Examining the Patient
Older patients present “atypically” for several reasons. Some of them relate to the physiologic, anatomic, and social realities of being old. Each of the following reasons is examined in-depth in the next sections
Poor historians
Older people may have sensory impairment, cognitive impairment, multiple active problems, or have inadequate social support.
Vague or multiple complaints
Often the “vague complaint” represents a change from normal and thus an indicator of something new, and potentially serious.
Self diagnosis
Older people may have had a lot of previous health problems – they may arrive in the ED, convinced that they have a specific problem “just like the last time.”
Delayed presentation
Older people may “put up” with problems for longer periods of time than younger patients.
Polymorbidity
Older people often have several different chronic conditions that mimic or exacerbate each other.
Polypharmacy
Drugs can cause symptoms which mimic disease, interact with other drugs to cause symptoms or may interact with diseases to cause symptoms.
Variable vitals
For several reasons older people may not become tachycardic, febrile, or hypotensive when “they’re supposed to!”
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Discussion: Examining the Patient
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these symptoms are vague and require more directed questions. More specific information is required. Not sure how long this comment is supposed to be as I keep getting an error message.
these symptoms are vague and require more directed questions. More specific information is required.
these symptoms are vague and require more directed questions.
Sounds good for an ED evaluation
Sounds good.
OK
hi
Por eso siempre el examen físico debe ir de la mano con una buena historia clínica, y verificar la misma con familiares o cuidadores cercanos.
It’s amazing how long older patients will put up with abdominal pain, which is why the threshold for CT scan is so low in these patients. Findings are frequently positive and often advanced, such as abscesses and even perforations.
true
very true
atypically atypical
I’ve seen many of these characteristics in older adults that live in the community. Definitely good food for thought when assessing those who are living independently at home!
interesting
got it
full history from patient and family will help with some of these difficulties
Very interesting
important list of risk factors to investigate
yep
okay
thank you
good to know
gather all the info
HYEAH
.
.
good reminders
ep
when examining apatient i like to speak with carefully
i also find it helpful to ask howthischange has affected their add
ok
Noted. Excellent module so far
ok
true
–
yes
okay great
G
good review of info
ok
difficult
ok
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Ok
helpful
.
great info
One of the first things we do is get a good med reconciliation when the patient enters th ED.
k
nice
–
thanks
ok
Good to know
helpful
yup
ok
Family is golden.
get multiple sources of info
great info
a lot of good info
lots of diagnostics
he needs a thorough assesment
ok
good to know
his blood pressure is still elevate d
great point
good learning points
great points
great learning points
ok
thoroughly examining the pt is important
good to know
family is useful
caregivers have valuable clues
acre givers are i,portant
Agree something is definitely wrong. collateral history from family, thorough examination and investigations will be of great help.
His heartrate of 90, he is on metoprolol which can make it more difficult for him to be tachycardic when he has a fever. He has a low grade temp, which could be higher in a younger person. These vital signs in a younger person not on these meds would be considered mostly normal. The fact he has had an acute change over the past several days–not feeling well, possibly decreased mentation (memory), not performing regular activities means something has changed and needs to be investigated.
true
agreed
agreed
agree.
great
Good to know
Also the normal range of vitals is different than that for younger people. A heart rate of 90 in an elder may be like 120 in a young person
helpful
ok
ok
agree
very true
so true
agree
Getting to the bottom of things is often quite a challenge due to all these stated factors
Keep in mind a broad differential.
caregivers can be helpful.
I totally agree that older adult do have the tendency to put up with problems for longer period of time than younger adult.
great
Healthcare providers need to be patient and get more detail spending more time.
The elderly can make our information gathering a challenge. Many factors come into play
Use pt, family and differential diagnostics (try not to get tunnel vision)
important to establish patients functional baseline and how these new symptoms have impacted his ability to carry out ADLs and IADLS.
how many times these points are neglected or overlooked.
cast a wide net
Skilled triage is vital.
havent had many self-diagnosis
makes sense
a lot of variables to consider!
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watch for use of internet wisdom
Use family here
warm blankets too.
These patients require extra effort and a little patience! Involve the family!
What is a Unicorn’s favorite ride?
A Unicycle!
ask the family or caregiver for all the complaints previously
hay que entrevistar al paciente buscando en la historia el familiar o cuidador mas adecuado
communicate with family
apoyo de la familia
Talk to the family, care givers, PCP. Look at all of the documentation available for this pt. ie old charts, pharmacy on line records. Assess ability to perform tasks, ambulate, recall accurate information.
repeat
hhh
Involves a lot of investigative testing
g
Collateral history (from family,caregivers..etc) is important and could provide clues to add.
The diagnosis can be anything and everything or at times nothing,
When examining a patient, I like to speak with care givers as they might have some insight into what is going on.
I also find it helpful to ask how this change has affected their ADLs/IADLs what is it they can no longer do?
often the caregivers have valuable clues to add
I hear a lot of older adults reporting that the symptoms that they are experiencing this time is “the same as last time”. I find it is good to ask if these symptoms are the same as last time but to not depend on this but rather keep it in mind when ordering bloodwork and to also always consider other possibilities in terms of a differential diagnosis