Patient Care

Physical Examination Fundamentals

• Physical Examination Definition: Quantifiable, objective patient information obtained through systematic clinical assessment.

• Clinical Approach: A caring, empathetic approach is essential to gain patient trust and obtain accurate diagnostic results.

• Required Readings & Standards:

  • Textbook: Nancy Caroline's Emergency Care in the Streets, Chapter 16 (pages $428\text{--}472$).

  • Basic Life Support Patient Care Standards (BLS-PCS): Paramedic Conduct Standard and General Measures Standard.

• Core Components of Physical Examination:

  • Obtaining Vital Signs.

  • Head-to-Toe Assessment (Focused Physical Exam).

• Four Primary Assessment Techniques:

  • Inspection: Visual observation of the patient as a whole or focused on a specific anatomical site ("Look… Don't touch!").

  • Palpation: Physical touching to gather objective clinical data, including tenderness, deformities, crepitus, masses, pulse quality, and arterial pulsations.

  • Percussion: Gently striking the body surface where it overlies internal cavities to evaluate density changes in underlying tissue structures.

  • Normal Lung: Medium to loud, low-pitched, resonant sound.

  • Muscle and Bone: Soft, high-pitched, flat sound.

  • Hollow Organs: Loud, high-pitched, tympanic sound (drum-like).

  • Auscultation: Listening to internal body sounds using a stethoscope to assess equal air entry at the apices and bases of the lungs, distinguishing between normal and adventitious breath sounds.

Vital Signs Assessment and Hemodynamic Parameters

• Comprehensive Battery of Vital Signs:

  • Blood Pressure (BP)

  • Pulse (Rate, Rhythm, Quality)

  • Respirations (Rate, Rhythm, Quality)

  • Pulse Oximetry ($\text{SpO}_2$)

  • Glasgow Coma Scale (GCS)

  • Capnography ($\text{EtCO}_2$)

  • Body Temperature

  • Skin Assessment (Color, Temperature, Condition)

  • Cardiac Monitor Tracing

  • Capillary Blood Glucose

  • Pupils (Size, Shape, Reactivity)

• Blood Pressure (BP):

  • Definition: Measurement of the force exerted by circulating blood against arterial walls during cardiac ventricular contraction and relaxation.

  • Common Assessment Sites: Peripheral arteries, including the brachial, radial, and femoral arteries.

  • Systolic Pressure: The force exerted against arterial walls when the ventricles contract.

  • Diastolic Pressure: The force exerted against arterial walls when the ventricles relax.

  • Hemodynamic Equations:

  • $\text{BP} = \text{CO} \times \text{SVR}$

  • $\text{CO} = \text{SV} \times \text{HR}$

  • Full Blood Pressure Equation: $\text{BP} = (\text{SV} \times \text{HR}) \times \text{SVR}$

  • Equation Variable Definitions:

  • Cardiac Output ($\text{CO}$): Total volume of blood ejected by the heart per minute.

  • Stroke Volume ($\text{SV}$): Volume of blood pumped out of the heart per contraction.

  • Heart Rate ($\text{HR}$): Number of cardiac contractions per minute ($\text{bpm}$).

  • Systemic Vascular Resistance ($\text{SVR}$ / Peripheral Vascular Resistance, $\text{PVR}$): Resistance against systemic vasculature that the heart must overcome to pump blood. Pathological or physiological factors influencing SVR include vasodilation, vasoconstriction, diabetes, high cholesterol, and hypertension.

  • Sphygmomanometer Cuff Sizing Rules:

  • The inflatable cuff bladder must measure $\frac{1}{2}$ to $\frac{2}{3}$ the circumference of the patient's upper arm.

  • Cuff Too Small/Tight: Yields an inaccurately high blood pressure reading.

  • Cuff Too Large/Loose: Yields an inaccurately low blood pressure reading.

  • Blood Pressure Diagnostic Classification Parameters:

  • Normotension: Systolic $\text{BP} \ge 100\text{ mmHg}$ (typical baseline values: $115/75\text{ mmHg}$ or $120/80\text{ mmHg}$).

  • Hypertension: Systolic $\text{BP} > 140\text{ mmHg}$.

  • Hypertensive Emergency: Diastolic $\text{BP} > 130\text{ mmHg}$.

  • Hypotension: Systolic $\text{BP} < 90\text{ mmHg}$.

  • Methods of Blood Pressure Measurement:

  • Palpation: Feeling for the return of a distal arterial pulse during cuff deflation.

  • Manual Sphygmomanometer: Auscultating Korotkoff sounds using an inflatable cuff, pressure gauge, and stethoscope.

  • Non-Invasive Blood Pressure (NIBP): Automated oscillometric measurement via an electronic cardiac monitor (e.g., LIFEPAK or ZOLL monitors).

• Pulse Assessment:

  • Definition: The tactile arterial pulsation produced as the heart contracts and propels blood. Serves as a rapid primary evaluation of tissue perfusion and cardiac output upon initial contact.

  • Technique: Gently press an arterial vessel against an underlying bony structure. Always compare proximal and distal pulses.

  • Primary Pulse Assessment Sites:

  • Responsive Patient: Radial artery.

  • Unresponsive Patient: Carotid artery.

  • Anatomical Pulse Point Locations:

  • Temporal: Lateral to the eye orbit.

  • Carotid: Medial to and below the angle of the jaw.

  • Brachial: Just medial to the biceps tendon in the antecubital fossa.

  • Radial: Thumb side of the wrist.

  • Ulnar: Little finger side of the wrist.

  • Femoral: Immediately below the inguinal ligament.

  • Popliteal: Directly behind the knee.

  • Dorsalis Pedis: Top surface of the foot.

  • Posterior Tibial: Posterior to the medial malleolus of the ankle.

• Pulse Parameters:

  • Rate:

  • Normal Adult Heart Rate: $60\text{--}100\text{ bpm}$.

  • Bradycardia: Heart rate less than $60\text{ bpm}$.

  • Tachycardia: Heart rate greater than $100\text{ bpm}$.

  • Rhythm: Pattern and consistency of intervals between beats (Regular, Irregular, Regularly Irregular, Irregularly Irregular).

  • Quality: Strength of the pulse wave felt against fingertips (Weak, Thready, Full, Bounding).

• Respiration Assessment:

  • Inspection: Evaluated by observing movement of the patient's chest wall, abdominal wall, neck, face, and overall accessory muscle use.

  • Parameters:

  • Rate: Number of breaths in $1\text{ minute}$ ($\text{RR/min}$).

    • Normal Adult Respiratory Rate: $12\text{--}20\text{ r/min}$.

    • Bradypnea: Respiratory rate less than $12\text{ r/min}$.

    • Tachypnea: Respiratory rate greater than $20\text{ r/min}$.

  • Rhythm: Regular or Irregular.

  • Quality: Depth and pattern of breathing (Full, weak, deep, agonal, shallow, laboured, apneic).

• Pathologic Breathing Patterns:

  • Eupnea: Normal rate and breathing pattern.

  • Tachypnea: Increased respiratory rate. Causes: Fever, anxiety, exercise, shock.

  • Bradypnea: Decreased respiratory rate. Causes: Sleep, drugs, metabolic disorder, head injury, stroke.

  • Apnea: Absence of breathing. Causes: Deceased patient, head injury, stroke.

  • Hyperpnea: Normal rate, but deep respirations. Causes: Emotional stress, diabetic ketoacidosis.

  • Cheyne-Stokes: Gradual increases and decreases in respirations with periods of apnea. Causes: Increasing intracranial pressure, brain stem injury.

  • Biot's: Rapid, deep respirations (gasps) with short pauses between sets. Causes: Spinal meningitis, central nervous system causes, head injury.

  • Kussmaul's: Combined tachypnea and hyperpnea. Causes: Renal failure, metabolic acidosis, diabetic ketoacidosis.

  • Apneustic: Prolonged inspiratory phase with shortened expiratory phase. Causes: Lesion in brain stem.

• Body Temperature:

  • Measurement: Tympanic temperature measurement device (accounting for ambient/extrinsic factors altering readings).

  • Normal Temperature: Maintained core temp of approximately $36\text{--}37.3\text{ }^\text{o}\text{C}$ ($98\text{--}100\text{ }^\text{o}\text{F}$).

  • Hypothermia: Drop in core body temperature to $35\text{ }^\text{o}\text{C}$ or less.

  • Hyperthermia / Fever: Core temperature elevated above $37.4\text{ }^\text{o}\text{C}$.

• Pulse Oximetry ($\text{SpO}_2$):

  • Measures percentage of hemoglobin saturated with oxygen in arterial blood and calculates pulse rate.

  • Clinical Directive: "Treat the patient, not the monitor"—never rely on pulse oximetry as an absolute indicator due to susceptibility to artifact and false readings.

• Skin Evaluation:

  • Involves concurrent inspection and palpation to evaluate cardiorespiratory status and perfusion changes.

  • Skin Parameters:

  • Color: Pallor, Cyanosed, Mottled, Flushed, Ashen, Jaundiced.

  • Moisture/Condition: Wet, Dry, Clammy, Diaphoretic.

  • Temperature: Normal, Hot, Cool.

• Cardiac Monitoring Devices:

  • Equipment: LIFEPAK or ZOLL monitors.

  • Capabilities: Displays and records electrical cardiac activity (ECG tracing), provides automated/manual defibrillation, non-invasive blood pressure (NIBP), pulse oximetry ($\text{SpO}_2$), end-tidal carbon dioxide capnography ($\text{EtCO}_2$), and respiratory rate monitoring.

• Capillary Blood Glucose Assessment:

  • Measures millimoles per liter ($\text{mmol/L}$) of glucose in capillary blood.

  • Normal Glucose: $4.0\text{ mmol/L}$.

  • Hypoglycemia: Less than $4.0\text{ mmol/L}$.

  • Hyperglycemia: Greater than $7.0\text{ mmol/L}$.

  • Glucometer "HI" Reading: Greater than $33.3\text{ mmol/L}$.

General Impression and Patient Severity Triaging

• Determining General Impression ("Sick vs. Not Sick"):

  • Begins immediately upon entering the scene during scene size-up.

  • Key Evaluation Criteria:

  • Eye Contact & Awareness: Alert and looking at examiner versus disoriented or unresponsive.

  • Patient Posture/Position: Prone, Supine, Semi-Sitting, Left/Right Lateral Recumbent, Sitting, Standing, Ambulating.

  • Level of Distress: Categorized as Mild, Moderate, or Severe degree of distress.

  • Airway Status: Patent versus Obstructed.

  • Breathing Effort: Evaluating overall work of breathing.

  • Circulation/Skin Appearance: Pale, Cyanotic, Ashen, Jaundiced, or normal for race (fastest, most reliable initial assessment tool for shock/perfusion changes).

• Indicators of Severe Patient Distress:

  • Altered mental status

  • Anxiousness

  • Laboured breathing

  • Difficulty speaking

  • Diaphoresis

  • Obvious pain

  • Obvious anatomical deformity

  • Guarding or splinting of a painful body region

• Focused Physical Examination vs. Primary Survey:

  • Focused Physical Examination: Systematic, comprehensive head-to-toe examination designed to uncover specific pathological findings without omitting details. Distinguishes the clinician approach from a technician approach.

  • Primary Survey: Rapid overview completed in under $2\text{ minutes}$ to detect immediate life threats (ABCs, traumatic injuries). Concludes with a transport decision ("Load-and-Go" vs. "Stay-and-Play").

Mental Status and Neurological Assessment

• Level of Awareness Assessment:

  • Alert and Oriented ($\text{AxO} \times 4$): Evaluates orientation to Person, Place, Time, and Events.

  • AVPU Scale: Rapid method for classifying level of consciousness:

  • A (Alert): Conscious and oriented to person, place, time, and events.

  • V (Verbal): Responds appropriately or inappropriately to verbal stimuli.

  • P (Painful): Responds to painful tactile stimuli (e.g., sternal rub or peripheral pressure).

  • U (Unresponsive): Fails to respond to any verbal or painful stimuli.

  • Note: Response is graded based on the best response elicited at any point during assessment.

• Glasgow Coma Scale (GCS): Objective assessment tool grading eye opening, verbal response, and motor response.

• Abnormal Motor Posturing:

  • Decorticate Posturing (Flexor Posturing):

  • Manifests as rigid extended legs, pointed and turned-in toes, arms bent inward toward the center of the body, with curled wrists and balled hands held tightly against the chest.

  • Indicates severe dysfunction at or above the upper brainstem.

  • Decerebrate Posturing (Extensor Posturing):

  • Manifests as rigid extended legs, pointed and turned-in toes, flexed wrists with curled fingers, and straight, tense arms held parallel to the body.

  • Indicates severe damage extending lower into the brainstem.

Detailed Assessment of Skin and Nails

• Skin Functions:

  • Temperature regulation of the core core body.

  • Transmission of environmental sensory information to the central nervous system.

  • Protective barrier between the internal environment and external hazards.

• Perfusion & Skin Assessment Findings:

  • Perfusion alterations present early in skin presentation.

  • Key Physical Findings to Evaluate:

  • Skin Color, Temperature, and Moisture

  • Turgor / Tenting: Assessment of hydration status.

  • Lesions & Scars: Evidence of underlying conditions or prior surgery/trauma.

  • Cyanosis: Bluish discoloration from hypoxemia.

  • Crepitus: Subcutaneous air or bony friction.

  • Ecchymosis: Subcutaneous extravasation of blood (bruising).

  • Erythema: Redness associated with inflammation or infection.

  • Edema Formation: Fluid retention in interstitial spaces.

  • Trauma: Direct structural skin damage.

• Nail Inspection:

  • Cyanosis: Dark or bluish nail beds indicating peripheral hypoxia.

  • Clubbing: Bulbing of fingertips from chronic tissue hypoxia.

  • Trauma: Evidence of crushing injuries or subungual hematomas.

Head, Eyes, Ears, Nose, and Throat (HEENT) Assessment

• Head Assessment:

  • Techniques: Combined Inspection and Palpation.

  • Skull Anatomy Regions:

  • Occiput: Posterior portion surrounding the foramen magnum.

  • Temporal Regions: Lateral aspects of the cranium.

  • Parietal Regions: Superior areas situated between the temporal regions and the occiput.

  • Frontal Region: Forehead area.

  • Structural Layers: Muscle fascia, scalp, skull, meninges (Dura Mater, Arachnoid Mater, Pia Mater), and Cerebrospinal Fluid (CSF).

  • Trauma Mnemonic (DCAP-BLS-TIC):

  • D: Deformities

  • C: Contusions

  • A: Abrasions

  • P: Punctures / Penetrations

  • B: Burns

  • L: Lacerations

  • S: Swelling

  • T: Tenderness

  • I: Instability

  • C: Crepitus

• Eyes Assessment:

  • Anatomical Structures & Parameters:

  • Sclera: Color inspection (White, Red/Injected, Jaundiced).

  • Pupils: Motor control evaluation checking size ($\text{mm}$), shape, and symmetry.

  • Conjunctivae: Mucous membrane appearance (Normal pink vs. Pale/Palled).

  • PERRL: Acronym standard: "Pupils Equal, Round, and Reactive to Light".

  • Subjective Diagnostic Symptoms: Evaluate for pain, redness, sudden loss of vision, diplopia (double vision), photophobia (light sensitivity), blurring, discharge, and corrective lens reliance.

  • Penlight Examination Protocol:

  • Inspect eyelids, eyelashes, and lacrimal (tear) ducts.

  • Check for foreign body impaction, discharge, or structural wounds.

• Ears Assessment:

  • Techniques: Inspection and Palpation.

  • Anatomy:

  • External Ear: Pinna and external auditory canal.

  • Middle Ear: Auditory ossicles (malleus/hammer, incus/anvil, stapes/stirrup) and Eustachian tube.

  • Inner Ear: Fluid-filled bony chambers containing nerve receptors responsible for sound perception and balance control.

  • Clinical Findings:

  • Check for alterations in hearing perception or equilibrium.

  • Inspect and palpate for soft tissue wounds, localized swelling, and drainage.

  • Mastoid Bruising (Battle Sign): Ecchymosis over the mastoid process indicating basilar skull fracture.

  • Fluid Drainage: Presence of clear fluid or blood (evaluating for CSF leak).

• Nose Assessment:

  • Techniques: Inspection and Palpation.

  • Anatomy & Function: Sensory organ for olfaction and taste; aids respiration by humidifying air as it passes over the three bony turbinate layers in each nare.

  • Clinical Evaluation:

  • Inspect anteriorly and inferiorly for facial asymmetry, structural deformity, open wounds, foreign bodies, active hemorrhage/discharge, and tenderness.

  • Inspect nasal septum for deviation from the midline.

• Mouth and Oropharynx Assessment:

  • Technique: Inspection.

  • Anatomical Regions: Lips, oral cavity, and oropharynx.

  • Clinical Criteria:

  • Hydration Status: Mucosa and gums should appear healthy and pink.

  • Tongue: Inspect for color, moistness, and anatomical swelling/size.

  • Oropharynx & Uvula: Check breath for unusual odors (e.g., fruity ketoacidosis, foul infection); inspect uvula for edema and redness; confirm absence of foreign bodies or aspiration threats.

• Neck Assessment:

  • Anatomical Landmarks: Jaw, cricothyroid membrane, thyroid cartilage, external jugular veins (EJV), suprasternal notch, and cervical spinous processes.

  • Palpation: Gently palpate suprasternal notch to confirm tracheal positioning.

  • Pathologic Assessment Signs:

  • Tracheal Deviation: Shift of trachea off-center (indicative of tension pneumothorax or mass).

  • Tracheal Tugging: Downward pull of the trachea during inhalation.

  • Accessory Muscle Use: Contraction of sternocleidomastoid or scalene muscles indicating respiratory distress.

  • Jugular Venous Distention (JVD): Engorgement of external jugular veins indicating elevated central venous pressure.

Physical Examination Fundamentals

• Definition: Objective, measurable patient information collected during an assessment.

• Approach: Always show care and empathy to build trust and get clear results.

• 2 Main Components:

  • Checking Vital Signs.

  • Head-to-Toe Assessment.

• 4 Main Techniques:

  • Inspection: Looking at the patient ("Look… Don't touch!").

  • Palpation: Touching to feel for pain, deformities, swelling, or pulses.

  • Percussion: Tapping the body to hear density changes:

  • Normal Lung: Loud, low-pitched sound.

  • Bone/Muscle: Soft, flat sound.

  • Hollow Organs: Loud, drum-like sound.

  • Auscultation: Listening with a stethoscope (e.g., checking lung sounds).

Vital Signs Simplified

• Blood Pressure (BP):

  • Systolic: Pressure when the heart pumps.

  • Diastolic: Pressure when the heart rests.

  • Equation: $\text{BP} = (\text{Stroke Volume} \times \text{Heart Rate}) \times \text{Systemic Vascular Resistance}$

  • Cuff Sizing Rule:

  • Too Small: Gives an inaccurately high reading.

  • Too Large: Gives an inaccurately low reading.

  • Key Ranges:

  • Normal: Systolic $\ge 100\text{ mmHg}$ (typical average: $120/80\text{ mmHg}$).

  • High (Hypertension): Systolic $> 140\text{ mmHg}$.

  • Low (Hypotension): Systolic $< 90\text{ mmHg}$.

• Pulse:

  • Where to Check: Radial (wrist) if awake; Carotid (neck) if unresponsive.

  • Normal Rate: $60\text{--}100\text{ bpm}$.

  • Bradycardia: Too slow ($< 60\text{ bpm}$).

  • Tachycardia: Too fast ($> 100\text{ bpm}$).

• Respirations:

  • Normal Rate: $12\text{--}20\text{ breaths/min}$.

  • Bradypnea: Too slow ($< 12\text{ breaths/min}$).

  • Tachypnea: Too fast ($> 20\text{ breaths/min}$).

  • Important Patterns:

  • Eupnea: Normal breathing.

  • Apnea: No breathing.

  • Kussmaul: Fast and deep (diabetic ketoacidosis).

  • Cheyne-Stokes: Alternating fast/slow breathing with pauses (brain injury).

• Body Temperature:

  • Normal: $36\text{--}37.3\,^{\circ}\text{C}$ ($98\text{--}100\,^{\circ}\text{F}$).

  • Hypothermia: $\le 35\,^{\circ}\text{C}$.

  • Fever: $> 37.4\,^{\circ}\text{C}$.

• Capillary Blood Glucose:

  • Normal: $4.0\text{ mmol/L}$.

  • Low (Hypoglycemia): $< 4.0\text{ mmol/L}$.

  • High (Hyperglycemia): $> 7.0\text{ mmol/L}$.

General Impression & Severity

• "Sick vs. Not Sick": Rapid judgment made immediately upon scene arrival.

• Signs of Severe Distress: Confusion, extreme anxiety, struggling to breathe, intense pain, heavy sweating, or major deformity.

• Primary Survey vs. Focused Exam:

  • Primary Survey: Rapid check ($< 2\text{ minutes}$) for life-threatening issues (ABCs).

  • Focused Exam: Detailed head-to-toe examination.

Mental Status & Posturing

• AVPU Scale (Level of Consciousness):

  • A (Alert): Conscious and oriented.

  • V (Verbal): Responds to voice.

  • P (Pain): Responds only to pain.

  • U (Unresponsive): No response.

• Abnormal Motor Posturing:

  • Decorticate: Arms bent inward toward the chest ("core"). Indicates upper brainstem dysfunction.

  • Decerebrate: Arms extended straight down by sides with wrists turned out. Indicates lower brainstem damage.

Head-to-Toe Quick Reference

• Trauma Exam Mnemonic (DCAP-BLS-TIC):

  • Deformities, Contusions, Abrasions, Punctures / Burns, Lacerations, Swelling / Tenderness, Instability, Crepitus.

• Eyes Assessment:

  • PERRL: Pupils Equal, Round, and Reactive to Light.

• Ears Assessment:

  • Look for clear fluid (CSF) or Battle Sign (bruising behind the ear indicating skull fracture).

• Neck Assessment:

  • Tracheal Deviation: Shifted windpipe (can indicate tension pneumothorax).

  • JVD: Bulging neck veins (indicates backpressure on the heart).