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 1st 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

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

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 HxOnset

• 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 HxProvocation

• 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 HxQuality

• 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

Crushing

Stabbing

Burning

OPQRST HxRadiation

• 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 HxSeverity

• 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 HxTime

• 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

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

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