Auto-Case History Midterm 1

HIPPIVRONELS (components of exam)

History

Inspection

Palpation

Percussion

Instruments

Vital Signs

ROM

Orthos

Neuros

X-rays

Labs

Special Test

HIPPIVRONELS Exceptions with trauma....

x-rays taken before patient is moved

HIPPIVRONELS Exceptions with abdominal....

exam listen before palpating

Chief Complain (focused)

- L-M-N-O-O-P-P-Q-R-S-T

- P-S-O-F-M-D

Overall Health

- S-H-I-I-T-E-M-D

- G-R-E-E-N-C-R-U-M-S

Inspection

• Standing posture• Gait Analysis walking & running (if needed)

• Antalgic lean, deformities & symmetry (or lack thereof)

• Bones: alignment & position

• Soft tissue: swelling, atrophy, scars, moles, color, texture, loss of hair, etc

Palpation

• Temperature

• Bones: pain, shape, abnormal or normal relationship

• Soft Tissue: pain, spasm, atrophy or swelling ; 128 Hz tuning fork for fracture

• Motion: normal vs abnormal, accessory, end play of joints

Percussion

• Spinous processes & other superficial bones

• Reflex hammer & finger tapping

• Thorax and abdomen: rule out visceral pain and referral

Instrumentation

• Auscultation; heart sounds, lung sounds, abdominal borborygmus, & peripheral vessels for bruits

• Technique specific instruments

• Subluxation Station

Vital Signs

• Height

• Weight

• Temperature

• Pulse

• Respiration

• Blood Pressure

Range of Motion

• Visualization or "eyeballing"

• Instrumentation most objective (inclinometers, goniometers, etc)

Instruments for ROM

- Goniometer

- Inclinometer

Orthopedics

• Stressing or relieving structures creates symptoms

• Understanding what findings mean is most important

• Understand positive, incidental, & pertinent negative scenarios

• Local, diffuse, or dermatomal

Neurologics

• Comparison from side to side; AKA bilaterally

• Myotomes

• Dermatomes

• Deep tendon reflexes

• Sensory testing

(E)X-ray

• Justification for radiographs is a must

• Initial x-ray report includes comments on Alignment, Bone, Cartilage, and Soft tissue (ABCs)

• X-ray narrative report (DACBR)

Laboratory Studies

• Base on findings from history and exam; Urinalysis (UA); Complete Blood Count (CBC) aka Blood Chemistry Basics

• Special blood labs (hormones, Vit D,T4, etc)

Special Studies

• Magnetic Resonance Imaging (MRI)

• Computed Tomography (CT)

• Ultrasound

• Nerve Conduction Velocity (NCV)

• Cerebral Spinal Fluid Study

• Motion Films

Narrative report

• Written summary of patient's pertinent history & physical examination findings

• X-ray narrative from clinic file

• Clinical impression in prioritized problems list format

• Case management plan

• Prognosis

• Goals of Care

SOAP

- Subjective Information

- Objective Information

- Assessment

- Plan

Components of a Case History

- Chief complaint or concern (CC)

- History of Presenting Illness (HxPI)

- Past History

- Family History

- Social History/Patient Profile

- Review of Systems (ROS)

Comprehensive History

- Determine if Disease is Present

- Act As Screening Process

- Determine Health Status

- Develop a Patient Profile

LMNOPQRST (history of presenting Illness; HxPI or HPI)

- Location of injury

- Mechanism of injury

- New injury?

- Onset

- Palliative(+)/Provocative(-)

- Quality

- Radiation/Referral

- Severity

- Timing

Quality of Pain

- Nerve

- Bone

- Visceral

- Muscular

- Vascular

- Angina

- Arterial dissection (aorta)

Nerve

Sharp, stabbing, shooting, burning, "pins & needles"

Bone

Deep, boring (unable to specifically localize the pain point)

Visceral

Dull, achy, crampy, colicky, wave-like, "hard to describe"

Muscular

Dull, achy, occasionally burning, twitches/jumps, knotty, hard

Vascular

Cold, pulses, throbs

Angina

Heavy chest, squeezing sensation, crushing, "something is sitting on my chest"

Arterial dissection (aorta)

Tearing, ripping (the general area is LB/Abdomen)

PSOFMD (Continuation of the Patient Interview; the reason patient has come to see you; CC)

- Past Hx

- Social hx (pateint profile - OSSSDDDE)

- Occupational Hx (past & present)

- Family Hx (CCDAMON)

- DC Hx

OSSSDDDE (social history)

- Occupation

- Sex

- Sleep

- Smoking

- Drinking

- Drugs

- Diet

- Exercise

SHITAMD (Continuation of the Patient Interview; components of patient past health history, includes any other 'active health issues)

- Surgeries

- Hospitalizations

- Illnesses (childhood or adult)

- Traumas

- Allergies (hematological/lymphatic)

- Medications (OTC, Rx, Recreational, Alcohol, Tobacco)

- Doctors of any kind (Naturopath, Acupuncturist, Psychiatrist, Rheumatologist, Dermatologist, etc.)

Surgeries

Dates, Reasons, Outcomes, Complications

Hospitalizations

Dates, Reasons, Outcomes, Complications (Not always the same information as surgeries)

Traumas

- Dates, Care taken, Outcome.

- When connected to medicolegal reasons, get the full history of the event. - Remember the 3 Ts?

Allergies (hematological/lymphatic)

Environmental, Seasonal, Food

Medications/MD Hx

- OTC, Rx, Recreational, and Supplements are considered.

- Ask about current dosages as well as any notable previous regimens

- Current MD/DO? Have you seen an MD/DO for this complaint?

- Recent screenings and results

Childhood illnesses

Acute rheumatic fever, Diphtheria, Type I Diabetes, Poliomyelitis, Asthma, Measles, Mumps, Whooping cough, Chickenpox, Scarlet fever, etc

Major Adult Illnesses

Tuberculosis, Hepatitis, Type IIDiabetes, Hypertension, Myocardial Infarction, Heart Disease, Stroke, Chronic obstructive pulmonary Disease (COPD), Tropical or Parasitic diseases, etc

GREENCRUMS (Continuation of the Patient Interview; review of systems)

- Gastrointestinal

- Respiratory

- Ears, eyes, nose, throat, head

- Endocrine

- Neurological

- Cardiovascular

- Reproductive

- Urinary

- Musculoskeletal

- Skin

Alternative strategy for GREENCRUMS

Look at the patient and run through possible complaints from HEAD to TOE

Acute/Traumatic Complaints

Portions of the interview to emphasize:

- Mechanism of injury

- Onset Phase of healing

- Quality of symptoms

- Social History

- Occupation/employment

- Habits

Chronic/Insidious/Non-traumatic Complaints

Portions of the interview to emphasize

- Location of injury

- Onset

- The arc of the symptoms

- Severity

- History

- Social history

- Occupational history

- Review of Systems

Next steps (starting the physical)

- Inspection

- Palpation

- Percussion

- Instrumentation

- Range of Motion

- Orthopedic Tests

- Neurological Tests

- Evaluation/Tests

- Lab Tests

Inspection

Scars, redness, symmetry, gait

Palpation

Nodules, pain, spasm

Percussion

Organs

Instrumentation

Myovision, Neurvoscope, tuning fork

Range of motion

Active, Passive

Evaluation/Test

X-ray, Ultra-sound, MRI, CT, etc.

Lab Tests

CBC, Urine, T-4 reuptake, etc