The Second Assessment: Diagnoses & Treatments

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Secondary Diagnosis and Treatment

A more extensive survey may be carried out after you have successfully determined the solution and a problem through the ABCDE method. This includes a focused history and physical examination involving the individual, family, and any witnesses, as relevant. Signs and symptoms, past medical history, allergies, medications (SPAM) combine to form the common guideline for treating the patient’s historical data.

The examination will be determined by the answers to the focused history. For example, a reported difficulty in breathing will prompt an airway and lung examination. A chest X-ray study may also be prompted in a hospital setting. The key is to study the patient from head to toe by completing an extensive survey. Whenever possible, make use of diagnosis tools to arrive at accurate results.

S: Signs & Symptoms
• Evaluate recent events related to
current problem
-Preceding illness, dangerous activity
• Examine patient from head to toe for
the following:
-Consciousness, delerium
-Agitation, anxiety, depression
-Fever
-Breathing
-Appetite
-Nausea/vomiting
-Diarrhea (bloody)
P: Past Medical History
• Complicated birth history
• Hospitalizations
• Surgeries
A: Allergies
• Any drug or environmental allergies
• Any exposure to allergens or toxins
M: Medications
• What medications is the child taking
(prescribed and OTC)?
• Could she have taken any inappropriate
medication or substance?

Table 8

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