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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
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