Assessment of the Medical Patient

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Trauma Patient Assessment

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Presentation transcript:

Assessment of the Medical Patient CHAPTER 11 Assessment of the Medical Patient

Responsive Medical Patient Unresponsive Medical Patient Medical Assessment Must determine if Responsive Medical Patient Unresponsive Medical Patient OR

Focused History and Physical Exam Responsive Medical Patient

Steps in Focused History and Physical Exam Responsive Medical Patient History of present illness SAMPLE history Focused physical exam Baseline vital signs

History of Present Illness = Onset P Provocation Q Quality R Radiation S Severity T Time

SAMPLE History S = Signs and symptoms A Allergies M Medications P Pertinent past history L Last oral intake E Events leading to injury or illness

SAMPLE & OPQRST Patient should be initial source of information. Family and friends may also be a useful source. Continued…

SAMPLE & OPQRST Certain medical conditions and chief complaints may allow for further treatment and/or assessment. In these cases, you will need to get certain additional information.

Get additional information for: Chest pain With prescribed nitroglycerin Difficulty breathing With prescribed inhaler Allergies With prescribed epinephrine auto-injector

Focused Physical Exam Utilize DCAP-BTLS! As appropriate, assess: Neck Head Neck Chest Abdomen Pelvis Extremities Posterior Utilize DCAP-BTLS!

Baseline Vital Signs Respirations Pulse Skin color, temperature, condition Continued…

Baseline Vital Signs Pupils Blood pressure Oxygen saturation, according to local protocol

Further Steps Provide any interventions required for specific conditions. Transport the patient.

Focused History and Physical Exam Unresponsive Medical Patient

Steps in Focused History and Physical Exam Unresponsive Medical Patient Rapid physical exam Baseline vital signs Consider requesting ALS History of present illness SAMPLE history

Rapid Assessment Utilize DCAP-BTLS! Start with rapid assessment: Head Neck Chest Abdomen Pelvis Extremities Posterior Utilize DCAP-BTLS!

Baseline Vital Signs Respirations Pulse Skin color, temperature, condition Pupils Blood pressure Oxygen saturation, according to local protocol

History of Present Illness = Onset P Provocation Q Quality R Radiation S Severity T Time

SAMPLE History Get SAMPLE history from bystanders, family, or friends.

Further Steps Provide any interventions required for specific conditions. Transport the patient.

Review Questions 1. What is the order of the focused history and physical exam of a responsive medical patient? 2. What do the letters in OPQRST stand for?

Review Questions 3. What questions do you ask to get a SAMPLE history? 4. What is the order of the four steps in the focused history and physical exam of an unresponsive medical patient?

STREET SCENES What is the priority of this patient? What are the next steps in the management of this patient? What part of the focused history and physical exam should follow next?

STREET SCENES What signs or symptoms would you look for to determine if the patient were getting better or worse?