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This document provides guidance on evaluating patients presenting with chest pain, edema, or palpitations. It outlines the key components of the medical history to obtain including onset/timing/duration of symptoms, aggravating/relieving factors, relevant medical, family, social and review of systems history. Examination skills are reviewed including vital signs, heart and lung auscultation, abdominal examination, and checking for extremity edema. Differential diagnoses for common complaints are referenced.
This document provides guidance on evaluating patients presenting with chest pain, edema, or palpitations. It outlines the key components of the medical history to obtain including onset/timing/duration of symptoms, aggravating/relieving factors, relevant medical, family, social and review of systems history. Examination skills are reviewed including vital signs, heart and lung auscultation, abdominal examination, and checking for extremity edema. Differential diagnoses for common complaints are referenced.
This document provides guidance on evaluating patients presenting with chest pain, edema, or palpitations. It outlines the key components of the medical history to obtain including onset/timing/duration of symptoms, aggravating/relieving factors, relevant medical, family, social and review of systems history. Examination skills are reviewed including vital signs, heart and lung auscultation, abdominal examination, and checking for extremity edema. Differential diagnoses for common complaints are referenced.
1. Chest pain 2. edema (ankle, leg or sacral) 3. Palpitations MEDICAL COMMUNICATION SKILLS General Data HPI
Risk factors: Age, gender, occupation
FOR EACH SYMPTOM, DESCRIBE - Onset/timing/duration/frequency - location - quality/character - severity or quantity - setting in which it occurs - aggravating and relieving factors - Associated manifestations: orthopnea, paroxysmal nocturnal dyspnea, easy fatigability (exercise tolerance/stairs), intermittent claudication, palpitations, dizziness, blackouts, heartburn - For DDx of chest pain, see Bates Table 8-1, pp. 350-351 and pp. 88-90, DDx of common complaints For DDx of palpitations, pp. 337-339, DDx of common complaints - For DDx of edema, pp. 379-381, DDx of common complaints; Bates Table 12-1
Past Medical History
Family History Social, Environmen tal History ROS
- hypertension, diabetes, hyperlipidemia, prior angina or
myocardial infarction, revascularization procedures, abdominal aortic aneurysm, cerebrovascular disease, peripheral arterial disease, chronic kidney disease - medications, dose and compliance (if any) - previous confinements - allergies - FOR CHEST PAIN: - Risk factors for pulmonary embolism: recent surgery, recent immobility (long flights, bedridden), on HRT, current diagnosis of cancer, previously diagnosed pulmonary embolism/deep vein thrombosis - recent straining/lifting/chest trauma - history of heartburn, hiatal hernia or reflux disease - hypertension, diabetes - premature cardiovascular disease or sudden death (men aged <55 or women aged <65) - smoking history (pack years) - alcohol intake - diet - physical activity 3-5 representative symptoms per system apart from those asked in the HPI
BASIC EXAMINATION SKILLS TO BE MASTERED (Please refer to
techniques of examination on Chapter 9 of Bates textbook as well as Bates videos) Vital Signs - blood pressure, heart rate, respiratory rate - calculate BMI - measure waist circumference HEENT -Palpate carotid upstroke and auscultate for carotid bruits - determine clinical JVP Heart - identify point of maximal impulse - palpate for heaves, lifts and thrills - identify rate and rhythm - identify S1 and S2 at the base and apex - auscultate for S3 (heard in early diastole) and S4 (heard later in diastole) - identify murmurs of MR, MS, AR and AS and describe according to timing, intensity, location and transmission; use maneuvers when needed (see two important maneuvers in Bates textbook p. 378 or Bates pdf p. 406) Lungs Auscultate for crackles Abdomen palpate for hepatojugular reflux - Observe the neck veins while pressing firmly over the patients mid-abdomen for 10 seconds. A positive test is when the JVP rises above 4 cm H20 and remains elevated for the entire 10 seconds. This is an accurate sign of elevated venous pressure and left heart disease, especially in patients with dyspnea Extremities Palpate for pitting edema