Focused History and Physical Exam:  Medical Patients
Focused History and Physical Exam:  Medical Patients <ul><li>Pt Hx </li></ul><ul><ul><li>Pt story of significant events re...
Focused History and Physical Exam:  Medical Patients <ul><li>What: </li></ul><ul><ul><li>Rapid assessment of medical condi...
SAMPLE HISTORY <ul><li>S= Signs and Symptoms </li></ul><ul><li>A = Allergies </li></ul><ul><li>M = Medications </li></ul><...
OPQRST HISTORY <ul><li>OPQRST Hx </li></ul><ul><ul><li>Branch of SAMPLE Hx </li></ul></ul><ul><ul><li>Focuses on Signs and...
OPQRST Hx Onset <ul><li>O = Onset </li></ul><ul><ul><li>When the complaint first started. </li></ul></ul><ul><ul><li>The p...
OPQRST Hx Provocation <ul><li>P = Provocation  </li></ul><ul><ul><li>What actions make the symptoms better/worse </li></ul...
OPQRST Hx Quality <ul><li>Q = Quality  </li></ul><ul><ul><li>Subjective description of complaint in pt own words </li></ul...
OPQRST Hx Radiation <ul><li>R= Radiation </li></ul><ul><ul><li>Is the pain local or does it travel to another part of the ...
OPQRST Hx Severity <ul><li>Severity </li></ul><ul><ul><li>1-10 scale gauging pain </li></ul></ul><ul><ul><ul><li>“ On a sc...
OPQRST Hx Time <ul><li>T = Time </li></ul><ul><ul><li>Duration of the C/C and assoc complaints </li></ul></ul><ul><ul><ul>...
Problem Focused Medical  Assessment  <ul><li>Responsive Medical Pt </li></ul><ul><li>Problem Focused Medical Assessment </...
Rapid Medical Assessment <ul><li>Unresponsive/AMS Medical Pt </li></ul><ul><li>Rapid Medical Assessment  </li></ul><ul><ul...
Focused History and Physical Exam: Medical Pt Recap  <ul><li>S – Signs/Symptoms </li></ul><ul><li>A - Allergies </li></ul>...
 
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13)Focused History And Physical Exam Medical

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13)Focused History And Physical Exam Medical

  1. 1. Focused History and Physical Exam: Medical Patients
  2. 2. Focused History and Physical Exam: Medical Patients <ul><li>Pt Hx </li></ul><ul><ul><li>Pt story of significant events related to current problem </li></ul></ul><ul><ul><li>Usually begins with pt C/C </li></ul></ul><ul><ul><li>Many disease conditions are 1 st suspected by symptomology </li></ul></ul><ul><ul><ul><li>MI </li></ul></ul></ul><ul><ul><ul><li>Diabetics </li></ul></ul></ul><ul><ul><ul><li>Allergic rxn </li></ul></ul></ul><ul><ul><ul><li>OD </li></ul></ul></ul>
  3. 3. Focused History and Physical Exam: Medical Patients <ul><li>What: </li></ul><ul><ul><li>Rapid assessment of medical conditions that may require emergency care OR early hospital tx. </li></ul></ul><ul><li>Who: </li></ul><ul><ul><li>Non traumatically injured pt with medical c/c </li></ul></ul><ul><li>How: </li></ul><ul><ul><li>Focus </li></ul></ul><ul><ul><ul><li>C/C </li></ul></ul></ul><ul><ul><ul><li>Signs/Symptoms </li></ul></ul></ul><ul><ul><ul><li>SAMPLE history </li></ul></ul></ul><ul><ul><ul><ul><li>Medical PAST </li></ul></ul></ul></ul><ul><ul><ul><li>OPQRST history </li></ul></ul></ul><ul><ul><ul><ul><li>Medical PRESENT </li></ul></ul></ul></ul><ul><ul><ul><li>Baseline vitals </li></ul></ul></ul><ul><ul><ul><ul><li>Plan of FUTURE treatment </li></ul></ul></ul></ul>
  4. 4. SAMPLE HISTORY <ul><li>S= Signs and Symptoms </li></ul><ul><li>A = Allergies </li></ul><ul><li>M = Medications </li></ul><ul><li>P = Past pertinent medical hx </li></ul><ul><li>L = Last oral intake </li></ul><ul><li>E = Events prior to the condition </li></ul>
  5. 5. OPQRST HISTORY <ul><li>OPQRST Hx </li></ul><ul><ul><li>Branch of SAMPLE Hx </li></ul></ul><ul><ul><li>Focuses on Signs and Symptoms </li></ul></ul><ul><ul><li>Gives a clearer picture of pt C/C and its severity </li></ul></ul>
  6. 6. OPQRST Hx Onset <ul><li>O = Onset </li></ul><ul><ul><li>When the complaint first started. </li></ul></ul><ul><ul><li>The pt activities at the time of onset/immediately before </li></ul></ul><ul><ul><ul><li>“ What were you doing when this started ” </li></ul></ul></ul><ul><ul><ul><ul><li>Chest pain pt – mowing lawn </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Anaphylaxis pt – stung by bee </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Diabetic pt – Working in hot day without food </li></ul></ul></ul></ul>
  7. 7. OPQRST Hx Provocation <ul><li>P = Provocation </li></ul><ul><ul><li>What actions make the symptoms better/worse </li></ul></ul><ul><ul><ul><li>“ Is there anything that makes it better? Anything that makes it worse?” </li></ul></ul></ul><ul><ul><ul><ul><li>Chest pains – Worse with activity Better with rest </li></ul></ul></ul></ul><ul><ul><ul><ul><li>SOB – Better when sitting Worse when lying flat </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Etc… </li></ul></ul></ul></ul>
  8. 8. OPQRST Hx Quality <ul><li>Q = Quality </li></ul><ul><ul><li>Subjective description of complaint in pt own words </li></ul></ul><ul><ul><ul><li>“ Would you please describe the pain. What does it feel like ” </li></ul></ul></ul><ul><ul><ul><ul><li>Chest pains – Crushing, vice-like, elephant </li></ul></ul></ul></ul>
  9. 9. OPQRST Hx Radiation <ul><li>R= Radiation </li></ul><ul><ul><li>Is the pain local or does it travel to another part of the body </li></ul></ul><ul><ul><ul><li>“ Is the pain in one place or does it spread to other parts of your body?” </li></ul></ul></ul><ul><ul><ul><ul><li>Chest pains </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>L shoulder, arm, jaw, neck ,back </li></ul></ul></ul></ul></ul>
  10. 10. OPQRST Hx Severity <ul><li>Severity </li></ul><ul><ul><li>1-10 scale gauging pain </li></ul></ul><ul><ul><ul><li>“ 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 ?” </li></ul></ul></ul>
  11. 11. OPQRST Hx Time <ul><li>T = Time </li></ul><ul><ul><li>Duration of the C/C and assoc complaints </li></ul></ul><ul><ul><ul><li>“ How long has this been going on ?” </li></ul></ul></ul><ul><ul><ul><ul><li>Chest pains – Woke pt from sleep that night </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Allergic rxn- 15-20 min </li></ul></ul></ul></ul>
  12. 12. Problem Focused Medical Assessment <ul><li>Responsive Medical Pt </li></ul><ul><li>Problem Focused Medical Assessment </li></ul><ul><ul><li>SAMPLE Hx </li></ul></ul><ul><ul><li>OPQRST Hx </li></ul></ul><ul><ul><li>Focused Physical Exam </li></ul></ul><ul><ul><ul><li>Chest/neck- chest pains </li></ul></ul></ul><ul><ul><ul><li>Pharynx/chest- SOB </li></ul></ul></ul><ul><ul><ul><li>Etc… </li></ul></ul></ul><ul><ul><li>Baseline Vitals </li></ul></ul>
  13. 13. Rapid Medical Assessment <ul><li>Unresponsive/AMS Medical Pt </li></ul><ul><li>Rapid Medical Assessment </li></ul><ul><ul><li>Rapid assessment of ALL body regions ( DCAP-BTLS ) </li></ul></ul><ul><ul><ul><li>Try to define C/C or ID trauma </li></ul></ul></ul><ul><ul><ul><li>Rule in/out trauma </li></ul></ul></ul><ul><ul><ul><li>Medical ID tags </li></ul></ul></ul><ul><ul><li>Baseline Vitals </li></ul></ul><ul><ul><li>SMAPLE & OPQRST Hx when/if possible </li></ul></ul><ul><ul><li>Tx in recovery position </li></ul></ul>
  14. 14. Focused History and Physical Exam: Medical Pt Recap <ul><li>S – Signs/Symptoms </li></ul><ul><li>A - Allergies </li></ul><ul><li>M - Medications </li></ul><ul><li>P – Past pertinent medical hx </li></ul><ul><li>L – Last oral intake </li></ul><ul><li>E – Events leading to condition </li></ul><ul><li>O - Onset </li></ul><ul><li>P - Provocation </li></ul><ul><li>Q - Quality </li></ul><ul><li>R – Radiation </li></ul><ul><li>S - Severity </li></ul><ul><li>T – Time </li></ul><ul><li>BASELINE VITALS </li></ul>
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