1. BASE HOSPITAL GROUP ONTARIO Chapter 4 for 12 Lead Training - ACS Assessment: History and Exam- Ontario Base Hospital Group Education Subcommittee 2008 TIME IS MUSCLE

2. OBHG Education Subcommittee ACS Assessment: History and Exam REVIEWERS/CONTRIBUTORS Neil Freckleton, AEMCA, ACP Hamilton Base Hospital Jim Scott, AEMCA, PCP Sault Area Hospital Ed Ouston, AEMCA, ACP Ottawa Base Hospital Laura McCleary, AEMCA, ACP SOCPC Tim Dodd, AEMCA, ACP Hamilton Base Hospital Dr. Rick Verbeek, Medical Director SOCPC 2008 Ontario Base Hospital Group AUTHOR Greg Soto, BEd, BA, ACP Niagara Base Hospital

3. OBHG Education Subcommittee 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

4. OBHG Education Subcommittee 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

5. OBHG Education Subcommittee Getting a Good History  It is HOW we ask the questions  Mnemonics (OPQRST) are memory aids  Should not be asked literally to a patient

6. OBHG Education Subcommittee Investigating the C/C  O– Onset  P– Provoke  Q– Quality  R– Radiation  S– Severity  T– Time

7. OBHG Education Subcommittee 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

8. OBHG Education Subcommittee Onset “When did this episode of chest pressure start?” “When did this asthma attack start?” “When did the accident occur?”

9. OBHG Education Subcommittee Onset  Avoid using closed or leading questions... “Did the pain start last night or this morning?”

10. OBHG Education Subcommittee  O – Onset  P – Provoke  Q – Quality  R – Radiation  S – Severity  T – Time  What makes it better or worse?  Note the position of the patient  What they were doing when it happened? What to Ask

11. OBHG Education Subcommittee Rule # 1 of Questioning While investigating a chief complaint, the only words you may use are the words the patient told you

12. OBHG Education Subcommittee 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?”

13. OBHG Education Subcommittee 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?”

14. OBHG Education Subcommittee What to Ask  O – Onset  P – Provoke  Q – Quality  R – Radiation  S – Severity  T – Time  What does pain feel like?  Avoid closed and leading questions  Let the patient have as many choices as they like to describe their “pain”

15. OBHG Education Subcommittee Quality “Jack, what does this “pain” feel like?” “What would I have to do to you to make that kind of “pain?”

16. OBHG Education Subcommittee Closed or Leading Questions “Is the pain sharp or dull?” “Does the pain kinda feel like a belt around your chest?”

17. OBHG Education Subcommittee What to Ask  O – Onset  P – Provoke  Q – Quality  R – Radiation  S – Severity  T – Time  Do they have any problems or pain anywhere else?  Watch for nonverbal clues  Where is the pain?  Pain may not “go” anywhere

18. OBHG Education Subcommittee 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?”

19. OBHG Education Subcommittee What to Ask  O – Onset  P – Provoke  Q – Quality  R – Radiation  S – Severity  T – Time  Scale of 1–10  Make sure you find out what the worst pain was.  Answers of >10 mean it hurts really BAD!

20. OBHG Education Subcommittee 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?”

21. OBHG Education Subcommittee What to Ask  O – Onset  P – Provoke  Q – Quality  R – Radiation  S – Severity  T – Time  The duration of the problem  How long the current episode has been going on?  If prolonged duration, was there a recent sudden severity increase?

22. OBHG Education Subcommittee Time “How long has this recent episode of chest pressure lasted, Jack?” “How long did Jack’s seizure last?”

23. OBHG Education Subcommittee 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?”

24. OBHG Education Subcommittee Tag-ons The best way to avoid a tag-on is to ask one question at a time and wait for the answer

25. OBHG Education Subcommittee SAMPLE History  S – Signs/symptoms  A– Allergies  M– Medications  P– Past History  L– Last meal  E– Events

26. OBHG Education Subcommittee Allergies “Jack, are you allergic to any medications?” “Jill, are you allergic to anything?” “Do you have any allergies, Jill?”

27. OBHG Education Subcommittee Medications “Do you take any doctor-prescribed medicines every day?”

28. OBHG Education Subcommittee Past Medical History  Ask one question at a time  Allow the patient time to answer  Explore what is pertinent

29. OBHG Education Subcommittee 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

30. OBHG Education Subcommittee 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?

31. OBHG Education Subcommittee 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

32. OBHG Education Subcommittee 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

33. OBHG Education Subcommittee 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

34. BASE HOSPITAL GROUP ONTARIO QUESTIONS?

35. BASE HOSPITAL GROUP ONTARIO Well Done! Education Subcommittee STARTQUIT