Patient Medical Record Assessment

The Medical Record and Medical History

• Essential for respiratory therapists (RT) to confirm physician orders for procedures are current and complete.
• Chief complaint (CC) and history of present illness (HPI) provide insights into current medical problems.
• Past medical history includes smoking history measured in pack-years.
• Family and social history may reveal genetic or occupational disease links.
• Review of systems (ROS) assesses patient’s overall health.
• Advance directive details patient’s medical care preferences.

Handwashing Techniques

• Hands should be wet with warm or cold water before applying soap.
• Rub hands to create a lather, scrubbing all areas for at least 20 seconds.
• Rinse thoroughly and dry with a clean towel.
• Alcohol-based gels: Use sufficient amount and rub hands until dry (at least 15 seconds).

Interviewing the Patient

• Establish rapport to gather essential diagnosis information.
• Monitor changes in symptoms and therapy responses.
• Factors affecting communication include sensory, emotional, environmental, and cultural influences.

Structuring an Interview

• Introduce yourself at a social distance (~4-12 feet) and move to a personal space (~2-4 feet).
• Maintain appropriate eye contact and position at the patient's level.
• Utilize neutral questions to avoid leading.

Recording Physical Examination

• Components include initial impression, vital signs, and systems: HEENT, neck, thorax, abdomen, extremities.

General Clinical Presentation

• Continuous assessment from first sight of the patient.
• Indicators: level of consciousness, distress, body hygiene, and positioning.

Level of Consciousness

• Assesses oxygenation status and brain health.
• Utilized Glasgow Coma Scale for objective assessment of consciousness.

Vital Signs (VS)

• Standard vital signs: temperature, pulse, respirations, blood pressure.
• Additional observations include pulse oximetry and clinical impression.
• Frequency of measurement depends on patient’s condition and treatment.

Understanding Vital Signs Trends

• Isolated measurements have limited value; trends over time offer better insight into a patient’s health.

Body Temperature

• Normal range is 97 to 99.5 °F (98.6°F average).
• Fever indicates an elevation above 38.3°C (101°F), linked to infections or serious illnesses.

Pulse (Heart Rate)

• Normal pulse rate: 60-100 beats/min; tachycardia >100, bradycardia <60 bpm.
• Rhythm types: regular, irregularly irregular (unfavorable).

Respiratory Rate (RR)

• Normal adult RR: 12-20 breaths/min; tachypnea >20, bradypnea <10.
• Abnormal rates can indicate respiratory distress, anxiety, or metabolic issues.

Common Breathing Patterns

• Apnea: absence of breathing; eupnea: normal breathing; tachypnea: rapid breathing; hypopnea: shallow breathing.

Blood Pressure (BP)

• Normal reading: 120/80 mm Hg; hypertension is 140/90 mm Hg or higher, while hypotension is <90/60 mm Hg.
• Measurement errors may arise from mismatched cuff size or improper application.

Shock and Blood Pressure

• Defined as inadequate delivery of oxygen/nutrients to vital organs.
• Various shock types: cardiogenic, hypovolemic, septic, and anaphylactic.

Pulse Oximetry

• Noninvasive monitoring of SpO2; should represent patient condition accurately.

Physical Examination Steps

• Four steps: Inspection, Palpation, Percussion, Auscultation, essential for ongoing patient assessment.

Examination of Head and Neck

• Neurological assessments include pupillary response for neurological condition.
• Cyanosis and nasal flaring indicators of respiratory distress.

Lung Topography

• Knowledge of lung borders, fissures, and landmarks is crucial for accurate respiratory assessment.

Examination of Thorax and Lungs

• Inspect for thoracic configuration, chest expansion, and breathing patterns.
• Pectus carinatum and excavatum indicate structural abnormalities.

Breathing Patterns

• Observe normal vs. abnormal breathing efforts and use of accessory muscles.

Chest Palpation

• Assess vocal and tactile fremitus changes in conditions like pneumonia or pneumothorax.

Percussion and Auscultation of Lungs

• Percussion determines resonance (normal, increased, decreased) and auscultation identifies normal and adventitious lung sounds.

Voice Sounds

• Evaluated by comparing sounds during speech; changes indicate pathological conditions.

Cardiac Examination

• Precordium assessed for pulsations indicating potential heart issues.

Auscultation of Heart Sounds

• Four primary heart sounds: S1 (AV closure), S2 (semilunar closure), S3 (abnormal fill), S4 (atria kick).

Abdominal Exam

• Inspect and palpate for tenderness or distension; can severely impact respiratory function.
• Abdominal compartment syndrome indicated by pressures exceeding 20 mm Hg.