History & Identification of Known Problems

History & Indentification of Known Problems

The purpose of the history is to lay out the known facts about the patient. This will provide you with a foundation for the physical examination, and data interpretation..

1. What type of patient are we dealing with? Elective surgical, emergency surgical or medical?

There are three types of patient in most intensive care units. Elective surgical patients are usually admitted for monitoring or awaiting reversal of abnormal perioperative physiology. One must be aware of complications, preoperative risk factors, fluid and electrolyte balance, analgesia etc. Medical patients usually have chronic multisystem problems with minimal reserve. Emergency surgical patients may have massive fluid and electrolyte shifts, rapidly progressive organ dysfunction and hemodynamic insufficiency requiring aggressive resuscitation efforts.
Be cautious: if the patient has just been transported from another part of the hospital or from another hospital, it is important to treat each piece of information accompanying the patient with suspicion. The patient in this situation requires a fresh appraisal: if the correct diagnosis or course of action had been made by the original physician, then the patient may not have been presently in intensive care. Do not accept the clinical diagnosis of others without confirming them yourself, if you are now responsible for the patient. I am not aware of any physician who has not been disastrously misled at one point in their career.

2.   What is the patient’s age and baseline health status?

What background medical problems does the patient have? We know that patients with major organ dysfunction (such COPD, pulmonary fibrosis, heart failure (EF<40%), chronic renal failure, cirrhosis or chronic hepatitis, previous myocardial infarction or active ischemia, connective tissue disease, inflammatory bowel disease, cancer, cerebrovascular disease, carotid arterial disease) have diminished physiologic reserve, and have a worse prognosis when admitted to intensive care. The greatest determinant of outcome, however, is the patient’s age: young patients do better in intensive care than older ones.

3.   What problem was the patient admitted with?

This is the patient’s presenting complaint (although it may not be the patient’s main current problem). The major problems are: respiratory failure, cardiovascular failure/ischemia, renal failure, liver failure, coma, fluid/electrolyte or endocrine imbalance.

4.   What complications followed?

Prolonged admission to intensive care is characterized by “second and third hits” - organ injuries such as nosocomial pneumonia, line sepsis, myocardial ischemia, renal failure etc. It is important that you are aware of these problems even if they have now resolved, as complete recovery of organ function at this stage is unlikely, and those organs remain vulnerable (for example, it is important that you do not prescribe non steroidal anti inflammatory agents (NSAIDS) to a patient who has recently recovered from acute renal failure).

5.   What problem is keeping this patient in intensive care?

The patient may remain in ICU for a problem wholly unrelated to the original presenting complaint – failure to wean from mechanical ventilation, failure to emerge from sedation etc. This is the patient’s main current problem, and it needs to be addressed. In addition, it is important to enumerate the other problems, even if they are apparently trivial.

6.   What physiologic targets have we set for this patient?

We can’t determine where we are going if we don’t know where we are now! From the outset, the physiological parameters under your control must be targeted: level of sedation, heart rate, CVP (or PA pressures), Blood pressure, PaO2, PaCO2, pH, urinary output, enteral feeding, fluid balance, mobilization

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 How to present the history findings:

“This is Mr John Doe, he is 74 years old, day 7 in ICU post repair of a ruptured abdominal aortic aneurysm. He has a background history of coronary arterial disease, three vessel CABG in 1997 and hypertension well controlled with lisinopril.

His post operative course has been complicated by early respiratory insufficiency, a non-ST segment elevation myocardial infarct, massive blood transfusion and acute renal failure requiring continuous dialysis, now discontinued.

His main current problem is failure to wean from mechanical ventilation; a tracheostomy is planned. Other problems include polyuric renal failure, hypokalemia, hyperbilirubinemia, a grade 2 decubitus ulcer on his sacrum and dehiscence of his abdominal wound.”

Copyright Patrick Neligan 2001-2002

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