Chapter 4 for 12 Lead Training - ACS Assessment: History and Exam -

BASE HOSPITAL GROUPONTARIO

Chapter 4 for 12 Lead Training

- ACS Assessment: History and Exam-

Ontario Base Hospital GroupEducation Subcommittee

2008

TIME IS MUSCLE

OBHG Education Subcommittee

ACS Assessment: History and Exam

REVIEWERS/CONTRIBUTORS

Neil Freckleton, AEMCA, ACPHamilton Base Hospital

Jim Scott, AEMCA, PCPSault Area Hospital

Ed Ouston, AEMCA, ACPOttawa Base Hospital

Laura McCleary, AEMCA, ACPSOCPC

Tim Dodd, AEMCA, ACPHamilton Base Hospital

Dr. Rick Verbeek, Medical DirectorSOCPC2008 Ontario Base Hospital Group

AUTHOR

Greg Soto, BEd, BA, ACPNiagara Base Hospital


Chapter 4 Objectives

Explain why getting a good medical history is so important in the AMI patient

List key elements to OPQRST & SAMPLE mnemonics for clinical investigation of possible ischemic problem


Importance of Clinical Presentation

No diagnostic test for acute myocardial infarction is perfect.

All medical literature related to ACS recognition suggest that the clinical presentation of the patient is of great importance.

Clinical presentation consists of:

•Incident history •Chief complaints•PMHX

•Risk factors•Vital signs•Assessment findings


Getting a Good History

It is HOW we ask the questions Mnemonics (OPQRST) are memory

aids Should not be asked literally to a

patient


Investigating the C/C

O – Onset P – Provoke Q – Quality R –

Radiation S – Severity T – Time


What to Ask

O – Onset P – Provoke Q – Quality R – Radiation S – Severity T – Time

Actual time this episode started

Open-ended questions

Try to get an actual time, i.e., 10:30 a.m.

Very important for cardiac patients


Onset

“When did this episode of chest pressure start?”

“When did this asthma attack start?”

“When did the accident occur?”


Onset

Avoid using closed or leading questions...

“Did the pain start last night or this morning?”



What makes it better or worse?

Note the position of the patient

What they were doing when it happened?

What to Ask


Rule # 1 of Questioning

While investigating a chief complaint, the only words you may use are the

words the patient told you


Rule # 1

If the patient tells you:

“I’m having a tightness in my chest.”You would reply:

“When did this tightness start, Jack?”Rather than:

“When did the pain start, Jack?”


Provoke

“Jack, does anything you do make the tightness worse?”

(Inspiration/Palpation/Movement/Position)

“Does anything you do make the tightness less?”

(Inspiration/Palpation/Movement/Position)

“Jack, what were you doing when this tightness first started?”


What to Ask


What does pain feel like?

Avoid closed and leading questions

Let the patient have as many choices as they like to describe their “pain”


Quality

“Jack, what does this “pain” feel like?”

“What would I have to do to you to make that kind of “pain?”


Closed or Leading Questions

“Is the pain sharp or dull?”

“Does the pain kinda feel like a belt around your chest?”


What to Ask


Do they have any problems or pain anywhere else?

Watch for nonverbal clues

Where is the pain? Pain may not “go”

anywhere


Radiation

Instead of:“Does it hurt in the center or side of your

chest?”

Try:“Where does it hurt?”

or“Can you draw a circle around it?”


What to Ask


Scale of 1–10 Make sure you find

out what the worst pain was.

Answers of >10 mean it hurts really BAD!


Severity

“On a scale of 1–10 with 10 being the worst pain you’ve ever had,

and 1 being barely any pain at all, how would you rate your pain right

now?”

“What was the worst pain you have ever felt?”


What to Ask


The duration of the problem

How long the current episode has been going on?

If prolonged duration, was there a recent sudden severity increase?


Time

“How long has this recent episode of chest pressure lasted, Jack?”

“How long did Jack’s seizure last?”


Tag-ons

Tag-ons are extra questions tacked on to the end of an ordinarily good question

“Do you have diabetes, hypertension, or cardiac disease?”

“Are you nauseated?” “Are you short of breath?”

“Are you having chest pain?” “Is it sharp or dull?”


Tag-ons

The best way to avoid a tag-on is to ask one question at a time and wait for the

answer


SAMPLE History

S – Signs/symptoms A – Allergies M – Medications P – Past History L – Last meal E – Events


Allergies

“Jack, are you allergic to any medications?”

“Jill, are you allergic to anything?”

“Do you have any allergies, Jill?”


Medications

“Do you take any doctor-prescribed medicines every day?”


Past Medical History

Ask one question at a time Allow the patient time to answer Explore what is pertinent


Last Oral Intake

Very important in diabetic emergencies

Important information for patient who may have to have surgery

Need to know when they ate last (time) and approximate amount


Events Leading up to C/C

What were they doing when the episode started?

Mechanism of injury? Useful for neuro exam in head

injuries Pain at rest or on exertion?


Physical Exam

Head to toe Look for JVD Assess lung and heart sounds Palpate the chest wall Palpate the abdomen Palpate radial pulses at the

same time


Physical Exam (cont.)

Blood pressure in each arm Positional changes for the patient Apical versus radial pulses Full auscultated blood pressure Look for peripheral edema


The 12 Lead ECG

Best “early” confirming diagnostic test Should be performed on any patient

with a “pulse and problem” between nose and naval that is suspicious for cardiac

Should be acquired and triaged in less than 10 minutes arrival on scene


QUESTIONS?


Well Done!

Education Subcommittee

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Chapter 4 for 12 Lead Training - ACS Assessment: History and Exam -

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