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Evaluation of a Terminal Patient

Evaluation of a Terminal Patient. Jay Peitzer, MD, FAAHPM. Goals. Improve skills in evaluating the signs and symptoms of terminal patients Correlate review of systems with physical findings Understanding how the improvement of diagnostic skills will result in improved clinical outcome.

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Evaluation of a Terminal Patient

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  1. Evaluation of a Terminal Patient Jay Peitzer, MD, FAAHPM

  2. Goals • Improve skills in evaluating the signs and symptoms of terminal patients • Correlate review of systems with physical findings • Understanding how the improvement of diagnostic skills will result in improved clinical outcome

  3. Basics • 80% HISTORY • 10% PHYSICAL EXAM • 10% DIAGNOSTICS

  4. History of Present Illness • How did this situation come about ? • Does the HPI fit the normal progression of the illness? • Has the patient had a functional decline ? • One of the most important parts of an H&P

  5. Functional Decline • Progressive Weakness • Unexplained weight loss • Rapid decline in level of consciousness

  6. BEWARE OF TUNNEL VISION • TERMINAL PATIENTS CAN HAVE ANY/OR ALL THE ILLNESSES OF A NON-TERMINAL PATIENT

  7. Medical History • Physical findings are easier to spot when anticipated based on patient medical history • Medication Profile • Scars and Chronic deformities

  8. Medical History • Review the History: Every Patient ! • Allergies (what happens?) • Smoking hx (ppd x years) • ETOH/Drug abuse (mild, moderate, a lot) • Significant medical problems/surgeries • Current medications

  9. Let the History (Hx) work for you • Believe patient’s answers! Don’t negatively quantify! • Has patient had similar symptoms? • What was the diagnosis? • How was it treated? • Did the treatment work? • (i.e. Bronchodilator for dyspnea)

  10. MOST COMMONLY MISSED/UNDER TREATED DISORDERS • DEPRESSION • COPD • ISCHEMIC HEART DISEASE (IHD) • NAUSEA/VOMITING • TERMINAL DELERIUM

  11. Review of Systems • Start with brief questions about each system • Expand ROS as medically indicated • Almost as important as HPI

  12. Pertinent Review of Systems • Dyspnea? At rest? Exertion? How much? • Chest pain? PQRST-Consider anginal equivalent (fatigue) • Wheezing/Chronic cough (dry or productive?) • Near syncope/syncope • Palpitations (rhythm disturbance) • Diaphoresis • XS fluid (pedal edema, orthopnea)

  13. PQRST Pain evaluation • Provokes or Palliates • Quality • Radiates • Severity • Temporality

  14. Physical Exam • Starts when I look across the room at the patient as I enter the room • Body Habitus • Color of skin • Emotional level in the room • Find a system that works for you, and then use it all the time

  15. Chest • Two major organ systems with overlapping signs and symptoms • Presenting S&S may result from one organ system affecting the other

  16. Parts Are Connected • Lung problems --> hypoxia --> angina • Heart failure --> pulmonary edema --> impaired pulmonary function

  17. Why is the patient short of breath? COPD • Sx’s improve with hydration • Fluids, Expectorants, Nebulizer tx’s • Not assoc. with cardiac symptoms • Wheezes and decreased breath sounds • Significant improvement with bronchodilators CHF • Sx’s improve with drying out • Diuretics • Assoc. with chest pain, diaphoresis, JVD, pedal edema • Rales progressed to no breath sounds may wheeze early • Modest improvement with bronchodilators

  18. Listen to the whole chest

  19. Breath sounds • Is the patient moving a normal volume of air? • Abnormal/Pathological Breath Sounds • Rales: fine (soda fizz) or coarse (blowing bubbles through a straw) • Rhonchi: wet sounds (harsh like a snore) • Wheeze: high pitched inspiratory or expiratory • Stridor: wheeze predominantly inspiratory and heard louder in neck than the chest Congestion is not a sound

  20. Breathing Patterns

  21. Heart Sounds listen to all foci • Aortic • Pulmonic • tricuspid • mitral

  22. Abnormal heart sounds • Murmurs • Rubs

  23. Cardiac Rhythm • Regular • Irregular • Irregular Irregular • Gallops

  24. Portable CVP

  25. Evaluation of the Abdomen • Bowel sounds • Tenderness • Distention • Masses • Fluid wave • Hepatomegaly

  26. HEENT • Symmetry • Bitemporal Wasting • Oral cavity mucosal changes • Adenopathy • Lesions/post operative changes

  27. Neurological Evaluation • Full exam usually not done • Focal exam as indicated nystagmus facial droop ptosis

  28. Extremities • Chronic changes c/w vascular disease arterial venous • Clubbing • Cyanosis • Ulcers and other lesions

  29. Look for symptom complexes • Ischemic disease (cardiac, cerebral, renal, bowel) • Atrial fibrillation/Chronic Obstructive Pulmonary Disease • Vague cardiac symptoms in diabetics and women

  30. 56 y.o. white male with bronchogenic carcinoma c/o chest pain What would you like to know?

  31. Summary • A working diagnosis can be formulated in a majority of patients solely based upon the patient’s history and physical

  32. Summary • Physical signs and symptoms are easier to find when anticipated based upon the patient’s history

  33. Summary • Making an accurate diagnosis leads to quality, cost effective treatment, and improved patient satisfaction

  34. The End

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