Prepared By: Bill Milan NREMTP, CCEMTP

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Medical Assessment Learning by Listening

• Prepared By Bill Milan NREMT-P, CCEMTP

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So what makes this so different from trauma
assessment?

• This is a more hands off approach that forces you
  to ask a lot of questions.
• History takes precedence over physical exam
• Physical exam is aimed at identifying medical
  complications rather than signs of injury
• Problems are not straight forward or obvious and
  can have subtle or misleading presentations

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The Assessment Approaches

• Medical Ask, Listen, Examine
• Trauma Observe, Examine, Ask, Listen

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The ability to elicit a good history lays the
foundation for good patient care
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Approaching the Patient

• You only have one chance to make a positive first
  impression
• The first few minutes sets the stage for success
  or failure
• Be Nice and Respectful

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Talking to the Patient

• Talk to the patient in language they understand
• Do not appear condescending
• When unable to communicate find someone to assist
  you
• PAY ATTENTION Do not appear you are not
  interested or to busy

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What is a patient assessment?

• Conducting a problem-oriented evaluation of your
  patient and establishing priorities of care based
  on existing and potential threats to human life

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What Kind of Questions should I ask?

• Use a combination of open-ended and closed-ended
  questions
• Questions should be related to the situation
• Dont ask inappropriate or misleading questions
• You are trying to solve a puzzle so get the
  pieces you need

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Components of Patient Assessment

• Scene Size up
• Initial Assessment
• Focused History
• Physical Assessment
• Detailed Assessment
• Ongoing Assessment

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Scene Size Up

• This is an overall picture of the scene to ensure
  the safest environment for yourself, your crew,
  other responding personnel, patient, and
  bystanders in that order

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Initial Assessment

• Designed to identify and immediately correct life
  threatening patient conditions
• This assessment should take less than 1 minute,
  unless you have to intervene with life saving
  measures
• This is a quick scan to note things when you do
  your other assessments

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Initial Assessment Steps

• Form a general impression
• Assess Baseline Mental Status
• Assess Airway
• Assess Breathing
• Assess Circulation
• Assess Priority of Transport

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The General Impression

• Is YOUR initial intuitive evaluation of the
  patient to determine the general clinical status
  and priority of transport

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Baseline Mental Status

• Check Responsiveness
• Alert
• Verbal Stimuli
• Painful Stimuli
• Unresponsive

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Airway Assessment

• Determine if patient is conscious and speaking
  clearly
• If patient is unconscious then open airway in
  appropriate manner (i.e. Head Tilt-Chin Lift,
  Modified Jaw Thrust)
• If there is a problem fix it ( suction,
  administer O2 with appropriate devices)

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Breathing Assessment

• Altered Mental Status
• Respiratory Effort
• Retractions
• Asymmetric Chest Wall Movement

• Accessory Muscle Use
• Cyanosis
• Audible Sounds
• Abnormal Rate and Pattern
• Nasal Flaring

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Circulation Assessment

• Altered Mental Status
• Determine Central vs. Perphial pulses
• Determine Rate and Quality
• Determine Skin Color and Condition
• Control any obvious hemorrhage

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Determine Transport Priorities
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Top Priority Patients

• Poor General Impression
• Unresponsive
• Conscious but cannot follow commands
• Difficulty Breathing
• Hypotension

• Complicated Childbirth
• Chest Pain and BP below 100 systolic
• Uncontrolled bleeding
• Severe Pain
• Multiple Injuries

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Focused History

• Obtain Chief Complaint
• Obtain history of present illness
• Obtain pertinent medical history
• Obtain Medications if available

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Chief Complaint

• This is the pain, discomfort, or dysfunction that
  caused the patient to request help

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Rapid Focused Physical Exam

• HEENT
• Lip and oral mucosa color
• Sputum and color
• Swelling, hives, or redness
• Symmetry

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Neck

• Accessory muscle use
• Retractions
• JVD
• Tracheal position

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Chest

• Symmetry of chest wall
• Scars
• Lung sounds
• Percussion

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Cardiovascular System

• Peripheral pulses
• Heart Sounds
• Skin color
• Capillary refill

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Abdomen

• Abdominal muscle use
• Distention
• Edema
• Tenderness
• Pulsation of descending aorta
• Palpate all 4 quadrants with the area of pain last

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Pelvis

• Palpate with in and down pressure
• DO NOT ROCK PELVIS
• If instability is found do not palpate again

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Extremities

• Pulses
• Sensation
• Movement
• Edema/Pitting Edema

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Base Line Vitals

• Blood Pressure
• Pulses Rate
• Respiratory Rate
• Pupils
• Orthostatic vitals ( if possible hypovolemia)
• Pulse oximetry
• ECG and 12 Lead if available on your monitor
• Blood Glucose

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Detailed Assessment

• Evaluate patient from head to toe again going
  slower this time
• Focus in on the Chief Complaint
• Fix any problems that you find or that may arise
  enroute

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Ongoing Assessment

• Detect trends in patient condition
• Determine changes you have found or may
  anticipate
• Assess interventions effects

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SAMPLE History

• Signs and Symptoms
• Allergies
• Medications including OTC and herbal
• Past Pertinent Medical History
• Last oral intake not just food
• Events leading to problem

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OPQRST-ASPN

• Onset
• Provocation
• Quality
• Region/ Radiation
• Severity 1-10 scale or smiley face scale
• Time

• Associated
• Symptoms
• Pertinent
• Negatives

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Now I have gained all this Information now what?

• Use reflective, anticipatory thinking when
  assessing and treating patients

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Now how do we use this information?

• With experience, you will learn to manage
  nervousness and maintain a steadfast, controlled
  demeanor
• Develop a routine mental check list to stay
  focused and systematic in your approach

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Putting it all together

• The Six Rs
• Read the scene
• Read the patient
• React
• Re-evaluate
• Revise the management plan
• Review your performance

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Food for thought!

• Do not allow the linear thinking, or cookbook
  medicine that protocols promote restrain you
  from thinking outside the box and treating your
  patients!

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Summary

• Scene Safety
• Develop a general impression
• Ask lots of questions to piece the puzzle
  together
• Do a rapid assessment
• Make transport decision
• Do a focused assessment
• Do a ongoing assessment
• Gather SAMPLE Hx and Medications
• Transport to appropriate facility while doing any
  treatments that need to be performed

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We are finished now!

• Questions?
• Comments?
• Concerns?
• Snide Remarks!
• If not thank you!
• Now who made this crazy presentation?