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23 Cards in this Set
- Front
- Back
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Taking a history applies to both orthopedic and __________ medical examinations. |
General |
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What information do you need when obtaining a history? |
- Chief Complaint - Signs and Symptoms - Mechanism of Injury/Nature of illness - Previous Hx and ContributingFactors |
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What are the three (3) histories you can take depending on the situation? |
– Essential Hx (Emergent Examination) – Focused Hx (On-site Examination) – Detailed Hx (Off-site Examination) |
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What type of history should you take when in an emergent situation? |
– Essential Hx (Emergent Examination) |
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What type of history should you take when in an on-site situation? |
- Focused Hx (On-site Examination) |
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What type of history should you take when in an off-site situation? |
– Detailed Hx (Off-site Examination) |
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From all of your complaints/problems, what is the most important/pressing; greatest need to be addressed? |
Chief Complaint |
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What are the relevant questions used to quickly determine the primary problem? |
- What's wrong? - What brings you to the clinic today? - Where is your pain? |
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How a person was injured |
Mechanism of Injury (MOI) |
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When determining a person's mechanism of injury, what information should you ascertain to narrow down the list of structures and type of damage that was done to the body? |
- Direction, location, type, and velocity of forces |
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What is compression? |
Crushing injury that ranges from a simple contusion to a compression fracture in the spine. |
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What is tension? |
Causes a tissue to exceed its length adn tensile strength; mechanism common to tendon and ligament injuries |
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What is twisting? |
When one body segment is fixed and another segment rotates to change direction. |
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What is shearing? |
Occurs when there is a transvere displacement between two structures |
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Further questioning to determine events leading to or associated with the injury/illness |
Nature of illness/condition |
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What is a symptom? |
Subjective findings; what the patient experienced/feels |
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What is a sign? |
Objective findings; things you can see/measure |
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What should be included when finding out the previous Hx and contributing factors? |
- Relevant information from before the onset of the injury/illness |
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Why is gathering a patients medical hx and contributing factors important? |
- Helps the clinician determine the progressive stages of the injury/illness |
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During which exam would you identify potential life threatening conditions? |
Emergent Examination |
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What are all the components in an essential hitory for an emergent examination? |
- Potentially life threatening condition - Primary survey (LOC, ABC's) - Essential info will affect immediate exam/care - Know medical hx, bracelet - Once stabilized continue hx |
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What are all the components in a focused history for an on-site examination? |
- Chief Complaint - MOI, location, and severity of injury - Immediate problems that need attn before removal from field |
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What are all the components in a detailed history for an off-site or clinical exam? |
- Comprehensive exam - Explores CC, MOI, S&S, and pre-existing conditions - Applies to acute and chronic conditions - Current medical hx - Previous medical hx |
