Assessment and Investigation of Patients' Problems Flashcards
Problem-Oriented Medical Records (POMR)
Method of recording the assessment, management and progress of a patient. Divided into 5 sections:
- Database
- Problem list
- Initial plans and goals
- Progress notes
- Discharge summary
POMR: Database (Def)
Contains a concise summary of the relevant information about the pt taken from the medical notes, together with the subjective and objective Ax made by the PT.
POMR: Database (Sections)
> History of Presenting Condition (HPC): summarizes pt’s current problems.
Previous Medical History (PMH): entire list of medical and surgical problems.
Drug History (DH): list of current medication (including dosage and allergies).
Family History (FH): list of any major diseases suffered by members of immediate family.
Social History (SH): picture of pt’s social situation. Particular emphasis on stairs, smoking and alcohol, contribution to household duties.
Pt examination: information collected in the PT’s subjective and objective Ax.
Test results
POMR: Database (Subjective Ax)
There are 5 main symptoms of respiratory disease: > Breathlessness (dyspnea) > Cough > Sputum and haemoptysis > Wheeze > Chest Pain
With each of these symptoms, enquiries should be made concerning:
> Duration: both absolute and present symptoms.
> Severity: in absolute terms and relative to recent and distant past.
> Pattern: seasonal or daily variations
> Associated factors: including precipitants, relieving factors, and associated factors.
Breathlessness
Subjective awareness of an ↑ work of breathing.
The duration and severity is most easily assessed through enquiries about the level of functioning in the recent and distant past.
The PT should always relate breathlessness to the level of function that the pt can achieve.
Breathlessness: NY Heart Association classification of breathlessness
Class I: No symptoms with ordinary activity, breathlessness only occurring with severe exertion (running up hills, fast bicycling, cross-country skiing).
Class II: Symptoms with ordinary activity (walking up stairs, making beds, carrying large amounts of shopping).
Class III: Symptoms with mild exertion (bathing, showering, dressing).
Class IV: Symptoms at rest*.
- Orthopnea: breathlessness when lying flat.
- Paroxysmal Nocturnal Dyspnea (PND): breathlessness that wakes the pt at night.
Cough
Protective reflex that rids the airways of secretions or foreign bodies.
Important features are: effectiveness, and whether is productive or dry.
Examples of cough and possible diseases:
- Loud, barking, “bovine”: laryngeal or tracheal disease.
- Recurrent after eating or drinking: aspiration.
- Chronic and productive every day: chronic bronchitis and bronchiectasis.
- Persistent, dry: interstitial lung disease.
- Nocturnal: asthma in children and young adults, cardiac failure in adults.
- Beta-blockers and some antihypertensive agents can cause chronic cough.
Sputum
Questioning should determine the colour, consistency, and quantity of sputum produced each day.
In clinical practice is often classified as:
- Mucoid.
- Mucopurulent.
- Purulent.
Wheeze
Whistling or musical sound produced by turbulent airflow through narrowed airways.
Chest pain
In respiratory pt usually originates from MSK, pleural or tracheal inflammation.
- Pleuritic chest pain: severe, sharp, stabbing pain that is worse on inspiration.
- Tracheitis: constant burning pain in the centre of the chest, aggr by breathing.
- MSK (chest wall) pain: well localized and exacerbated by chest and/or arm mvmt. Palpation usually reproduces the pain.
- Angina pectoris: dull central retrosternal gripping or band-like sensation, which may radiate to either arm, neck or jaw.
- Pericarditis: similar pain to angina or pleurisy.
POMR: Database (Objective Ax)
> General observation: from end of the bed. Appearance, speech pattern, distressed, level of ventilatory support, level of cardiovascular support, drugs, consciousness level (Glasgow Coma Scale).
Objective Ax: pt observation
> Body temperature: fever > 37.5ºC. Every 1ºC rise = +10% O2 consumption and CO2 production.
> Heart Rate: Tachycardia > 100 bpm, Bradycardia < 60 bpm.
> Blood Pressure (BP): Systole = arterial pressure rises, Dyastole = arterial pressure drops. Normal = 140-95/90-60.
> Respiratory Rate: Normal = 12-16 breaths/min. Tachypnea > 20, Bradypnea < 10.
> Body Weight: Underweight BMI = <20; Normal BMI = 20-25 kg/m2; Overweight >25-30; Obese >30.
> Apparatus
> Intercostal drains: bubbling indicates that air is entering the tube from the pleural space. If the fluid doesn’t swing, the tube is not patent and requires medical attention.
> The hands: fine tremor, warm and sweaty with irregular flapping tremor, weakness and wasting of the small muscles, clubbing.
> The eyes: pallor (anaemia), plethora (high haemoglobin) or jaundice (yellow colour due to liver or blood disturbances).
> Cyanosis
> Jugular Venous Pressure
> Peripheral oedema
Objective Ax: Observation of the chest
- Chest shape: kyphosis, kyphoscoliosis, pectus excavatum, pectus carinatum, hyperinflation.
- Breathing pattern: inspiratory to expiratory time (I:E ratio) is 1:1.5 to 1:2.
Prolonged expiration: obstructive lung disease, expiratory airflow severly limited by dynamic closure of the smaller airways. 1:3 to 1:4.
Pursed-lip breathing: seen in pt with severe airways disease.
Hypopnea: shallow breathing (<50% normal) for >10”.
Kussmauls’s respiration: rapid, deep breathing with high minute ventilation. Seen in acidosis.
Cheyne-Stokes respiration: irregular with cycles of a few relatively deep breaths, progressively shallower breaths, and then slowly increasing depth again. Associated with heart failure, severe neurological disturbances or drugs.
Ataxic breathing: haphazard, uncoordinated deep and shallow breaths. Seen in cerebellar disease.
Apneustic breathing: characterized by prolonged inspiration. Seen in brain damage. - Chest mvmt: pump and bucket handle.
Intercostal indrawing: skin between ribs drawn inwards during inspiration. Seen mostly in children with severe inspiratory airflow resistance.
Objective Ax: Palpation of the chest
- Trachea: to assess its position in relation to sternal notch.
- Chest expansion: pt instructed to expire slowly to residual volume. PT places thumbs touching in the midline posteriorly. Then the pt is instructed to inspire slowly and the mvmt of both thumbs is observed. Both sides should move equally, with 3-5 cm being normal.
Paradoxical breathing: some or all of the chest wall moves inwards on inspiration and outwards on expiration. - Surgical emphysema: air in the subcutaneous tissues of the chest, neck or face.
- Vocal fremitus: measure of speech vibrations transmitted through the chest wall to the examiner’s hands. Say “99”.
Objective Ax: Percussion
Performed by placing left hand firmly on chest wall so fingers have good contact with skin. Middle finger L hand struck over the distal IF joint with the middle finger of the R hand.
Normal resonance is heard over aerated lung.
Consolidated lung sounds dull.
Pleural effusion sounds stony dull.
Pneumothorax increases resonance.
