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CHAPTER 11 Focused History and Physical Examination for Medical Patients In the seriously ill patient, treatment may begin before the entire assessment is completed. Responsive Medical Patients The Patient’s History Listen carefully to what patients tell you... open-ended questions if you are …ask unsure of their responses. Signs and symptoms A llergies Medications Pertinent past medical history Last oral intake (solid or liquid) Events leading to injury or illness Onset Provocation Quality Radiation Severity Time Rapid Assessment A rapid assessment is a HEAD-TOTOE examination guided by the chief complaint. Inspect and palpate the head. Assess the neck. Expose the chest, look for symmetry and auscultate lung sounds. P4-10A(2) Palpate the abdomen by quadrants. If the patient complains of extremity or back pain, these areas need to be evaluated. Vital Signs Vital Signs Breathing Pulse Skin Pupil size and reactivity Blood pressure Emergency Care Provide emergency medical care based on the information gained from the rapid assessment and SAMPLE history. Unresponsive Medical Patients History from Bystanders Unresponsive medical patients should receive a rapid assessment. Unresponsive Medical Patients Maintain patent airway Adjuncts Position Constantly monitor airway If assisted ventilations not needed, provide high-flow oxygen If history unknown, immobilize for transport Keep warm SUMMARY Responsive Medical Patients Unresponsive Medical Patients
