1 – History and Examination




1 History and Examination


Lachlan Miles and Joseph E Arrowsmith




The first rule of diagnosis, gentlemen!

Eyes: first and most; hands: next and least; tongue: not at all!

Sir Lancelot Spratt – as played by James Robertson Justice

In: Doctor in the House (1954, The J. Arthur Rank Organisation)


Introduction


Patients may be admitted to the specialist cardiothoracic critical care unit from a variety of sources (Figure 1.1). In all elective admissions, and in the majority of emergency admissions, a clinical history will already have been elicited and a physical examination performed – often more than once. Most patients will already have undergone extensive investigation or therapeutic intervention, and the underlying diagnosis or diagnoses will have been established. Despite this seemingly ideal situation, the cardiothoracic intensivist should adopt an inquisitive attitude and use the so-called ‘history and physical examination’ to confirm previous findings, assess disease progression and exclude new pathology. Contrary to popular belief, this is often the most efficient and effective means of predicting and detecting significant comorbid conditions. Clinical investigations should therefore be considered an adjunct to, rather than a substitute for, basic medical assessment.





Figure 1.1 Cardiothoracic critical care admission sources.


In the critical care setting, particularly when a patient is physiologically unstable or has reduced consciousness, the conventional stepwise approach to the history and physical examination will usually require modification (Table 1.1). Indeed it may have to be conducted during or after initial resuscitation.




Table 1.1 Modification of conventional history and physical for use in critical care




















Conventional Critical care
History


  • History of presenting complaint



  • Past medical history



  • Past surgical/anaesthetic history



  • Drug history, allergies, sensitivities



  • Recreational substance (mis)use



  • Educational level/native language



  • Social/employment history



  • Religious/cultural beliefs



  • Family history



  • Systematic enquiry



  • Sensory impairments



  • Review of medical notes




  • Handover information



  • Review of medical notes



  • Information from family members

Physical


  • Patient supine – reclining at 45°



  • Cardiovascular



  • Respiratory



  • Gastrointestinal



  • Genitourinary



  • Neurological



  • Integument




  • Patient supine, lateral or prone



  • ABC (Airway, Breathing, Circulation)



  • Lines, tubes, drains and catheters



  • Drug and fluid infusions



  • Ongoing physiological monitoring



  • Anatomical examination



History



The Conscious Patient


All available sources of information should be drawn upon to construct as detailed a history as possible. Where the patient is conscious and able to respond to direct questioning, this important primary source of information should not be overlooked. Rather than using ‘open’ questions and expecting them to recount their entire current and past medical history in a concise fashion and in chronological order, it is often easier to ask the patient to confirm previously documented information and append newly acquired information as necessary. When faced with an acutely unwell and possibly deteriorating patient, the skilled intensivist needs to be able to quickly gather sufficient information to aid diagnosis and guide management. Of particular importance is the patient’s understanding of their medical condition, their insight into treatment options and prognosis, and their expectations. Corroborative history from family and carers is also invaluable, especially in the setting of acute delirium or dementia, where the patient’s own account may be unreliable. This information should be solicited and documented whenever possible.


Symptoms of cardiorespiratory disease (e.g. angina pectoris, dyspnoea, orthopnoea, syncope, palpitations, ankle swelling, etc.) (Table 1.2) should be actively sought, as should any recent progression in symptom severity. Symptoms should be described in terms of their nature (using the patient’s own words), onset, duration, progression, modifying factors and associations. The impact of symptoms on functional status should be documented using the New York Heart Association (NYHA) classification and the Canadian Cardiovascular Society (CCS) angina scale.




Table 1.2 Common symptoms associated with cardiorespiratory conditions











































Cardiovascular Respiratory
Syncope Recent overseas travel
Chest pain Fever and/or rigors
Fatigue or exercise intolerance Facial or sinus pain
Exertional dyspnoea Chest pain
Paroxysmal nocturnal dyspnoea Cough
Orthopnoea Sputum production (volume, time course, purulence)
Palpitations Haemoptysis
Intermittent claudication or ischaemic rest pain Dyspnoea
Stroke or transient ischaemic attack Exercise intolerance
Cough or sputum production History of bird keeping, asbestos exposure, or other sources of occupational lung disease
Peripheral oedema

Enquiry into the patient’s past medical history should include coexisting conditions, previous hospital admissions, surgical procedures and complications, prolonged hospitalisation and unplanned admissions to a critical care unit. It is important to note the indication for any surgical procedure or therapeutic intervention (e.g. splenectomy, permanent pacemaker, angioplasty), the outcome of the procedure and any anaesthetic related morbidity. A history of difficult tracheal intubation is of particular note, both with respect to the unintubated patient who may require intervention during their stay, and the patient who is already intubated who will require extubation before discharge to the ward. Factors known to be associated with increased mortality and morbidity (e.g. congestive cardiac failure, peripheral vascular disease, renal insufficiency, arterial hypertension, pulmonary hypertension, diabetes mellitus, chronic pulmonary disease, neurological disease and previous cardiovascular surgery) should be documented.


Where the patient has been admitted following a diagnostic or therapeutic intervention (e.g. coronary angiography or angioplasty), a comprehensive medical and nursing ‘handover’ is essential. This is particularly important when the patient has been brought to hospital by emergency ambulance and taken directly to the angiography suite. Similarly, when a patient is transferred from another hospital for specialist cardiothoracic care (e.g. surgical repair of acute type A aortic dissection), a formal handover of clinical information and documentation is an absolute prerequisite for the transfer of clinical responsibility and for safe ongoing care. In many areas a formal handover document or aide memoire is used both to guide and to document the comprehensive handover of clinically relevant information.


It is essential to record current and recent prescription drug administration, including formulation, dosage and route of administration. In addition, the medication history should include drugs taken ‘as required’, proprietary or ‘over-the-counter’ medicines, complimentary or alternative therapies, and recreational drugs. This latter category should include alcohol and tobacco products. A history of allergic or other idiosyncratic reaction to a specific drug (e.g. suxamethonium) or class of drugs (e.g. penicillins) should be sought and documented.


Where adherence to a particular cultural or religious belief system (e.g. Jehovah’s Witnesses) has the potential to influence any aspect of critical care management, this should be comprehensively documented. In some instances it may be appropriate to explore and document a patient’s specific wishes in a number of hypothetical clinical scenarios, including limits of care. It is often preferable that limits of care be discussed with the patient and family early on in the critical care stay, rather than late in the course of the illness when the patient is in extremis. It is important that both the patient and the family have a realistic understanding of what intensive care can offer, rather than relying on preconceived ideas.

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Jan 9, 2021 | Posted by in CARDIOLOGY | Comments Off on 1 – History and Examination
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