORY TAKING AND EXAMINATION 2015-16 Copyright University College London Medical School University College London 1 Contents The Medical History ................................................................................ 3 How to take a Respiratory History ..................................................... 12 How to take a Cardiovascular History ............................................... 13 How to take a Locomotor History ....................................................... 14 How to take a history of pain ............................................................... 14 Presenting patients Workshop ............................................................. 15 General Tips on How to Perform an Examination ........................... 16 Dress and Behaviour Expected in Clinical Area ............................... 18 Cardiovascular Examination ................................................................ 19 Respiratory Examination ...................................................................... 24 Abdominal Examination ....................................................................... 26 Musculoskeletal Examination- GALS Screen ................................... 30 Motor Examination of Lower Limbs ................................................... 32 Examination of the Upper Limbs ........................................................ 35 Sensory Examination of Lower Limbs ................................................ 38 Cranial Nerve Examination .................................................................
    [Show full text]
  • Introduction to the Clinical Practice Guidelines
    INTRODUCTION TO THE CLINICAL PRACTICE GUIDELINES First Nations and Inuit Health Branch (FNIHB) Clinical Practice Guidelines for Nurses in Primary Care. The content of this chapter was revised in December 2011. Table of Contents PURPOSE .................................................................................................................I–1 STRUCTURE ............................................................................................................I–1 Format of Body System Chapters .......................................................................I–1 Format of Medical Diagnosis/Condition Descriptions .........................................I–1 CULTURE ..................................................................................................................I–2 Commonly Cited Value ........................................................................................I–2 Culture and Health ..............................................................................................I–2 Culture and Health Care .....................................................................................I–3 TRAUMA INFORMED CARE ....................................................................................I–4 COMMUNICATION ....................................................................................................I–4 Therapeutic Relationships ..................................................................................I–4 History Taking ......................................................................................................I–4
    [Show full text]
  • SOAP Notes Format in EMR
    SOAP Notes Format in EMR SOAP stands for Subjective, Objective, Assessment, and Plan Standard Elements of SOAPnote Date: 08/01/02 Time: Provider: Vital Signs: Height, Weight, Temp, B/P, Pulse S: This ___ yr old fe/male presents for ____ History of Present Illness symptoms: Review Of Symptoms/Systems: (For problem-focused visit, document only pertinent information) Past Medical History: (For problem-focused visit, document only pertinent information) Current Medications: Medication allergies: Social History: (For problem-focused visit, document only pertinent information) Family History: ((For problem-focused visit, document only pertinent information) Genogram: 3 generations with health problems, causes of deaths, etc. or History of major health or genetic disorders in family, including early death, spontaneous abortions or stillbirths. Social History: Past Medical History History of Present Illness: Cultural Background: Hospitalizations: Location: Education Level: Surgical History: Quality Economic Condition: T&A: Severity: Housing: Appendectomy: Duration: Number in household: Hysterectomy: Timing (Onset): Marital Status: Hernia: Timing (Frequency): Lives with: Coronary Artery Bypass: Context: Children: Other: Relieved by: Chronic Medical Problems: Occupation: Hypertension Worsened by: Occupational Health Diabetes Associated signs and symptoms: Hazards: Coronary Heart Disease Nutrition: Cerebrovascular Disease Exercise: Asthma or other COPD Tobacco use: Arthritis Review Of Symptoms (Systems): Constitutional: Caffeine: Gout Sexual activity:
    [Show full text]
  • History and Physical Ms 117
    HISTORY AND PHYSICAL MS 117 Manual Medical Staff Effective Date 02/28/2007 Policy # MS 117 Date Revised 12/31/2014 Responsible Director, Medical Staff Services Next Scheduled Review 12/31/2017 Person PURPOSE To define the elements of a patient’s history and physical examination and medical history on admission or before any operative or interventional procedure. POLICY A. Contents of a History and Physical Examination (H&P) 1. The H&P shall be performed by a qualified member of the medical staff or designee with appropriate privileges, except as noted in B.2 below. 2. The H&P shall consist of chief complaint, history of present illness, allergies and medications, relevant social and family history, past medical history, review of systems and physical examination, appropriate to the patient’s age. B. Inpatient Admission 1. Within 24 hours after admission or immediately before, an H&P examination shall be performed, providing the patient’s condition permits. 2. If a complete history and physical was performed within thirty (30) calendar days prior to the patient’s admission to the Ronald Reagan UCLA Medical Center an interval history and physical is required within twenty-four (24) hours of admission. A history and physical from a non-medical staff member will be acceptable if the medical staff physician assumes the responsibility for the accuracy of the clinical information. The medical staff physician will document in the medical record that the history and physical has been reviewed and accepted. An update is required if the history and physical is performed prior to the admission.
    [Show full text]