Principles of Assessment/ Secondary Assessment
Responsive medical pt.
History of present illness (HPI) past medical history (PMH) focused on physical exam baseline vital sign s
Past Medical History (PMH)
info gathered regarding PAST health problems obtained using SAMPLE
History of Present Illness (HPI)
info gathered regarding symptoms and nature of pt obtained using OPQRST
musculoskeletal sys physical exam
inspect for signs of injury palpate areas of suspected injury compare for symmetry alert for crepitation assess pt HEAD TO TOE
Immune system physical exam
inspect point of contact w allergen pt. skin for rash/hives inspect face, mouth, lips listen to pt. speak listen to lungs for adequate breath
Secondary assessment of medical pt.
- AMS/unresponsive rapid medical exam pt. environment - Alert/ oriented chief complaint physical exam
Resp. system physical exam
- mental status -level of resp. distress - chest wall motion -auscultate lung sounds - pulse Ox - observe edema - fever
Respiratory system Hx
- obtain Hx of existing resp. conditions + meds taken for each - determine If meds have been taken before - determine if signs/symptoms of episode match previous ep.
History-taking techniques
- talking to pt - if pt is unable to respond -> family member, bystander, meds present
Unresponsive medical Pt
-Inability to communicate shifts initial focus from chief complaint + history taking -begin with physical exam + baseline vitals -gather Hx from bystanders - rapid test of entire body
Secondary Assessment
1. Scene size up 2. initial/ primary assessment 3. secondary assessment 4. detailed assessment 5. Reassessment
techniques
1. develop a rapport with pt 2. ask open-ended questions 3. only close ended questions if need immediate answer
3 techniques for physical examination
1. observe- look at pt. for overall sense of pt. condition 2. Auscultate- listen for sounds of abnormal condition 3. palpate- feel area for deformities or other abnormal findings
Endocrine system physical exam
AMS? pt. skin obtain blood glucose level insulin pump medical jewelry
Important physical findings
Neck: JVD, med identification devices Chest: breath sounds Abdomen: distention, firmness (internal bleeding) Pelvis: Incontinence of urine/ feces extremities: pulse, motor func, sensation (PMS), SpO2
Immune system Hx
allergy Hx Hx of asthma tightness in chest/throat GI distress, itchiness, rash medications
Physical examination
before, during, after pt. Hx -3 primary techniques
traditional approach
includes interview of pt. in controlled environment of clinic/office - assess pt - list of differential diagnoses - further evaluation -final diagnosis
Trauma Pt.
components of secondary assessment - PMI, PMH ADDITIONAL HPI ?'s nature of force direction + strength of force actions taken to prevent injury -physical exam -vital signs
DCAP-BTLS
deformities contusions abrasions punctures - burns tenderness lacerations swelling
Endocrine system Hx
diabetes/ thyroid disease meds taken properly eaten/ exerted energy @ usual level pt taken blood glucose ^ or uses insulin pump
cardiovascular system Hx
existing cardial cond. + meds signs + symptoms description of chest pain using OPQRST determine specific characteristics of discomfort
Pediatric PE
least invasive -> most invasive (toes/trunk -> head) - explain tools before use
Nervous sys Hx
mental status normal state func neurological conditions note pt. speech
EMS approach
must be efficient work in uncontrolled environment limited tools/skill set narrow educational focus
cardiovascular sys physical exam
obtain pulse BP note pulse pressure jugular vein distention (JVD) palpate chest observe posture
OPQRST
onset-> sudden, gradual provocation -> chest pain? quality -> describe pain region -> radiation: does it go anywhere? severity -> 1-10 time -> when did it occur
GI system Hx
pain oral intake GI Hx issues vomiting bowel movement
Musculoskeletal sys Hx
prior injuries blood-thinning meds? underlying conditions Hx to determine med problem caused by traumatic injury
GI system physical exam
pt. position assess abdomen inspect other GI inspect vomit/feces
Emergency medicine approach `
quickly rule out/ treat immediate life threats gather info from pt perform physical exam focus on ruling out worse case scenario
Body system examinations
respiratory cardiovascular nervous GI immune endocrine musculoskeletal
SAMPLE
signs/symptoms -> sign is measurable, symptom is told to you allergies -> med + latex first medications -> that pt takes pertinent past history -> all history, most relevant to sitch last oral intake -> what was it? when? Events leading to -> what were you doing
rapid physical exam
similar to physical exam for trauma assess head, neck, chest, abdomen, pelvis, posterior - ALS back up
Chest (upper torso) check
start @ clavicle check sternum - apply c-collar complete sternum check HIGH + WET (lung sounds) check for paradoxical motion crepitation (snap, crackle, pop)
nervous sys physical exam
stroke scale peripheral sensation + movement palpate spine check extremity strength Pt. PEARL examine pt gait (walk)