20091023 - Chapter 11 Class Notes

Post date: Oct 24, 2009 12:46:8 AM

Steps in Focused History and Physical Exam:

Responsive:

- History of present illness
  - O - Onset; "How long have you been suffering?"
  - P - Provocation; "Is there anything that makes the pain worse?", "Is there anything that you do that makes the pain better?", "Have you ever had this kind of pain before?"
  - Q - Quality; ASK OPEN ENDED QUESTIONS: "Could you describe the pain?"
  - R - Radiation; "Does the pain go anywhere?", "Where does it hurt most?"
  - S - Severity; "On a scale of 1-10 with 1 being little or no pain and 10 being the worst pain that you have ever felt, how would you rate the pain?"
  - T - Time; "When did you start feeling this way?"
- sample history
  - S: Signs and symptoms
  - A: Allergies
  - M: Medications (any Non-steroidal anti-inflammatory drugs?)
  - P: Pertinent past history
  - L: Last oral intake
  - E: Events leading to injury or illness
  - Your patient should be the initial source of information
  - Family and friends may also be a useful source
  - Certain medical conditions and chief complaints may allow for further treatment and/or assessment
    - seizure
    - chest pain (prescribed nitroglycerin - 0.4 milligrams in a tablet)
    - Difficulty breathing (with prescribed inhaler)
      - respiratory patients - can deteriorate very rapidly (Have they ever been intibated before?)
      - Do you have a multi-dose inhaler?
      - Albuterol - 1or 2 puffs every four hours
    - Allergies (with prescribed epinephrine auto-injector)
  - In these cases, you will need to get certain additional information
- focused physical exam
- As appropriate assess:
  - Head
  - Neck
  - Chest
  - Abdomen
  - Pelvis
  - Extremities
  - Posterior
- baseline vital signs
  - Respirations
  - Pulse
  - Skin color, temperature, condition
  - Pupils
  - Blood pressure
    - treat the patient not the Pulse Oximeter
  - Oxygen saturation, according to local protocol
- Provide any interventions required for specific conditions
- Transport the patient

Unresponsive (Treat Similar to Trauma):

- Rapid Physical Exam
  - Head
  - Neck
  - Chest
  - Abdomen
  - Pelvis
  - Extremities
  - Posterior
- Baseline vital signs
  - Respirations
  - Pulse
  - Skin color, temperature, condition
  - Pupils
    - Blood pressure
    - treat the patient not the Pulse Oximeter
  - Oxygen saturation, according to local protocol
- Consider requesting ALS
- History of present illness (obtained from family member or friend)
  - O - Onset
  - P - Provocation
  - Q - Quality
  - R - Radiation
  - S - Severity
  - T - Time
- SAMPLE history
  - S: Signs and symptoms
  - A: Allergies
  - M: Medications (any Non-steroidal anti-inflammatory drugs?)
  - P: Pertinent past history
  - L: Last oral intake
  - E: Events leading to injury or illness
- Then Transport

Trauma is AUTOMATIC cspine and oxygen. Your only choice as a basic is or a non-rebreather if patient is breathing adequately or a BMV w/oxygen attached is patient

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