Chapter 012[1]

Copyright © 2007, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Chapter 12Chapter 12

Focused History and Physical Focused History and Physical ExaminationExamination

forforMedical PatientsMedical Patients


OverviewOverview

Responsive Medical PatientsResponsive Medical Patients Patient HistoryPatient History Rapid AssessmentRapid Assessment Vital SignsVital Signs Emergency CareEmergency Care

Unresponsive Medical PatientsUnresponsive Medical Patients


Focused History and Physical Focused History and Physical Examination: Medical PatientsExamination: Medical Patients

Every patient Every patient receives a focused receives a focused history and physical history and physical examexam



Unresponsive Unresponsive medical patients are medical patients are treated as are treated as are unresponsive unresponsive trauma patientstrauma patients



Proceed to the focused history and physical Proceed to the focused history and physical exam after completing the scene size-up exam after completing the scene size-up and initial assessmentand initial assessment


Responsive Medical PatientsResponsive Medical Patients



Assess the patient’s historyAssess the patient’s history

Assess complaints and signs or symptomsAssess complaints and signs or symptoms

Use the techniques of physical exam learned Use the techniques of physical exam learned in the in the Focused History and Physical Focused History and Physical Examination: Trauma PatientsExamination: Trauma Patients



O-P-Q-R-S-TO-P-Q-R-S-T acronym acronym

OOnsetnset

PProvocationrovocation

QQualityuality

RRadiationadiation

SSeverityeverity

TTimeime

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.


OOPQRST AcronymPQRST Acronym

OOnsetnset What was the patient doing when the What was the patient doing when the

signs/symptoms started?signs/symptoms started?


OOPPQRST AcronymQRST Acronym

PProvocation/rovocation/PPalliationalliation What makes the signs and symptoms better or What makes the signs and symptoms better or

worse?worse?


OPOPQQRST AcronymRST Acronym

QQualityuality The patient’s description of the symptomThe patient’s description of the symptom


OPQOPQRRST AcronymST Acronym

RRadiationadiation Is there radiation of the symptoms?Is there radiation of the symptoms?


OPQROPQRSST AcronymT Acronym

SSeverityeverity An opportunity for the patient to quantify the painAn opportunity for the patient to quantify the pain Typically done with a 1-10 scaleTypically done with a 1-10 scale

• The Wong-Baker ScaleThe Wong-Baker Scale


OPQRSOPQRSTT Acronym Acronym

TTimeime How long have the signs and symptoms been How long have the signs and symptoms been

present?present?



Remember that a physical exam is required Remember that a physical exam is required for all patientsfor all patients

In the responsive patient, assess the body In the responsive patient, assess the body systems associated with the chief complaintsystems associated with the chief complaint



D-C-A-P-B-T-L-SD-C-A-P-B-T-L-S acronym acronymDDeformitieseformities

CContusionsontusions

AAbrasionsbrasions

PPenetrationsenetrations

BBurnsurns

TTendernessenderness

LLacerationsacerations

SSwellingwelling

Reminder of injuries and signs of injuries

to look for while assessing.



Assess the head, as necessaryAssess the head, as necessary


Responsive Medical PatientsResponsive Medical Patients Assess the neck, as necessaryAssess the neck, as necessary



Assess for JVD, as Assess for JVD, as necessarynecessary



Assess the patient’s chest, as necessaryAssess the patient’s chest, as necessary



Assess the breath Assess the breath soundssounds



Assess the abdomen, as necessaryAssess the abdomen, as necessary



Assess the four Assess the four quadrants of the quadrants of the abdomen, as abdomen, as necessarynecessary



Assess the pelvisAssess the pelvis



Assess the lower extremities, as necessaryAssess the lower extremities, as necessary



Assess pulse, motor, and sensation in the lower Assess pulse, motor, and sensation in the lower extremities, as necessaryextremities, as necessary



Assess the upper extremities, as necessaryAssess the upper extremities, as necessary


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

necessarynecessary


Patient HistoryPatient History


Patient’s HistoryPatient’s History

Assess Assess SAMPLESAMPLE History History

SS SSigns and igns and SSymptomsymptoms

AA AAllergiesllergies

MM MMedicationsedications

PP PPast medical historyast medical history

LL LLast oral intakeast oral intake

EE EEvents leading to injury or illnessvents leading to injury or illness


Vital SignsVital Signs


Vital SignsVital Signs

Assess baseline vital signsAssess baseline vital signs BreathingBreathing SkinSkin PupilsPupils Blood pressureBlood pressure


Emergency Care for Emergency Care for Unresponsive Medical PatientsUnresponsive Medical Patients



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


SummarySummary Responsive Medical PatientsResponsive Medical Patients

Patient HistoryPatient History Rapid AssessmentRapid Assessment Vital SignsVital Signs Emergency CareEmergency Care


Chapter 012[1]

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