Focused History and Physical Exam: Medical Patients

Focused History and Physical Exam: Medical Patients Pt Hx Pt story of significant events related to current problem Usually begins with pt C/C Many disease conditions are 1 st suspected by symptomology MI Diabetics Allergic rxn OD

Pt Hx

Pt story of significant events related to current problem

Usually begins with pt C/C

Many disease conditions are 1 st suspected by symptomology

MI

Diabetics

Allergic rxn

OD

Focused History and Physical Exam: Medical Patients What: Rapid assessment of medical conditions that may require emergency care OR early hospital tx. Who: Non traumatically injured pt with medical c/c How: Focus C/C Signs/Symptoms SAMPLE history Medical PAST OPQRST history Medical PRESENT Baseline vitals Plan of FUTURE treatment

What:

Rapid assessment of medical conditions that may require emergency care OR early hospital tx.

Who:

Non traumatically injured pt with medical c/c

How:

Focus

C/C

Signs/Symptoms

SAMPLE history

Medical PAST

OPQRST history

Medical PRESENT

Baseline vitals

Plan of FUTURE treatment

SAMPLE HISTORY S= Signs and Symptoms A = Allergies M = Medications P = Past pertinent medical hx L = Last oral intake E = Events prior to the condition

S= Signs and Symptoms

A = Allergies

M = Medications

P = Past pertinent medical hx

L = Last oral intake

E = Events prior to the condition

OPQRST HISTORY OPQRST Hx Branch of SAMPLE Hx Focuses on Signs and Symptoms Gives a clearer picture of pt C/C and its severity

OPQRST Hx

Branch of SAMPLE Hx

Focuses on Signs and Symptoms

Gives a clearer picture of pt C/C and its severity

OPQRST Hx Onset O = Onset When the complaint first started. The pt activities at the time of onset/immediately before “ What were you doing when this started ” Chest pain pt – mowing lawn Anaphylaxis pt – stung by bee Diabetic pt – Working in hot day without food

O = Onset

When the complaint first started.

The pt activities at the time of onset/immediately before

“ What were you doing when this started ”

Chest pain pt – mowing lawn

Anaphylaxis pt – stung by bee

Diabetic pt – Working in hot day without food

OPQRST Hx Provocation P = Provocation What actions make the symptoms better/worse “ Is there anything that makes it better? Anything that makes it worse?” Chest pains – Worse with activity Better with rest SOB – Better when sitting Worse when lying flat Etc…

P = Provocation

What actions make the symptoms better/worse

“ Is there anything that makes it better? Anything that makes it worse?”

Chest pains – Worse with activity Better with rest

SOB – Better when sitting Worse when lying flat

Etc…

OPQRST Hx Quality Q = Quality Subjective description of complaint in pt own words “ Would you please describe the pain. What does it feel like ” Chest pains – Crushing, vice-like, elephant

Q = Quality

Subjective description of complaint in pt own words

“ Would you please describe the pain. What does it feel like ”

Chest pains – Crushing, vice-like, elephant

OPQRST Hx Radiation R= Radiation Is the pain local or does it travel to another part of the body “ Is the pain in one place or does it spread to other parts of your body?” Chest pains L shoulder, arm, jaw, neck ,back

R= Radiation

Is the pain local or does it travel to another part of the body

“ Is the pain in one place or does it spread to other parts of your body?”

Chest pains

L shoulder, arm, jaw, neck ,back

OPQRST Hx Severity Severity 1-10 scale gauging pain “ On a scale of 1-10, 1 being the least pain you’ve felt and 10 being the worst pain you’ve ever felt can you rate the pain ?”

Severity

1-10 scale gauging pain

“ On a scale of 1-10, 1 being the least pain you’ve felt and 10 being the worst pain you’ve ever felt can you rate the pain ?”

OPQRST Hx Time T = Time Duration of the C/C and assoc complaints “ How long has this been going on ?” Chest pains – Woke pt from sleep that night Allergic rxn- 15-20 min

T = Time

Duration of the C/C and assoc complaints

“ How long has this been going on ?”

Chest pains – Woke pt from sleep that night

Allergic rxn- 15-20 min

Problem Focused Medical Assessment Responsive Medical Pt Problem Focused Medical Assessment SAMPLE Hx OPQRST Hx Focused Physical Exam Chest/neck- chest pains Pharynx/chest- SOB Etc… Baseline Vitals

Responsive Medical Pt

Problem Focused Medical Assessment

SAMPLE Hx

OPQRST Hx

Focused Physical Exam

Chest/neck- chest pains

Pharynx/chest- SOB

Etc…

Baseline Vitals

Rapid Medical Assessment Unresponsive/AMS Medical Pt Rapid Medical Assessment Rapid assessment of ALL body regions ( DCAP-BTLS ) Try to define C/C or ID trauma Rule in/out trauma Medical ID tags Baseline Vitals SMAPLE & OPQRST Hx when/if possible Tx in recovery position

Unresponsive/AMS Medical Pt

Rapid Medical Assessment

Rapid assessment of ALL body regions ( DCAP-BTLS )

Try to define C/C or ID trauma

Rule in/out trauma

Medical ID tags

Baseline Vitals

SMAPLE & OPQRST Hx when/if possible

Tx in recovery position

Focused History and Physical Exam: Medical Pt Recap S – Signs/Symptoms A - Allergies M - Medications P – Past pertinent medical hx L – Last oral intake E – Events leading to condition O - Onset P - Provocation Q - Quality R – Radiation S - Severity T – Time BASELINE VITALS

S – Signs/Symptoms

A - Allergies

M - Medications

P – Past pertinent medical hx

L – Last oral intake

E – Events leading to condition

O - Onset

P - Provocation

Q - Quality

R – Radiation

S - Severity

T – Time

BASELINE VITALS