ICU Assessment

• Review of systems• Current diagnosis• Pertinent lab data• Pertinent physical examination findings• Allergies/sensitivities• Airway Assessment• Surgical/anesthesia history• Medication history• Social history

• Other

Patient History:

• General state of well-being• Daily activity level• The patient’s understanding of:

• Medical condition • Coexisting medical conditions

• Review of old records

Present Illness:

• Diagnostic studies• Presumptive diagnosis

• Treatments • Responses to treatments• Review available vital sign data• Review available fluid balance data

Coexisting medical conditions:

• Evaluate in a systems approach• Assess recent changes in symptoms• Assess current treatment regimens• Specialty consultation when needed

Medications:Medications:

• Review medications, doses, schedules• Cardiac • Seizure• Endocrine • Anticoagulants• Antidepressants

• Decision to continue/discontinue

Allergies and drug Allergies and drug reactions:reactions:• True allergic reactions• Non-allergic responses

• Adverse reactions• Side effects• Drug-drug interactions

Social History:

• Smoking• Alcohol• Recreational drug use

Smoking:

• Productive Cough• Hemoptysis• How many pack years?

Alcohol:• Self-reporting of use typically

underestimates actual use• Withdrawal

• Increase anesthetic requirements• Hypertension• Tremors• Delirium• Seizures

Review of Systems: (continued)

• Respiratory• Asthma• Recent history of URI

Review of systems: (continued)

• Cardiac• HTN

Review of Systems: (continued)

• Gastro/intestinal• / hiatal hernia

• Increased risk of pulmonary aspiration

Review of Systems: (continued)

• Pregnancy• All women of childbearing age should be

questioned regarding last menses and the likelihood of current pregnancy.

Physical Exam:

• Direct attention to:• Airway • Heart • Lungs• Neuro

Physical Exam: (continued)

• Baseline Vital Signs:• Height and weight• Blood pressure • Resting pulse • Respirations

Physical Exam: (continued)

• Airway assessment• Size of oral opening and tongue• Observe/document loose or chipped teeth,

“caps”, dentures, other orthodontic devices, piercings

• Observe/document range of cervical motion in flexion, extension, and rotation

• Observe/document tracheal deviation, masses

Airway Assessment

The loose tooth

Normal Airway AnatomyNormal Airway Anatomy

The larynx

Difficult airways

Physical Exam: (continued)

• Heart• Murmur• Pericardial rub

Physical Exam: (continued)

• Lungs• Wheezes• Rhonchi• Rales• Correlate what you hear with

observation of how patient is breathing…. easy vs. labored

• Use of accessory muscles

Physical Exam: (continued)

• Abdomen• Distention• Ascites• Predisposition to regurgitation

Physical Exam: (continued)

• Extremities• Clubbing• Cyanosis• Cutaneous infection

Physical Exam: (continued)

• Neuro• Document neuro status• Cranial nerve function• Cognition• Peripheral sensorimotor function

labs:

• Hematocrit and Hemoglobin• Evaluate each pt. individually for the

etiology and duration of their anemia

labs:

• Serum Chemistry• Hypokalemia/hyperkalemia

• Coagulation Screen• When indicated

EKG:• All patients over 40 years old• New Q waves• ST-segment depression/elevation• T-wave inversions• Rhythm disturbances

• PVC’s• A-fib, a-flutter• LBBB• 2nd or 3rd degree AV block