Focused history & physical exam and behavior emergencies

Barry Kidd 2010Barry Kidd 2010 11

Focused History & Physical Focused History & Physical Exam: Behavioral Exam: Behavioral

Emergencies Emergencies


ObjectivesObjectives Describe the elements that lead up Describe the elements that lead up

to a behavioral emergency.to a behavioral emergency. Describe the EMS provider’s role in Describe the EMS provider’s role in

controlling the setting in a behavioral controlling the setting in a behavioral emergency.emergency.

List eleven classifications of List eleven classifications of psychiatric disorders and provide an psychiatric disorders and provide an example of each.example of each.


Objectives Objectives (continued)(continued)

Provide examples of specific Provide examples of specific behaviors manifested by persons behaviors manifested by persons with emotional and psychiatric with emotional and psychiatric disorders.disorders.

List a major misconception List a major misconception concerning behavioral emergencies.concerning behavioral emergencies.

Describe examples of nonverbal Describe examples of nonverbal communication.communication.


Describe specific risk factors the EMS Describe specific risk factors the EMS provider should screen for during the provider should screen for during the focused history of a patient focused history of a patient experiencing a behavioral emergency.experiencing a behavioral emergency.

Describe the components of the Describe the components of the mental status examination.mental status examination.

List the most common behavioral List the most common behavioral emergencies the EMS provider is emergencies the EMS provider is called for.called for.

Objectives (continued)Objectives (continued)


List medical conditions that mimic List medical conditions that mimic behavioral disorders.behavioral disorders.

List the possible signs and symptoms List the possible signs and symptoms of ineffective or failing coping of ineffective or failing coping mechanisms of stress that may be mechanisms of stress that may be seen in EMS providers.seen in EMS providers.

Objectives (continued)Objectives (continued)


IntroductionIntroduction Every type of illness/injury will come Every type of illness/injury will come

with some type of emotional or with some type of emotional or psychological element.psychological element.

Behavioral emergencies occur when Behavioral emergencies occur when a person with/without a psychiatric a person with/without a psychiatric hx becomes stressed & overwhelmed hx becomes stressed & overwhelmed or feels they are “loosing control.”or feels they are “loosing control.”


Introduction Introduction (continued)(continued) A crisis occurs when a person’s perception A crisis occurs when a person’s perception

of an acute distressing event results in an of an acute distressing event results in an abnormal behavioral response. abnormal behavioral response.

Crisis is an internal response that can Crisis is an internal response that can create reactions such as:create reactions such as: Severe anxietySevere anxiety PanicPanic ParanoiaParanoia Other psychotic eventsOther psychotic events


The EMS Provider’s RoleThe EMS Provider’s Role You must be able to take an active You must be able to take an active

role in controlling the situation without role in controlling the situation without being threatening:being threatening: Upon arrival make a clear, short and calm Upon arrival make a clear, short and calm

statement of who you are and why you are statement of who you are and why you are there.there.

Determine the problem and how many people Determine the problem and how many people are involved.are involved.

Get a description of any unusual activities, risk Get a description of any unusual activities, risk factors, prior episodes.factors, prior episodes.

Remember scene safety! Is this a crime scene?Remember scene safety! Is this a crime scene?


Common Psychiatric Disorder Common Psychiatric Disorder ClassificationsClassifications

MentalMental EmotionalEmotional BehavioralBehavioral Effect in Canada an estimated:Effect in Canada an estimated: 6% to 9% of the population has a personality 6% to 9% of the population has a personality

disorder. disorder. Onset usually occurs during adolescence or in Onset usually occurs during adolescence or in

early adulthood.early adulthood. Anti-social personality disorder is frequently Anti-social personality disorder is frequently

found among prisoners (up to 50%).found among prisoners (up to 50%). Of hospitalizations for personality disorders in Of hospitalizations for personality disorders in

general hospitals, 78% are among young adults general hospitals, 78% are among young adults between 15 and 44 years of age. between 15 and 44 years of age.


Psychological DisordersPsychological Disorders Features:Features:

Observe the patient’s body language Observe the patient’s body language and verbal responses for cluesand verbal responses for clues

Various disorders have distinctive Various disorders have distinctive characteristicscharacteristics


Psychological DisordersPsychological Disorders Effect in Canada an estimated:Effect in Canada an estimated: 6% to 9% of the population has a personality 6% to 9% of the population has a personality

disorder. disorder. Onset usually occurs during adolescence or Onset usually occurs during adolescence or

in early adulthood.in early adulthood. Anti-social personality disorder is frequently Anti-social personality disorder is frequently

found among prisoners (up to 50%).found among prisoners (up to 50%). Of hospitalizations for personality disorders Of hospitalizations for personality disorders

in general hospitals, 78% are among young in general hospitals, 78% are among young adults between 15 and 44 years of age. adults between 15 and 44 years of age.


General Appearance:General Appearance: Neglect in personal hygiene, groomingNeglect in personal hygiene, grooming Inappropriate dressInappropriate dress Excessive attention to details Excessive attention to details

(obsessive-compulsive)(obsessive-compulsive) Unilateral neglect (brain lesion)Unilateral neglect (brain lesion)

Psychological Disorders Psychological Disorders (continued)(continued)



Intellectual Function:Intellectual Function: Assess memory, concentration, Assess memory, concentration,

judgment and orientationjudgment and orientation Psychiatric disorders may affect short, Psychiatric disorders may affect short,

long and recall memorylong and recall memory Assessment is done in the patient Assessment is done in the patient

interviewinterview


Thought Content:Thought Content: Thought content and perceptions should Thought content and perceptions should

be logical, consistent and connected be logical, consistent and connected with the current situationwith the current situation

Delusions – a false personal belief or Delusions – a false personal belief or idea is portrayed as trueidea is portrayed as true

Hallucination – a perception of Hallucination – a perception of something that is not presentsomething that is not present




Physical Complaints:Physical Complaints: Often vague – headache, muscle ache, Often vague – headache, muscle ache,

weight loss, lack of energyweight loss, lack of energy Consider medical causes firstConsider medical causes first

Motor Activity:Motor Activity: Tense, restlessness, pacing, crying, Tense, restlessness, pacing, crying,

fidgeting or slow movingfidgeting or slow moving Consider drug intoxication, pain, Consider drug intoxication, pain,

abnormal blood sugar or hypoxia firstabnormal blood sugar or hypoxia first



Speech & Language:Speech & Language: Consider word choice, quality, pace and Consider word choice, quality, pace and

articulation of speech and languagearticulation of speech and language Consider other causes for alterations such Consider other causes for alterations such

as stroke, tumors or trauma.as stroke, tumors or trauma. Body Language:Body Language:

Body language is the expression of thoughts Body language is the expression of thoughts or emotions by means of posture or or emotions by means of posture or gesturesgestures

Stay alert to non-verbal cues for potential Stay alert to non-verbal cues for potential violenceviolence



Mood:Mood: Assess mood and affect through facial Assess mood and affect through facial

expressions, body language and expressions, body language and responses to questionsresponses to questions

Should be appropriate for the current Should be appropriate for the current situation and transitions according with situation and transitions according with topics in conversationtopics in conversation


AssessmentAssessment Scene Safety:Scene Safety:

A major misconception “all mental A major misconception “all mental patients are unstable and dangerous”patients are unstable and dangerous”

Many behavioral emergencies begin as Many behavioral emergencies begin as medical calls. ALWAYS assess scene medical calls. ALWAYS assess scene safety in every call.safety in every call.

Respect a patient’s personal space.Respect a patient’s personal space. Limit the number of people and avoid Limit the number of people and avoid

overwhelming the patient.overwhelming the patient.


Assessment Assessment (continued)(continued) Focused History:Focused History:

Obtaining a history may be difficult, Obtaining a history may be difficult, these patients are often unreliable, poor these patients are often unreliable, poor historians or uncooperativehistorians or uncooperative

Family or caretakers may not be Family or caretakers may not be available or may distort the informationavailable or may distort the information

Assess predisposing risk factors such as Assess predisposing risk factors such as depression or major life eventdepression or major life event


Assessment Assessment (continued)(continued) S – What type of crisis is the patient S – What type of crisis is the patient

having? Any associated symptoms?having? Any associated symptoms? A – Are there any allergies to meds?A – Are there any allergies to meds? M – What meds and any recent M – What meds and any recent

changes to medication schedule?changes to medication schedule? P – What is the patient’s behavioral P – What is the patient’s behavioral

history? Any substance abuse?history? Any substance abuse? L – meds, meals, alcohol?L – meds, meals, alcohol? E – new stress, changes in social E – new stress, changes in social

status?status?


Assessment Assessment (continued)(continued) O – Where, when and how did the event O – Where, when and how did the event

begin?begin? P – What is the problem today? Did the P – What is the problem today? Did the

patient intend on harming him/herself?patient intend on harming him/herself? Q – What type of crisis is the patient Q – What type of crisis is the patient

experiencing?experiencing? R – Are there any concomitant medical R – Are there any concomitant medical

factors?factors? S – Is this event similar to previous episodes?S – Is this event similar to previous episodes? T – How long has this been going on?T – How long has this been going on?


Mental Status ExamMental Status Exam Obtain baseline assessment and Obtain baseline assessment and

verify finding with family/caretaker, verify finding with family/caretaker, MDMD

Appearance – note physical position Appearance – note physical position and posture, personal hygiene, and posture, personal hygiene, appropriate dress, age and genderappropriate dress, age and gender

Affect – what feelings is the patient Affect – what feelings is the patient exhibitingexhibiting


Mental Status Exam Mental Status Exam (continued)(continued)

Behavior – what is the patient doing?Behavior – what is the patient doing? Cognitive function – assess level of Cognitive function – assess level of

consciousness, memory, mood and consciousness, memory, mood and affect.affect.

Speech – assess word choice, Speech – assess word choice, content, intonation, clarity and pace.content, intonation, clarity and pace.

Thought process – assess if judgment Thought process – assess if judgment is reasonable for the current is reasonable for the current situation.situation.


Behavioral EmergenciesBehavioral Emergencies Depression is a common reaction to Depression is a common reaction to

major life stress:major life stress: Feelings of sadness, discouragement, and Feelings of sadness, discouragement, and

hopelessnesshopelessness Reduced activity levels, inability to Reduced activity levels, inability to

function, and sleep disturbancesfunction, and sleep disturbances Severe depression is a risk factor for Severe depression is a risk factor for

suicidesuicide May present as symptoms of disease May present as symptoms of disease

(organic illness, cardiac or respiratory (organic illness, cardiac or respiratory conditions)conditions)


Mental IllnessMental Illness There are many pathologies for There are many pathologies for

behavioral and psychiatric disorders:behavioral and psychiatric disorders: GeneticGenetic Chemical imbalanceChemical imbalance Organic illnessOrganic illness


Substance AbuseSubstance Abuse Dependence, abuse and intoxication.Dependence, abuse and intoxication. True addiction is both psychological True addiction is both psychological

and physical.and physical. Alcoholism is particularly insidious Alcoholism is particularly insidious

among the elderly.among the elderly.


Suicide AttemptsSuicide Attempts Occur when a patient has a true desire to Occur when a patient has a true desire to

die.die. Gestures are pleas for help.Gestures are pleas for help. Whether “attempt” or “gesture” do not Whether “attempt” or “gesture” do not

discount the patient’s emotional state in discount the patient’s emotional state in any way.any way.

Be direct and ask:Be direct and ask: ““Where you trying to kill yourself?”Where you trying to kill yourself?” ““Do you want to die?”Do you want to die?”

Clearly report and document your Clearly report and document your findings.findings.


Attention/Pleas for HelpAttention/Pleas for Help Some behavior calls are related to a Some behavior calls are related to a

patient’s cry for attention:patient’s cry for attention: Suicide gestureSuicide gesture HypochondriacHypochondriac Lonely person calling repeatedly for no Lonely person calling repeatedly for no

apparent medical reasonapparent medical reason Safest approach is to assume something is Safest approach is to assume something is

seriously wrong until proven otherwise.seriously wrong until proven otherwise. Often people who want help are unaware Often people who want help are unaware

of available resources and they call the HC of available resources and they call the HC or 9-1-1. or 9-1-1.


Assisting a TransportationAssisting a Transportation Mental health evaluation order.Mental health evaluation order.

The police should have an order and be The police should have an order and be on the sceneon the scene

Inmates feigning illness.Inmates feigning illness. Complete a thorough assessmentComplete a thorough assessment


Patients who are a danger to Patients who are a danger to themselves or another.themselves or another. Major concern is safety for EMS providers Major concern is safety for EMS providers

and the patientand the patient Do not use excessive force and be aware of Do not use excessive force and be aware of

the dangers of restraintthe dangers of restraint Never restrain a patient in a prone position!Never restrain a patient in a prone position! Review your policy and procedure on Review your policy and procedure on

patient restraintpatient restraint

Assisting a TransportationAssisting a Transportation


Medical Conditions that Mimic Medical Conditions that Mimic Behavioral DisordersBehavioral Disorders

Stroke, tumors, or trauma can affect Stroke, tumors, or trauma can affect speech.speech.

Medications, severe infections, Medications, severe infections, hypoxia, hypo or hyperglycemia can hypoxia, hypo or hyperglycemia can cause altered mental status, cause altered mental status, depression or psychosis.depression or psychosis.

Psychotropic meds can have Psychotropic meds can have powerful side effects and severe powerful side effects and severe interactions with other medications. interactions with other medications.


Stress and the EMS ProviderStress and the EMS Provider Emergency responders are routinely Emergency responders are routinely

subjected to both positive and subjected to both positive and negative stress.negative stress.

Stress disorders may be acute or Stress disorders may be acute or develop into chronic conditions if not develop into chronic conditions if not recognized and managed.recognized and managed.

Be watchful and recognize Be watchful and recognize signs/symptoms of stress in yourself signs/symptoms of stress in yourself and coworkers.and coworkers.


Stress and EMS Providers Stress and EMS Providers (continued)(continued)

Signs and symptoms of ineffective or Signs and symptoms of ineffective or failing coping mechanisms include:failing coping mechanisms include: Increased absenteeismIncreased absenteeism WithdrawalWithdrawal DepressionDepression HyperactivityHyperactivity IrritabilityIrritability Increased smoking or alcohol useIncreased smoking or alcohol use Sleep disturbancesSleep disturbances HeadachesHeadaches Poor concentration and decision makingPoor concentration and decision making


ConclusionConclusion Response to crisis varies by person.Response to crisis varies by person. Inability to cope or failing Inability to cope or failing

mechanisms can cause impaired mechanisms can cause impaired functionality.functionality.

Some become withdrawn/depressed, Some become withdrawn/depressed, others overactive/violent. others overactive/violent.


Conclusion Conclusion (continued)(continued) Many factors can alter a patient’s Many factors can alter a patient’s

behavior (regardless of any mental behavior (regardless of any mental health history).health history).

Personal safety comes first! Take an Personal safety comes first! Take an active role in controlling the situation active role in controlling the situation and supporting the patient’s and supporting the patient’s emotional and physical needs.emotional and physical needs.

Whenever possible obtain a complete Whenever possible obtain a complete history! history!


QuestionsQuestions 1: 1: The best way to gain the confidence The best way to gain the confidence

of, and effectively communicate with, a of, and effectively communicate with, a frightened patient is to:frightened patient is to:A:A: shout at the patient. shout at the patient.

B:B: use medical terminology. use medical terminology. C:C: let the patient have some time alone. let the patient have some time alone. D:D: make and keep eye contact with the make and keep eye contact with the

patient patient


AnswerAnswer 1: 1: The best way to gain the confidence of, and The best way to gain the confidence of, and

effectively communicate with, a frightened effectively communicate with, a frightened patient is to: patient is to:

D:D: make and keep eye contact with the make and keep eye contact with the patient.patient.

Reason:Reason: The best way to communicate with a The best way to communicate with a frightened patient is to make and keep eye frightened patient is to make and keep eye contact in order to help the patient keep calm. contact in order to help the patient keep calm.


QuestionQuestion 2: 2: A woman is lethargic and moving A woman is lethargic and moving

around slowly. She is speaking coherently around slowly. She is speaking coherently but does not show any expression when but does not show any expression when speaking. These signs and symptoms speaking. These signs and symptoms suggest:suggest:A:A: mania. mania.

B:B: paranoia. paranoia. C:C: depression. depression. D:D: a potential suicide attempt a potential suicide attempt


AnswerAnswer 2: 2: A woman is lethargic and moving around A woman is lethargic and moving around

slowly. She is speaking coherently but does slowly. She is speaking coherently but does not show any expression when speaking. not show any expression when speaking. These signs and symptoms suggest: These signs and symptoms suggest:

C:C: depression. depression.

Reason:Reason: Extreme lethargy, slow movement, Extreme lethargy, slow movement, and very little facial expression while talking and very little facial expression while talking are signs of possible depression. are signs of possible depression.


QuestionQuestion ..3: 3: Your primary responsibility in the initial Your primary responsibility in the initial

management of a disruptive patient is to:management of a disruptive patient is to:A:A: make a specific diagnosis. make a specific diagnosis.

B:B: lecture the patient about the dangers of lecture the patient about the dangers of substance abuse.substance abuse.

C:C: take charge of the situation but protect take charge of the situation but protect yourself if necessary.yourself if necessary.

D:D: play along with the patient if he or she play along with the patient if he or she sees or hears things that are not real. sees or hears things that are not real.


AnswerAnswer 3: 3: Your primary responsibility in the initial Your primary responsibility in the initial

management of a disruptive patient is to: management of a disruptive patient is to:

C:C: take charge of the situation but protect take charge of the situation but protect yourself if necessary.yourself if necessary.Reason:Reason: Your primary responsibility in the Your primary responsibility in the initial management of a disruptive patient initial management of a disruptive patient is to take charge of the situation and to be is to take charge of the situation and to be mindful of your personal safety. mindful of your personal safety.


QuestionQuestion 4: 4: Your patient is displaying Your patient is displaying

disruptive behavior and needs to be disruptive behavior and needs to be restrained. You should:restrained. You should:A:A: threaten the patient. threaten the patient.

B:B: use handcuffs if available. use handcuffs if available. C:C: ask law enforcement to handle it. ask law enforcement to handle it. D:D: use whatever means are available. use whatever means are available.


AnswerAnswer 4: 4: Your patient is displaying disruptive Your patient is displaying disruptive

behavior and needs to be restrained. You behavior and needs to be restrained. You should: should:

C:C: ask law enforcement to handle it. ask law enforcement to handle it.

Reason:Reason: Whenever a patient who is Whenever a patient who is displaying disruptive behavior needs to be displaying disruptive behavior needs to be restrained, you should ask law restrained, you should ask law enforcement to handle the situation. enforcement to handle the situation.


QuestionQuestion 5: 5: The driver in a one-car crash has no The driver in a one-car crash has no

apparent injuries but is acting unruly. A half-apparent injuries but is acting unruly. A half-full whiskey bottle is lying on the passenger full whiskey bottle is lying on the passenger seat. The appropriate course of action would seat. The appropriate course of action would be to:be to:A:A: assume that the driver is drunk. assume that the driver is drunk.

B:B: ask bystanders to help you restrain the ask bystanders to help you restrain the driver.driver.

C:C: let law enforcement officials handle the let law enforcement officials handle the matter.matter.

D:D: assess the situation to determine why the assess the situation to determine why the driver is acting unruly. driver is acting unruly.


AnswerAnswer 5: 5: The driver in a one-car crash has no apparent The driver in a one-car crash has no apparent

injuries but is acting unruly. A half-full whiskey injuries but is acting unruly. A half-full whiskey bottle is lying on the passenger seat. The bottle is lying on the passenger seat. The appropriate course of action would be to: appropriate course of action would be to:

D:D: assess the situation to determine why the assess the situation to determine why the driver is acting unruly driver is acting unruly

Reason:Reason: The appropriate course of action in this The appropriate course of action in this situation would be to assess the scene to situation would be to assess the scene to determine why the driver is being disruptive. Do determine why the driver is being disruptive. Do not "write" off the unruly or abusive patient as not "write" off the unruly or abusive patient as "just another drunk." "just another drunk."


QuestionQuestion 6: 6: A patient with organic brain A patient with organic brain

syndrome who is exhibiting disruptive syndrome who is exhibiting disruptive behavior will most likely be:behavior will most likely be:A:A: elderly. elderly.

B:B: paralyzed. paralyzed. C:C: terminally ill. terminally ill. D:D: unable to speak unable to speak


AnswerAnswer 6: 6: A patient with organic brain A patient with organic brain

syndrome who is exhibiting syndrome who is exhibiting disruptive behavior will most likely disruptive behavior will most likely be: be:

A:A: elderly. elderly.Reason:Reason: Most patients with organic Most patients with organic brain syndrome are elderly. brain syndrome are elderly.


QuestionQuestion 7: 7: Which of the following statements about Which of the following statements about

restraining a patient is FALSE?restraining a patient is FALSE?

A:A: Soft, wide leather or cloth restraints should be Soft, wide leather or cloth restraints should be used.used.

B:B: You should talk to the patient throughout the You should talk to the patient throughout the process.process.

C:C: There should be two law enforcement officers There should be two law enforcement officers present.present.

D:D: Use the minimum force necessary to restrain Use the minimum force necessary to restrain the patient. the patient.


AnswerAnswer 7: 7: Which of the following statements Which of the following statements

about restraining a patient is FALSE?about restraining a patient is FALSE? C:C: There should be two law enforcement There should be two law enforcement

officers present.officers present.

Reason:Reason: To safely restrain a patient, To safely restrain a patient, there should be at least four officers there should be at least four officers present. Each should be responsible for present. Each should be responsible for one extremity. one extremity.


QuestionQuestion 8: 8: A suicidal act can be described as a A suicidal act can be described as a

state in which the patient might:state in which the patient might:A:A: believe that people are plotting to harm believe that people are plotting to harm or kill him or her.or kill him or her.

B:B: not want to do anything and might not not want to do anything and might not cooperate or answer questions.cooperate or answer questions.

C:C: be threatening to kill himself or herself be threatening to kill himself or herself or might already have made an attempt.or might already have made an attempt.

D:D: be severely agitated, speaking rapidly, be severely agitated, speaking rapidly, and usually not finishing a sentence or a and usually not finishing a sentence or a complete thought. complete thought.


AnswerAnswer 8: 8: A suicidal act can be described as a A suicidal act can be described as a

state in which the patient might: state in which the patient might: C:C: be threatening to kill himself or herself be threatening to kill himself or herself

or might already have made an attempt.or might already have made an attempt.Reason:Reason: A suicidal act is a situation in A suicidal act is a situation in which a patient may be threatening to kill which a patient may be threatening to kill himself or herself or may have already himself or herself or may have already made an attempt. made an attempt.


QuestionQuestion 9: 9: When caring for a patient with a When caring for a patient with a

behavioral emergency, if the patient is behavioral emergency, if the patient is sitting on the edge of his or her seat, sitting on the edge of his or her seat, tense, rigid, and speaking loudly and tense, rigid, and speaking loudly and making obscene comments, the EMR making obscene comments, the EMR should consider that:should consider that:A:A: the patient might become violent. the patient might become violent.

B:B: the patient is only nervous. the patient is only nervous. C:C: standing close to the patient will help to standing close to the patient will help to

reassure him or her.reassure him or her. D:D: all of the above. all of the above.


AnswerAnswer 9: 9: When caring for a patient with a When caring for a patient with a

behavioral emergency, if the patient is sitting behavioral emergency, if the patient is sitting on the edge of his or her seat, tense, rigid, on the edge of his or her seat, tense, rigid, and speaking loudly and making obscene and speaking loudly and making obscene comments, the EMR should consider that: comments, the EMR should consider that:

A:A: the patient might become violent. the patient might become violent. Reason:Reason: A patient who is sitting on the edge A patient who is sitting on the edge

of his or her seat, appears tense or rigid, of his or her seat, appears tense or rigid, speaks loudly, and makes obscene comments speaks loudly, and makes obscene comments has the potential to become violent. has the potential to become violent.


QuestionQuestion 10: 10: A behavioral crisis can be defined as:A behavioral crisis can be defined as:

A:A: any emergency in which the patient is any emergency in which the patient is mentally crazy.mentally crazy.

B:B: any reaction that is psychological in any reaction that is psychological in nature.nature.

C:C: any situation in which the patient cannot any situation in which the patient cannot act appropriately.act appropriately.

D:D: any reaction to events that interferes any reaction to events that interferes with the activities of daily living.with the activities of daily living.


AnswerAnswer 10: 10: A behavioral crisis can be defined as:A behavioral crisis can be defined as: D:D: any reaction to events that interferes any reaction to events that interferes

with the activities of daily living. with the activities of daily living.

Reason:Reason: A behavioral crisis is any reaction A behavioral crisis is any reaction to events that interferes with the activities to events that interferes with the activities of daily living or has become unacceptable of daily living or has become unacceptable to the patient, family, or community. to the patient, family, or community.

Healthcare

Focused history & physical exam and behavior emergencies