HEENT Flashcards
Inspection: Nose and Sinuses
-anterior and inferior surface- asymmetry or deformity
-inside nose: muscosa and septum
-muscosa- color, swelling, epistaxis, or exudates, ulcers, or polyps
-septum- deviation, inflammation, hematoma, or perforation
-inspection is always done in a physical exam
Palpation
-sinuses- frontal and maxillary
components of history
-chief complaint- one sentence, patients own words
-history of present illness (HPI)- OLD CARTS
-other active problems (OAP)
-past medical history (PMH)- hx
-social history (SH)
-family history (FH)
-review of systems (ROS)- signs and symptoms of every system
OLD CARTS
-onset
-location- radiating?
-duration- intermittent?
-character- describe
-aggravating/alleviating factors
-radiation /relieving factors
-timing- what were you doing
-severity
48 year old man comes to primary clinic complaining of headache. Previously healthy who describes having a severe right sided headache for the past 5 nights
Medications
-name
-dose
-frequency
-route
allergies
-seasonal
-food
-medications
How to approach a case: Evans 1974
- the same clinical syndrome may be produced by a variety of infectious pathogens
- the same pathogen may produce a variety of syndromes
- the most likely cause of a syndrome may vary by age, year, geography, and setting
- dx of pathogen is frequently impossible on the basis of clinical findings alone
- causes of a large portion of infectious disease syndromes are still unknown
Basic structure of the clinical reasoning process
-gathering initial patient information (health history and physical exam)
-organizing and interpreting information to synthesize the problem (problem representation)
-generating hypotheses (differential diagnosis) for pts problem
-testing hypotheses until a working diagnosis is selected
-planning the diagnostic and treatment strategy
approaches to searching for probable causes of the findings
-generate an exhaustive list
-match findings against all conditions that can produce them
-eliminate diagnostic possibilities that fail to explain the findings
-weigh competing possibilities and select the most likely diagnosis
-give special attention to potentially life threatening conditions (meningitis, subarachnoid hemorrhage)
premature closure
-close mindedness to certain diseases / conditions
physical exam
-vitals
-general appearance
-HEENT
-cardiovascular: heart and peripheral vascular system
-respiratory system
-GI system
-genitourinary system
-musculoskeletal system
-neurologic system
-you dont have to do all of these exams for each patient but consider them
PERRL
-pupils equal
-round
-reactive to light
assessment and plan
-assessment- beyond description and observation to analysis and interpretation
-select and cluster relevant information, analyze significance, try to explain them logically using principles of biopsychosocial and biomedical science
-clinical reasoning process is pivotal to how you interpret the pts hx and physical exam, single out problems identified in the assessment, and move form each problem to its action plan
-promotes communication and coordination among the professionals who care for your pt and documents the pts problems and management for medicolegal purposes
summary statement
-most likely diagnosis
-makes a case for your working diagnosis
-written in patients health record as the summary statement
-often starts the assessment section of the clinical record
-short (no more than 2-3 sentences
-not just facts
-restated pts CC and its clinical context with historical information, physical exam findings, study data result
-aligns with the illness script
-ex. 57 year old male with congestive heart failure and a 35 pack-year smoking hx presenting with acute, severe, exertional, retrosternal pain and associated shortness of breath. His examination is notable for a new S3 gallop, bibasilar crackles, and bilateral lower extremity edema.
