Chapter 14 Principles of Assessment and 15 Secondary Assessment and 16 reassessment

2 lines of questioning for conscious patients

• History of present illness

• Overall past history

OPQRST

• Used to learn chief complaint and history of present injury, all subjective from patients POV

  • Onset: Chronic or acute issue, how did this begin?

  • Provocation: does anything make this pain better or worse? Relevant if the patient is in pain. Does it help if u lay down

  • Quality: can you describe the pain, what does it feel like? Dull vs sharp pain

  • Radiation: Is this causing pain anywhere else? like when you have an earache and your head hurts.

  • Severity: 1-10 how bad does it hurt? Make sure they know what 10 means

  • Time: How long has this been happening?

  • Can expand on questions, 

SAMPLE

• objective questions

  • Signs+Symptoms: what is going on today? Why did you call 911? Do you have any other s+s?

  • Allergies: drug+food allergies? Have you come into contact with these allergies?

  • Medications: Do you currently take any medications? Did you take them today? Medication can interact badly. 

  • Pertinent Past History: Do you have any medical history? People don't always know what's relevant, same with medication. If it is life or death you have to ask directly, what's important to EMS does not always mean it is life threatening. (anaphylaxis and they have stage 4 cancer, cancer not important)

  • Last oral intake: What was the last thing you ate (food or drug)

  • Events leading to injury or illness: what were you doing exactly when this began?

3 parts of physical assessment

• Look for overall sense of condition as well as evaluate chief complaint

• Listen (Auscultate) normally done with stethoscope, look for abnormalities

• Feel: Palpate for deformities or abnormalities

Pediatrics physical assessment

• Approach slowly, start from least invasive (feet) part to most invasive (head), never lie if something will hurt, they will be scared, carry stuffies, protect kids from onlookers if you have to take off clothing

Respiratory system examination

• History:

  • Determine onset (how long have you had this?)

  • Dyspnea or exertion (is it increasingly difficult to catch breath after exerting themselves)

  • Weight gain: has the patient had recent rapid weight gain? (can say if they've had heart failure)

  • Orthopnea: Does the patient have difficulty breathing when lying down?

  • Does patient sleep on pillows, have they needed more recently

  • Do they have a cough?

  • ANy respiratory conditions recently?

  • Any chronic illness

• Physical Assessment

  • Are they breathing adequately, get history of existing respiratory conditions and medications

  • Mental status? AVPU

  • • Level of respiratory distress

  • • Chest wall motion

  • • Auscultate lung sounds

  • • Use pulse oximetry 

  • • Observe edema

  • • Fever (can be covid ect)

cardiovascular assessment

• Involves heart/blood vessels, applies to 2 sections, those with shock and vascular issues, and the cardiac patient

• History:

  • Any cardiac issues and medications, are they prescribed

  • Do s+s for this match previous episodes

  • Description of chest discomfort with OPQRST

  • Does discomfort change with breathing, 

• Physical Examination:

  • Look for signs the condition may be severe, note mental status

  • Obtain pulse

  • Obtain bp

  • Obtain pulse pressure (systolic-distolic)

  • Palpate chest

  • Observe posture and breathing

  • Notice jugular vein distention (jugular vein empties blood to right atrium/ventricle, if blood backs up you see this, says circulation isn't fast enough.

Nervous system assessment

• 2 elements, mental status and body exam

• History:

  • Determine alert+oriented x4

  • Determine patients normal state of mental functioning (are they always like this)

  • History of conditions

  • Note speech

• Physical Assessment

  • Perform a stroke scale (cincinnati prehospital stroke scale) Fast

    • Facial droop(smile droopy on one side), arm drift (cant push down using both arms equally), slurred speech (you can't teach an old dog new tricks) time (when symptoms started)

  • Check Pupils (PERRL)

  • Examine gait (manner of walking)

  • Check peripheral sensation and movement (finger test)

  • Palpate spine for tenderness or deformity

  • Check extremity strength 

Endocrine assessment

• Most common is diabetic related

• History:

  • Obtain a history of endocrine conditions

  • Determine medications and when last taken

  • Last oral intake

  • Have been exerting themselves at unusual level\

  • Currently sick?

  • Taken blood glucose reading recently?

  • Do they have insulin pump

• Physical Exam

  • Evaluate mental status

  • Observe skin

  • Obtain glucose level

  • Look for insulin pump

  • Look for medical jewelry that identifies diabetes

gastrointestinal assessment

• Look for what has gone in and what comes out

• History

  • Any pain or discomfort (OPQRST)

  • Oral intake

  • Any history of issues/meds

  • Have they vomited

  • Any recent bowel movements

• Physical Assessment:

  • Observe patient position

  • Assess abdomen, inspect then palpate, palpate painful areas last

  • Inspect other parts of system if appropriate

  • Inspect vomit

immune system assessment

• Most relevant is allergic reaction

• History

  • Do they have allergies

  • Have they been exposed to an allergen

  • What are other patients allergic reactions typically like

  • Do they have asthma

  • Do they feel tightness in chest or throat, difficulty breathing, swelling around face and tongue

  • Do they have GI distress

  • Do they have itchiness or rash

  • Do they have medications

• Physical Exam

  • Inspect point of contact with the allergen

  • Inspect skin for rash/hives

  • Check face, lips, and mouth for swelling

  • Listen to patient speak what does it sound like

  • Listen to patientś lungs to ensure adequate breathing

Musculoskeletal assessment

• Most commonly injured by trauma

• History

  • Any prior injuries in area with injury

  • Any blood thinning meds

  • Any diseases/conditions that make fractures more common

  • Use history to determine if medical problem caused injury

• Physical exam

  • Inspect for signs of injury like deformity swelling or bruising

  • Palpate areas where you suspect injury, do it gently

  • Compare sides of body

  • Be alert for crepidation (feeling of bone ends rubbing together) as you palpate

  • In head to toe exam palpate all major areas, do this when multiple injuries or patient is unresponsive

diagnosis

a description or label for a patient's condition that assists a clinician in further evaluation and treatment. EMTs learn enough to make generalized diagnoses

EMTs diagnosis

•  a description or label for a patient's condition based on patients history, physical exam, and vital signs that assists EMT in further evaluation and treatment. Can also be referred to as field diagnosis, presumptive diagnosis, or working diagnosis.

Differential diagnosis

•  second step, a list of potential diagnoses compiled early in assessment

Signs vs symptoms

• Sign: visible, don't need to ask patient

• Symptom: something the patient tells you (my head hurts)

Components of secondary assessment

• Physical examination, patient history (history of present illness and past medical history), vital signs

Responsive medical patients order

• Obtain history: Obtain from patient first, then family/bystanders

  •  Base questions on chief complaints or observations/Sample, open-ended questions

• perform physical exams: tailor to chief complaint, usually brief since med issue not trauma, examine areas of concern

  • If shortness of breath check all lung/breathing related+edema

  • If chest pain check skin, bp, pulse, lung sounds, JVD, edema

  • If mental status do FAST check for stroke

  • If allergic check for stinger, urticaria, lung sounds, edema

•  obtain baseline vital signs: take manual bp to verify accuracy of automatic

• ,administer interventions and transport.

Unresponse medical patients order

• Rapid Physical exam: assess head, neck(jugular vein distention, id devices), chest (breath sounds), abdomen (distention, firmness), pelvis (incontinence), extremities(pulse, motor function, sensation, O2 saturation, id devices), and posterior, and pupils (most important time to check when eyes closed)

• Baseline vitals: pulse, RR, skin, pupils, BP, SPO2

• History from others: ask bystanders for name, what happened, did patient complain before this happened, any known illnesses, any known meds

• Administer interventions and transport: look for MOI or spine injury

• Consider request for als based on protocol

Not seriously injured trauma patients order

1. determine chief complaint and elicit info on history of present illness

2. perform physical exam based on chief complaint and MOI

3. get baseline vitals

4. get past medical history

seriously injured trauma patients order

1. determine chief complaint and rapidly get history of present illness

2. continue spinal precautions

3. consider als

4. perform rapid trauma assessment

5. baseline vitals

6. patient history

What to look/auscultate/palpate for in physical exam DCAP BTLS

• Look for issues with symmetry, color, shape, movement, palpate for temp, texture, sensation, listen for breath sounds

• DCAP-BTLS

  • Deformities

  • Contusions (bruises)

  • Abrasions (scrapes)

  • punctures/penetrations

  • Burns

  • Tenderness

  • Lacerations (cuts/open wounds)

  • Swelling

Rapid head to toe for trauma patients

•  

  • perform rapid trauma (head to toe) assessment: quick, on scene, care provided on route based on this, check for wounds, tenderness, and deformities

    • Head:

      • Palpate cranium, face, ears, eyes, nose, and mouth

      •  Blood or clear fluid and Battle’s signs (bruises behind ears that indicate skull injury), blood in anterior chamber of eye are serious findings.

        • If cerebrol spinal fluid leaking out make sure to keep ear clean so brain doesnt get infected

    • Neck:

      • Check for wounds, tenderness, deformities, jugular vein distention, stoma/tracheostomy

        • If you see flat neck veins in a patient laying down could mean blood loss

    • Apply cervical collar

    • Chest: paradoxical motion (movement of part of chest in opposite direction to rest of chest during respiration), crepitation, breath sounds, rib cage/chest exposed, auscultation for breath sounds

    • Abdomen: distention(larger than normal), pulsating mass, press down on quadrants

    • Pelvis: bleeding, priapism

    • extremities:Wounds, tenderness, deformities Circulation, sensation, and motor function (assess distal circulation from radial pulses, assess motor function but have them move both hands, assess strength in the hands by asking patient to squeeze fingers, check posterior tibial pulse)

Posterior: roll patient on side, slide in an extrication device to enable

How to apply cervical collar

• Cervical spine immobilization device should be rigid, collar right size by measuring patients neck (front height should fig between point of chin and suprasternal (jugular) notch, collar should rest on clavicles and support lower jaw) 

• Complete primary assessment and life threatening issues before using collar, use MOI to determine need, assess neck before placing collar, reassure patient

• To apply: size collar, remove jewelry and hair, keep head in line

If a steering wheel is broken what does it mean

patient is high priority

Detailed physical exam

• Typically completed en route to hospital, gathers additional info, helps determine treatment/helps emergency department staff, performed most often on trauma patient with significant injury, only do after performing all critical interventions, so reassess

  • For those patients you will have assessed whole body during head to toe, now need to assess more thoroughly to reveal s+s of injury you may have missed or changed

  • Before beginning remember to perform only after performing all critical interventions

    • If treating severely injured patient and are too busy to complete detailed exam, it is not a failure

  • When performing expose patients, work around immobilization equipment, components similar to rapid trauma but more detail and focused.

  • If a patient is not seriously injured, they do not need a detailed physical exam, but keep a high index of suspicion, and be aware of patient fear.

what to do if you can't tell if patient is medical or trauma

assume trauma first and do rapid physical first.

Reassessment

• Repeat key elements of assessment to identify changes and trends, don't skip except when giving lifesaving interventions

• Identify changes, trends, deterioration and improvement

• Repeat primary assessment

• Mental status of unresponsive kid can be checked by shouting or flicking feet, crying is expected response with child with good mental status

• reassess/record vital signs

• Repeat pertinent parts of history/physical exam, check interventions to make sure its going well

• Notice vital trends, important, don't take blood pressure cuffs off.

• Reassess stable patients 15 minutes, unstable 5, if change in patient condition repeat primary assesment