Overview Responsive Medical Patients Unresponsive Medical Patients

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Presentation transcript:

Chapter 12 Focused History and Physical Examination for Medical Patients

Overview Responsive Medical Patients Unresponsive Medical Patients Patient History Rapid Assessment Vital Signs Emergency Care Unresponsive Medical Patients

Focused History and Physical Examination: Medical Patients Every patient receives a focused history and physical exam

Focused History and Physical Examination: Medical Patients Unresponsive medical patients are treated as are unresponsive trauma patients

Focused History and Physical Examination: Medical Patients Proceed to the focused history and physical exam after completing the scene size-up and initial assessment

Responsive Medical Patients

Responsive Medical Patients Assess the patient’s history Assess complaints and signs or symptoms Use the techniques of physical exam learned in the Focused History and Physical Examination: Trauma Patients

Responsive Medical Patients O-P-Q-R-S-T acronym Onset Provocation Quality Radiation Severity Time The O-P-Q-R-S-T acronym is useful for remembering what questions should be asked. Not all the questions will always have to be asked, nor will they need to be asked in this order. O-P-Q-R-S-T is primarily used to evaluate pain but can also be used for other medical conditions.

OPQRST Acronym Onset What was the patient doing when the signs/symptoms started?

OPQRST Acronym Provocation/Palliation What makes the signs and symptoms better or worse?

OPQRST Acronym Quality The patient’s description of the symptom

OPQRST Acronym Radiation Is there radiation of the symptoms?

OPQRST Acronym Severity An opportunity for the patient to quantify the pain Typically done with a 1-10 scale The Wong-Baker Scale

OPQRST Acronym Time How long have the signs and symptoms been present?

Responsive Medical Patients Remember that a physical exam is required for all patients In the responsive patient, assess the body systems associated with the chief complaint

Responsive Medical Patients D-C-A-P-B-T-L-S acronym Deformities Contusions Abrasions Penetrations Burns Tenderness Lacerations Swelling Reminder of injuries and signs of injuries to look for while assessing.

Responsive Medical Patients Assess the head, as necessary

Responsive Medical Patients Assess the neck, as necessary

Responsive Medical Patients Assess for JVD, as necessary

Responsive Medical Patients Assess the patient’s chest, as necessary

Responsive Medical Patients Assess the breath sounds

Responsive Medical Patients Assess the abdomen, as necessary

Responsive Medical Patients Assess the four quadrants of the abdomen, as necessary

Responsive Medical Patients Assess the pelvis

Responsive Medical Patients Assess the lower extremities, as necessary

Responsive Medical Patients Assess pulse, motor, and sensation in the lower extremities, as necessary

Responsive Medical Patients Assess the upper extremities, as necessary

Responsive Medical Patients Log-roll the patient and assess the posterior, as necessary

Patient History

Patient’s History Assess SAMPLE History S Signs and Symptoms A Allergies M Medications P Past medical history L Last oral intake E Events leading to injury or illness

Vital Signs

Vital Signs Assess baseline vital signs Breathing Skin Pupils Blood pressure

Emergency Care for Unresponsive Medical Patients

Unresponsive Medical Patients Complete a rapid head-to-toe assessment, as in the Focused History and Physical Examination: Trauma Patients

Summary Responsive Medical Patients Unresponsive Medical Patients Patient History Rapid Assessment Vital Signs Emergency Care Unresponsive Medical Patients