focused history and physical examination for medical patients chapter 11

Focused History Focused History

and Physical and Physical

Examination for Examination for

Medical PatientsMedical Patients

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In the In the seriously illseriously ill

patient, treatment may patient, treatment may

begin begin beforebefore the entire the entire

assessment is completed.assessment is completed.

Responsive Responsive Medical PatientsMedical PatientsResponsive Responsive Medical PatientsMedical Patients

The Patient’s HistoryThe Patient’s History

ListenListen carefully to carefully to what patients tell you...what patients tell you...

……askask open-ended open-ended questionsquestions if you are if you are

unsure of their responses.unsure of their responses.

SSigns and symptomsigns and symptoms

AAllergiesllergies

MMedicationsedications

PPertinent past medical historyertinent past medical history

LLast oral intake (solid or liquid)ast oral intake (solid or liquid)

EEvents leading to injury or illnessvents leading to injury or illness

OOnsetnset

PProvocationrovocation

QQualityuality

RRadiationadiation

SSeverityeverity

TTimeime

Rapid Rapid AssessmentAssessment

Rapid Rapid AssessmentAssessment

A rapid assessment A rapid assessment

is ais a HEAD-TO-TOEHEAD-TO-TOE

examination guided examination guided

by the chief by the chief

complaint.complaint.

Inspect and palpate the Inspect and palpate the head.head.

Assess the Assess the neck.neck.

P4-10A(2)

Expose the chest, look for symmetry and auscultate lung sounds.

Palpate the Palpate the

abdomen abdomen by by quadrants.quadrants.

If the patient complains If the patient complains

of of extremityextremity or or back pain,back pain,

these areas need to be these areas need to be

evaluated.evaluated.

Vital SignsVital SignsVital SignsVital Signs

Vital Signs Vital Signs BreathingBreathing

PulsePulse

SkinSkin

Pupil size and reactivityPupil size and reactivity

Blood pressureBlood pressure

Emergency Emergency CareCare

Emergency Emergency CareCare

Provide emergency Provide emergency

medical care based on the medical care based on the

information gained from information gained from

the the rapid assessmentrapid assessment and and

SAMPLE history.SAMPLE history.

Unresponsive Unresponsive Medical PatientsMedical PatientsUnresponsive Unresponsive Medical PatientsMedical Patients

History from Bystanders

History from Bystanders

Unresponsive

medical

patients

should receive

a rapid

assessment.

Unresponsive Medical Patients Unresponsive Medical Patients

Maintain patent airwayMaintain patent airway AdjunctsAdjuncts PositionPosition

Constantly monitor airwayConstantly monitor airway

If assisted ventilations not needed, provide high-flow oxygenIf assisted ventilations not needed, provide high-flow oxygen

If history unknown, immobilize for transportIf history unknown, immobilize for transport

Keep warmKeep warm

SU

MM

AR

YS

UM

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RY Responsive Medical PatientsResponsive Medical Patients

Unresponsive Medical PatientsUnresponsive Medical Patients