Getting the Most From Your History and Physical: Chest Pain Patients

This is the first of a four-part series that will appear bimonthly through August.

“Paramedics do not make diagnoses.”

This is a quote uttered frequently in prehospital emergency medicine, and it’s one of the larger myths that still exists. It is a throwback idea from a bygone era and a thought pattern that restrains the true potential of the field. It supports the erroneous assumption that prehospital emergency medicine is not a true profession with highly skilled and knowledgeable personnel who provide daily advanced assessment and treatment across our nation.

If paramedics never made a preliminary prehospital diagnosis, how would they know which protocol to follow or to which specialty destination a patient must be transported? Indeed, both the National EMS Core Content and the National EMS Scope of Practice Model describe the need for paramedics to develop a differential diagnosis, or field impression, based upon advanced assessment skills in order to provide correct treatment for the patient.^1,2

Gone is the time when paramedics had limited training and skills. Paramedics are now routinely called upon to perform advanced emergency medicine skills such as rapid sequence intubation, interpreting 12-lead EKGs, intraosseous line insertion and many others that were once performed solely by physicians. It is time for prehospital healthcare workers to accept their role as professionals.

As professionals, it is important for EMS personnel to formalize and enhance skills in the area of obtaining history and physical examinations. It is the art of patient assessment that separates a technician who performs procedures from a true professional equipped with the scientific knowledge and finely tuned assessment skills to make accurate prehospital diagnoses and deliver accurate high-quality medical care.

Dr. William Osler, often credited as the “father of modern medicine,” promoted the importance of patient history and physical examination. He is quoted as saying, “Listen to your patient, he is telling you the diagnosis.”³ In this multipart series we will follow Osler’s example and stress the importance of developing the art and skill of the patient history and physical assessment. We will attempt to impart an enhanced ability to skillfully obtain this vital information in order to formulate a differential diagnosis. These skills are essential to ascertaining the correct prehospital diagnosis and determining the correct treatment and transport destination.

The intent of this series is to assist paramedics in developing a systematic, targeted history and physical exam by focusing on the patient’s chief complaint and considering the differential diagnoses by using the inclusion and exclusion information provided by the patient. The goal is to quickly and accurately determine the prehospital diagnosis so immediate lifesaving treatment can begin. This first installment will discuss the differential diagnosis of chest pain and the manner in which a targeted history and physical exam can narrow down the prehospital diagnosis.

H&P Background

The history and physical exam have long been the basis for determining a diagnosis. It is often said the diagnosis is made 90% of the time by the history, 9% of the time by the physical exam and 1% of the time by laboratory examination. This has been found to be true: In at least two studies on the relative value of the history and physical exam in making the correct diagnosis, clinicians were found to use a combination of chief complaint and history to make the correct diagnosis in 74%–96% of cases, the physical exam added up to 12%, and the laboratory evaluation supplied the remaining minor amount of information needed.^4,5 Even today, with all the sophisticated diagnostic tests available, the history and physical are still the gold standard for determining a diagnosis. Laboratory tests and imaging studies are largely ordered to confirm or in some cases exclude a diagnosis already determined through the information obtained from the history and physical exam.  

Unfortunately, the history and physical exam are probably the most neglected aspects of patient care in today’s prehospital setting. Besides conducting improper or incomplete histories and physicals, many paramedics miss a diagnosis because they look only for its “classic” signs and symptoms. As anyone who has been in the field for a while can attest, many patients don’t have “classic” presentations.

By understanding the etiology and pathophysiology of an illness and conducting the proper history and physical exam, the paramedic’s ability to make the correct prehospital diagnosis will significantly increase. Learning to assess and understand what is going on with your patient is a skill far more important to making a correct diagnosis than just remembering the classic presentations of an illness. Making a correct prehospital diagnosis requires that knowledge and experience be combined with the subjective/objective information obtained from the history and physical exam. Together this information will form the basis of the prehospital diagnosis.

As in the days of Osler, bedside experience is emphasized. Much of medicine is pattern recognition. The authors feel strongly that paramedics should routinely follow up on the patients they transport to the hospital. It is critical to the development of accurate pattern recognition that paramedics discover the actual final diagnoses of the patients they have cared for and then compare each one to their prehospital diagnosis to reinforce the recognized pattern or correct their misdiagnosis and thus adjust that recognition for future cases.

The value of establishing an accurate diagnosis is to provide a logical basis for treatment and transport destination. Seriously ill patients need prehospital intervention tailored for their particular diagnosis. Today paramedics are well trained and should be able to recognize, treat and/or stabilize most medical emergencies.

The following is an outline of a prehospital history and physical exam. Although histories and physical exams vary depending on the chief complaint, all should follow this general outline. However, transport should never be delayed to conduct lengthy histories and physical exams. Unstable patients cannot afford such delays, and stable patients don’t require such in-depth histories and physical exams. Remember, stabilization and rapid transport are the goals of prehospital medicine, and the assessment skills outlined in this article are designed to enhance the success of that mission. We begin with the framework of what information will be gathered and then discuss how to apply it specifically to patients with a chief complaint of chest pain.

This article has two main objectives: first to develop a focused systematic approach to the history and physical exam, and second to develop a better understanding of the etiology, pathophysiology and signs and symptoms of specific diseases so a prehospital diagnosis can be quickly and accurately determined. This concept is important because even patients with the same disease can have different clinical presentations. The process involves four steps, and each should be completed before advancing to the next. Once you become proficient with the process, you will be able to quickly and accurately determine a prehospital diagnosis within 2–3 minutes.

1. Chief complaint;

2. History:

• History of the present illness;
• Past medical;
• Social;
• Family history;

3. Targeted physical exam;

4. Prehospital diagnosis and differential diagnosis.

Chief Complaint

The chief complaint is the primary reason a patient seeks medical attention. It acts as the logical starting point for determining which emergency medical conditions potentially exist and which follow-up questions will help narrow down those possibilities. Some patients will list multiple complaints, which can make it difficult to determine the actual chief complaint. When treating patients with multiple complaints, determine the patient’s main reason for calling 9-1-1 by asking a question such as, “Of all of those problems, which one concerns you the most?” Consider the answer to be the patient’s chief complaint. This will give you a reference point to begin targeting your history and physical exam.

However, don’t disregard the other complaints; unifying them will help determine the prehospital diagnosis. In patients with chronic illnesses, the “frequent fliers,” it’s easy to become complacent and forego the history and physical exam. Give your patient the benefit of conducting a history and physical exam for every encounter so you can make an informed decision regarding their treatment. Patients with chronic illnesses are likely to develop new medical conditions and complications from their chronic condition or even from their medical treatment.

History

The importance of obtaining a good history cannot be overemphasized. The history combined with the physical exam provides the necessary subjective and objective information to make a prehospital diagnosis. A complete history includes history of present illness, past medical, social and family history. Traditionally there is little emphasis on the family and social history in paramedicine. They are included because often they provide important clues in helping to determine a prehospital diagnosis.

History of the present illness (HPI)—If you only learn one thing from this article, understand that the single most important part of any history and physical exam is the history of the present illness. The sole purpose of the HPI is to get a clear picture of the events that led the patient to seek medical attention. Listen carefully to the patient—most of the information you need to make the prehospital diagnosis is in the history of the present illness. Keep in mind that the HPI is an evolving process, and as you proceed use the inclusion and exclusion information supplied by the patient to narrow the diagnostic possibilities.

As we are all aware, patients are not always the best historians. Paramedics will need to have a degree of investigative prowess to extract the information necessary to arrive at the correct diagnosis. A patient’s fear, confusion and denial can all be obstacles to overcome to obtain a good history. It’s important as a paramedic to have confidence in your history-taking ability. Taking a history is a skill similar to starting an IV or intubating a patient. Skills take time to develop. Avoid histories that amount to nothing more than a series of random questions, as opposed to questions presented in a logical sequence. In addition, avoid confusing medical terminology or leading the patient with your questioning. Allow the patient to use their own words, but don’t be afraid to clarify vague answers. If necessary, use your resources; family, friends and healthcare workers can help fill in the gaps.

The history of the present illness is based on the chief complaint. Apply the acronym OPQRSTA to the chief complaint to ensure all necessary questions are asked. Avoid skipping around, as it is confusing, and you are more likely to forget a key question!

• Onset—When did symptoms begin? Was the onset gradual or sudden?
• Provoke—What makes the symptoms worse?
• Palliative—What makes symptoms better?
• Previous similar episodes—This question will often give you the diagnosis if previous episodes have already been diagnosed.
• Quality of pain—Sharp, dull, pressure, squeezing, aching, burning?
• Region—Where is the pain located? Is the pain localized or diffuse?      
• Radiation—Does the pain radiate?
• Severity—What is the severity of the pain on a scale of 1–10?
• Time—Duration, frequency, constant/intermittent?
• Associated signs and symptoms—Review of related body systems.                       

Past medical history (PMHx)—Because time is limited in the prehospital setting, past medical histories are limited to significant illnesses or diseases. In general inquire about any recent surgeries, cardiovascular disease (coronary artery disease, hypertension, congestive heart failure, arrhythmias), pulmonary disease (COPD, asthma), stroke, diabetes, kidney failure or past similar episodes of their chief complaint.

The past medical history also includes any prescription or over-the-counter medications the patient is taking. Pay particular attention to medications the patient has been prescribed, as they will provide some insight into underlying conditions and general health. Memorizing the most common medications and what they are used for will often let you elicit a patient’s past medical history just by looking at the medications they take. It’s also important to inquire about any recent medication or dosage changes, as either could be responsible for the patient’s condition, as can adverse side effects from a medication or combination of medications.

Also included in the past medical history are allergies to any medications. A urticarial rash, angioedema or wheezing characterizes a true allergic reaction. What many patients consider an allergic reaction is really a sensitivity or side effect of the medication—e.g., many patients claim they are allergic to morphine because it makes them nauseous.

Social history (SHx)—As paramedics we tend to overlook a patient’s social history. A patient’s social habits can provide insight into their general health and potential medical conditions. Specifically inquire about smoking, drug abuse and alcohol consumption. Smokers have an increased incidence of coronary artery disease, hypertension and stroke. Use of drugs, specifically cocaine and other stimulants, can cause ischemic chest pain, hypertension, arrhythmias and stroke. Always inquire about possible drug abuse in patients with ischemic chest pain, especially patients who would be considered too young for coronary artery disease. Alcohol abuse can cause neurological, cardiovascular and gastrointestinal problems.

Travel history is part of the social history. With the ever-prevalent risk of new transmissible illnesses spreading from one continent to another, this is an additional important piece of information to gather from patients who present with an infectious-disease problem.

Family history (FHx)—Family histories are limited in the prehospital setting, as a positive or negative family history cannot rule out a specific illness or disease. Include family histories as part of the big picture. Coronary artery disease, hypertension, diabetes and strokes all have a high incidence of running in families. A positive family history is relevant with immediate family members only (mother, father, brothers, sisters or adult children). Because coronary artery disease, hypertension, diabetes and strokes are more prevalent in the fifth, sixth and seventh decades, a family history provides little information for a patient 50 or older. However, a 35-year-old patient complaining of chest pain whose father died of a myocardial infarction at 38 is significant.

Limited Prehospital Physical Exam

The following outline is an example of a limited physical exam. This is the minimum acceptable physical exam and should be done on all adult medical patients. This exam should also include ECG and glucose testing if warranted based upon the chief complaint. Caution: This exam is not for trauma patients.

Vital Signs

• Blood pressure;
• Pulse rate and quality;
• Respiratory rate and quality;
• Skin: color, condition, temperature;
• Pulse oximetry;

General

• Position (supine, tripod, etc.);
• Level of distress;

Chest

• Heart: rate and rhythm;
• Lung sounds;

Abdomen

• Soft or rigid;
• Tender or nontender;
• Distention;

Neurological

• Level of consciousness (AVPU);
• Orientation;
• Gross motor and sensory exam;

Extremities

• Lower extremity edema.

Once the history and physical exam are completed, there will be enough information to make an informed decision regarding your patient’s care.

Prehospital and Differential Diagnosis

Now let’s apply this template to a chief complaint of chest pain.

In the world of medicine, there exist nearly innumerable potential diagnoses for specific complaints. Memorizing the nuances of each one would be impractical. However, since we are in the field of emergency medicine, and since our major role is that of initial stabilization and transport to the correct facility, we can limit our evaluation to those conditions that fall into two major categories: the potentially deadly/disabling and the statistically most common etiologies. This list of possible diagnoses is termed a differential diagnosis.

Taking a look at the chief complaint of chest pain, there are several potential life threats that must be addressed. These include myocardial infarction/ischemia, aortic dissection and pulmonary embolism. There are also several common etiologies that must be considered: pneumonia, pleurisy, spontaneous pneumothorax, acid reflux and costochondritis.

The reader is cautioned that laypersons may misinterpret some questions and assume “heaviness” in their chest is not actually chest “pain.” It may be better to ask if there is any chest “discomfort” to ensure you elicit the correct response. Once the chief complaint of chest pain is elicited, the next step is to formulate a logical mental framework or algorithm to help distinguish the above list of differential diagnoses from each other. Knowing the presentations expected with each and combining the information gathered from OPQRSTA will assist in arriving at the correct prehospital diagnosis. Figure 1 presents an example of how to set up this mental framework. For brevity’s sake we will limit the discussion to the deadly possibilities and defer discussion of the less severe causes of a chest pain chief complaint.

After the initial history, the paramedic should have a fair idea of which possible diagnoses are present. The next step is to add the past, social and family histories to the equation. Specifically look for risk factors (Figure 2) to support or refute the suspected diagnosis.

For example, if the paramedic suspects ischemic heart disease, the past history may show risk factors of hypercholesterolemia, the social history may reveal smoking or cocaine, and the family history may reveal history of MI at a young age. All of these would support the prehospital diagnosis of MI/ischemic heart disease.

Alternatively, a patient with a past medical history of Marfan syndrome and hypertension along with a social history of cocaine abuse and a negative family history of MI would favor aortic dissection.

Finally, a past history of DVT, cancer, recent surgery, birth control pills or current pregnancy plus a social history of smoking and a family history of coagulation disorder all favor PE.

The idea is these follow-up questions are not random. We are searching in a systematic way for evidence for or against specific diagnoses the first part of our history suggests may be present.

As we move on to the physical exam, we again will be looking for evidence of a specific diagnosis (Figure 3). While we will in general be performing a rapid generalized head-to-toe exam on most patients, we will in addition be performing a more focused detailed exam looking for evidence of the suspected diagnosis.

If we suspect from our history that a patient may be suffering an aortic dissection, we will pay special attention to bilateral pulses and blood pressure, looking for asymmetry. If there is a combination of severe chest pain and one-sided neurological deficits, the exam findings support the diagnosis of dissection.

Alternatively, if we suspect the patient has a PE and we find them to be tachycardic, tachypneic and mildly hypoxic with a slight wheeze along with a unilateral swollen leg, then the exam is consistent with pulmonary embolism.

Conclusion

For as long as medicine has existed, the history and physical exam have been the core information-gathering tool to develop a differential diagnosis. Paramedics can improve their diagnostic acumen by adopting this systematic search for clues from the history and physical exam to enable them to accurately formulate a field impression or preliminary diagnosis. After transport to the appropriate facility, following up to learn what the patient’s final diagnosis is will help to either reinforce or correct a paramedic’s pattern recognition, and with it diagnostic accuracy, for future similar cases.

This process can be applied to most common chief complaints such as shortness of breath, neurological complaints and abdominal pain. Like all skills, the history and physical exam require practice and repetition in order to become proficient. We encourage readers to apply this organized method to all medical patient encounters. As individual proficiency improves, so will the ability to determine the correct prehospital diagnosis.

References

1. National Highway Traffic Safety Administration. National EMS Core Content, https://www.nhtsa.gov/people/injury/ems/EMSCoreContent/.

2. National Registry of Emergency Medical Technicians. National EMS Scope of Practice Model, https://www.nremt.org/nremt/about/scopeofpractice.asp.

3. Tuteur A. Doctor, Listen to Your Patient. The Skeptical OB, https://www.skepticalob.com/2009/06/doctor-listen-to-your-patient.html.

4. Gruppen LD, Woolliscroft JO, Wolf FM. The contribution of different components of the clinical encounter in generating and eliminating diagnostic hypotheses. Res Med Educ, 1988; 27: 242–7.

5. Peterson MC, Holbrook JH, Von Hales D, Smith NL, Staker LV. Contributions of the history, physical examination, and laboratory investigation in making medical diagnoses. West J Med, 1992; 156(2): 163–5.

Ken Scheppke, MD, is medical director for Palm Beach County Fire Rescue. 

Keith Bryer is deputy chief of operations for Palm Beach Gardens Fire Rescue in Florida.