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ICU Assessment
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Review of systems
Current diagnosis
Pertinent lab data
Pertinent physical examination findings
Allergies/sensitivities
Airway Assessment
Surgical/anesthesia history
Medication history
Social history
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Other
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Patient History:
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General state of well-being
Daily activity level
The patient’s understanding of:
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Medical condition
Coexisting medical conditions
Review of old records
Present Illness:
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Diagnostic studies
Presumptive diagnosis
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Treatments
Responses to treatments
Review available vital sign data
Review available fluid balance data
Coexisting medical conditions:
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Evaluate in a systems approach
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Assess recent changes in symptoms
Assess current treatment regimens
Specialty consultation when needed
Medications:
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Review medications, doses, schedules
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Cardiac
Seizure
Endocrine
Anticoagulants
Antidepressants
Decision to continue/discontinue
Allergies and drug reactions:
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True allergic reactions
Non-allergic responses
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Adverse reactions
Side effects
Drug-drug interactions
Social History:
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Smoking
Alcohol
Recreational drug use
Smoking:
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Productive Cough
Hemoptysis
How many pack years?
Alcohol:
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Self-reporting of use typically underestimates
actual use
Withdrawal
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Increase anesthetic requirements
Hypertension
Tremors
Delirium
Seizures
Review of Systems:
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Respiratory
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Asthma
Recent history of URI
(continued)
Review of systems:
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Cardiac
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HTN
(continued)
Review of Systems:
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(continued)
Gastro/intestinal
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/ hiatal hernia
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Increased risk of pulmonary aspiration
Review of Systems:
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(continued)
Pregnancy
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All women of childbearing age should be
questioned regarding last menses and the
likelihood of current pregnancy.
Physical Exam:
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Direct attention to:
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Airway
Heart
Lungs
Neuro
Physical Exam:
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Baseline Vital Signs:
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Height and weight
Blood pressure
Resting pulse
Respirations
(continued)
Physical Exam:
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(continued)
Airway assessment
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Size of oral opening and tongue
Observe/document loose or chipped teeth,
“caps”, dentures, other orthodontic devices,
piercings
Observe/document range of cervical motion in
flexion, extension, and rotation
Observe/document tracheal deviation, masses
Airway Assessment
The loose tooth
Normal Airway Anatomy
The larynx
Difficult airways
Physical Exam:
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Heart
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Murmur
Pericardial rub
(continued)
Physical Exam:
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(continued)
Lungs
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Wheezes
Rhonchi
Rales
Correlate what you hear with observation of
how patient is breathing…. easy vs. labored
Use of accessory muscles
Physical Exam:
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(continued)
Abdomen
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Distention
Ascites
Predisposition to regurgitation
Physical Exam:
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Extremities
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Clubbing
Cyanosis
Cutaneous infection
(continued)
Physical Exam:
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(continued)
Neuro
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Document neuro status
Cranial nerve function
Cognition
Peripheral sensorimotor function
labs:
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Hematocrit and Hemoglobin
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Evaluate each pt. individually for the etiology
and duration of their anemia
labs:
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Serum Chemistry
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Hypokalemia/hyperkalemia
Coagulation Screen
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When indicated
EKG:
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All patients over 40 years old
New Q waves
ST-segment depression/elevation
T-wave inversions
Rhythm disturbances
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PVC’s
A-fib, a-flutter
LBBB
2nd or 3rd degree AV block