Clinical Assessmentpart 1

Dr Doha Rasheedy

Lecturer of Geriatric Medicine

Department of Geriatric and Gerontology

Ain Shams University

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Key Principles of Patient Assessment

• It is estimated that 80% of diagnoses are based on history taking alone.

• Use a systematic approach.• Establish a rapport with the patient.• Ensure the patient is as comfortable as

possible.• Listen to what the patient says.

(Scott 2013, Talley and O’Connor 2010, Jevon 2009)

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Key Principles of Patient Assessment

• Ensure consent has been gained. • Maintain privacy and dignity. • Summarise each stage of the history taking

process. • Involve the patient in the history taking

process. • Maintain an objective approach. • Ensure that your documentation (of the

assessment) is clear, accurate and legible.(Scott 2013, Talley and O’Connor 2010, Jevon

2009)

Domains of Comprehensive Geriatric Assessment

Medical assessmentCognitive dysfunctionAffective DisordersVisual ImpairmentHearing ImpairmentDental HealthFunctional StatusNutritional StatusSleepGait and Balance ImpairmentSocial historyEnvironmentAdvance directives

History taking • Personal history• 1ry health problem from patient/ caregiver perspectives.• Past history:

• Medical• Geriatric giants• Surgical• Sleep • Leisure• Exercise• Nutritional status• Health promotion• Sensory deprivation• Accidents and trauma• Previous hospitalization• Medications review• Social history, advance directives

• Description of major health problems.• Assessment tools

Personal history• Patient identification:

– Name, age, sex, caregiver, contact method(telephone number, address).

– Education

• Special habits, Menstrual history, handedness• Social:

– occupation, marital status, children– Living arrangement (where, with whom, appropriateness for

patient)– Finances(aids, pension/ satisfaction), retirement (cause, effect) – Caregiver issues (caregiver stress, elderly abuse)– Community resources– Hobbies, Social life– Significant life experiences

1ry health problem from patient/ caregiver perspectives.

• The rule: Multiple complaints• Select the bothering one• The recently changing one• The new one• The backache for last 10 y with same ccc isn’t

worrisome but increasing severity is

• Patient/ caregiver perspectives• Onset• Course• Duration

Types of Onset1-Acute onset

Dramatic: within seconds or minutes e.g. cerebral hemorrhage or embolism

Sudden onset: within hours e.g. cerebral thrombosis

Rapid onset :within days e.g inflammation

2-Gradual onset:

(Within weeks, months or years ) e.g. degenerative diseases and tumors

3-Accidental onset:

(Discovered by the patient by chance)

e.g. breast mass , mass in inaccessible site as back

Types Of The Course1. Regressive: as inflammation , vascular

, trauma

2. Progressive: as malignancy and degenerative diseases

3. Stationary: emphysema, chronic bronchitis

4. Remission and exacerbation: as autoimmune diseases (SLE, rheumatoid arthritis), disseminated sclerosis.

Past history

1. Baseline functional, medical and cognitive status.

2. Each condition: analyze cause, complications, treatment, follow up, effect on function

3. Confirmed by which investigations

A• Anemia: history of blood transfusion iron therapy,

erythropoietin injection, laboratory diagnosis.• Asthma: dyspnea, wheezes, intermittent free in

between if not overlap disease, precipitating factors, season, history of other allergies, frequency of attacks

• Arthritis: which joint, what is the cause,character, signs of inflammation, stiffness duration, gelling, ROM, deformity, effect on function, Analgesic use

• Allergies: anaphylaxis, angioedema, asthma, allergic rhinitis, contact dermatitis

B• Bilharziasis:

1) complications• Colonic polyposis with bloody diarrhea (Schistosoma mansoni mostly)• Portal hypertension with hematemesis and splenomegaly (S. mansoni,

S. japonicum)• Cystitis and ureteritis (S. haematobium) with hematuria, which can progress

to bladder cancer;• Pulmonary hypertension (S. mansoni, S. japonicum, more rarely

S. haematobium)• Glomerulonephritis• and central nervous system lesions.

2) Tartar emetic injection, Praziquantel tablets

3) Exposure to infected water with snails

• Blood transfusion: when, amount, cause, if repeated why

• Behavioral disturbance: Anxiety, agitation, verbal and physical aggression, self neglect, why(depressed, delirious, demented)

C• Cancer: where/ when / chemotherapy radiotherapy/ their

complication/ surgery therapeutic or palliative.• Cataract: which eye, operation, with IOL, post operative visual

acuity.(GLUCOMA)• COPD: chronic cough, productive, small amount, whitish,

morning, exacerbations, O2 therapy, previous hospitalization, ICU, ventilation

dd: supporative lung disease, emphysema, IPF, asthma.• Constipation: usual habits, Alteration of bowel habits,

frequency, flatulence, associated abdominal pain, anal pain on defecation or rectal bleeding, possible cause

Don’t forget Medications: Calcium channel blockers, antidepressants, anticholinergics, opioid agonists, iron supplements

Don’t forget diet

D• Diabetes mellitus: Duration, therapy , complications, follow up

• Depression: not only depressed mood + rest of DSM V ± diagnosis made by physician ± antidepressant treatment

• Dementia:• Memory (recent and remote) and learning • Language (word-finding problems, difficulty expressing self) • Visuospatial skills (getting lost) • Executive functioning (calculations, planning, carrying out multistep tasks) • Apraxia (not able to do previously learned motor tasks, eg, slicing a loaf of bread) • Behavior or personality changes • Psychiatric symptoms (apathy, hallucinations, delusions)

FFalls: when, indoors or outdoors, once or repeated,

1) Pre-fall history: activities before falling, e.g. standing rapidly, palpitation- environmental hazards

2) During the fall: fits, loss of consciousness

3) Post-fall history: physical (fractures, contusion, wounds), psychic (phobia, anxiety, depression, fear)

G

• Glucoma:

Visual impairment, IOP measurement, Pharmacological therapy, surgery

H

• Heart disease: IHD, HF, arrythmia, anticoagulant use.

• Hypertension• Hepatitis, cirrhosis (hematemsis, melena,

jaundice,splenomegaly, ascites)

I

• Incontinence:1. Urinary: acute, chronic, character, volume,

activity during attack, associated symptoms, causes mainly drugs.

2. Fecal: acute, chronic, diarrhea, constipation (stool impaction) , mucus blood, dietary and toilet habits, immobility, and chronic laxative abuse

• Impotence:

K

• Kidney disease:– Renal colic, stones– CKD, RRT

P

• PU, Gastritis: Dyspepsia, epigastric pain, UGI endoscopy, hematemsis, therapy.

• Prostatism (LUTs):– Obstructive: weak stream, bifid stream,

straining during micturation, hesitancy, sense of incomplete emptying, impaction, dribbling.

– Irritative: nocturia, dysuria, urgency, frequency, incontince

S

• Seizure• Syncope• Stroke/ TIA

Surgical history

• Type• When• Where• GA/LA• Complications• Blood transfusion

Accidents trauma

1. Ask about any accidents  or falls  number and timing           

2. Circumstances before the event        

3. Complications after the event  

4. Comment possible causes and consequences.             

Other hospitalization

• When • Why• Similar attacks• Management done

Medication review

• Type• Dose• Duration• Indication• Side effects• Herbal medicine, vitamin supplements

Sensory impairement

• Hearing, visual impairment:– Unilateral/ bilateral– Cause– Corrected– Aids– Effect on function, QOL

Sleep

• Duration of night, daytime sleep• Sleep latency• Interrupted sleep• Inverted sleep rhythm• Arousal time• Satisfaction• Sleep apnea

exercise

• Type• Duration• Frequency• If stopped when why

leisure

• Activity • Duration• Frequency• With whom• where

Health promotion

• Regular clinic visit• Life style: healthy diet, exercise, smoking

cessation, dental care• Chemoprohylaxis (aspirin, vitamin D,

calcium, omega 3, multivitamins) • Vaccination• Screening (malignancy, common

diseases)

Description of major health problems.

• Complete analysis of each symptom:• o Onset• o Course• o Duration• o Associated symptoms• o Investigations• o Treatment• Review for the other systems

Thank you