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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

Evaluation of a Terminal Patient

Jay Peitzer, MD, FAAHPM

goals
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
basics
Basics
  • 80% HISTORY
  • 10% PHYSICAL EXAM
  • 10% DIAGNOSTICS
history of present illness
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
functional decline
Functional Decline
  • Progressive Weakness
  • Unexplained weight loss
  • Rapid decline in level of consciousness
beware of tunnel vision
BEWARE OF TUNNEL VISION
  • TERMINAL PATIENTS CAN HAVE ANY/OR ALL THE ILLNESSES OF A NON-TERMINAL PATIENT
medical history
Medical History
  • Physical findings are easier to spot when anticipated based on patient medical history
  • Medication Profile
  • Scars and Chronic deformities
medical history8
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
let the history hx work for you
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)
most commonly missed under treated disorders
MOST COMMONLY MISSED/UNDER TREATED DISORDERS
  • DEPRESSION
  • COPD
  • ISCHEMIC HEART DISEASE (IHD)
  • NAUSEA/VOMITING
  • TERMINAL DELERIUM
review of systems
Review of Systems
  • Start with brief questions about each system
  • Expand ROS as medically indicated
  • Almost as important as HPI
pertinent review of systems
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)
pqrst pain evaluation
PQRST Pain evaluation
  • Provokes or Palliates
  • Quality
  • Radiates
  • Severity
  • Temporality
physical exam
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
chest
Chest
  • Two major organ systems with overlapping signs and symptoms
  • Presenting S&S may result from one organ system affecting the other
parts are connected
Parts Are Connected
  • Lung problems --> hypoxia --> angina
  • Heart failure --> pulmonary edema --> impaired pulmonary function
why is the patient short of breath
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
breath sounds
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

heart sounds listen to all foci
Heart Sounds listen to all foci
  • Aortic
  • Pulmonic
  • tricuspid
  • mitral
cardiac rhythm
Cardiac Rhythm
  • Regular
  • Irregular
  • Irregular Irregular
  • Gallops
evaluation of the abdomen
Evaluation of the Abdomen
  • Bowel sounds
  • Tenderness
  • Distention
  • Masses
  • Fluid wave
  • Hepatomegaly
heent
HEENT
  • Symmetry
  • Bitemporal Wasting
  • Oral cavity mucosal changes
  • Adenopathy
  • Lesions/post operative changes
neurological evaluation
Neurological Evaluation
  • Full exam usually not done
  • Focal exam as indicated nystagmus facial droop ptosis
extremities
Extremities
  • Chronic changes c/w vascular disease arterial venous
  • Clubbing
  • Cyanosis
  • Ulcers and other lesions
look for symptom complexes
Look for symptom complexes
  • Ischemic disease (cardiac, cerebral, renal, bowel)
  • Atrial fibrillation/Chronic Obstructive Pulmonary Disease
  • Vague cardiac symptoms in diabetics and women
56 y o white male with bronchogenic carcinoma

56 y.o. white male with bronchogenic carcinoma

c/o chest pain

What would you like to know?

summary
Summary
  • A working diagnosis can be formulated in a majority of patients solely based upon the patient’s history and physical
summary32
Summary
  • Physical signs and symptoms are easier to find when anticipated based upon the patient’s history
summary33
Summary
  • Making an accurate diagnosis leads to quality, cost effective treatment, and improved patient satisfaction