History and Physical Exam

in the
Emergency Department
COMPLETE YET FOCUSED
Principles of Emergency Care

 Theimmediate initial recognition,

evaluation, care, and disposition of
patients with acute illness and injury.
Emergency Department Care

Initial Approach and Stabilization

Clinical assessment
History and Physical exam
Clinical Reasoning
Preliminary differential diagnosis
Initiate management
Diagnostic Adjuncts
“Working diagnosis”
Disposition
History

 Patient
 Family
 Caregiver
 EMS
 Nursing Home
 Transfer form
 Call them
 Primary care physician

Language line if needed

Document where history is from
History

 Patient Comfort
 Positioning
 Fear/ pain
 HOH
 Noisy

 PA Comfort
 Sit down if you can
 Ask family to leave if disruptive
 Safe distance
Chief Complaint

 Triage note

 Hopefully only one

 Start considering your differential diagnosis

 HPI based on this complaint

History of Present Illness (HPI)

 Open-ended question
 “What problem are you having?”

 “Tell me about your headache.”

 Are you having stomach pain? Tell me about it.”

 “What brings you to the hospital today?”

HPI

P-Q-R-S-T A-A-A
 Position
 Quality
 Radiation
 Severity
 Timing
 Duration
 Constant/ intermittent

 Alleviating factors
 Aggravating factors
 Associated symptoms
HPI

 Previous episode

 What Changed Today?

Neurologic History
Altered Mental Status
 When was patient last seen normal?
 What is normal?
 Was change gradual or abrupt?
 Does the patient complain of anything?
 Assess thorough R.O.S.
 Has condition changed since initially recognized?
 PMH?
 Current medications?
 Is there substance abuse?
Neurologic History
Headache
 Severity
 “Worst HA of my life”
 Onset of pain/ Location
 History of headache
 History of head trauma
 Anticoagulation
 Associated neurologic symptoms
 Infectious symptoms
 Age
 Prodrome
 Family History
 Exposure- travel v toxic
Neurologic History
Seizure
 Prior history
 How often?
 Compliant with medication?
 What happened?
 Onset-
 Aura, trauma

 Tongue biting
 Incontinence
 Focal v generalized
 Post-ictal?
 Medication history
 Drug/ alcohol abuse
 Recent illness?
 PMH
Neurologic History
Stroke
 Exact onset of symptoms
 Nature of symptoms
 Weakness, speech, gait, vision, level of consciousness
 Associated symptoms
 History of similar in past?
 Baseline?
 Risk factors for stroke?
 Anticoagulants?
Cardiovascular History
Chest pain
 Character of the pain
 P-Q-R-S-T A-A-A
 Associated symptoms
 SOB
 Dizziness
 Diaphoresis
 Nausea/ vomiting
Cardiovascular History
Chest pain
 Risk Factors
 Age
 Male
 Hypertension
 Diabetes
 Smoker
 Known h/o CAD
 High cholesterol
 Family History of CAD
 Oral contraceptives in female >35yo
Cardiovascular History
Syncope
 Inciting event?
 Prodrome?
 Urination/ defacation?
 Dehydration/ blood loss?
 Chest pain / dyspnea/ palpitation?
 Seizure activity / neuro symptom?
 Pregnant?
 Trauma?
 H/o syncope?
 Diabetes?
Cardiovascular History
Hypertension
 Neurologic symptoms
 Chest pain
 Congestive heart failure
 Hematuria
 Pregnancy
 Previous episode?
 Medication history / compliance
 Drug use
Gastrointestinal History
Abdominal pain
 P-Q-R-S-T A-A-A
 Nausea/vomiting
 Change in bowel habits
 Anorexia
 Urgency to defecate
 Genitourinary symptoms
Gastrointestinal History
Abdominal pain
 Extra-abdominal symptoms
 Chest pain
 SOB
 Fever
 Medical illness
 Past surgery
 Menstrual history
 Alcohol use
 Medication
 Asa/ nsaids
 corticosteroids
Gastrointestinal History
GI Bleeding
 How long?
 How frequent?
 Black stools / melena/ bright red blood?
 Estimate of blood loss?
 Syncope
 H/o Gi bleed?
 Related medical illness
 Liver, PUD, etoh use, nsaid/ asa use
 Abdominal pain?
 Other bleeding?
 Extra-abdominal symptoms?
 Chest pain, dizziness, sob
Gastrointestinal History
Diarrhea
 Duration?
 Frequency?
 Appearance ? Bloody?
 Worse with eating / drinking?
 Previous history of diarrhea?
 Fever
 Vomiting
 Abdominal pain
 Weight loss
 Travel history
 Recent antibiotics
 Unusual foods?- recent picnics??
 Sick contacts?
 Sexual orientation?
Pulmonary History
Shortness of breath
 Sudden / gradual onset?
 How long?
 Pleuritic?
 Position?
 Exertional?
 H/o similar in past?
 Medication taken?
 Tobacco use?
 Associated symptoms-
 Chest pain, cough, fever, hemoptysis, DOE
 Past Medical History
 COPD, DVT, CHF, asthma, PE
 Recent travel/ immobilization
Pulmonary History
Wheezing
 History of asthma/ COPD?
 P-Q-R-S-T A-A-A
 Associated URI sx
 Fever
 Medications tried- ?compliance
 Severity of underlying COPD / asthma
 Hospitalizations
 Intubations
 Weight gain
 Toxic exposure
 Tobacco use
 Foreign –body aspiration (peds patients)
 Cardiac history
Unstable Patient/ Trauma

 A Allergies
 M Medications
 P Past Medical History
Past Surgical History
Pregnant
 L Last meal
Last tetanus
LMP
 E Events
Pediatric History

 Birth History
 Term?
 C-section/ vaginal
 Complications
 Perinatal infections
 Immunizations
 Feeding
 Wet diapers
Pregnant History

 Last menstrual period

 Vaginal bleeding
 Abdominal pain
 Fetal movement
 Previous pregnancy history
 Previous delivery history
 Complications this pregnancy
 STD history
Pregnant History
G’s and P’s
 Gravida
 Number of pregnancies

 Para
 “Texas Power And Lighting”
 T- term infants
 P- preterm infants
 A- abortions (both elective and spontaneous)
 L- living children

 G3P1102
Psychiatric History

 Previous history
 Suicidal
 Homicidal
 Hallucinations
 Hospitalizations
 Compliance with medication
 Agitation, paranoia, delusions
 Flight of ideas
 Substance abuse
 Medical complaints
Wound History

 Force of injury
 Time since injury
 Contamination
 Tetanus status
 Handedness of patient (with UE injury)
 Medical illness
 Medication
Review of Systems
General
 Fever
 Chills
 Change in weight
 Weakness
 Fatigue
 Sweats
Review of Systems
Eyes
 Corrective lens/ contact lens
 Change in vision
 Double vision
 Tearing
 Pain
 Light sensitive
 Redness
 Discharge
 History of glaucoma
 Injury
Review of Systems
Ears
 Loss of hearing
 Discharge
 Dizziness
 Pain
 Ringing in ears
 Infection
Review of Systems
Nose
 Nosebleeds
 Infections
 Discharge
 History of injury
 Sinus infections
 Hay fever
Review of Systems
Mouth/ Throat
 Pain
 Hoarseness
 Voice change
 Difficulty swallowing
 Difficulty breathing
 Post nasal drainage

 Dental pain
 Bleeding gums
Review of Systems
Neck
 Lumps/ swelling
 Goiter
 Pain on movement
 Tenderness
Review of Systems
Respiratory
 Cough
 Pain
 Shortness of breath
 Sputum production- ?color
 Pleuritic pain
 Hemoptysis
 Wheezing
Review of Systems
Cardiovascular
 Chest pain
 Palpitations
 SOB with exertion
 Orthopnea
 High blood pressure
 Leg swelling
 Dizziness
 Pleuritic pain
 Pain in legs/ calves
Review of Systems
Gastrointestinal
 Appetite
 Nausea
 Vomiting
 Diarrhea/ constipation
 Abdominal pain
 Change in stool
 Hematemesis
 Rectal bleeding
 Jaundice
 Abdominal distension
Review of Systems
Genitourinary
 Dysuria
 Urinary frequency
 Urgency
 Hematuria
 Incontinence
 Flank pain
 Retention
Review of Systems
Male Genitalia
 Lesions on penis
 Discharge
 Impotence
 Pain
 Scrotal swelling or pain
 Bleeding
Review of Systems
Female Genitalia
 Lesions/ Rash
 Discharge
 Vaginal bleeding
 Dyspareunia
 h/o STD
Review of Systems
Musculoskeletal
 Weakness
 Paralysis
 Stiffness
 Limited ROM
 Joint pain
Review of Systems
Neurologic
 Syncope
 Dizziness
 Weakness/ paralysis
 Numbness
 Tremor
 Amnesia
 Loss of consciousness
 Difficulty with speech
 Unsteady / change in gait
 Confusion
Review of Systems
Skin
 Rash
 Pruritic/ Painful
 Hives
 Bruising
 Discoloration
 Warmth
Review of Systems
Psychiatric
 Depression
 Suicidal / homicidal
 Insomnia
 Hallucinations
 Anxiety
 Agitation
Past Medical History

 Medical illness
 Previous surgery
 Hospitalizations
 Immunizations
 Mental Health History
Medication

 Current medication
 Any recent changes

 Dosage not so important!!

Allergies

 Allergies to medication
 Ask reaction
 ?anaphylaxis
 ?intolerance
Social History

 Alcohol
 Tobacco
 Illicit drugs
 Living situation
Family History

 Not always necessary

 Chest pain/ CAD

 Abdominal pain/ diarrhea
 DM
 Migraine
 Palpitations- sudden death
Physical Exam
Getting Ready
 Lights

 Undress

 Equipment

 Wash Hands

 Gloves if necessary
PHYSICAL EXAM

Inspection
Palpation
Percussion
Auscultation
Physical Exam

DEVELOP
A
ROUTINE!!
Physical Exam
Vital Signs
 Temperature

 Respiratory Rate

 Heart Rate

 Blood Pressure

 Oxygen Saturation

 Fetal Heart Tones (6th vital sign if pregnant)

Physical Exam
General
 Appearance

 Level of consciousness

 Respiratory status

 Discomfort
Physical Exam
HEENT
 HEAD
 Inspect

 Palpate
Physical Exam
HEENT- EYE
PUPIL
 Inspect
 Miosis /Mydriasis
 Irregular

 Reactive
 Marcus Gunn Pupil
Physical Exam
HEENT- EYE
 Sclera

 Lid

 Conjunctiva
Physical Exam
HEENT- EYE
 Cornea
 Clear
 Foreign body
 Abrasion
 Ulceration

SLIT LAMP EXAM

Physical Exam
HEENT- EYE
 Visual Acuity

 Visual Fields

 Ocular movements
 Nystagmus

 Fundoscopic Exam

 Ocular pressure
 Tonopen
Physical Exam
HEENT- EAR
 External Ear
 Pinna
 External auditory canal

 Middle Ear
 Tympanic Membrane
Physical Exam
HEENT- Nose
 Obstruction

 Discharge

 Bleeding
Physical Exam
HEENT- THROAT
 Oral Cavity
 Buccal mucosa
 Lips
 Tongue
 Hard and soft palate
 Teeth
 Pharynx
 Tonsils
 Uvula
Physical Exam
NECK
 Lymphadenopathy

 Masses

 Symmetry

 Thyroid gland

 Carotid bruits
Physical Exam
LUNGS
 INSPECTION
 Retracting/ tugging
 Symmetry
 Respiratory rate
 PALPATION
 Tenderness
 Crepitus
 Subcutaneous emphysema
 PERCUSSION
Physical Exam
LUNGS
AUSCULTATION
 Stridor
 Crackles
 Wheezes
 Rhonchi
 Pleural Rub
Physical Exam
Cardiovascular
 AUSCULTATION
 Rhythm

 S1 and S2
 S3 and S4
 Murmurs
 Graded 1-6
 Systolic v diastolic
 Rub
Physical Exam
Cardiovascular
 MURMURS
I Lowest intensity, often not heard by inexperienced
II Low intensity, usually audible by experienced listeners
III Medium intensity without a thrill
IV Medium intensity with a thrill
V Loudest murmur that is audible when the stethoscope is placed on
the chest
VI Loudest intensity; audible when stethoscope is removed from the
chest
Physical Exam
Cardiovascular
 JVD

 Hepatojugular Reflex

 Symmetrical Pulses

 Edema
Physical Exam
Abdomen
 INSPECTION
 Distention

 Grey Turner’s sign

 Flank ecchymosis

 Cullen’s sign
 Umbilical ecchymosis

 Hernia

 Surgical Scars
Physical Exam
Abdomen
 AUSCULTATION
 Bowel sounds

 Abdominal bruits
Physical Exam
Abdomen
 PERCUSSION
 Tympany

 Ascites
Physical Exam
Abdomen
 PALPATION
 Rigidity
 Tenderness
 Murphy’s Sign
 Rebound
 Guarding
 Hepatomegaly
 Splenomegaly
 Masses
Physical Exam
Abdomen
 Rectal Exam
 External exam

 Palpate rectal walls

 Palpate prostate gland

 Test for occult blood

Physical Exam
Musculoskeletal
 Inspection
 Deformity

 Swelling/ Edema

 Color
 Ecchymosis
 Erythema
 Pale/ mottled

 Wounds
Physical Exam
Musculoskeletal
 PALPATION
 Tender
 Swelling
 Edema
 Effusion
 Warmth
 Ecchymosis
Physical Exam
Musculoskeletal
 RANGE OF MOTION
 ?Limited
 Pain
 Active v passive

 Pulses

 Neurologic Function
Physical Exam
Musculoskeletal
 SPINE
 C-spine
 C-collar
 Palpate midline

 Thoracic and Lumbar Spine

 Palpate midline
 ?Step-off
 Swelling/ bruising
Physical Exam
Genitourinary
 MALE GENITALIA
 Penis
 Lesions/ rash

 ?circumcised

 Edema

 Discharge
Physical Exam
Genitourinary
 MALE GENITALIA
 SCROTUM
 Palpate testes

 Palpate epididymis

 Palpate for inguinal hernias

 INGUINAL LYMPHADENOPATHY
Physical Exam
Genitourinary
 FEMALE GENITALIA
 External Genitalia
 Lesions/ rash
 Swelling
 Discharge

 Inspect Labia
 Bartholin’s abscess
Physical Exam
Genitourinary
 FEMALE GENITALIA

 SPECULUM EXAM
 Vagina

 Cervix
 Discharge
 Bleeding
 Lesions/ mass
Physical Exam
Genitourinary
 FEMALE GENITALIA

BIMANUAL PALPATION
 Cervical Motion Tenderness
 Palpate uterus
 Palpate adnexa
Physical Exam
Neurologic
 MENTAL STATUS
 Level of Consciousness

 Speech

 Orientation
Physical Exam
Neurologic- CRANIAL NERVES
I Olfactory Smell
II Optic Vision
III Oculomotor Eye movement, pupil constriction
IV Trochlear Eye movement
V Trigeminal Sensation of face, scalp, teeth
VI Abducens Eye movement
VII Facial Taste; sensation of palate/ ear; facial expression
VIII Vestibulocochlear Hearing; equilibrium
IX Glossopharyngeal Taste; elevates palate
X Vagus Taste; swallowing; phonation; parasympathetic
XI Spinal accessory Phonation; head, neck, shoulder movement
XII Hypoglossal Tongue movement
Third Cranial Nerve
Trigeminal Nerve
Facial nerve palsy
Physical Exam
Neurologic
 MOTOR FUNCTION
0 No contraction detected
1 Slight contraction detected
2 Movement with gravity eliminated
3 Movement against gravity
4 Movement against gravity with some resistance
5 Movement against gravity with full resistance
Physical Exam
Neurologic
 MOTOR FUNCTION
 Upper Extremity
 Lower extremity

 Isolate each muscle group from proximal to distal

Physical Exam
Neurologic- Motor Function
Nerve Root Muscle Primary Function
C3, C4 Diaphragm Respiration
C5 Deltoid Abduction of forearm
C5 Bicep Flexion of forearm
C6 Brachioradialis Flexion of forearm
C7 Tricep Extension of forearm
L3, L4 Quadricep femoris Extension of knee
L5 Extensor hallucis longus Dorsiflexion of great toe
S1 Gastrocnemius Plantar flexion
Physical Exam
Neurologic
 REFLEXES
0 No response
1+ Diminished
2+ Normal
3+ Increased
4+ Hyperactive
Physical Exam
Neurologic
 REFLEXES
 Bicep C5-6
 Brachioradialis C5-6
 Tricep C6-8
 Patellar L2-4
 Achilles S1-2
Physical Exam
Neurologic
 SENSORY FUNCTION
 Light Touch
 Pain Sensation- Sharp/ dull
 Vibration Sense
 Proprioception
 Two-Point Discrimination
Dermatome Map
Physical Exam
Neurologic
 CEREBELLAR FUNCTION
 Finger-to- Nose Test
 Heel- to – Shin Test
 Romberg’s Test
 Gait
Not Quite….
Physical Exam
Skin
 General Condition
 Color, turgor, moisture
 Rash description
 Macular
 Papular
 Vesicular
 Petechial
 Urticarial
 Pustule
 Purpura
History and Physical Exam

 CHIEF COMPLAINT

 FOCUS

 ESTABLISH ROUTINE

 COMPILE INFORMATION
Presentation

 Concise
 Present <3min
 State chief complaint first and stay focused on CC unless other
concerning problems

 Essential information
 Use clinical judgement to edit patient information

 Emphasize findings that include/ exclude potential diagnosis

Oral Presentation

 Chief Complaint
 HPI
 Include pertinent PMH / PSH in first line
 Include pertinent ROS, Social Hx, Family Hx
 Meds
 Physical Exam
 Pertinent positives/ negatives
 Summary Statement
 1-2 sentence clinical picture
 Problem Assessment
 Opinion
 Problems from most  least serious
 Plan