History and Physical Exam: Trauma

Areas to assess: head, neck, chest, abdomen, pelvis, extremities, posterior

• Assess the head
  Using a penlight, illuminate the eyes, ears, nose, and mouth.
  • Eyes Equal and reactive?
    Blood/CSF (cerebrospinal fluid)?
    
  • Ears Blood/CSF (cerebrospinal fluid)?
    
  • Nose Blood/CSF (cerebrospinal fluid)?
    
  • Mouth Is the airway open?
  Palpate the head for deformity, maintaining contact from the jaw, back of head, forehead, to cheekbones.
• Assess the neck
  Presence of tracheal deviation?
  Presence of JVD (Jugular Vein Distention)?
• Assess the chest
  Palpate the chest, sternum, and ribs.
• Assess the abdomen
  Palpate the abdominal quadrants.
• Assess the pelvis
  Palpate the pelvis by placing hands at the bony aspects (ASISs), then GENTLY pushing in (toward the center), then down (toward the floor). Verbalize stability/instability of the pelvis.
  Visualize the genitalia/perineum for incontinence and/or bleeding. Verbalize findings.
• Assess the extremities
• Assess the posterior
  On the head (wo)man's count, log roll the patient and palpate from c-spine to sacrum for spinal alignment.
• Note: as per NYS DOH requirements, manage any secondary injuries/wounds appropriately.