Book contents
- Intensive Care Medicine
- Intensive Care Medicine
- Copyright page
- Dedication
- Dedication
- Epigraph
- Contents
- Contributors
- Preface
- Foreword
- Abbreviations
- Section 1 Resuscitation and Management of the Acutely Ill Patient
- Section 2 Diagnosis, Assessment, Investigation, Monitoring and Data Interpretation
- Introduction
- The SBAR Tool
- Introduction
- Initial Primary Assessment
- Secondary Assessment
- Continuing Assessment
- Introduction
- Common Immediate Tests
- ECG Modes and Configurations
- Rate
- Cardiac Axis
- Bundle Branch Block
- QT Interval
- Other Abnormalities
- ST Abnormalities and Ischaemic Changes
- Inherited Disorders
- Introduction
- Types of Infection and Related Organisms
- Surveillance
- General Principles of Sampling
- Special Tests – Lumbar Puncture
- Introduction
- Indications for Arterial Blood Gas Samples
- Contraindications
- Sampling Sites
- Technique (Follow Local Hospital Procedure)
- Problems
- Complications
- Potential Sources of Error
- ABG Interpretation
- A Quick Approach to Deciphering the ABG
- Some Caveats
- Stewart’s Physicochemical Approach to Acid–Base
- Plain Film Radiographs (X-ray)
- Computed Tomography
- Magnetic Resonance Imaging
- Radiation
- Introduction
- Challenges of Portable Chest Radiography in ICU
- Systematic Assessment of ICU CXRs
- The ‘LLL’ Approach
- Pneumonia versus Pulmonary Oedema versus ARDS – Which Is It?
- Introduction
- CT Head Anatomy
- Meninges
- CT Checklist: ‘AB BCS’
- Grey–White Matter Differentiation
- CSF Spaces
- Skull/Scalp
- Introduction
- Systematic Assessment of the Abdominal X-ray: BBC
- B: Bones/Soft Tissue
- C: Calcifications/Artefacts
- Abdominal Pathology on CT
- Introduction
- Features of NEWS Scoring Systems
- Updated NEWS 2 Scoring System
- Advantages
- Disadvantages
- Introduction
- Clinical Reasoning and Critical Thinking
- The Clinical Reasoning Process
- Important Steps to Making a Differential Diagnosis
- Acknowledgements
- 2.1 Principles of Obtaining a History
- 2.2 Principles of Performing an Accurate Clinical Examination
- 2.3 How to Undertake Timely and Appropriate Investigations
- 2.4 General Principles of Performing and Interpretation of Electrocardiography Results
- 2.5 General Principles of Obtaining Appropriate Microbiological Samples and Interpretation of Results
- 2.6 Obtaining and Interpretation of Results from Blood Gas Samples (Acid–Base Balance and Disorders)
- 2.7 Principles of Interpreting Imaging Studies (X-ray/CT/MRI)
- 2.8 Imaging of the Chest
- 2.9 Imaging of the Head
- 2.10 Imaging of the Abdomen
- 2.11 Importance of Monitoring and Responding to Trends in Physiological Variables
- 2.12 How to Integrate Clinical Findings with Laboratory Investigations to Form a Differential Diagnosis
- Domain 3 Disease Management: Recognition, Causes and Management
- Section 4 Therapeutic Interventions and Organ Support
- Domain 5 Practical Procedures
- Section 6 Perioperative Care
- Section 7 Comfort and Recovery
- Section 8 End-of-Life Care
- Section 9 Paediatric Care
- Section 10 Transport
- Section 11 Professionalism, Patient Safety, Governance and Health Systems Management
- Index
- References
2.1 - Principles of Obtaining a History
from Section 2 - Diagnosis, Assessment, Investigation, Monitoring and Data Interpretation
Published online by Cambridge University Press: 27 July 2023
Book contents
- Intensive Care Medicine
- Intensive Care Medicine
- Copyright page
- Dedication
- Dedication
- Epigraph
- Contents
- Contributors
- Preface
- Foreword
- Abbreviations
- Section 1 Resuscitation and Management of the Acutely Ill Patient
- Section 2 Diagnosis, Assessment, Investigation, Monitoring and Data Interpretation
- Introduction
- The SBAR Tool
- Introduction
- Initial Primary Assessment
- Secondary Assessment
- Continuing Assessment
- Introduction
- Common Immediate Tests
- ECG Modes and Configurations
- Rate
- Cardiac Axis
- Bundle Branch Block
- QT Interval
- Other Abnormalities
- ST Abnormalities and Ischaemic Changes
- Inherited Disorders
- Introduction
- Types of Infection and Related Organisms
- Surveillance
- General Principles of Sampling
- Special Tests – Lumbar Puncture
- Introduction
- Indications for Arterial Blood Gas Samples
- Contraindications
- Sampling Sites
- Technique (Follow Local Hospital Procedure)
- Problems
- Complications
- Potential Sources of Error
- ABG Interpretation
- A Quick Approach to Deciphering the ABG
- Some Caveats
- Stewart’s Physicochemical Approach to Acid–Base
- Plain Film Radiographs (X-ray)
- Computed Tomography
- Magnetic Resonance Imaging
- Radiation
- Introduction
- Challenges of Portable Chest Radiography in ICU
- Systematic Assessment of ICU CXRs
- The ‘LLL’ Approach
- Pneumonia versus Pulmonary Oedema versus ARDS – Which Is It?
- Introduction
- CT Head Anatomy
- Meninges
- CT Checklist: ‘AB BCS’
- Grey–White Matter Differentiation
- CSF Spaces
- Skull/Scalp
- Introduction
- Systematic Assessment of the Abdominal X-ray: BBC
- B: Bones/Soft Tissue
- C: Calcifications/Artefacts
- Abdominal Pathology on CT
- Introduction
- Features of NEWS Scoring Systems
- Updated NEWS 2 Scoring System
- Advantages
- Disadvantages
- Introduction
- Clinical Reasoning and Critical Thinking
- The Clinical Reasoning Process
- Important Steps to Making a Differential Diagnosis
- Acknowledgements
- 2.1 Principles of Obtaining a History
- 2.2 Principles of Performing an Accurate Clinical Examination
- 2.3 How to Undertake Timely and Appropriate Investigations
- 2.4 General Principles of Performing and Interpretation of Electrocardiography Results
- 2.5 General Principles of Obtaining Appropriate Microbiological Samples and Interpretation of Results
- 2.6 Obtaining and Interpretation of Results from Blood Gas Samples (Acid–Base Balance and Disorders)
- 2.7 Principles of Interpreting Imaging Studies (X-ray/CT/MRI)
- 2.8 Imaging of the Chest
- 2.9 Imaging of the Head
- 2.10 Imaging of the Abdomen
- 2.11 Importance of Monitoring and Responding to Trends in Physiological Variables
- 2.12 How to Integrate Clinical Findings with Laboratory Investigations to Form a Differential Diagnosis
- Domain 3 Disease Management: Recognition, Causes and Management
- Section 4 Therapeutic Interventions and Organ Support
- Domain 5 Practical Procedures
- Section 6 Perioperative Care
- Section 7 Comfort and Recovery
- Section 8 End-of-Life Care
- Section 9 Paediatric Care
- Section 10 Transport
- Section 11 Professionalism, Patient Safety, Governance and Health Systems Management
- Index
- References
Summary
Key Learning Points
1. Use a systematic and structured approach to obtain the initial history.
2. Focus on the relevant features of the patient’s clinical presentation.
3. Take a more thorough history when the patient is stable.
4. Ensure knowledge of the SBAR approach to communicate among medical professionals.
5. Call for additional help early, especially if there are any life-threatening conditions.
Keywords
- Type
- Chapter
- Information
- Intensive Care MedicineThe Essential Guide, pp. 21 - 23Publisher: Cambridge University PressPrint publication year: 2021
References
References and Further Reading
1000 Lives Plus. 2011. Improving clinical communication using SBAR. www.1000livesplus.wales.nhs.uk/sitesplus/documents/1011/T4I%20%283%29%20SBAR.pdfGoogle Scholar
National Institute for Health and Care Excellence. 2007 (updated review 2016). Acutely ill adults in hospital: recognising and responding to deterioration. Clinical guideline [CG50]. www.nice.org.uk/guidance/cg50Google Scholar
Royal College of Physicians. Acute care toolkit 6. The medical patient at risk: recognition and care of the seriously ill or deteriorating medical patient. London: Royal College of Physicians; 2013.Google Scholar
World Health Organization. Patient safety solutions. Volume 1, solution 3. Geneva: World Health Organization; 2007.Google Scholar