The "First 21" Flashcards
Step 1
Ensure the exam room is set up with standard clinic tools and supplies. Check all equipment to ensure it is operational. Verify th scale’s batteries are charged.
Step 2
Introduce yourself and confirm the patient’s identity, i.e. “ Hello, I’m HS3 Hastings. Can you please tell me your name, DOB, and last four of your social.
Step 3
Offer same sex chaperone i.e “would you like a chaperon present during the exam?”
If pt is not familiar reference policy located in exam room
Step 4
Obtain an initial impression of the patient. Ask the following:
* Does the pt appear to be in distress?
* If yes, is the distress mild, moderate, or severe?
* Could this be an emergency situation?
Step 5
Obtian Pt’s height and weight
Attempt to obtain this prior to the Pt sitting down
Step 6
Document Pt’s age, race, rank, gender born with, gender identity as and job within the Coast Guard.
Document all findings on the SF-600 or MHS genesis
Step 7
Obtain Pt’s pregnancy status and LMP. Ask “When was your last menstrual period? Was it normal?” If not ask, “ what was different?”
If the Pt is male defer this question
Step 8
Ask Pt’s chief complaint
Use plain language when addressing and speaking with Pts. Avoid the use of any medical terms or Jargon
Step 9
Determine major signs and symptoms of Pt’s chief complaint.
If the Pt already declared why they are being seen, ask amplifying questions
Step 10
Obtain the Pt’s OPQRSTTT
This is a mere tool, not a set in stone method to determine a diagnosis
Step 11
Determine wether or not the Pt has had any contact with people possessing similiar symptoms
Ask,” have you been in close contact with anyone who has had similar symptoms such as roommates, partners, or co-workers?”
If the Pt has been in contact ask if they were diagnosed and had seen a Doctor
Step 12
Ask 3 System Specific Questions
i.e. Circulatory, respiratory, GI, Nervous, Endocrine, Lymphatic etc…
Step 13
Determine any pertinent symptoms in related systems. Ask, “Do you have any nausea, vomiting, or Diarrhea? Any fever or chills? Headaches? A general feeling of tiredness or lack of energy?
(Malaise)
Step 14
Obtain Pt’s Medical History (PMH) i.e.
Have you ever felt this way before? if yes ask, “Did you see a doctor and was there a diagnosis?”
or
Do you have any history of significant injuries or past medical history such as: asthma, high blood pressure, high cholestrol, diabetes, cancer, or heart disease? If yes ask,” When were you diagnosed and how was it treated?”
Step 15
Obtain Pt’s Surg Hx. i.e.
Have you ever had surgery?
if yes ask,
“What for, at what age, and were there any complications?”
Step 16
Obtain Pt’s Family Hx. i.e.
Has anyone in your family had similar symptoms?
If yes ask:
Who?
When?
What was the result?
Also, “Do you have family Hx of asthma, high blood pressure, high cholesterol, diabetes, cancer, or heart disease?
If yes ask:
Who?
When?
How old they were?
What is their current condition?
Step 17
Determine if Pt has any allergies i.e.
“ Do you have any allergies to food, medication, or the environment?
if yes ask
When was your last reaction?
What kind of reaction do you experience?
Step 18
Determine if the Pt takes any MEDS either prescription or OTCs. i.e.
Do you take any prescribed MEDS/OTCs/dietary supplements/herbal remedies/ or vitamins?
If yes ask
What do you take?
What for?
What dosage and frequency?
How long have you been taking them?
Step 19
Obtain information on Pt’s Social Hx. i.e.
“Do you smoke, vape, dip or use any type of tobacco products? if yes, ask how much and for how long? also ask
,” Would you like to quit? if yes refer the Pt to the tobacco cessation counselor.
Do you drink any alcoholic beverages like beer or wine? if yes,
“What do you drink?”
“How much and how often?”
Do you exercise? if yes.
“ what kind of exercise, for how long, and how many times per week?”
“What is your daily water intake?”
“What is your daily intake of caffeine?
Does that include energy drinks?”
Follow up with
“What do you drink?”
“How much and how often?”
Step 20
Utilize A&Ox3 (Alert and oriented x1 alert to self, x2 alert to place, x3 alert to time) Document Pt’s mental status and general appearance. i.e Pt is WNWD 24 yr old female in mild distress, /guarding lower left quadrant, A&Ox3
Step 21
Obtain Pt’s vitals: temp, pulse, blood pressure, respirations, SpO2
