Steps of a Medical Assesment

Step 1: Scene Size-Up

1. BSI

2. Scene Safety

3. Nature of illness/Mechanism of injury

4. How many patients are there?

5. Do you need additional resources?

6. Consider Spinal

Step 2: Primary Assessment

1. General Impression

2. Level of Responsiveness (A&O scale, AVPU scale)

3. Chief Complaint

4. ABCD’s (Maintain patent airway, obtain IPASSO, check pulse, CTC and bleeding, make a decision)

5. Update EMS with a brief history report of the patients history

Step 3: Secondary Assessment (AFTER TRANSPORT DECISION)

1. Attempt to obtain SAMPLE, if the patient isn’t able to speak, attempt with nearby family/friends

2. Obtain vitals (pulse rate and quality, respiratory rate and quality, blood pressure, skin color, temperature and condition)

3. Do focused assessment based on body system effected (Cardiac/Respiratory, Neurological, Allergic Reaction, Obstetrical/Reproductive, Pyschiatric)

4. Restate general impression

5. Provide appropriate interventions and treatment

Reassessment (ongoing)

1. Repeat primary assessment (chief complaint, ABC’s

2. Repeat vitals every 5 minutes (unstable patient) or every 15 minutes (stable patient)

3. Repeat focused assessment

4. Examine any interventions

5. Identify and treat any changes int he patients condition

6. Verbalize report to hospital (CHART)

What to take into consideration for transport decision:

Altered mental status, chest pain, difficulty breathing, poor general impression, shock, severe pain anywhere and abnormal delivery

Cardiac/Respiratory physical exam

1. CTC

2. Lung Sounds

3. Check for edema in the extremities

4. Check equal and regular pulse

5. Check JVD

Cardiac/Respiratory questions to ask

OPQRSTI

Onset- What were you doing when your symptoms began?

Palliative/Provoking- Does anything make it better/worse?

Quality- In your own words, what does it feel like?

Radiating- Does it travel anywhere?

Severity- How bad does it hurt on a Cale of 1 to 10, 10 being the worst?

Time- When did the symptoms begin? Are they intermittent?

Interventions- Have you taken/done anything for the pain?

Neurological questions to ask

WITNSS

Weight- Approximate the patients weight.

Interventions- Have they taken/done anything? What did they take? How much did they take? When did they take it?

Trauma- Is there any evidence of trauma? Should we consider immobilization?

Normal- When was the last time the patient was seen normal?

Seizures- Does the patient have a history of seizures?

Symptoms- When did the symptoms begin?

Neurological physical exam

1. Reassess lung sounds

2. CTC

3. Does the patient have the ability to speak or swallow?

4. Any signs of drug abuse?

5. Incontinence?

6. Tongue biting?

7. Abnormal odor on the patient’s breath?

8. Mental Status

9. FAST Stroke Scale (Facial drop, unilateral arm movement, slurred speech, when was the last time the patient was seen normal?)

Allergic Reaction questions to ask

EASI

Exposure- What was the patient exposed to? How was the patient exposed (inhalation, orally, etc)? When was the patient exposed?

Allergies- Does the patient have any known allergies?

Symptoms- Does the patient have any progression of symptoms, has it gotten worse?

Interventions- Has the patient taken/administered any interventions (EpiPen)?

Allergic Reaction physical exam

1. Reassess lung sounds

2. Is there accessory muscle use when breathing?

3. Respiratory rate and depth

4. CTC

5. Urticaria (hives)

6. Swollen lips/tongue

7. Difficulty swallowing/speaking/breathing?

8. Pulse Quality

9. Mental Status

Obstetrical/Reproductive questions to ask

3PMBC

Pregnant- Is the patient pregnant?

Prior Pregnancy- Has the patient had any prior pregnancies?

Push- Does the patient feel a need to push (ONLY IF PREGNANT)?

Menstrual- When was the patients last menstrual cycle?

Obstetrical/Reproductive physical exam:

1. Estimate quantity of vaginal discharge

2. Meconium staining: this shows the baby is in distress

3. Crowning?

4. Edema evident?

5. CTC

Psychiatric questions to ask

SMFT

Suicidal tendencies- Does the patient have suicidal tendencies? Have they made a plan for suicide?

Medical issues- Does the patient have an underlying medical issues?

Feel- How does the patient feel?

Trauma- Is there any evidence of trauma?

Psychiatric physical exam

1. CTC

2. Is the scene safe?

3. Signs of trauma?

4. Rule out hypoglycemia, drugs, stroke, etc?