This chapter was reproduced from the Emergency Medicine Clerkship Primer, 2008, Chapter 7, with the permission of the Editor, for ease of viewing on mobile devices.
Performing a focused, complaint-directed H&PE is the cornerstone of diagnosis and treatment in the emergency department. In the majority of cases, a focused differential diagnosis and eventual disposition can be derived from the initial H&PE. Although a single piece of historical information or finding on physical examination may not rule in or rule out a particular diagnosis, taken in aggregate, the H&PE is a powerful diagnostic tool that drives further evaluation. The H&PE provides much of the information necessary to develop a patient-specific problem list, which allows you to formulate your differential diagnosis. Subsequently, as you master the art of focusing your H&PE, you will improve your diagnostic skills and care for patients with increased comfort and efficiency.
Early on, the emergency department safety net (cardiac monitoring, IV access, and supplemental oxygen) should be incorporated into the management of all potentially sick patients.
Each specialty has a slightly different approach to performing an H&PE. In the emergency department, our approach to the H&PE is partly time sensitive because of patient volume and acuity. In the emergency department, the depth of the H&PE will be based on the patient’s complaint,
sometimes brief and focused, other times more comprehensive. Remember, the time required to perform a comprehensive H&PE for a new patient visit in an office practice is vastly different than the time necessary to evaluate many patients that you will encounter in the emergency department. In emergency medicine, you must balance the time needed to perform a focused but inclusive H&PE with the time-sensitive nature of diagnosis, treatment, and disposition. A recommended rule of the thumb for students is to complete your initial evaluation within 10 to 15 minutes. However, regardless of the patient complaint, your evaluation should be thorough.
The primary goal of the complaint-directed H&PE is to diagnose or exclude potentially life- or limb-threatening disease or injury. More simply stated, the goal is to determine who is “sick” and who is “not sick,” a familiar theme that you will hear more than once in this Primer. The other goal is to exclude any potential causes of serious morbidity and, if possible, to arrive at the correct diagnosis. The dynamic differential diagnosis developed from your H&PE is what drives many of the case-specific questions that you will ask the patient during the encounter. The more information you gather during the H&PE, the more your differential diagnosis narrows and the more detailed and specific your evaluation becomes. Although the H&PE are often performed simultaneously, in this section we will discuss them separately.
For the majority of patients you will encounter, it will be obvious that their airway is unobstructed, that they are breathing without distress, and that there is no sign of systemic hypoperfusion. However, some of the patients that you encounter may have acute life- or limb-threatening presentations that cannot afford even the minimal 10 to 15 minutes required for a focused H&PE. In these cases (e.g., trauma, hypotension, shortness of breath, chest pain, altered mental status), your approach to the H&PE will deviate from the traditional approach of interviewing the patient followed by a systematic but focused physical examination.
Think of the medical history as a conversation with a purpose. It starts by identifying the chief complaint; that is, why did the patient come to the hospital?
When a patient presents with a serious health condition, the initial goal of the primary survey is to identify any immediate life-threatening condition and intervene as warranted. This is accomplished by approaching the patient in a systematic fashion. A classic example of this strategy is taught in the advanced trauma life support course. When evaluating a victim of trauma (or a seriously ill medical patient), focus first on evaluating airway patency and assessing for signs of airway obstruction. The next step is to evaluate the patient to ensure adequate oxygenation and ventilation. This may require exposure of the neck and chest; inspection, palpation, auscultation of the chest; pulse oximetry; and perhaps even obtaining an ABG in selected cases. See the case study shown on this page for an example.
As a medical student, it is always important to realize that you will be working under the guidance of a senior emergency medicine resident or an attending physician. If at any time you encounter a critically ill patient, you should immediately notify your supervisor—another recurring theme. Remember, in the emergency department, the varied pathology and high acuity often causes the health care provider to deviate from the standard approach of obtaining a medical history followed by a physical examination. Early on, the emergency department safety net (cardiac monitoring, IV access, and supplemental oxygen) should be incorporated into the management of all potentially sick patients.
Consider a patient who presents after penetrating trauma to the right anterior chest. An emergency physician would identify that the patient has a patent airway, that he can phonate normally, but that he appears to be in significant respiratory distress. On further evaluation after full exposure, a 1-cm stab wound to the right anterior chest wall, fourth intercostal space, midclavicular line is noted. On palpation of the right chest, subcutaneous air is discovered, and, on auscultation, breath sounds are diminished. His blood pressure is 70/40 mm Hg; his skin is cool and clammy. Rapidly putting the case together, the patient has subcutaneous air, decreased breath sounds on the side of the injury, and hypotension. Because a rapid primary survey was performed in a systematic fashion, a life-threatening condition (suspected tension pneumothorax) was immediately identified. Emergently, this patient would undergo needle decompression of the pneumothorax followed by the placement of a chest tube.
The Medical History
The depth and detail of your medical interview will vary depending on the patient’s chief complaint. Some patients will present to the emergency department with a very straightforward complaint or injury: sore throat, twisted ankle, cutaneous abscess, laceration, and the like. Other complaints such as weakness, dizziness, or abdominal pain in the elderly will require a much more extensive medical interview. Because of the complaint-oriented nature of our patient presentations, it is important for you to learn how and when to focus your medical interviewing skills. Remember, a focused history does not mean cursory.
Think of the medical history as a conversation with a purpose. It starts by identifying the chief complaint; that is, why did the patient come to the hospital? For most ambulatory emergency department patient encounters, this information can often be obtained from the nursing triage form. In the emergency department, a triage nurse interviews ambulatory patients before they see a physician. The purpose of this brief, limited evaluation is to determine the order in which patients need to be evaluated. The triage form will provide you with some basic information, but it should not be a substitute for obtaining or verifying information directly from the patient. Information commonly documented on a nursing triage form includes the patient’s chief complaint, past medical history, medications, allergies, and vital signs.
When interviewing a patient, a simple opening statement can often provide you with a wealth of information. For example; “Hello Mr. Smith, I am student doctor________. How can I help you today?” or “What seems to be wrong today?” Open ended questions will allow the patient to respond in his or her own words. It is important not to interrupt patients when they are responding to your opening statement. Demonstrating exemplary listening skills will help you develop rapport with your patient. The upfront information that you obtain from the patient will serve to direct you as you investigate the HPI.
Basic Information to Gather
- Onset: Identify when the problem started, the surrounding circumstances, and the severity of the complaint when it began.
- Location: If it is a painful complaint such as chest pain or abdominal pain, ask the patient to point where it hurts and elicit whether the pain has moved to a different location since it started.
- Duration: Determine how long the patient has been having the complaint and whether it has been constant or intermittent. If the complaint is intermittent, it may be of importance to establish how long each episode lasts.
- Quality: How does the patient describe his or her complaint or pain?
For many chief complaints, certain basic information should be obtained: the onset of the problem, the location of the complaint, the duration of the problem, and the quality of the pain. At times it may be necessary to supplement this question with specific modifiers (e.g., sharp, dull, pressure).
Other key features that may be necessary to obtain include the presence of aggravating or alleviating factors, response to prior therapy or treatment, associated symptoms, and risk factors for certain medical conditions such as coronary artery disease or venous thromboembolism. A mnemonic to remember when trying to obtain cardinal characteristics of a patient’s chief complaint is “OPQRST” (onset, provocative/palliative, quality, region, radiation, severity, timing, temporal relationships, and therapeutics). Obtaining an accurate history is the first of many crucial steps that will allow you to offer the best care to your patients. Remember, many times, a preliminary diagnosis will be made on the basis of the history alone. This will depend of course on your ability to elicit, synthesize, and interpret the relevant information.
Other important aspects of the medical history are a complaint-directed review of systems (ROS); past medical, surgical, and obstetrical history; social and family history; medications; and allergies. Early on, some medical students have difficulty focusing their ROS questioning. At the bedside, it is common to intertwine questions that pertain to both the HPI and the ROS. However, it is usually not necessary to perform a comprehensive ROS evaluation on patients in the emergency department. One recommended approach that can be used after completion of your focused H&PE is to ask the patient if there is anything else that they would like to talk about that was not already covered. For most patients, a thorough evaluation can be obtained by focusing on the presenting problem. However, never ignore a pertinent finding that is discovered even incidentally when interviewing or examining a patient.
In certain clinical scenarios, it will be beneficial to obtain additional history (if possible) from witnesses, family, or prehospital personnel. For example, when evaluating a 45-year-old male restrained driver involved in a motor vehicle accident, fire department personnel can provide valuable information. Was the patient trapped in the car? Was the windshield cracked or the steering wheel deformed? Was there intrusion of the driver’s side door into the vehicle? What was the condition of the patient at the scene? Was the patient able to self-extricate?
In the emergency department, a number of patient-related barriers can affect your ability to obtain an accurate or thorough history. These include encounters with young children, the actively psychotic, the debilitated or demented, patients presenting with an altered mental status, and patients with limited English proficiency. Remember that as a result of federal mandates, a hospital must offer and provide language assistance services to patients with limited English proficiency, including bilingual staff or interpreter services, at no cost to the patient, in a timely manner during all hours of operation. In general, to limit miscommunication or bias, family and friends should not be used to provide interpretation services, except at the request of the patient.
Keep in mind that when describing their presenting complaint, some patients will use certain terms that have a different meaning to them than to you. This may be encountered in the patient who complains of a migraine headache. Many patients presenting with the complaint of a headache have not had a formal evaluation but will use the term migraine headache. This is likely because of the common misuse of the term migraine by the lay public. Another example is the use of the term dizziness. This commonly used descriptive, when looked at more closely, may reflect any of the following meanings: lightheadedness, unsteadiness, or vertigo. Other patients may have cultural differences or language difficulties that can affect their ability to describe certain complaints or conditions.
Remember, when patients describe their symptoms, they may use different language than you would use to describe the same symptoms. This can make it more difficult to determine what is wrong with the patient and may lead to frustration. If you are having difficulty understanding a patient describing his or her symptom complex, try to have him or her explain it in different terms or repeat it back to ensure that you both understand each other. Many times, it can be helpful to summarize and clarify the history with the patient. Please keep in mind the cultural differences that you may encounter in the emergency department and be sensitive to these issues if they arise.
The physical examination usually starts with an appreciation of the general appearance of the patient, followed by an immediate review of the vital signs (blood pressure, heart rate, respiratory rate, and temperature). With the advent of noninvasive bedside testing, many physicians consider pulse oximetry testing the fifth vital sign. Beware of the statements “vital signs are stable” or “vital signs are within normal limits.” Remember, the normal range of vital signs varies with the age of the patient. It is much more important to appreciate the vital signs in context to the presenting complaint and bedside examination. A patient with a history of poorly controlled hypertension with a blood pressure of 102/58 mm Hg technically has a normal pressure; however, in this case, the patient is relatively hypotensive. In some cases, baseline vital signs obtained from old medical records may be of assistance. Often, vital sign trends are much more important than isolated readings. Also, keep in mind that elevated blood pressure measurements are as common in the emergency department population as they are in the general population. Many of these patients do not require acute intervention to lower their blood pressure.
An appreciation of the general appearance of the patient is crucial. Simply stated, how does the patient look when you walk into the room?
An appreciation of the general appearance of the patient is crucial. Simply stated, how does the patient look when you walk into the room? The concept of “sick or not sick” can often be made at the bedside during the first 5 to 10 seconds of the encounter. The more patients you encounter, the better you will become at making this determination. Up to this point, the assessment of the vital signs and an appreciation of the general evaluation should have taken just a minute or two. A seasoned clinician will determine whether to continue with a systematic evaluation or to deviate from this traditional approach and perform a focused physical examination and initiate diagnostic or therapeutic measures as warranted.
Remember, the template for performing a comprehensive head to toe physical examination has its place; however, in many circumstances, a patient presenting to the emergency department does not require a comprehensive examination. In the stable patient presenting with a minor or nonurgent complaint, your physical examination can proceed in a systematic, yet focused, fashion. The exam should follow the typical order of inspection, palpation, percussion, and auscultation, if applicable. An adequate knowledge of surface and bony anatomy will be helpful, especially in patients presenting with musculoskeletal complaints. In some patients with nonspecific complaints or when you need to perform a more comprehensive evaluation, think of the physical examination as a screening tool. If pertinent or positive findings are detected, a more detailed and focused exam can then be performed supplanted by additional bedside or other diagnostic tests.
In certain clinical scenarios, such as abdominal pain, shortness of breath, or altered mental status, avoid the pitfall of relying solely on your initial examination.
In certain clinical scenarios such as abdominal pain, shortness of breath, or altered mental status, avoid the pitfall of relying solely on your initial examination. Presentations such as these require serial examinations to ensure a response to therapy or to identify a change in condition during the time the patient is being observed. A change in condition for better or worse may affect your ultimate disposition of the patient. Another pitfall to avoid when performing your physical examination is inadequate exposure of the affected area. At times because of emergency department overcrowding, a patient may be in a treatment area that is not conducive to a proper examination An example may be the patient with right lower quadrant abdominal pain who is in a hallway bed. If warranted, move the patient to a separate examination area to perform a proper evaluation.
Despite the importance and utility of the H&PE, it is also useful to acknowledge its limitations. It is uncommon that a single historical feature or physical examination finding will reveal the diagnosis in many patients. This is especially important to remember in catastrophic diseases, which may not present classically. For example, the lack of vaginal bleeding does not rule out an ectopic pregnancy. That being said, medical interviewing and physical examination skills are crucial to providing excellent patient care. The constellation of signs, symptoms, and examination findings will help direct your diagnostic workup.
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