1. Chapter 18 Medical Overview
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2. Objectives
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3. Medical Patient Considerations
The patient’s level of responsiveness helps determine the type of physical exam needed
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For the medical patient, the patient’s level of responsiveness is the first important factor in determining the type of physical examination you need to perform.

4. Responsive Medical Patient
If your patient is responsive, find out his medical history first
Helps guide where you look and what you are looking for in the focused physical exam

5. Responsive Medical Patient
After the focused physical exam:
Obtain vital signs
Assess skin color, temperature, and moisture
Assess pupils
Check capillary refill in infants and children younger than 6 years of age.

6. Unresponsive Medical Patient
If your patient is unresponsive or has an altered mental status:
Perform a quick head-to-toe physical exam (rapid medical assessment)
Obtain vital signs
Get medical history from family, friends, and clues in the area
If your primary survey reveals that the patient is unresponsive or has an altered mental status, a rapid secondary survey (head-to-toe assessment) needs to be done to find out what is wrong. A quick secondary survey of a medical patient who is unresponsive or has an altered mental status is called a rapid medical assessment. Then proceed with getting the patient’s vital signs. Try to get the patient’s medical history from family, friends, and clues in the area. Some examples of clues are a “puffer” (inhaler), nitroglycerin tablets or other medications, and medical identification, such as a necklace or bracelet.

7. Unresponsive Medical Patient
Avoid tunnel vision
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8. Head and Neck Reassess mental status Assess Head
Face, eyes, ears, nose, mouth
Neck
Begin the rapid medical assessment by reassessing the patient’s mental status and then checking the patient’s head. The skull normally feels smooth and symmetric. There is normally no tenderness to palpation. Check for DCAP-BTLS. Look and feel for signs of trauma from a previous injury. Look at the patient’s face for symmetry focusing on the symmetry of the eyebrows, eyelids, and sides of the mouth. Asymmetry, such as drooping on one side of the face, is a sign of a possible stroke. Examine the sclerae, which are normally white in color. Note any color change, such as jaundice, which suggests liver disease.
Look in the ears and nose for leakage of blood or fluid. Note if the patient is wearing a hearing aid. Note any deformity of the nose and look for signs of nasal flaring. Check the pupils for size, reactivity, and equality. Assess the conjunctiva, which should be pink and moist.
Reassess the mouth for blood, vomitus, a foreign body, or secretions. Suction as needed. The oral mucosa should be pink and moist. Note the presence of any unusual odors on the patient’s breath, body, or clothing.
Assess the neck and look at the neck veins. Flat neck veins may be a sign of dehydration or blood loss. The presence of jugular venous distention when the patient’s torso is at a 45° angle suggests fluid overload, which may be seen in heart failure. Look to see if the patient has a laryngeal stoma (surgical opening in the neck). Is the patient using the accessory muscles in the neck during breathing? Check to see if the patient is wearing a medical identification necklace or other medical jewelry.

9. Chest Check for DCAP-BTLS Assess respiratory effort
Assess symmetrical chest rise and fall
Assess breath sounds
Note shape of the patient’s chest
Look for rash, surgical scars
Note the presence of medical devices or medication patches
Expose the patient’s chest. Check for DCAP-BTLS. Assess the ease of the patient’s respiratory effort. Is the patient using accessory chest muscles during breathing? Note if the chest rises and falls symmetrically. Note the shape of the patient’s chest. Look at the skin for signs of a rash and surgical scars. Listen to breath sounds and determine if they are present, diminished, or absent, equal or unequal, and clear or noisy. Note the presence of any medical devices, such as a pacemaker, or medication patches.

10. Abdomen and Pelvis Check for DCAP-BTLS Obvious pregnancy?
Abdominal distention
Surgical scars
Palpate all four quadrants
Look for signs of obvious bleeding
Note incontinence of urine or stool
Assess the abdomen. Check for DCAP-BTLS. If applicable, look for signs of obvious pregnancy. Look to see if abdominal distention is present. Also, note the presence of any surgical scars. Using the pads of your fingers, palpate all four quadrants of the abdomen. Watch the patient’s face while you palpate. A grimace may indicate tenderness over a particular abdominal area. Determine if the abdomen is soft or hard (rigid). Note the presence of any masses, pulsations, or medical devices. In a pregnant patient, note movement or the absence of movement in the fetus.
Assess the pelvis for DCAP-BTLS. Look for signs of obvious bleeding or incontinence of urine or stool.

11. Extremities Assess for DCAP-BTLS.
Look for swelling abnormal positioning, medical ID tag.
Check PMS in each extremity.
Compare each extremity with the opposite extremity.
Check for DCAP-BTLS. Look for a medical identification bracelet. Assess pulses, motor function, and sensation in each extremity. Look for edema of the hands, feet, and ankles. Look for signs of a possible insect bite or sting, or signs of possible intravenous drug abuse.

12. Posterior Body Assess for DCAP-BTLS.
Look for swelling in the sacral area.
If possible, listen to breath sounds on the posterior chest.
Assess the posterior body for DCAP-BTLS. Look for swelling in the sacral area. In patients confined to bed, fluid collects in this area. If possible, listen to breath sounds on the posterior chest.

13. Unresponsive Medical Patient
After the rapid medical assessment:
Assess vital signs
Obtain medical history
Provide emergency care based on your physical exam findings.
After the rapid medical assessment, assess the patient’s vital signs, and then proceed with getting the patient’s medical history from family and friends and from clues such as medical jewelry, pill containers, and medical devices. Provide emergency care based on your physical exam findings.
Do not forget about family members at the scene. Explain to the family the emergency care provided and where the patient will be transported for further care.

14. Questions?