Evaluation of a Terminal Patient

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Evaluation of a Terminal Patient

• Jay Peitzer, MD, FAAHPM

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Goals

• Improve skills in evaluating the signs and
  symptoms of terminal patients
• Correlate review of systems with physical
  findings
• Understanding how the improvement of diagnostic
  skills will result in improved clinical outcome

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Basics

• 80 HISTORY
• 10 PHYSICAL EXAM
• 10 DIAGNOSTICS

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History of Present Illness

• How did this situation come about ?
• Does the HPI fit the normal progression of the
  illness?
• Has the patient had a functional decline ?
• One of the most important parts of an HP

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Functional Decline

• Progressive Weakness
• Unexplained weight loss
• Rapid decline in level of consciousness

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BEWARE OF TUNNEL VISION

• TERMINAL PATIENTS CAN HAVE ANY/OR ALL THE
  ILLNESSES OF A NON-TERMINAL PATIENT

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Medical History

• Physical findings are easier to spot when
  anticipated based on patient medical history
• Medication Profile
• Scars and Chronic deformities

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Medical History

• Review the History Every Patient !
• Allergies (what happens?)
• Smoking hx (ppd x years)
• ETOH/Drug abuse (mild, moderate, a lot)
• Significant medical problems/surgeries
• Current medications

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Let the History (Hx) work for you

• Believe patients answers! Dont negatively
  quantify!
• Has patient had similar symptoms?
• What was the diagnosis?
• How was it treated?
• Did the treatment work?
• (i.e. Bronchodilator for dyspnea)

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MOST COMMONLY MISSED/UNDER TREATED DISORDERS

• DEPRESSION
• COPD
• ISCHEMIC HEART DISEASE (IHD)
• NAUSEA/VOMITING
• TERMINAL DELERIUM

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Review of Systems

• Start with brief questions about each system
• Expand ROS as medically indicated
• Almost as important as HPI

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Pertinent Review of Systems

• Dyspnea? At rest? Exertion? How much?
• Chest pain? PQRST-Consider anginal equivalent
  (fatigue)
• Wheezing/Chronic cough (dry or productive?)
• Near syncope/syncope
• Palpitations (rhythm disturbance)
• Diaphoresis
• XS fluid (pedal edema, orthopnea)

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PQRST Pain evaluation

• Provokes or Palliates
• Quality
• Radiates
• Severity
• Temporality

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Physical Exam

• Starts when I look across the room at the patient
  as I enter the room
• Body Habitus
• Color of skin
• Emotional level in the room
• Find a system that works for you, and then use it
  all the time

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Chest

• Two major organ systems with overlapping signs
  and symptoms
• Presenting SS may result from one organ system
  affecting the other

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Parts Are Connected

• Lung problems --gt hypoxia --gt angina
• Heart failure --gt pulmonary edema --gt impaired
  pulmonary function

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Why is the patient short of breath?

• COPD
• Sxs improve with hydration
• Fluids, Expectorants, Nebulizer txs
• Not assoc. with cardiac symptoms
• Wheezes and decreased breath sounds
• Significant improvement with bronchodilators
• CHF
• Sxs improve with drying out
• Diuretics
• Assoc. with chest pain, diaphoresis, JVD, pedal
  edema
• Rales progressed to no breath sounds may wheeze
  early
• Modest improvement with bronchodilators

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Listen to the whole chest
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Breath sounds

• Is the patient moving a normal volume of air?
• Abnormal/Pathological Breath Sounds
• Rales fine (soda fizz) or coarse (blowing
  bubbles through a straw)
• Rhonchi wet sounds (harsh like a snore)
• Wheeze high pitched inspiratory or
  expiratory
• Stridor wheeze predominantly inspiratory and
  heard louder in neck than the chest
• Congestion is not a sound

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Breathing Patterns
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Heart Sounds listen to all foci

• Aortic
• Pulmonic
• tricuspid
• mitral

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Abnormal heart sounds

• Murmurs
• Rubs

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Cardiac Rhythm

• Regular
• Irregular
• Irregular Irregular
• Gallops

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Portable CVP
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Evaluation of the Abdomen

• Bowel sounds
• Tenderness
• Distention
• Masses
• Fluid wave
• Hepatomegaly

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HEENT

• Symmetry
• Bitemporal Wasting
• Oral cavity mucosal changes
• Adenopathy
• Lesions/post operative changes

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Neurological Evaluation

• Full exam usually not done
• Focal exam as indicated nystagmus facial
  droop ptosis

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Extremities

• Chronic changes c/w vascular disease arterial
  venous
• Clubbing
• Cyanosis
• Ulcers and other lesions

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Look for symptom complexes

• Ischemic disease (cardiac, cerebral, renal,
  bowel)
• Atrial fibrillation/Chronic Obstructive Pulmonary
  Disease
• Vague cardiac symptoms in diabetics and women

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56 y.o. white male with bronchogenic carcinoma

• c/o chest pain
• What would you like to know?

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Summary

• A working diagnosis can be formulated in a
  majority of patients solely based upon the
  patients history and physical

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Summary

• Physical signs and symptoms are easier to find
  when anticipated based upon the patients history

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Summary

• Making an accurate diagnosis leads to quality,
  cost effective treatment, and improved patient
  satisfaction

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The End