|Part of||NREMT Skillset|
|SDGs Sustainable Development Goals||SDG03 Good health and well-being|
|Published by||Catherine Mohr
|License||CC BY-SA 4.0|
|Translate to||Français, Español, Kiswahili, 中文, العربية, Русский, more|
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|Cite as Catherine Mohr, Josh Hantke, Dwh904 (2021). "Medical Patient Assessment". Appropedia. Retrieved 2021-10-18.|
How to use this page[edit | edit source]
Medical patient assessment and history taking differs depending on the chief complaint. Familiarize yourself with the general framework of the medical patient assessment on this page, and then review the complete material on their three separate pages:
- Medical Patient Assessment for Altered Mental Status
- Medical Patient Assessment for Chest Pain
- Medical Patient Assessment for Respiratory Distress
Medical Patient Assessment (General)[edit | edit source]
The medical patient assessment is used for assessing a non-trauma patient (i.e. no or minor injuries). Medical patients may also have an injury as result of a medical complaint, and the first responder needs to be observant to the possible signs and symptoms that the patient could be injured, but it is important to stay primarily focused on their medical complaint and not be distracted from their chief complaint.
The assessment can be done on a stable or unstable medical patient.
Primary Assessment[edit | edit source]
As with any assessment you should start with performing the following:
- Scene size up (PENMAN mnemonic)
- General Impression (rapid identification of potential life threats and severity to determine priority)
- Primary Assessment (ABCs and Alertness and Orientation)
- Priority/transport decision
Assessment on a stable medical patient should be performed on the scene. For high priority, unresponsive and/or unstable patients, the rest of the medical assessment should be performed inside the ambulance en-route to the hospital.
SAMPLE History[edit | edit source]
After the primary assessment, the history of the present illness should be explored with the patient. The mnemonic SAMPLE is used by first responders to remember to ask the important questions, as well as to give a framework for an orderly report. SAMPLE stands for:
- S – Signs/Symptoms (Symptoms are important but they are subjective.)
- A – Allergies
- M – Medications
- P – Past Pertinent medical history
- L – Last Oral Intake
- E – Events Leading Up To Present Illness / Injury
Signs and symptoms in medical patients may be extremely varied, and when taking a history it is important to focus on the most relevant aspects of the chief complaint. There several useful mnemonics that are used to obtain a more complete, relevant history from your patient during the "S" step of SAMPLE:
- For patient's with an altered mental status, use the mnemonic AEIOU-TIPS to focus in on sources for the altered mental state.
- For patient's who is short of breath, use the mnemonic PASTE to characterize the breathing difficulties.
- For patient's complaining of chest or other severe pain that isn't caused by an injury, use the OPQRST to narrow in on a potential sources.
Secondary Assessment (Medical)[edit | edit source]
Following the History, take Vital signs and perform a Detailed Medical Exam. The Secondary Assessment is an in depth assessment aimed at investigating the patient's chief complaint. Pertinent follow up questions should be asked when assessing areas of the body associated with the chief complaint (e.g. "Are you experiencing dizziness/lightheadedness or changes to your vision or hearing" for a patient with a headache). For the high priority transport patient, this step should be done in the ambulance en route to the hospital. Steps in the detailed medical exam include:
Head[edit | edit source]
- Examine the face for droop or asymmetry - if any signs of stroke, perform a FAST exam
- Evaluate pupillary response, noting unequal pupils or discoloration of sclera
- Look in the mouth for loose dentures/teeth, fluid, and any other potential obstructions.
- Note abnormal skin signs such as flushing, cyanosis or diaphoresis (profuse sweating).
Neck[edit | edit source]
- Look for JVD (jugular vein distention) which indicates fluid backup from several causes.
- Note accessory muscle use for breathing, such as Sternocleidomastoid muscle, as these could indicate inadequate breathing possibly due to asthma, emphysema, pneumonia, etc.
- Look for a stoma (surgical hole below larynx).
- Note the contents of any medical alert necklaces as these can provide additional history and warnings on allergies, medications, etc.
Chest[edit | edit source]
- Assess for accessory muscle use, such as intercostal retractions (between the ribs), or abnormal diaphragm movement assisting breathing.
- Auscultate lung sounds on both sides of the chest listening for diminished or adventitious (abnormal) breath sounds which could indicate possible asthma, emphysema, pneumonia... etc.
Abdomen[edit | edit source]
- The abdomen can be divided into 4 quadrants, and all four quadrants should be evaluated to elicit pain, tenderness, rigidity, distention which can indicate internal bleeding, infection, appendicitis or peritonitis. It is important to note in which quadrant you elicit a finding.
- Palpable pulsating mass in the midline of the abdomen is a sign for aortic aneurysm (weakened area of the abdominal aorta) which should trigger a discontinuation of the on-site physical exam and initiation of rapid transport.
- An extremely distended abdomen could indicate pregnancy or ascites (fluid build up in abdomen).
Pelvic region[edit | edit source]
- Observe and assess for any distention or tenderness in the pelvic region, especially with complaints of lower abdominal pain and missed menstrual periods. Suspect ectopic pregnancy in females of child-bearing age. Note - The pelvis creates a bowl in the lower portion of the abdomen and has the ability to hide nearly 2000cc of blood. Patients may be in danger of shock due to bleeding within the abdominal cavity with no outward visual evidence.
Extremities[edit | edit source]
- Evaluate circulation, motor and sensory function in both hands and feet.
- Look for edema (swelling): excessive edema indicates congestive heart failure, fluid overload, or pain, redness or swelling to one calf indicating a DVT (deep vein thrombosis),
- Be alert for any shunts or fistulas which could indicate the patient is on dialysis or track marks from possible illegal drug use
- Note any abnormal tissue discoloration.
Back[edit | edit source]
- Inspect the back for discoloration, edema and tenderness. Edema in the sacral region in bedridden patients indicates possible congestive heart failure.
The stable medical patient should have a re-check of vitals and be re-evaluated every 15 minutes, or more often if you have any concerns to follow up on the patients situation.
Unresponsive Medical Patient[edit | edit source]
If in your primary assessment, you determine that the patient is unresponsive, or has severely altered mental status then perform a Medical Patient Assessment in conjunction with rapid transport to an appropriate facility as follows:
- Rapid medical assessment focused on the ABCs. In 2-2.5 minutes, rapidly assess from head to toe for signs of a medical problems.
- Establish an airway, support breathing with BVM if required and supply supplemental oxygen.
- Do not dismiss the possibility of trauma. Look for trauma signs and manage any severe bleeding by applying pressure and dressing.
- Specifically look for signs of conditions such as opioid overdose or hypoglycemia for which treatment may be started in the field.
- Perform a baseline set of vitals
- Move patient to gurney or other transport device
- Get any available SAMPLE history from bystanders and family if possible
- Perform a full head to toe physical exam in the ambulance en-route to the hospital
- Continue to reassess vitals every 5 minutes
Documentation[edit | edit source]
Documentation of a medical patient assessment should be included in the Patient Care Report (PCR) in the form:
- Full history of chief complaint. Example: "Patient is a 48 yo Female who was walking with her husband after dinner when she began experiencing 8/10 non-radiating substernal chest pressure which she describes as 'an elephant sitting on my chest'. Pressure is exacerbated by exertion and is not provoked by palliation, deep inspiration, or positioning. Patient has a history of x3 MI (last MI x2 years ago) and CABG x2 months ago and has taken x2 doses of her prescribed nitroglycerine without relief. Patient states that this pressure feels like the last time she had an MI."
- Pertinent positive and negative findings. Example: "Patient assessment reveals bibasilar crackles and tachypnea with 2+ pitting edema. Patient denies SOB at this moment but reports that he becomes fatigued much more quickly than normal."
Tips and Tricks[edit | edit source]
- There is no single stroke scale that works best for evaluating patients in the prehospital environment. The Cincinnati Prehospital Stroke Scale (CPSS) is scale used for this course, but others include the Los Angeles Prehospital Stroke Scale (LAPSS), the Rapid Arterial Occlusion Evaluation Scale (RACE), and the National Institute of Health Stroke Scale (NIHSS).
- When assessing a patient using an acronym such as AEIOUTIPS or SAMPLE, unless the information gained from the assessment may be placed elsewhere in the PCR it should be included in the narrative. In the case of AEIOUTIPS or PASTE, pertinent negatives such as lack of associated chest pain (A in PASTE) should also be added so that a reader can easily see that you did check for their presence.
- OPQRST was designed to be utilized to assess for potential cardiac complications of chest pain but may be fairly easily changed to fit a wide variety of complaints. For instance, P (Provocation/Palliation) can be used to assess if a patient's dizziness is worsened by standing, head position change, or movement.
Additional Resources[edit | edit source]
TBD - extra videos to watch, links to other pages for more reading
References[edit | edit source]
TBD - Footnotes, references, standards