Medical Patient Assessment

From Appropedia

Medical Patient Assessment is included in this California-based EMT program as it is required for both National NREMT registration and skills verification for California Registration.

HOW TO USE THIS PAGE

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 (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:

  1. Scene size up (PENMAN mnemonic)
  2. General Impression (rapid identification of potential life threats and severity to determine priority)
  3. Primary Assessment (ABCs and Alertness and Orientation)
  4. 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:

  • SSigns/Symptoms (Symptoms are important but they are subjective.)
  • AAllergies
  • MMedications
  • PPast Pertinent medical history
  • LLast Oral Intake
  • EEvents 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. 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

  • 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

  • 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

  • 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.
    • Lung crackles upon auscultation could indicate congestive heart failure or pneumonia.
    • Wheezing indicates constriction of bronchiole smooth muscles which could be possible asthma, allergic reaction, emphysema or congestive heart failure.
    • Stridor indicates an upper airway obstruction.

Abdomen

  • 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

  • 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

  • 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

  • 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:

  1. Rapid medical assessment focused on the ABCs. In 2-2.5 minutes, rapidly assess from head to toe for signs of a medical problems.
  2. Establish an airway, support breathing with BVM if required and supply supplemental oxygen.
  3. Do not dismiss the possibility of trauma. Look for trauma signs and manage any severe bleeding by applying pressure and dressing.
  4. Specifically look for signs of conditions such as opioid overdose or hypoglycemia for which treatment may be started in the field.
  5. Perform a baseline set of vitals
  6. Move patient to gurney or other transport device
  7. Get any available SAMPLE history from bystanders and family if possible
  8. Transport
  9. Perform a full head to toe physical exam in the ambulance en-route to the hospital
  10. Continue to reassess vitals every 5 minutes
 
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