Examination of the patient

• a careful, systematic examination of the pt

• is performed in two stages –
• First stage involves taking the pt’s history, which traces
the sequence of events related to the injury or illness
• The second stage consists of the physical exam of the
pt, in which signs are looked for that might indicate the
severity and/or cause of the pt’s health problem.
• must be recorded concisely, accurately and
completely, since this information may have to be
communicated by radio
• The length of time and depth of detail required for an
examination will clearly depend on the complexity of
the health problem
 CONSENT
• In general, no one, medically qualified or not, can conduct a
physical exam of another person, or give them any form of Rx,
without their consent

• You must always (with the exceptions noted below) have the
patient’s consent before you begin any exam or give any Rx

• Each crew member should be informed of his or her right to give

or refuse consent to exam and Rx

• It is not necessary for the pt to sign a document to indicate

consent, or for his consent to be witnessed
Patients also have the right

 to read all notes and records made in connection with their Rx

 to be given a copy of their medical records when leaving the ship

or going to see a doctor

 to see a doctor of their choice at the next port

You can give treatment without consent
 to an unconscious pt – BUT if a pt refuses Rx when conscious and
then becomes unconscious the Rx cannot be given

 to a mentally ill pt endangering other

 in some countries, but not in others, to a mentally ill pt

endangering themselves, and to some pts with infectious diseases

 in an emergency, when taking the time to seek consent might

endanger the pt
 Seek medical advice whenever

 a pt asks a question which they consider relevant to their consent but

which you cannot answer confidently

a pt refuses Rx of a serious illness or injury

a pt refuses Rx for an infectious disease or one likely to impede the safe

operation of the ship

 a mentally ill pt is endangering himself

 PRIVACY AND CONFIDENTIALITY

• Everything you learn about a pt while caring for them is

confidential, or secret
• This applies both to things the pt tells you and things you learn
by examining them or from their medical records.
• Information about a pt should not be given to others not involved
in the pt’s care unless it is absolutely necessary. For example, the
master
• Be careful that any discussion involving confidential information
is held out of hearing of those who do not need to be involved
• Charts and medical records should be kept where visitors cannot
read them
• Many people may have legitimate reasons to want this
information, and may claim that they have a right to be informed
• do not provide any information until you have asked the pt
• Always ask the pt before you give any information to anyone,
even family members
• If the pt refuses to allow you to give out information you must
not do so unless
 How to take a patient’s history

■ Write down the time, date and your name on the case record
■ Record that the pt has consented to the examination
■ Begin by asking general questions
(let the pt respond without interrupting), such as:
● When were you last perfectly well?
● What was the first thing that made you think you were not well?
● What happened then? And then?
• Ask specifically about each symptom the pt reports:
• What were the first symptoms?
• Exactly how, where and when did the symptom start?
• Has the symptom changed over time? If so, how?
• Ask about other symptoms that the pt may not have reported
• Have you noticed any changes in other parts of your body or in
any bodily functions, since this problem appeared?
• Ask if there has been even slight
• breathlessness
• change in bowel habit
• change in the amount, color, or consistency of urine passed
• headache , fever
 Pay careful attention to the exact sequence of events at the
beginning of the illness

 Avoid leading questions (questions that suggest an answer), such

as: “The pain is worse when you breathe in, isn’t it?”. Instead ask
“When you breathe in, does it make the pain better or worse?”

 Avoid ambiguous questions

 Ask if the pt: ● has consulted other physicians or caregivers

about the problem and, if so, what they said or did;
Ask about smoking habits
● How many cigarettes a day?
● For how many years?

Ask about alcohol consumption

● On how many days per week is alcohol consumed?
● How many drinks are consumed on an average
Ask about recreational drug use
Ask about sexual activity
Ask about allergies to anything any medication
• The vital signs indicate how well the body is performing its
essential functions

• The main vital signs are

 body temperature
pulse rate and rhythm
 respiration rate
 blood pressure
level of consciousness
How to take the body temperature

• Use a temperature chart or, if temperature charts are not on

board, write down your findings, noting the hour
• Take Temp readings twice a day, always at the same time of day,
say, 07:00 and 19:00 (7 a.m. and 7 p.m.) or more frequently if
justified by the severity of the symptoms; note
• it is rarely necessary to record the Temp more frequently than
once every four hours
• exceptions in which more frequent Temp recordings are required
are cases of severe head injury , acute abdominal conditions ,
Heat stroke and other heat disorders
• Use a clinical thermometer to take body temperature, except in cases of
hypothermia, for which you should use a low-reading thermometer

• Shake down the mercury in the clinical thermometer to about 35°C

• Place the thermometer under the pt’s tongue and keep it there for at
least one minute, asking the pt to keep the lips closed and not to speak

• After one minute, read the thermometer, then put it back in the
patient’s mouth for a further minute.
• Check the reading: if it is the same as the first reading, record the
temperature on the chart; if it is different, repeat the procedure

• Disinfect the thermometer If a rectal temperature reading is

necessary, as for example in a case of hypothermia

• use a rectal thermometer, which has a short, blunt tip to prevent

injury to the rectum:
• lubricate the thermometer , with the pt lying on one side, push
the thermometer gently into the rectum for a distance of about 5
cm and leave it there for two minutes; record the temperature;
disinfect the thermometer
How to assess level of consciousness
• Use the Glasgow Coma Scale to determine and track changes in a
pt with disturbed consciousness and also to inform a medical
consultant
• A large part of brain must be affected to produce alterations in
consciousness
• Neurological diseases are not common causes of alterations of
consciousness
• If brain disease or injury is responsible , it is very severe and the
outlook is poor
• Common causes are sudden marked fall in BP ,paralysis ,drugs
and alcohol , low blood sugar
The Glasgow Coma Scale
• Eye opening - spontaneously 4 , in response to verbal
commend 3 , in response to pain 2 , No eye opening 1

• Best verbal response – oriented 5 , confused 4 ,

inappropriate words 3 , Incomprehensible words 2 , No speech 1
•
• Best motor response – obeys commands 6 , move a
hand to site of painful stimulus 5 , pulls away from painful
stimulus 4 , flexes limbs when painful stimulus 3 , straightens
limbs when painful stimulus 2 , No motor response 1

• The score can range from 3 the worst to 15 the best

 Measuring blood pressure
• A normal blood pressure is 120–140 / 70–85 mmHg
• The upper, systolic value represents the pressure in the arteries
when the heart is contracting
• The lower, diastolic value represents the pressure in the arteries
between the contractions of the heart
• If BP is measured carelessly and hastily, the readings can be even
10–20 mmHg higher than the real values
• The BP is higher when a person is standing, lower when sitting
down, and lowest when lying down
• Anxiety, tension, and pain, as well as many diseases, and physical
exertion raise the BP
 Measuring instruments
• Sphygmomanometer (BP gauge) for adults, the rubber bag part
of the cuff should be at least 14 cm wide and 40 cm long
• Stethoscope - When you place the stethoscope in the ears, make
sure that the angle of the earpieces is slightly upwards, in the
same direction as the ear passage
• Most stethoscopes have both a bell and a diaphragm mode for
auscultation
• Make sure before the measurement that you have chosen the
right side of the chest piece for listening
• This can be checked by lightly tapping with the fingers the side
that will be placed on the pt. If you can hear the sound via the
earpieces, measurement is possible
Measuring blood pressure with a
stethoscope
Procedures
• Remove any clothing that constricts the arm
• Preferably the whole arm is bare during the measurement. Wrap
the deflated cuff snugly around the upper arm.
• Start wrapping from the rubber bag part, ending with the Velcro
tape
• The air tubing from the cuff should point toward the pt’s wrist.
• The tubing should not cover the elbow fold, from which you
listen to the pulse with the stethoscope
•
• Make sure that the chest piece of the stethoscope is in
auscultation mode and place it at the middle of the elbow fold
over the artery.
• Pump air into the cuff and follow the pressure from the
sphygmomanometer.
• Raise the pressure about 30 mmHg higher than the patient’s
assumed blood pressure level
• Lower the cuff pressure slowly by deflating
• Follow the meter reading; at the same time listen with the
stethoscope for the appearance and disappearance of the pulse
Measuring blood pressure without a
stethoscope
• Diastolic BP can be determined only with a sphygmomanometer
and a stethoscope

• However, it is possible to measure the systolic pressure even

without a stethoscope

• Take the reading by feeling the wrist pulse at the same time as
you deflate the cuff

• Systolic pressure is the pressure level when the wrist pulse

• Common symptoms by organ or organ system