The group medic must learn the skills to place a tourniquet or splint a sprain, Let’s face it, you have to deal rapidly with emergencies, but in a long-term off-grid setting, you have to know more than that. Learning the basic skills of how to obtain a pertinent medical history and perform a general physical exam is just as important to make a diagnosis and plan an appropriate course of treatment.
THE MEDICAL HISTORY
For those willing to take responsibility for the medical care of others after a disaster, success involves familiarity with the patient’s history as much as the reason for the current visit. It’s important to compile as complete a medical history as possible for every person in your group before a disaster occurs. In this way, you can help them plan to stay healthy in hard times and save yourself some real problems down the road.
During the medical history and the physical exam, you must communicate with your patient in a calm manner and, if they don’t already know you, let them who you are, what you will be doing, and why.
You should first ask about past surgeries and hospitalizations, chronic illnesses, injuries, allergies, risk factors, and current medications. They will all factor into your evaluation. For example, a healthy young patient comes to you complaining of nausea after having a few drinks with friends. He usually has no problem with alcohol, but your medical history reveals that he’s on an antibiotic called metronidazole, which happens to cause nausea if mixed with alcohol. You still must examine the patient, but you have a head start in making the likely diagnosis: an adverse reaction to the drug.
Even things you might not think would matter in a survival setting, like a patient’s smoking history, might help you make sense of unusual respiratory complaints later. A history of alcohol abuse might explain a patient’s shakes, sweats, and other symptoms. These commonly occur not too long after the booze runs out.
Unless you’re on the run and have to travel light, you should keep a written record of all this information. Don’t depend on your memory; it isn’t perfect, and it won’t help other medics if you’re not around.
PRINCIPLES OF PHYSICAL EXAMINATION
In addition to taking a history, you must learn how to physically evaluate a patient and make a diagnosis. This means putting your (gloved, if possible) hands upon them and looking for physical signs of illness or injury. Sometimes the problem is obvious in seconds; other times, you will have to examine the entire body to determine the problem.
This can be done efficiently and in an organized manner. The most basic information is obtained by simply looking at and talking with the patient. What’s their general appearance like? Are they well-nourished or sickly-looking? Are they calm or obviously in distress? Does one side of the patient match the other? Is there an injury?
How do you perform full examinations in a way that is efficient and most likely to make the diagnosis? Your approach should:
1) Allow you to evaluate the whole patient without excessive or awkward movements by yourself or the patient.
2) Establish a routine that is easily reproducible, allowing to you to progress through full exams the same way for multiple patients.
3) Evaluate sections of the body in groups based on their location, even though there may be signs of problems in another area. For example: Although foot swelling (also called “edema”) could be a sign of heart problems or high blood pressure, the legs are usually examined later than the heart or the vital signs (after the abdomen) in a complete general exam).
4) Take into account the patient’s modesty. Expose only the area currently being examined. A naked patient is an anxious patient.
Every exam should begin by washing your hands and putting on gloves, if you have them. A well-equipped hospital tent will have a hand washing station and an exam table. Usually, the exam begins with the head and works its way down. You can do it differently, but the important thing is to be organized and have a routine.
The four cornerstones of physical examination are:
Sometimes, the problem is obvious just by inspection
Each part of the body is evaluated using vision, hearing, and even smell to assess normal or abnormal states. Assess for color changes, size, location, movement, texture, symmetry, odors, and sounds as you inspect each body system.
Palpation requires you to touch the patient with your hands, using various positions and degrees of pressure. Be sure to keep your fingernails short and your hands warm. Assess for texture, tenderness, temperature, moisture, elasticity, mobility, pulsations, and masses. This technique is especially helpful to feel enlargement of internal organs, like the liver, spleen, or lymph nodes.
Percussion involves tapping a finger (usually the middle finger) of one hand sharply onto the middle finger of another hand against parts of the patient’s body. Is there a flat, dull quality to the sound or is it drum-like? This helps you locate organs and determine if an area is solid or filled with fluid or gas. This is usually done over the abdomen or lungs.
Auscultation involves listening for various lung, heart, and bowel sounds with a stethoscope. Most instruments have two heads, a “diaphragm” and a “bell.” Use the diaphragm to pick up high-pitched sounds and the bell for low-pitched sounds, the bell should be held against the skin with more pressure than the diaphragm to better hear softer sounds.
In future articles, we’ll discuss in detail some aspects of examining different areas of the body, and show you a simple documentation system that can be concise and informative.
Joe Alton MD
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