focused history and physical examination for medical patients chapter 11
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Focused History Focused History
and Physical and Physical
Examination for Examination for
Medical PatientsMedical Patients
CH
AP
TER
11
CH
AP
TER
11
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
MA
RY Responsive Medical PatientsResponsive Medical Patients
Unresponsive Medical PatientsUnresponsive Medical Patients
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