Unit 14, 15 flashcards
what is the history of present illness (HPI)?
information gathered regarding symptoms and nature of patient’s current concern
What is past medical history (PMH)?
information gathered regarding patient’s health problems in past
What is SAMPLE? to learn about the patient’s past medical history.
signs and symptoms, allergies, medications, pertinent past history, last oral intake, and events leading to injury or illness
OPQRST to learn about the chief
complaint and history of the present illness/injury.
– Onset
– Provocation
– Quality
– Region; radiation
– Severity
– Time
Respiratory Assessment—Physical
Examination
Mental status
Level of respiratory distress
Chest wall motion
Auscultate lung sounds
Use pulse oximetry
Observe edema
Fever
Cardiovascular System—History
- Existing cardiac conditions and medications
- Signs and symptoms of episode
- Description of chest pain using O P Q R S T
- Determine specific characteristics of discomfort
cardiovascular system examination
1) look for signs condition may be severe
2) obtain pulse
3) obtain blood pressure
4) note pulse pressure
5) look for jungular vein distantion
6) palpate the chest
7) observe
nervous system assessment
1) mental status
2) determine their normal state of mental functioning
3) obtain history of neurologic conditions
4) note patients speech
nervous system examination
1) perform a stroke scale
2) check peripheral sensation and movement
3) gently palpate the spine
4) check extremity strength
5) check patients
6) examine the patient gait (pattern of walking)
The most common endocrine emergency
is the diabetic
patient.
Endocrine Assessment—History
- Diabetes mellitus or thyroid disease history
- Current medications and whether being taken properly
- Whether patient has eaten or exerted energy at an unusual level
- Whether patient is sick
- Whether patient has taken blood glucose or uses insulin pump
Endocrine Assessment—Physical
Examination
Evaluate patient’s mental status.
Observe the patient’s skin.
Obtain a blood glucose level.
Look for an insulin pump.
Look for medical jewelry.
Gastrointestinal System Looking for
– What has gone in
– What has come out
– What it looks like when it comes out
Gastrointestinal Assessment—
History
Pain or discomfort (OPQRST)
Oral intake
History of gastrointestinal issues
Vomiting
Bowel movements
Gastrointestinal Assessment—
Physical Examination
- Observe patient’s position.
- Assess the abdomen.
- Inspect other parts of the gastrointestinal system.
- Inspect vomitus or feces if available.
immune system problem most relevant for EMS
allergic reaction
anaphylaxis
Immune System—Physical
Examination
- Inspect point of contact with allergen.
- Inspect patient’s skin for rash or hives.
- Inspect the face, lips, and mouth for swelling.
- Listen to the patient speak.
- Listen to lungs to ensure adequate breathing.
Musculoskeletal Assessment—
History
- Prior injuries
- Whether patient takes blood-thinning medication
- Underlying diseases or conditions that make
fractures more common - History to determine if a medical problem caused
the traumatic injury
Musculoskeletal Assessment—
Physical Examination
1) inspect for signs of injury, such as deformity
2) palpate areas with suspected injury
3) compare sides for symmetry
4) be alert for crepitation
5) Assess patient head-to-toe if there are multiple injuries or if the patient is unresponsive
Crepitation
the grating sound or feeling of broken bones being rubbed together
EMT diagnosis
Diagnosis is label for condition.
– Based on history, physical examination, vital signs
– Involves both physical and intellectual activity
Diagnosis shortcuts and biases
– Representativeness
– Availability
– Overconfidence
– Confirmation bias
– Illusory correlation
– Anchoring and adjustment
– Search satisfying
Secondary Assessment of MEDICAL pateint
- Assessment varies depending on patient’s ability to
communicate.
– Responsive medical patient
▪ Can answer history questions
– Unresponsive medical patient
▪ Cannot answer history questions
Responsive Medical Patient
1) Obtain a patient history.
2) Perform physical exam.
3) Obtain baseline vital signs.
4) Administer interventions and transport the patient.
