Doing a thorough history and physical (H&P) is important in practice and for the Physician Assistant Exam (PANCE). Any medical professional should be able to pick up more than 90 percent of the information needed to diagnose the underlying medical condition from the H&P. The key is asking the patient the right historical questions and paying close attention to detail on the physical examination.
For testing-taking purposes, understand the clinical scenario presented and pay attention to the clues in the questions. In clinical practice, pay attention to the H&P. Sometimes the symptoms presented and your physical examination can point you in a totally different direction than you first thought.
Ask the right questions about symptoms
Whether you work in the surgical arena or have been through a surgical rotation, you know the importance of asking the right questions. A common reason for a surgical consultation, especially in the emergency room, is to evaluate abdominal pain. The basic question is whether the person needs to go to the operating room (OR) immediately or should simply be kept under close observation.
When you’re asking questions about the etiology of pain, remembering the alphabet can help you, especially the letters O, P, Q, R, S, and T:
O — onset: Did the pain begin suddenly or gradually?
P — provocation or palliation: For example, can the person pinpoint what may have caused the pain in the first place? In the case of a hernia, was the person lifting something heavy and/or employing improper lifting techniques? Does anything make the pain better or worse? With some forms of abdominal pain, especially a duodenal ulcer, the affected person may say that eating makes the pain better.
Q — quality: Is the pain cramping, sharp, crushing, or ripping? Is the pain dull, or does it burn?
R — region or radiation: Where is the pain located? Does the pain stay in one spot, or does it travel somewhere else? Pancreatitis, for example, often radiates to the back. Symptoms of cholecystitis can include radiation to the right shoulder.
S — severity, usually on a scale of 1 to 10: If someone is bent over double in pain, some badness is going on. A pain scale allows the affected person to give an assessment of his or her own pain. Remember that pain is subjective; tenderness is a finding obtained on physical examination.
T — time: When did the pain begin? Is the pain constant or intermittent? What was the person doing when the pain began?
Focus on the patient’s medical history
Past medical problems that you’re presented with in a clinical scenario are important. Knowing whether hypertension, diabetes, or coronary artery disease is present provides insight into pre-operative risk as well as into the etiology of the person’s pain.
For example, if someone has a history of coronary artery disease, carotid disease, or peripheral vascular disease and is presenting with intermittent abdominal pain after a meal, you may think about mesenteric angina or mesenteric ischemia.
If the person has a history of multiple surgeries, especially abdominal surgeries, and is presenting with nausea/vomiting, you may suspect that adhesions from prior bowel surgeries may be causing a bowel obstruction. And if the person fell or was involved in a motor vehicle accident and is complaining of pain pointing to the left side of the abdomen, you may be dealing with a splenic injury.
Knowing the patient’s medication regimen is crucial. Before surgery, you need to know if a person is on a blood thinner, such as aspirin, clopidogrel (Plavix), or warfarin (Coumadin). With warfarin, for example, you may need to reverse the prothrombin time/INR with fresh frozen plasma (FFP) prior to taking the patient to the OR.
If the person has a metal valve replacement, you need to know how soon you can restart anticoagulation after surgery. Pay attention to all medications a person is taking, both prescription and nonprescription.
Social and family history is important as well. A person who smokes may have diminished lung function or peripheral circulation present. If a person drinks and has drunk alcohol recently, that can interfere with anesthesia. If cirrhosis is present, you may see a clotting problem. You need to know if a patient has a family history of a bleeding diathesis or a clotting problem.
The physical exam
Test-makers can and will transform many physical exam signs into great test questions, especially in the field of general surgery. Many test questions about a physical examination give you a sense of the person’s hemodynamic stability.
For example, are his or her vital signs okay? If the person has abdominal pain, has a barely palpable blood pressure, and is tachycardic, then the person is in shock and likely needs to go to the OR emergently. If the vitals are stable and if you see no red flags on physical examination, then maybe the patient simply requires close observation.
What are some of the red flags on examination? The biggest is one that says a surgical emergency may be present — that is, an acute abdominal emergency. This means evidence of peritonitis or perforation.
If on examination you see evidence of rebound tenderness, then that’s a surgical emergency, too. It suggests that a perforation may be spilling intestinal contents into the peritoneal space, causing peritonitis. A laundry list of conditions can cause an abdominal perforation, including intestinal malignancy, inflammatory bowel disease (IBD), acute appendicitis, and peptic ulcer disease (PUD), to name a few.
In the emergency room, you’re evaluating a 74-year-old woman who presented with abdominal pain. She states it began abruptly and radiates to her back. On physical examination, she is in pain. Blood pressure in the right arm is 160/90 mmHg, whereas blood pressure in the left arm is 82/60 mmHg. You notice decreased pulses in the lower extremities. Which one of the following is your next immediate step in management?
(A) Admit to the ICU for observation.
(B) Obtain a stat CT scan of the thorax and abdomen with IV contrast.
(C) Call a general surgeon for consultation.
(D) Perform an ultrasound of the left upper extremity.
(E) Perform an ECG stat.
The correct answer is Choice (B). This patient most likely has an aortic dissection, so she needs a CT scan of the abdomen and pelvis with intravenous contrast to determine whether an aortic dissection is present. The question contains important clues — sudden onset of pain with radiation to the back, differential blood pressure measurements in the upper extremities, and decreased pulses in the lower extremities.