Patient Assessment Part 3

Rapid Physical Exam

• Overview: Conducted in under 90 seconds, focusing on identifying obvious abnormalities while ensuring thoroughness in all steps.

• Mnemonic: DCAPBTLS for assessing injuries:

  • Deformities

  • Contusions

  • Abrasions

  • Punctures

  • Burns

  • Tenderness

  • Lacerations

  • Swelling

• Crepitus: Sensation felt when bone ends grind together, often associated with rib fractures.

Assessment Steps

Head Assessment

• Scan the head for DCAPBTLS.

• Examine the back and front of the head.

Neck Assessment

• Key points to check:

  • JVD (Jugular Venous Distention)

  • Trachea position (midline check)

  • Palpate for any step-offs in the back of the neck.

Chest and Respiratory Assessment

• Lung Sounds: Check for lung sounds by auscultating in various areas:

  • Over the clavicle

  • Axilla area

  • Middle of the chest (sternal area)

• Examine Chest Movement: Observe for rise and fall of the chest.

Abdominal Assessment

• Palpation: Check abdomen for rigidity or softness and tenderness.

• Pelvis Examination: Apply pressure to assess for abnormalities.

Extremities Assessment

• Scan the legs and arms.

  • Assess pulse, motor, and sensory functions.

Back Assessment

• Spinal Check: Feel along the spine for abnormalities.

• Lung Sounds: Obtain sounds from the back as they may be clearer.

History Taking

• Purpose: Gather patient history and event details for accurate assessment.

• Key Concepts:

  • Emphasize the importance of pertinent negatives, which indicate what the patient denies related to their condition (e.g., chest pain but denies difficulty breathing).

Mnemonics for History Taking

OPQRST (Pain Investigation)

• O: Onset - What caused the symptoms?

• P: Provocation - What makes it better or worse?

• Q: Quality - How would you describe the pain?

• R: Radiates - Does the pain move anywhere else?

• S: Severity - Rate the pain from 0 to 10.

• T: Time - Duration of the symptoms.

SAMPLE (Medical History)

• S: Signs and Symptoms - What were they experiencing?

• A: Allergies - Any allergies?

• M: Medications - Current medications?

• P: Past Medical History - Any significant medical events?

• L: Last Oral Intake - When did they last eat/take medications?

• E: Events - What led up to this condition?

Secondary Assessment

• Detailed Examination: More thorough than the primary assessment.

Head Inspection

• Inspect front and back of the head for DCAPBTLS.

• Examine eyes and ears using a penlight for further abnormalities.

Neck Reassessments

• Check for JVD, trachea deviation, and step-offs.

Chest Reassessment

• Repeat auscultation of lung sounds and observe chest movement again.

Abdominal Reassessment

• Look for patient guarding and palpate again for any rigidity or tenderness.

Extremities Reassessment

• Check pulse, motor, and sensory functions again.

Back Reassessment

• Reassess the spine and obtain lung sounds from the back.

Reassessment Guidelines

• Frequency:

  • Unstable patients: every 5 minutes.

  • Stable patients: every 15 minutes.

• Key Point: Continually reassess primary assessments, secondary assessments, vital signs, and chief complaints.